110

AESTHETICS

Treatment of a Class IV
Anterior Fracture
Conservative Direct Composite Restorations
James H. Peyton, DDS

INTRODUCTION
With the advent of new composite resins and advances in adhe-
sive dentistry, direct composite resins are the dental material of
choice for conservative replacement of tooth structure. There is
no longer a need to aggressively and irreversibly prepare away
healthy tooth structure. There will most likely be a need for indi-
rect restorations in the foreseeable future, but it is our charge to
remain an advocate for our patients to assess every clinical need
and to make recommendations based upon the current trends
of responsible aesthetics.
This article will discuss how to restore a Class IV fracture
(Figure 1) using conservative preparation principles and one of
the latest aesthetic direct composite material options. A step-by-
step procedure will be demonstrated to show how the teeth are
prepared, layered with composite, contoured and polished to
create a lifelike polychromatic aesthetic restoration.
Knowing and Selecting a Dental Material for the Case
When restoring anterior direct composite resins, it is crucial
that the dentist possess a strong working knowledge of the
fundamentals of color, tooth anatomy, and function.1,2 This
appreciation of the physiology and design found in nature is
what will facilitate the creation of restorations that will invis-
ibly dissolve into the surrounding dentition. Most successful
contemporary composite systems have a complete spectrum
of shades, often with a special subset of materials that attempt
to replicate the individual optic parameters of enamel and den-
tin. When critiquing the material options, it is essential that the
resin has the appropriate handling properties that will enhance
your predictability in creating beautiful natural results through
the techniques of stratification and contouring that we will dis-
cuss3-7 (Figures 2 and 3).
Estelite Omega (Tokuyama Dental America) was selected
to use on this case due to its excellent handling properties,
ability to obtain a high polish, and a nice range of compos-
ite shades that allow the clinician to create a polychromatic
aesthetic restoration. Estelite Omega has a great blending effect
from the composite to the natural tooth structure. Due to the
aforementioned characteristics found in this composite
resin, it is an excellent material choice for most aesthetic ante-
rior composite cases.
CASE REPORT
A 42-year-old female was unhappy with the old composite fill-
ing on her front tooth No. 8. The old composite filling was dis-
colored, had open margins, and was unaesthetic. She desired to
have the filling replaced with a new one that would look better.
The old composite restoration was covering an existing Class IV
fracture on the mesial incisal of tooth No. 8.
Clinical Protocol
The first step in the clinical appointment was shade selection. A
custom shade guide was used from the Estelite Omega kit to
select shade EB1. To verify that the shade was correct, the actual
shade of composite was placed on the middle of the tooth (with-
continued on page 112

CLASS IV COMPOSITE ­— OMEGA COLOR MAP

MCO
(Medium Chroma
Shade EB1 Opaquer)
(Body Shade) Shade DA2
(Opaque Dentin
Shade)
MW
DA2 Dentin (DA2)
Trans Trans
EB1
MW (Lingual
Make incisal backing MW
shelf)
thin on lingual White tint
MW (Milky White Enamel) Trans (translucent)
Deep transclucent layer (Incisal Shade & Lingual Shelf) (Between Dentin Lobes)

Figure 1. The smile view shows the right
central incisor (tooth No. 8) with a dark
filling that has an open margin and staining.
Figure 2. Side view of the color map shows the
layers of composite material used in creating the
restoration.
Figure 3. The frontal view of the color map shows
the outline of the dentin mamelons (lobes), the
clear composite layer between the lobes (Trans,
short for “translucent”) the outline of the restora-
tion, and any incisal effects added (white tint).

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Figure 4. A custom shade guide was used
to obtain the correct shade.
Figure 8. The dentin layer of composite
was then applied using dentin shade DA2
(Estelite Omega). It was placed where the
dentin of the tooth should reside. (Note the
still-visible fracture line.)
Figure 12. A thin layer of composite was
removed on the facial-incisal one-third. The
tooth was then microetched (MicroEtcher II
[Zest Dental Solutions]).
Treatment of a Class IV Anterior...
continued from page 110
out acid etching and an adhesive) and
light cured (Figures 4 and 5).
Since the old restoration was still
in place, a putty matrix was taken
directly in the patient’s mouth using a
bite registration material (Blu-Mousse
[Parkell]). The putty matrix was
trimmed at precisely the facial-incisal
line angle using a No. 12 Bard-Parker
scalpel blade. This would help pro-
vide the anatomic framework of the
lingual, mesial, and incisal aspects of
the restoration to be placed.
Next, the patient was anesthetized
with one-half cartridge (0.9 ml) of
lidocaine 2% with 1/100,000 epineph-
rine. The old composite restoration
was completely removed (Figure 6).
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AESTHETICS
Figure 5. The actual composite material
chosen for use in this case (Estelite Omega
[Tokuyama Dental America]) was placed in
the middle of the tooth to determine the
exact shade.
Figure 9. An opaquer (Medium Chroma
Opaquer; Estelite Color [Tokuyama Dental
America]) was used to make the fracture
area disappear. Clear incisal composite
(Trans Estelite Omega) was added between
the dentin mamelons.
Figure 13. A small brush (Estelite Omega’s
Artist Brush [Tokuyama Dental America])
was used to apply the white tint (Estelite
Color [Tokuyama Dental America]).
A long bevel (1.5 mm) was placed on
the facial margin, and a small cham-
fer was placed on the lingual margin.
The long bevel on the facial helps to
blend the restoration into the natural
tooth structure and to mask the frac-
ture line. The putty matrix was tried
in and the lingual margin was lightly
scratched to mark where the first
layer of composite material was to be
placed. Teflon tape was then placed on
the mesial of the adjacent tooth No.
9 to protect it from the acid etchant
and the bonding agent. Acid-etch gel
(Ultra-Etch [Ultradent Products]) was
placed on the prepared tooth, extend-
ing it slightly beyond the margin.
Two applications of Prime&Bond NT
(Dentsply Sirona) were placed and
light cured (Valo LED Curing Light
[Ultradent Products]) for 20 seconds.
Figure 6. The old restoration was removed,
showing the extent of the original fracture.
Figure 10. The tooth was then restored to
full contour.
Figure 14. A surface layer of semi-translu-
cent milky white enamel shade (MW) was
placed over the entire facial surface of the
restoration using a Gold Almore instrument
(Almore International) to evenly spread it
out.
The first layer of composite, shade
MW (Estelite Omega) was applied to
the putty matrix to create the lingual
shelf. The putty matrix was placed
back on the teeth, making sure that
the composite contacted the tooth.
This layer of composite is made very
thin (approximately 0.3 mm) and
thus becomes translucent and also
provides a nice milky-white incisal
halo (Figure 7).
The next layer of composite
was the dentin shade DA2 (Estelite
Omega). The dentin shade comprises
the area where the dentin was for-
merly located prior to the fracture.
Care is taken to simulate the dentin
lobes. The dentin shade should also
mask the fracture line. In fact, if a frac-
ture line is evident at this stage, an opa-
quer should be used. The subsequent
Figure 7. The composite layer, called the
lingual shelf, was added using shade MW
(Estelite Omega). This layer serves to
provide the incisal edge and lingual contour.
Figure 11. The postoperative smile photo
shows sharp developmental depressions
with a lack of faint white opacities.
Figure 15. The post-op close-up view shows
a nice polychromatic restoration with faint
white incisal effects. The anatomy was
much improved, as seen by the matching
light-reflective surfaces.
layer of enamel shade will not block
out a fracture line since this material
is more translucent than the dentin
shade (Figure 8).
In this particular case, the fracture
line was evident after the dentin shade
was added and an opaquer was used.
The fracture line was blocked out with
Medium Chroma Opaquer (Estelite
Color) by placing a thin amount of
material on the tip of a small brush
right on the visible fracture line, along
with a little to each side. The opaquer
was applied in small increments and
light cured until the fracture line disap-
peared (Figure 9). To optically lock-in
the incisal effects of the dentin mam-
elons, a small amount of clear com-
posite material (Trans Estelite Omega
[Tokuyama Dental America]) was
sculpted in between the mamelons.

Figure 16. The final restoration can be con-
sidered to be excellent when it is difficult to
tell which tooth was restored. The post-op
smile view shows that it is, in fact, difficult
to tell which tooth was restored.
The final shade of composite used
was EB1 (Estelite Omega), which is an
enamel shade. The composite material
was spread out over the entire area of
the restoration. A mylar strip was used
to pull-through the composite mate-
rial from the facial to lingual to create
a nice contact area and a nice facial
embrasure. The large end of Estelite
Omega’s Artist Brush (Tokuyama Den-
tal America), which had been wetted
with Modeling Resin (BISCO Dental
Products), was used to smooth out the
facial contours. The composite was
then light cured for a full minute (Fig-
ure 10). Finally, the restoration was con-
toured using Sof-Lex XT (3M) discs. The
coarse, red disc was used first to estab-
lish the primary anatomy, and the
final polish was achieved using blue
and pink polishing cups (FlexiCups
[Cosmedent])8 (Figure 11).
The patient was seen for a one-
week postoperative check and, at this
appointment, the decision was made
to make a few minor corrections to
make the restoration ideal. The inci-
sal edge lacked some of the faint white
opacities and, in addition, the devel-
opmental depressions on the facial
were too sharp. Photographs were
used as a guide to make the final aes-
thetic corrections. There was no need
to completely redo the restoration,
as only a small amount of composite
material (0.5 mm) was reduced on the
incisal area on the facial. The restora-
tion was then microetched (Micro-
Etcher II [Zest Dental Solutions]) and
acid etched, and a bonding adhesive
was applied (Prime&Bond NT)9 (Fig-
ure 12). A small amount of white tint
(Estelite Color) was placed with the
small end of Estelite Omega’s Artist
Brush. Tooth No. 9 was used as a guide
to replicate the pattern of diffuse opac-
ities (Figure 13). The white tint was
then light cured, and a surface layer of
semi-translucent milky white enamel
shade (MW [Estelite Omega]) was
AESTHETICS 113
The results can rival or exceed a porce- 6. Manauta J, Salat A. Layers: An Atlas of Compos-
lain veneer or crown, and it is a mini- ite Resin Stratification. Milan, Italy: Quintessence
Publishing; 2012:349-375.
mally invasive alternative. In the case 7. Finlay SW. Stratification: an essential principle in
demonstrated here, the extra effort in understanding class IV composite restorations.
Journal of Cosmetic Dentistry. 2012;28:32-34.
redoing the incisal area of the restora- 8. Peyton JH. Finishing and polishing techniques:
tion was well worth it to improve the direct composite resin restorations. Pract Proced
Aesthet Dent. 2004;16:293-298.
aesthetics in the final restoration. The 9. Baratieri LN. Esthetics: Direct Adhesive Restora-
final restoration looks natural, blend- tion on Fractured Anterior Teeth. Carol Stream, IL:
Quintessence Publishing; 1998.
ing into the actual tooth without the 10. Rufenacht CR. Fundamentals of Esthetics. Chicago,
restoration or fracture line showing. IL: Quintessence Publishing; 1990:117-127.
The first step in providing this level
of care is an understanding of the pos- Dr. Peyton graduated from the University of
sibilities, and then seeking the knowl- California, Los Angeles (UCLA) School of Den-
edge and clinical training to create tistry in 1982. His private practice is located
in Bakersfield, Calif, and he is also a part-time
predictable results using minimally clinical instructor at the UCLA School of Den-
invasive techniques. F tistry. In addition, Dr. Peyton is a lecturer at
Esthetic Professionals Education Center (Tar-
References zana, Calif) and a part-time clinical instructor
1. Fahl N Jr. Mastering composite artistry to create at the Fahl Institute in Curitiba, Brazil. He has
anterior masterpieces—part 1. Journal of Cos- published several articles for Practical Proce-
metic Dentistry. 2010;26:56-68. dures and Aesthetic Dentistry and The Journal
2. Dawson PE. Functional Occlusion: From TMJ to of the American Academy of Cosmetic Dentistry
Smile Design. St. Louis, MO: Mosby; 2007. (AACD). Dr. Peyton is a Fellow, an accredited
3. Crispin BJ. Contemporary Esthetic Dentistry: Prac-
tice Fundamentals. Tokyo, Japan: Quintessence
member, and an examiner for the AACD. He is
Publishing; 1994:116-127. also a contributing editor for the Journal of Cos-
Figure 17. This clinical protocol resulted in
4. Terry DA. Natural Aesthetics with Composite Resin. metic Dentistry. He can be reached at (661)
a very happy patient.
Mahwah, NJ: Montage Media; 2004:106-114. 323-1888 or via jhpeyton21@gmail.com.
5. Fahl N Jr. Mastering composite artistry to create
anterior masterpieces—part 2. Journal of Cos-
placed over the entire facial surface of metic Dentistry. 2011;26:42-55.
Disclosure: Dr. Peyton received payment from
the restoration. This composite mate- Tokuyama for writing this article.
rial was evenly spread out using a Gold
Almore instrument (Almore Interna-
tional) and then smoothed out using
the large end of Estelite Omega’s Art-
ist Brush wetted with Modeling Resin
(Figure 14). The entire restoration
was light cured for one minute. Once
again, the restoration was contoured
with the red (coarse) Sof-Lex XT
disc. The primary anatomy was estab-
lished, with the incisal edge and proxi-
mal line angles matching the adjacent
tooth No. 9. Tooth No. 8 was polished
with blue and pink polishing cups
(FlexiCups). Pencil lines were drawn
on teeth Nos. 8 and 9 to verify the
position and shape of the line angles.
The secondary anatomy was created
using a flame-tip diamond (F888 012
[Kerr]), which made smooth develop-
mental depression areas on tooth No.
8. A damp 2-x-2 gauze was wiped over
the facial surfaces of teeth Nos. 8 and
9 to ensure that there was symmetry
in light-reflective surfaces. The central
incisors should end up being mirror
images of each other in every respect.
Digital photos were also taken and
checked on a large monitor to verify
that the contour and incisal effects
were correct. The final, high-gloss pol-
ish was obtained using a FlexiBuff
(Cosmedent) polisher with Enamelize
(Cosmedent) paste (Figures 15 to 17).10
CLOSING COMMENTS
A Class IV anterior direct composite
resin restoration can be very aesthetic.
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