Q U I N T E S S E N C E I N T E R N AT I O N A L
RESTORATIVE DENTISTRY
Contemporary options for restoration of
anterior teeth with composite
Eva Wirsching, Dr med dent 1
The present article gives an overview of modern adhesive res-
toration in the anterior area, in view of the fact that modern
dental therapy should be as minimally invasive as possible.
Illustrated with multiple cases, the article shows possible pro-
Key words: corrections of form, direct composite resin restoration, direct composite veneer, fiber-reinforced-
composite fixed partial dentures (FRC-FPD), space closure
Tooth-colored restorative materials have been estab-
lished in the anterior region as durable standard treat-
ment options. Continual improvement to ceramic and
composite materials has enlarged the spectrum for
indications. To an increasing degree, esthetic motiva-
tion plays an important role in today’s dentistry
because of the greater awareness of an attractive visual
appearance. Hence treatment of caries lesions is no
longer the only requirement.
Minimally invasive means a preparation that is
guided not only by cavity design. The term has to be
defined in a more complex way. Aspects such as exca-
vation, infiltration, sustainability, and reparability
should be included, and these generate the “star of
minimally invasive dentistry” in restorative dentistry:
composite resin.1
Today’s dentistry shows a trend towards more con-
servative dentistry.2 Due to optimized adhesive tech-
1
Private Practice, Stuttgart, Germany.
Correspondence: Dr Eva Wirsching, Rotenwaldstrasse 99, 70197 Stutt-
gart, Germany. Email: evawirsching@gmx.de
VOLUME 46 • NUMBER 6 • JUNE 2015
Eva Wirsching
spective fields of indication. (Quintessence Int 2015;46:457–463;
doi: 10.3290/j.qi.a33989; Originally published in Quintessenz
2014;65(9):1067–1075)
niques it is possible to reach the boundaries of cur-
rently defined indications. However, academic research
into these additional fields of application is neglected.
Therefore, the present article depicts realistic possible
treatment options in the anterior region and illustrates
potential further options. Evidence-based data on lon-
gevity are limited, but clinical experience is promising.
In this context, treatments without data on long-term
sustainability are shown, demonstrating their practica-
bility and feasibility.
Restoration options using direct technique
Today composite is used for direct color and shape cor-
rection of teeth. The direct build-up technique can also
be applied for layering the complete vestibular surface,
creating direct veneers. Modern composites have
proven longevity and show good consistency. In the
past, failures occurred due to discoloration of the ma-
terial or excessive loss of superficial lustre. The percep-
tion of composite as a minor restorative material is now
outdated. The clinical success of this material depends
on its correct application and proper indication.
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Fig 1a Situation after orthodontic treatment with spaces remain-
ing in the anterior region.
Fig 2a Young patient with amelogenesis Fig 2b Situation after removal of the old
imperfecta and inadequate restoration. composite material.
Fig 3a Situation after periodontal thera- Fig 3b After removal of the splinting.
py.
Closing diastemas and recontouring teeth in
combination with orthodontic therapy
Figure 1 shows noninvasive treatment of anterior teeth
with asymmetric gaps and rotations. By proximally
broadening the teeth with direct composite build-ups a
harmonious situation could be created. This direct tech-
nique can also be used for distinctive shape correction of
teeth with structural malformation.3 Figure 2 shows a
young patient with amelogenesis imperfecta who was
treated in the past alio loco with partial composite res-
torations. After removing the old material, the teeth
could be recontoured with direct veneers using the
layering technique. The result has been stable for 2
years and the patient is undergoing orthodontic therapy.
458
Fig 1b After restoration with direct composite build-ups at the
maxillary central and lateral incisors.
Fig 2c Situation after restorative treat-
ment with directly made composite
veneers.
Fig 3c Situation after restoration using
the direct composite layering technique.
Harmonization after periodontal therapy
After successful periodontal therapy the outcome is
often esthetically poor. Damaged by periodontal dis-
ease, a prosthetic restoration is not possible due to the
uncertain prognosis. Restoring these teeth with direct
composite build-ups is a useful alternative for long-
term provisional restoration and to create esthetically
pleasing conditions.
Figure 3 shows an adult patient after periodontal
treatment. After removing the splinting and the com-
posite material, the restoration was made using the
direct layering technique. The result has remained sta-
ble for 5 years and the patient is still under periodontal
recall.
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Figs 4a to 4c Young patient with traumatic loss of teeth 11 and 21 and aplasia of tooth 22.
Fig 4a Situation at initial consultation. Fig 4b Intraoral situation 5 years after
restoration with direct composite build-ups.
Aplasia and traumatic loss of teeth
In cases of traumatic loss of teeth and aplasia, when
treatment of gap closure is chosen, direct shape correc-
tions are possible.
Figure 4 shows a 14-year-old boy who lost both
maxillary central incisors at the age of 9 during a car
accident. The right lateral incisor was a peg tooth and
there was an aplasia of the left lateral incisor. Orthodon-
tic treatment was used with the aim of positioning the
canines in the region of the missing central incisors. The
peg tooth was positioned in the region of the right lat-
eral incisor and the primary left canine persisted in the
region of the left lateral incisor, until an implantation in
adulthood is possible. To bridge the time until adult-
hood, direct composite build-ups of the lateral incisors
and canines were undertaken. Figure 4 shows the situa-
tion after orthodontic treatment (brackets removed)
and initial consultation. The noninvasive treatment used
the direct layering technique with composite veneers.
After 4 years a small gap was present between the cen-
tral incisors due to transverse growth of the maxilla. This
gap was closed successfully using the same composite.
The young patient is now at the age of 19 and the situa-
tion has been stable for 5 years (Figs 4b and 4c).
The key advantage of this treatment is its noninva-
sive nature. At this young age the tooth substance
could be preserved. Initially it was clear that due to
asymmetric tooth position and unequal gaps, an
esthetically perfect result might not be possible. There-
fore the treatment was intended to generate stable
conditions and to help provide the young patient with
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Fig 4c Smile at 5 years after treatment.
a socially acceptable appearance, preserving possible
future prosthetic and implant treatment options. The
treatment was seen as a long-term provisional treat-
ment until there is no further transverse growth of the
maxilla. In adulthood, prosthetic restoration of the
maxillary canines and right lateral incisor, as well as the
implant at the left lateral incisor, could be planned.
Esthetic shape correction in adulthood
Comprehensive shape corrections can also be per-
formed in adult teeth with direct composite build-ups.
In these cases there is often a higher demand for a
quality result. Figure 5 shows a young woman who felt
uncomfortable with the appearance of her maxillary
teeth. Due to tooth wear, the maxillary anterior teeth
were shorter, and the lateral incisor showed rotation.
The patient did not want orthodontic treatment. The
treatment option of ceramic veneers was discussed but
the young patient wanted to be treated noninvasively.
To visualize the possible treatment outcome, the den-
tist can perform a direct mock-up, either via direct com-
posite application without etching the tooth, or via wax-
up by the technician. Thereby the dentist plans the shape
corrections and gap closures. The restoration using direct
layered composite veneers can be seen as a long-term
provisional restoration. Only a few studies can be found
in the literature,4-6 but the published data show that
application of this type of restoration leads to promising
results. Peumans et al5 showed that 89% of the investi-
gated esthetic shape corrections made using composite
could be graded as clinically acceptable after 5 years.
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Fig 5a Intraoral situation: excessive wear and rotation of anter-
ior teeth.
Fig 5c Smile at initial consultation before treatment.
COMBINATION OF DIRECT AND
INDIRECT TECHNIQUES
Complete rehabilitation of teeth with
general destruction
There is a tendency in contemporary conservative den-
tistry to use a combination of direct and indirect tech-
niques. Figure 6 shows a 12-year-old boy with a diagno-
sis of amelogenesis imperfecta (hypoplastic type) and a
loss of vertical dimension of occlusion (VDO). The treat-
ment plan was an elevation of the bite with a new VDO
using a combination of direct composite build-ups,
indirect composite veneers, and composite crowns in a
modified three-step technique and sandwich tech-
nique.7 Owing to the use of composite, treatment could
be noninvasive. The material also requires no minimum
layer thickness.
At the initial consultation at the age of 11, orth-
odontic treatment proceeded to regulate the cross-
bite. Because of favorable temporomandibular joint
growth, the conservative therapy started at the age of
460
Fig 5b Intraoral situation after directly layered composite res-
torations of anterior teeth.
Fig 5d Smile after treatment.
11. In this case the bite elevation / elevation of VDO
was defined by the pathologic bite collapse. The orth-
odontic treatment also had the aim of generating suf-
ficient proximal space with interproximal gaps for fur-
ther restoration. The bite was to be raised by 3 mm.
After taking an occlusal impression, a diagnostic wax-
up was created of the anterior and posterior teeth to
plan and control the definitive restorations. For testing
and adaptation of the new VDO, the patient had a
splint. The following restorations were planned:
• posterior teeth: 16 indirect composite crowns on
teeth 14 to 17, 24 to 27, 34 to 37, and 44 to 47
(according to FDI nomenclature)
• mandibular anterior teeth 33 to 43: six indirect buc-
cal composite veneers, six direct lingual composite
veneers
• maxillary anterior teeth 13 to 23: six direct buccal
composite veneers and six indirect palatal compos-
ite veneers (Fig 6c).
The laboratory-made composite crown (Fig 6c) was
made from SR Adoro (Dentin A3, Enamel TS2; Ivoclar
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Fig 6a 12-year-old boy with amelogenesis imperfect: smile
before treatment.
Fig 6c Palatal composite veneers of the maxillary anterior teeth
and composite crowns of the posterior teeth.
Vivadent), a veneer composite with good clinical per-
formance.8,9 The treatment was performed within 1
week. At the initial appointment, 16 posterior compos-
ite crowns were adhesively inserted (Tetric EvoFlow A3,
Ivoclar Vivadent). Due to the bite elevation there was a
temporary open bite in the anterior region. The patient
was instructed that biting in the anterior region would
not be possible for 1 week. After 1 week, at the second
appointment, insertion of the palatal composite
veneers was undertaken (Fig 6d). The vestibular aspects
of the maxillary anterior teeth were directly layered by
the dentist using composite (Enamel Plus HFO, UD3.5,
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Fig 6b Intraoral situation before treatment.
Fig 6d Situation after cementation of the palatal composite
veneers and posterior composite crowns.
Fig 6e Direct composite build-ups/directly made composite
veneers of the maxillary anterior teeth with Enamel Plus HFO.
Enamel GE2; Micerium; Fig 6e). At the third appoint-
ment 1 day later, the same procedure was performed in
the mandibular anterior region. At the control appoint-
ment 2 months later, the clinical situation showed a
natural appearance (Figs 6f to 6i).
Application of occlusal composite onlays in the pos-
terior region for bite elevation is described in the litera-
ture within case reports. To generate a new VDO, so-
called repositioning onlays are currently applied.10
These are based on a minimally invasive, defect-orien-
tated concept. In the described case, due to the age of
the patient and the minimal available space, composite
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f g
Figs 6f to 6i Stable situation after restorative rehabilitation. (f) Maxilla. (g) Mandible.
(h) Intraoral situation after treatment. (i) Smile after treatment.
restoration was more suitable. Further cases of patients
who were treated using this technique (eg, for molar
incisor hypomineralization) also showed good clinical
results. If chipping fractures occur at a later date due to
jaw growth or functional wear, the restorations can be
repaired intraorally. The surface lustre should be moni-
tored to ensure it remains stable.
Replacement of missing teeth (traumatic
loss/aplasia) by fiber-reinforced composite
fixed partial denture (FRC-FPD)
When single anterior teeth are missing and the gap
should be preserved, FRC-FPDs show promising clinical
results. Figure 7 demonstrates the restoration of a sin-
gle tooth gap in the anterior region, where implanta-
tion was not possible due to low interradicular space.
FRC-FPDs show esthetically pleasing appearance and
they seem to be an alternative to all-ceramic fixed par-
tial dentures. Data in the literature reveal good results,
so they could be possible alternatives for implants or
prosthetic restorations in the future.
The patient in Fig 7 was referred to the orthodontic
department because of her compromised right lateral
incisor. The remaining root was affected so an orth-
odontic extrusion was not advisable, and the tooth was
therefore extracted. The patient declined orthodontic
treatment to widen the gap in order to facilitate
implantation, so an implant was not inserted. After
extraction a pontic was placed provisionally. The FRC-
FPD could then be inserted. In the literature, studies
show good long-term stability of FRC-FPDs. Vallittu11
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i
reported a Kaplan-Meier survival rate of 75% after 63
months, and Freilich et al12 reported a survival rate of
74% after 3.75 years. In a retrospective study by Wolff
et al,13 only one of 32 examined FRC-FPDs was rated as
a failure after 18 months (USPHS/Ryge-criteria).
CONCLUSION
The objective of the present article was to show indica-
tions for minimally invasive treatment in conservative
dentistry in addition to orthodontic, prosthetic, and
implant treatment options and to suggest future pos-
sible therapies. It has to be assumed that new forms of
therapy can always show failings because boundaries
concerning application techniques and materials were
reached. The described cases demonstrate that modern
conservative dentistry represents a wide spectrum of
indications, and that more comprehensive cases can be
treated. FRC-FPDs are an additional treatment option
for replacement of a single tooth. They can also be used
as high-quality, long-term provisional restorations in
implantology.
Modern composites seem to be beneficial and fulfil
expectations. The combination of direct and indirect
techniques when restoring anterior teeth is promising
for the future. It facilitates complex treatment steps
such as generating proper occlusion, and allows more
efficient, economical dentistry.
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Figs 7a to 7d Restorative treatment of missing tooth 12 by fiber-reinforced composite fixed partial denture (FRC-FPD).
Fig 7a Situation at initial consultation: compromised tooth 12
and provisional crown.
Fig 7c Situation before the insertion of the FRC-FPD.
ACKNOWLEDGMENT
The author thanks the technician K. Halbleib (Poliklinik für Zahnerhal-
tung und Parodontolgie, Universitätsklinikum Würzburg) for the pro-
duction of the indirect restorations.
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