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Direct composite restorations in anterior teeth. Managing symmetry in

central incisors

Article  in  The International Journal of Esthetic Dentistry · April 2014

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 CLINICAL RESEARCH

Direct composite restorations

in anterior teeth. Managing
symmetry in central incisors

Gaetano Paolone, DDS

Private practice, Rome, Italy

Correspondence to: Gaetano Paolone, DDS

Viale dei Quattro Venti, 233, 00152 Rome, Italy;

Tel: +39 3474425470; E-mail: gaetano.paolone@gmail.com

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Abstract
In direct restorations of anterior teeth,
particularly central incisors, symmetry
plays an important role. The clinician
can take advantage of silicone indexes
based on a wax-up to build palatal and
incisal walls; however, when he has to re-
produce free-hand chair-side symmetri-
cal items like interproximal emergence
PAOLONE
profiles, macro- and microsurface tex-
tures, and chromatic characteristics,
the result can often be unpredictable. A
step-by-step class IV restoration treat-
ment will be described, as well as a sim-
ple procedure to help reproduce, check
and correct symmetrically interproximal
wall contours and chromatic character-
istics.
(Int J Esthet Dent 2014;9:12–25)
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Introduction
Humans are bilateria,1 they have a bi-
lateral symmetry2 with respect to the
sagittal plane. Bilateral symmetry (also
referred to as reflection symmetry, mir-
ror symmetry, mirror-image symmetry)
is well represented by the two maxillary
central incisors.
When treatment plans include the res-
toration of central incisors, there are many
aspects related to symmetry that the clin-
ician has to take into consideration:
„Symmetry in central incisors is rele-
vant, while in other teeth, as in lateral
incisors, is not so present.3
„Rarely central incisors show asym-
metries in one of the three dimensions
(length, width or thickness) bigger
than 0.2 to 0.3 mm.4,5
„In a natural appealing smile, the pleas-
ant symmetry is near the middle line,
while pleasant asymmetric irregulari-
ties are far away from it.6
„A relationship between bilateral sym-
metry and physical attractiveness has
been reported.7
For all these reasons, central incisors
should be kept as symmetrical as pos-
sible.
In indirect restorations of the anterior
teeth, like crowns or veneers, charac-
teristics like symmetry, form and pro-
portions are comfortably managed in a
dental laboratory.
In direct restorations, the clinician can
take advantage of some “tools” made
in the laboratory (like wax-ups, silicone
indexes) but this is not always possible
because they only help in reproduc-
ing palatal and incisal margins through
molding techniques.8
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Reproducing symmetrically interprox-
imal emergence profiles, interproximal
wall contours, macro- and microsurface
textures and chromatic characteristics
has to be done freehand chairside and
is not always predictable.
In this article a step-by-step class IV
restoration treatment will be described,
as well as a simple procedure to help
reproducing, checking and correcting
symmetrically interproximal wall con-
tours and chromatic characteristics.
Case presentation
A 16-year-old male patient was pre-
sented to the practice referring thermal
sensitivity and complaining about the
esthetic appearance of 1.1 (Fig 1).
He reported that 1.1 was restored 3
years earlier after a traumatic accident.
After a clinical examination, the patient
presented gingival inflammation and in-
correct brushing technique. The restor-
ation on 1.1 was incongruous for color,
degree of finish and had discolored
margins. The cervical portion of the
tooth was not covered by the filling and
revealed exposed dentin. The restor-
ation was esthetically and anatomically
inadequate. A radiographic examination
confirmed the inadequate restoration
(Fig 2). After thorough diagnosis and
planning, a treatment plan was devised.
The treatment procedure consisted of
the following stages:
„Thorough periodontal therapy involv-
ing scaling and oral hygiene
„Color chart, impressions, wax-up
„Composite direct restoration
„Follow-up controls
 PAOLONE

Fig 1 Frontal view at presentation. Fig 2 Radiograph at presentation.

Fig 3 One week after initial periodontal therapy. Fig 4 Extra hard plaster casts and diagnostic
wax-up.

Fig 5 Extra hard plaster casts and diagnostic Fig 6 Silicone indexes.
wax-up.

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Careful cleaning with a motivating oral

hygiene session was performed during
the first appointment. One week later,
no gingival inflammation was detected
(Fig 3).
Precision silicone impressions were
taken in order to make extra hard plaster
casts and a diagnostic wax-up (Figs 4
and 5). These plaster models were used
to create a series of laboratory-made
rigid silicone indexes, both palatal and
Fig 7 Silicone indexes. sagittal (Figs 6, 7).
These indexes are useful in building
palatal and incisal walls and in check-
ing composite thickness while perform-
ing layering technique as described
by several authors.8-12 In the same ap-
pointment, a personalized color chart
was compiled under a light source of
5,500 K.12,13
Some horizontal bands with a pecu-
liar path can be detected on 2.1 and
may be better outlined using computer
software (increasing contrast and ad-
justing brightness (Fig 8).14 These hori-
Fig 8 Computer software is sometimes useful to zontal bands may be classified as type
better understand chromatic characteristics. IV intensive.8

Figs 9 and 10 Inverted black and white pictures are used to understand volumetric discrepancies.

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Figs 11 and 12 Rubber dam isolation.
Fig 13 1.1 after old restoration removal.
Volumetric discrepancies of the pre-
sent restoration can be detected remov-
ing color, using black and white or in-
verted pictures (Figs 9 and 10).
On the third appointment, teeth 15 to
25 were isolated with a thin weight rub-
ber dam (Isolante, Natursint) and two “2”
clamps (Ivory, Heraeus) (Figs 11 and 12).
The rigid silicone palatal index was
checked to fit perfectly and passively.
For this purpose, interdental silicone
was removed from the index with a No.
15 scalpel blade where necessary.12
PAOLONE
Fig 14 212 clamp allowed accessibility to cervi-
cal area.
The old composite filling was removed
using a medium grain cylindrical dia-
mond bur. (Diagram 1, step 2) The cer-
vical area was not completely exposed
by rubber dam isolation (Fig 13). The
application of another clamp (modified
212, Ivory) on 1.1 (Fig 14) allowed that
area to be accessible.
The 212 clamp did not allow the use of
the palatal silicon index, so the cervical
area had to be treated before the rest
of the restoration before performing the
rest of the restoration. The cavity design
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Diagram 1

was characterized by a chamfer on the
buccal finishing line to make the transi-
tion from composite to natural enamel
invisible.8 A butt-joint finishing line was
made in the interproximal margin in or-
der to control excesses and make pol-
ishing in this area easier.12
Great care was taken to finish and
polish margins using silicone points
mounted on a blue ring, low-speed hand

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piece, under a constant cooling spray.

Creating smooth margins is very im-
portant because it helps to remove un-
supported enamel prisms, which could
break off during light-curing contraction,
causing the pigmentation of the resto-
ration’s margin.12 Adhesive procedures
were performed with a three-step etch
and rinse system (Optibond FL, Kerr). A
37% phosphoric acid was used to etch
enamel (30 s) and dentin (15 s). Primer
was applied and then air was applied Figs 15 and 16 After having restored the cervi-
cal portion of 1.1 (left), clamp 212 was removed
gently. Bonding was applied and ex-
(right).
cesses were removed through the use
of paper points and dry brushes. Light
curing was performed for 120 s, moving
the lamp tip in different directions. The
cervical portion was restored with high
opacity and high value dentins (Enamel
plus Hri, GDF). Once the cervical portion
was completed, the 212 was removed
(Figs 15 and 16).
A sharpened probe, with the silicone
index in situ, was used to scratch the
margin of the palatal preparation in or-
der to outline the portion where the
composite had to be placed directly on Fig 16
the index. In the interproximal portions
of 1.1, the silicone index was incised
with a No. 12 scalpel blade to allow the
housing of preformed sectional matrixes
(KerrHawe, Bioggio, Switzerland).
The silicone index was examined
once again to check that a “passive” fit
was maintained even when using trans-
parent matrixes and wooden wedges in
it (Fig 17).
Composite resin was placed directly
on the silicone index, at the incisal, palatal
and interproximal portion of 1.1. In order
to apply thin layers of composite resin,
Fig 17 Silicone index, matrixes and wedges: all
a silicon white soft brush (Micerium) and elements are checked to remove interferences and
synthetic brushes (Syntec, Smile Line) have a “passive fit.”

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Fig 18 Composite is layered directly on the sili- Fig 19 Incisal, palatal and interproximal walls are
cone index. set in one single step.

Fig 20 Sagittal silicone index on the wax-up. Fig 21 Checking space for dentin and enamel.

Fig 22 Dentin layering. Fig 23 Finishing and polishing was performed

after final curing.

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Fig 24 Asymmetry between 1.1 and 2.1.
were used, with the aid of a conditioner
(Ena Seal, Micerium) (Fig 18).12
Masses were chosen based on the
initial color chart (Enamel plus Hri, GDF;
Enamel plus HFO, GDF; Miris 2, Coltène
Whaledent; Empress Direct, Ivoclar Vi-
vadent). The index, along with the com-
posite masses yet to be cured (Fig 18),
were reinserted to check that it was fully
fitted, that the interproximal marginal ad-
aptation (obtained with wooden wedg-
es) was good, that the masses were of
appropriate thickness and volume. After
that, composite masses were cured for
2 min from the buccal side.
The index was then gently removed
and a further curing of 2 min with dif-
ferent light directions was performed
(Fig 19). Once the tooth’s frame was
defined, dentin was layered, checking
its thickness with sagittal silicone in-
dexes obtained from the original wax-
up (Figs 20 and 21). The dental body
was modeled, leaving space to add the
specific opalescent masses according
to the color scheme compiled in the pre-
liminary appointment (Fig 22).
PAOLONE
Fig 25 Silicon index after buccal portion removal.
Once the final layer was applied and
cured with enamel mass (no thicker
than 0.5 mm), a further 60 s curing was
performed under glycerin, in order to
increase the composite resin’s polymer-
ization and surface performance.12 The
restoration was then finished and finally
polished (Fig 23). For this purpose, fine
and ultra-fine diamond burs were used,
as well as silicone rubbers, diamond
pastes (Prisma Gloss, Dentsply DeTrey)
applied with brushes, and aluminum ox-
ide paste applied with felt.15
Once the polishing procedure was
performed (Fig 24), symmetry between
1.1 and 2.1 was not satisfactory, being
that the size and morphology of the dis-
tal portion of 1.1 was different from that
of 2.1 (Diagram 1, step 3).
For this reason a “guideline” based on
2.1 was made. With a silicone impres-
sion material (Elite HD+, Zhermack), an
incisal index was obtained putting the
impression material directly on the iso-
lated elements (Diagram 1, step 4). All
the buccal portion of the index was re-
moved using a scalpel blade (Fig 25).
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Fig 26 A transparent matrix band is inserted in
the silicon index parallel to central incisors.
Fig 28 Horizontal stripes are outlined in black.
With the same scalpel blade an inci-
sion of 5 mm of depth was made bucca-
lly, in the front of and parallel to the labial
surface of the incisors. In this incision
a transparent matrix band was inserted
(Fig 26) (Diagram 1, step 5).
With a green felt pen, the midline and
the distal portion of 2.1 was marked (Di-
agram 1, step 5). Removed and flipped,
the band was then reinserted centering
the midline; the distal portion of 2.1 was
marked once again (Diagram 1, step 6).
In this way, it was possible to highlight
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Fig 27 After several comparisons, the distal as-
pects are symmetrical.
Fig 29 Horizontal stripes are now on 1.1.
any discrepancies between the distal
portions of the central incisors. Based
on this reference index and checking it
continuously, the distal portion of the res-
toration (Diagram 1, step 7) was modi-
fied (using diamond burs and discs) in
order to improve the symmetry with 2.1
as much as possible (Fig 27).16
Using the same transparent matrix,
the pattern of horizontal stripes was
marked with a black permanent marker
(Fig 28) (Diagram 1, step 8). The matrix
was then removed, flipped once again
 PAOLONE

and reinserted into the index. Referenc-

es of distal portions and midline were
used for a correct matrix repositioning.
The pattern of horizontal stripes of 2.1
was then on 1.1 (Fig 29).
In order to transfer the pattern of hori-
zontal stripes, a small piece of 8 microns
articulating paper, coated on one side
(Arti-fol BK-21, Bausch), was interposed
between the matrix and the labial sur-
face of the element. Tracing the path on
the matrix band with one probe and with Fig 30 Pressing gently on the transparent matrix
band with a probe.
light pressure, it was possible to transfer
the information on the stripes’ path on
1.1 (Figs 30 and 31; Diagram 1, steps 9
and 10).
Small diameter multiblade burs (H1
314 006, Komet) were used to create
space for effect masses (Fig 32). Once
these masses were applied, the element
was polished once again and the dental
dam was removed (Fig 33).
One week after treatment, the teeth
were rehydrated (Fig 34). Seventeen
months after the end of the treatment,
the restoration showed a good integra-
Fig 31 Horizontal stripes path is transferred on
tion with the marginal tissues (Fig 36). 1.1.
Cold and EPT tests produced positive
responses. The patient appeared mo-
tivated and has changed his attitude
toward oral hygiene, causing gingival
inflammation to disappear.

Fig 32 Space for effect masses is created.

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Fig 33 After dental dam removal, rehydration is Fig 34 One week after treatment.
remarkable.

Fig 35 Palatal aspect. Fig 36 Follow-up after 17 months.

Conclusions
Reproducing “specular symmetry” is
rather difficult, especially when it has
to be done freehand chairside. While
some aspects can be planned in the la-
boratory, others cannot. In this article,
a simple and inexpensive technique
helpful in reproducing symmetric char-
acteristics has been described. “Visual”
guides like this one could be prepared
Fig 37 Periapical radiography of 1.1 at the end in advance, and in a more precise way,
of treatment. from the wax-up or with photographs

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 PAOLONE

and graphic design software. Although Acknowledgements

these procedures would require an ac-
curate cost-benefit analysis, the author
thinks that further investigation should
be done.
Wax-up: Mr Paolo Santi Laurini, Grosseto, Italy. The
author would like to thank StyleItaliano and A.I.C.
(Accademia Italiana di Conservativa) for being a
source of inspiration.

References
1. Finnerty JR. The origins
of axial patterning in the
metazoa: how old is bilateral
symmetry? Int J Dev Biol
2003;47:523–529.
2. Finnerty JR, Pang K, Burton
P, Paulson D, Martindale MQ.
Origins of bilateral symmetry:
Hox and dpp expression in
a sea anemone. Science
2004;304:1335–1337.
3. Gallão S. Lúcia C, Ortolani
F, Dos A, Dos L, Faltin K.
Photographic analysis of
symmetry and aesthetic
proportion of the anterior
teeth. Rev Inst Ciênc Saúde
2009;27:400–404.
4. Garn SM, Lewis AB, Walen-
ga AJ. Maximum-confidence
values for the human mesio-
distal crown dimension of
human teeth. Arch Oral Biol
1968;13:841–844.
5. Mavroskoufis F, Ritchie GM.
Variation in size and form
between left and right maxil-
lary central incisor teeth. J
Prosthet Dent 1980;43:254–
257.
6. Rufenacht C. Fundamentals
of Esthetics. Chicago: Quin-
tessence Publishing, 1990.
7. Edler RJ. Background con-
siderations to facial aesthet-
ics. J Orthod 2001;28:159–
168.
8. Vanini L, Mangani F, Kli-
movskaia O. Conservative
Restoration of Anterior Teeth.
Viterbo: Acme, 2005.
9. Dietschi D. Layering con-
cepts in anterior composite
restorations. J Adhes Dent
2001;3:71–80.
10. Devoto W. Clinical procedure
for producing aesthetic strat-
ified composite resin restor-
ations. Pract Proced Aesthet
Dent 2002;14:541–543.
11. Devoto W, Pansecchi D.
Composite restorations in
the anterior sector: Clinical
and aesthetic performances.
Pract Proced Aesthet Dent
2007;19:465–470.
12. Devoto W, Saracinelli M,
Manauta J. Composite in
everyday practice: how
to choose the right mater-
ial and simplify application
techniques in the anterior
teeth. Eur J Esthet Dent
2010;5:102–124.
13. Vanini L, Mangani F. Deter-
mination and communica-
tion of color using the five
color dimensions of teeth.
Pract Proced Aesthet Dent
2001;13:19–26.
14. Salat A, Devoto W, Manauta
J. Achieving a precise color
chart with common computer
software for excellence in
anterior composite restor-
ations. Eur J Esthet Dent
2011;6:280–296.
15. Antonson SA, Yazici AR,
Kilinc E, Antonson DE,
Hardigan PC. Comparison
of different finishing/polish-
ing systems on surface
roughness and gloss of
resin composites. J Dent
2011;39(Suppl 1):e9–e17.
16. Terry DA, Geller W, Tric O,
Anderson MJ, Tourville M,
Kobashigawa A. Anatomical
form defines color: Func-
tion, form and aesthetics.
Pract Proced Aesthet Dent
2002;14:59–67.

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