specialfeature

Tetric N-Collection ®

Fulfilling new patient expectations

Dr Eduardo Mahn, Santiago, Chile

Invisible restorations Esthetic posterior restorations

Dr Ratnadeep Patil, Mumbai, India Dr Cristian Higashi, Dr João Carlos Gomes, Curitiba, Brazil

Meeting challenges successfully The objective is to imitate nature
Dr Roberto M. Yoshida Jr, Londrina, Brazil Prof. Dr Abelardo Báez Rosales, Viña del Mar, Chile

Tetric N-Collection
®

® ® ® ®
Tetric N-Ceram | Tetric N-Flow | Tetric N-Bond | Tetric N-Bond Self-Etch
2 Tetric® N-Collection

Editorial

Since the first composites were introduced by Bowen* in the

late 1950s, this class of materials has evolved into a mature
technology. Irrespective of the composite material per se, re-
search over the past 50-60 years has clearly shown that this
type of restorative needs a strong partner to be successful: a
dental adhesive. In the category of adhesives, we can look
back on an impressive amount of research which has yielded
substantial improvements. Modern adhesives are reliable ma-
terials as long as dentists observe the manufacturers’ instruc-
tions for use.

Tetric N-Collection is a very good example of this product evo-

lution. Due to Ivoclar Vivadent’s long experience in the devel-
opment of composites and adhesives, it was possible to create
a product system that is optimized and tailored for easy
application and handling without sacrificing on the excellent
clinical behaviour.

This little brochure clearly shows how dentists from all over
the world can achieve outstanding esthetic and functional re-
storative results in the anterior and posterior region. Each of
these professionals works in his/her individual way, but all of
them benefit from the good properties this family of products
offers: operators are free to choose either a self-etching or an
etch&rinse adhesive and take advantage of the clever pho-
toinitiator technology which gives them ample time to sculpt
and contour the restoration. There is no risk that the material
prematurely reaches the gelation point due to the exposure to
ambient light. In addition, users can employ an efficient pro-
cedure with comparatively short curing cycles due to the ef-
fective photoinitiator system. As a result of the unique filler
mix, the product is not only easy to polish but also shows
good radiopacity due to the ytterbium trifluoride filler fraction.
In a nutshell, Tetric N-Collection offers a range of optimally
coordinated products for dental professionals who strive to
provide a high standard of care. However, this brochure also
shows that high-quality materials are no substitute for the
good skills every dentist requires.

Prof. Jean-François Roulet

*Bowen RL. Silica-resin direct filling material and

method of preparation. 1962; Patent No. US3194783.
 Tetric® N-Collection 3

Contents

Fulfilling new patient expectations

New options for composite treatments 4

Invisible restorations
Esthetic management of mild enamel hypoplasia with direct composite 8

Meeting challenges successfully

Esthetic posterior restorations with Tetric® N-Ceram 12

Esthetic posterior restorations

Current developments in composite resin materials and techniques 15

The objective is to imitate nature

Replacement of amalgam restorations with composites 19
4 Tetric® N-Collection
Fulfilling new patient
expectations
New options for composite treatments
Composites have been used both in the anterior and
posterior region for quite a number of years. Other ma-
terials such as amalgam and glass ionomers are still
being used in the posterior region. However, the ante-
rior region is the exclusive domain of composites due to
their high esthetics and ability to blend in with dental
tissues. Originally the goal of restorative treatment was
to recover dental tissue function. Thus, if a tooth was
affected by caries, it was removed and the cavity was
filled with composite, or if there was a fracture, the lost
tissue was reconstructed with the same material.
Down the years materials have advanced both in terms of me-
chanical and optical properties, but our patients’ expectations
and needs have also changed at the same time. Conse-
quently, it is no longer sufficient to just reconstruct a class IV
cavity with a single layer of composite. Although this is bound
to recover the function, a single layer of composite will never
provide the required optical properties.
The response from manufacturers to new patient expectations
was to create composite systems which comprised dentin,
enamel and effect materials featuring different translucencies.
At the same time, the esthetic potential of these new compos-
ites allowed new types of “elective” treatments to be carried
out. These include the reconstruction of peg lateral teeth, di-
rect veneers and the closure of both multiple and median
diastemas. This type of treatment is characterized by the
absence of a functional motive. The restoration is only per-
formed to improve the shape, shade or the dimensions of the
teeth. Therefore, the clinician has to have a grasp of dental
anatomy, proportions, how to design a smile and both oral
and facial esthetics in addition to basic knowledge of biology,
biomechanics, dental surgery and dental materials. It is note-
worthy that there are three great challenges to diastema clo-
sure and the technique to be used has to be designed to solve
them.
1 - It is an essential requirement to have a perfect transition
between a tooth and a filling in order to avoid periodontal
problems, plaque build-up and caries adjacent to restorations
in the long term. In the case of diastema closure, this is even
more difficult to achieve than with other indications, as we
are creating an artificial overcontour adding composite to the
Dr Eduardo Mahn,
Santiago, Chile
tooth and enlarging its shape. As a result, an undercut is cre-
ated that did not exist previously. In the present case, we
solved this problem by using flowable composite together
with a matrix band.
2 - The tooth‘s emergence profile needs to be rounded and
needs to follow natural lines, which we obtained by using the
transparent matrix band positioned in a way that we will ex-
plain later.
3 - The final result must be esthetic and satisfy the patient, so
we have to consider the change in proportion between the
width and the length of the tooth. In most cases a width to
length ratio of between 70 to 80% is deemed to be accept-
able. If we exceed this ratio, we have to modify the contours
to create the illusion that the tooth is narrower than it really is
at the end of the treatment.
Before realizing this type of treatment, the clinician has to ob-
tain information on the limitations of the materials that he or
she is going to use. In the clinical case involving the closure of
a median diastema which will be presented below, the mate-
rial used was Tetric® N-Ceram in conjunction with the Tetric®
N-Bond adhesive system.
Tetric N-Ceram is a nano-hybrid composite which can be used
both in the posterior and anterior region as it provides a bal-
anced combination of good mechanical properties, combined
with a high ability to blend into the natural surroundings and
a final polish similar to that of dental tissues. Another charac-
teristic of the chosen system to take into account is that it has
enamel, dentin and effect materials which allow invisible res-
torations to be achieved. Tetric N-Ceram comes in 16 differ-
ent shades, two of which are dentin, one translucent, three
bleach and the rest (10) universal enamel shades ranging from
A to D. It is also important to have a sufficiently broad range
of flowable composite shades as they are used, particularly in
the anterior region, alongside universal composites. The Tetric
N-Collection of composites comprises 10 different flowable
shades. The adhesive system used was Tetric N-Bond, a 5th
generation adhesive which, using ethanol as a solvent, allows
more gradual solvent evaporation and prevents dentin dehy-
dration and the subsequent collapse of the collagen fibres.
 Tetric® N-Collection 5

Clinical Case
A female patient, aged 35, arrived at our practice enquiring
about available treatment options for closing her median di-
astema. As she had undergone orthodontic treatment a few
years ago, she rejected having it once again. A more invasive
treatment such as indirect ceramic veneers was also rejected
in this case, as it offered few benefits in addition to the draw-
back of having to prepare the oral enamel.

Figure 1 shows the preoperative situation, the teeth con-

trasted against a black background to highlight the most
translucent, opalescent areas and the individual characteristics
of each tooth to be treated. Note that the incisal edge of the
two teeth has a different contour. In addition, the median di- Fig. 1: Preoperative situation
astema that the patient exhibits is quite wide which makes it
difficult to obtain an esthetic result due to the loss of propor-
tions between the width and the length of the teeth. As we
will see later, there are techniques for compensating for this
change in ratio.

The procedure for closing the diastema begins by placing a

retraction cord (Fig. 2), which is followed by the correct appli-
cation of the transparent matrix band (Fig. 3). There are many
clinicians which perform diastema closure by means of a “free
hand” method. This technique is inadequate as it does not
ensure a good transition between composite and tooth. The
next step was to etch with phosphoric acid (N-Etch) for 60
seconds and rinse and dry the preparation prior to applying
Tetric N-Bond at least for 10 seconds. After having evapo- Fig. 2: Placement of a retraction cord
rated the solvent, the adhesive layer was light-cured for 10
seconds with the bluephase® curing light.

The next step was to apply the flowable composite (Tetric®

N-Flow in shade A1) to form the “skeleton” of our restoration
(Fig. 4). This type of composite has a consistency suitable for
this purpose as it flows into the groove created with the ma-
trix band and adapts of its own accord. In addition, owing to
the matrix band we have an immediate convex emergence
profile which simulates the natural contour of the tooth. Af-
terwards, universal composite (Tetric N-Ceram in shade A1)
was applied to fill the remaining space (Fig. 5). Figure 6 shows
the completed restoration in tooth 21. Note the overcontour.
The restoration obtains its final shape and contour during the
finishing and polishing procedure (Fig. 7). Once the first Fig. 3: Positioning of the transparent matrix band prior to acid etching
6 Tetric® N-Collection

restoration is completed, the retraction cord and the matrix

band are positioned on the other tooth. Then etching with
N-Etch is performed (Fig. 8). Tetric N-Flow is placed after the
adhesive has been applied and light-cured (Fig. 9).
Tetric N-Ceram A1 is applied following light polymerization
of the flowable composite to build the restoration to its final
contours. The next step is to remove the band, revealing rela-
tively symmetrical restorations, prior to proceeding to finish
tooth 11 (Fig. 10). Finishing is performed with 16- and
30-fluted carbide burs before proceeding to subsequent final
polishing with the 3-step Astropol® silicone polishing system
(Figs 11 a-c).

Figure 12 shows the final result in which the teeth do not Fig. 4: After etching the tooth with N-Etch and applying Tetric N-Bond
seem as wide as they really are after treatment thanks to a adhesive, Tetric N-Flow A1 flowable composite was applied.
natural emergence profile and incisal edge rounding! Owing
to a good diagnosis, a suitable technique which solves the
challenges posed by the indication and the use of an excellent
adhesive and restorative system such as the Tetric N-Collec-
tion of products, a satisfactory result was achieved for both
the clinician and patient in equal measure.

Fig. 5: Application of Tetric N-Ceram shade A1

Fig. 6: Restoration overcontour after light-curing the composite. The Fig. 7: Final shape after finishing tooth 21
final shape and contour is attained during finishing and polishing.
 Tetric® N-Collection 7

Fig. 8: Acid etching with N-Etch Fig. 9: Application of flowable composite to create the restoration’s
“skeleton”

Fig. 10: Both restorations during finishing. Note that the retraction Figs 11 a-c: Final polish with the Astropol polishing system
cords have not yet been removed

Contact details:
Dr Eduardo Mahn
Clinica Tres Puntas
Av. Irrarazaval 2821 Oficina 627 Torre B
Santiago, Chile
Fig.12: Final result
8 Tetric® N-Collection

Invisible restorations
Esthetic management of mild enamel
hypoplasia with direct composite
Dr Ratnadeep Patil,
Mumbai, India

Tooth enamel defects, i.e. unsightly pits and dents re-

stricted to the anterior teeth, can be effectively masked
by direct composite restorations. The key is being able
to determine the thickness of each defect and to use
the optical properties of resin materials as well as the
layering technique to achieve a natural-looking, esthetic
restoration.

Any local, systemic or genetic disruption occurring during the

period of tooth development has the potential to cause
enamel hypoplasia in the developing tooth. The defect can be
a small pit in the tooth, or it can be so widespread that the
entire tooth is small and/or misshaped. This type of defect
may result in tooth sensitivity or cause teeth to be unsightly Fig. 1: Mild enamel hypoplasia in upper central incisors, lower
and more susceptible to dental caries. Local, systemic and ge- central and lateral incisors
netic factors associated with enamel hypoplasia of permanent
teeth include trauma, excessive ingestion of fluoride, neonatal
infection, nutritional deficiencies due to low birth weight and
amelogenesis imperfecta.

In the esthetic zone, the masking of mild hypoplastic defects

using composite bonding procedures is considered to be the
most conservative and least invasive technique to restore miss-
ing, diseased and unsightly tooth structure. In order to restore
the appropriate colour, form and function of teeth, a multi-
factorial approach to treatment planning and execution is re-
quired. For the creation of composite restorations that mimic
the natural tooth structure, it is essential to have a compre-
hensive understanding of the restorative materials and their Fig. 2: Note the rugged border of the incisal edge with hypoplastic
application, the principles of adhesion, appropriate shade se- areas
lection and most importantly, matching the shades of the dif-
ferent composite layers applied. Adding incisal effects, surface
textures and subtle imperfections will further enhance the
overall value of the restoration. Finishing and polishing is cru-
cial in finalizing the composite restoration for longevity. There
is no shortcut in fabricating lifelike restorations. Appropriate
finishing and polishing allows for a proper marginal seal,
which influences the durability of the restoration and ensures
minimal plaque accumulation and staining.

Clinical case
A 20-year-old girl presented to our office with maxillary and
mandibular central incisors and first molars that had pitted
surfaces (Figs 1 and 2). Her chief complaint was her unsightly Fig. 3: Localized inflammation and recession of the gingival tissue
 Tetric® N-Collection 9

smile which was due to the pitted appearance of the central

incisors. She admitted that she had ceased to smile because of
her ugly teeth. However, she did not report any pain or tooth
sensitivity.

Examination revealed various degrees of hypoplasia, dark dis-

colourations, anatomical abnormalities and caries in the ante-
rior teeth and all first molars. Localized inflammation and
recession of the gingiva around the lower right central incisor
was observed (Fig. 3). Oral prophylaxis was performed and the
patient was advised to apply Cervitec® Gel (containing 0.2%
chlorhexidine and 900 ppm fluoride) on the affected areas of
the gums twice daily for five consecutive days. This restored
the gingival health in the area. Fig. 4: Labial preparation covers the entire defect and will allow ease
in contouring and precise placement of the composite restoration.
We decided to restore the anterior teeth with Tetric® N-Ceram
composite, which offers a choice of different shades and ex-
hibits a chameleon effect upon layering.

Preparation design
The hypoplastic pits and dents were smoothed and saucered
with a 0.6 mm diameter round diamond bur. Further prepara-
tion was performed with a 1 mm diameter chamfer diamond
bur not only to entirely cover the saucer defects but also to
extend beyond them. Such a labial preparation extent allowed
ease in contouring and precise placement of the composite
restorative. Care was taken that the extension did not end ex-
actly on the line angles of the facial planes. This preparation
allowed good support and predictable esthetic results (Fig. 4). Fig. 5: Acid etching using the total-etch technique

Total-etch technique
OptraGate® was effectively used during the entire procedure
for patient comfort and appropriate retraction. Additional cot-
ton rolls were used to maintain isolation of the working area.
All cut enamel surfaces were etched with 37% phosphoric
acid for 30 seconds (Fig. 5), rinsed with water and lightly air-
dried to leave behind the ‘just moist’ surface recommended
for bonding. Then Tetric® N-Bond, which is supplied in the
convenient, user-friendly VivaPen with disposable applicator
tips, was applied (Fig. 6). The adhesive was agitated for ten
seconds and then gently air-dried to remove excess pools in
surface dents and to achieve a thin layer. The adhesive layer
was cured with the bluephase® C8 LED curing light for 10 sec-
onds in the low-power mode. Fig. 6: Comfortable and time saving direct application of the adhesive
with VivaPen
10 Tetric® N-Collection

Layering technique
Very small amounts of Tetric® N-Flow (shade A2) were applied
in undulated surface areas. Enamel shade A2 of Tetric
N-Ceram was used for the surface pits and deeper areas
(Fig. 7). OptraSculpt hand instruments provided optimal con-
trol and allowed the required pressure to be exerted when
adapting layer on layer of composite. The incisal morphology
was established with a layer of Tetric N-Ceram A1 enamel
shade (Fig. 8). As a final layer, IPS Empress® Direct Trans 30
was applied to the entire surface of the restoration. As this
material allows 30% of the light to pass through, it added the
much desired final enamel-like translucency (Fig. 9). This was
followed by additional 20 seconds of curing in the high-power
mode. It is crucial to achieve the same value in the restoration Fig. 7: Tetric N-Ceram A2 for deeper hypoplastic areas
as that exhibited by the natural tooth. Hence, while adding
layers, the clinician should constantly review the value of every
layer until the desired final result is attained.

Finishing and polishing

The finishing sequence was established based on the grit
sizes. Small, flame shaped burs from the Astropol® finishing
and polishing kit were used. Astropol F was used for the re-
moval of excess material and for pre-polishing (Fig. 10a). As-
tropol P ensured a smooth surface finish (Fig. 10b). Astropol
HP was used to attain the final high polish (Fig. 10c). Very
smooth, highly lustrous surfaces were achieved with a regular
Astrobrush®.

The restorations, which replicated the texture, form and col- Fig. 8: Incisal edge built with Tetric N-Ceram A1
our of the natural teeth (Figs 11 and 12), were highly appreci-
ated and well accepted by the patient.

Conclusion
Mild enamel hypoplasia can be managed with composite ma-
terials. These materials provide extremely satisfying results
when layered meticulously using the principles of illusion and
by virtue of their optical properties. Once the unsightly hypo-
plastic areas have the exquisite beauty of natural enamel and
dentin in terms of depth of colour, contour and light reflec-
tion, the illusion of reality is created by means of the final fin-
ishing and polishing procedure.

Fig. 9: Clear shade of IPS Empress Direct Trans 30 on entire surface

of the restoration
 Tetric® N-Collection 11

Fig. 10a: Astropol F for removal of excess Fig. 10b: Astropol P for smooth surface finish

Fig. 10c: Astropol HF for final polish Fig. 11: Natural and harmonious appearance of the final result

Contact details:
Dr Ratnadeep Patil
Smile Care Clinic Pvt. Ltd., Sujata Niwas SV Road,
Bandra (W), Mumbai-50, India
drpatil@smilecareindia.com
Fig. 12: Healthy gingiva and lifelike restorations
12 Tetric® N-Collection
Meeting challenges
successfully
Esthetic posterior restorations
with Tetric® N-Ceram
In the forties, first attempts were made at developing
dental restorative materials based on acrylic acid, a sub-
stance that had been discovered in 1843. The results
were not very satisfactory, however, as the material
showed proneness to discolouration and polymeriza-
tion shrinkage. As a consequence, recurrent decay and
inflammation of the pulp occurred very frequently. In
the mid-fifties, the American Raphael Bowen succeeded
in creating a composite material that was suitable for
use as a dental restorative. Based on a resin molecule he
had developed himself, he produced a resin matrix and
added inorganic filler particles (quartz powder) to it.
Even though from the sixties onwards composite materials
were available that opened up new esthetic possibilities, they
still did not represent a reliable clinical solution. In order to
provide dentists with a restorative that would enable them to
meet the challenge of restoring teeth both functionally and
esthetically, the composite materials were consistently further
developed. Simultaneously, the restorative procedures under-
went several modifications, so as to ensure that perfect resto-
rations could be created. Dental professionals who keep
themselves updated on the most recent developments are
clearly noticing a trend towards more shade nuances, smaller
filler particles and improved processing properties.
Composite resins are primarily used to esthetically restore teeth
using minimally invasive procedures. They allow dental profes-
sionals to place restorations that seamlessly blend in with the
natural dentition while preserving valuable tooth structure.
Suitable restoratives applied in combination with the respective
techniques are requisite for the artistic reconstruction of the
missing tooth structure and the establishment of a sound bond
between the restoration and the natural tooth structure.
Moreover, the procedure should be guided by the biological
principles of natural tooth form and function. The low cost and
the dentist’s independence of laboratory work clearly speak in
favour of composite restorations. As a result, it makes good
sense to use composites rather than amalgam, gold or ceramic
inlays wherever possible.
Only recently, a new generation of micro-hybrid composites
have been developed, which incorporate nano-technology and
nano-particles. As the new materials are suitable for use both
in the anterior and posterior region, they are referred to as uni-
versal composites. The formulation of the new universal com-
posite Tetric N-Ceram combines high-tech components with
Dr Roberto M. Yoshida Jr,
Londrina, Brazil
the proven ingredients of the predecessor product
Tetric® Ceram. The result is a composite material that features
outstanding optical and mechanical qualities. Tetric N-Ceram is
thus suitable for use in conjunction with state-of-the-art proce-
dures that use a straightforward approach and are capable of
reproducing the fine details of the natural tooth anatomy.
Clinical case
A 32-year-old female patient requested that a defective Class I
amalgam filling in tooth 37 be replaced with a more esthetic
restoration. The clinical and radiological examination neither
revealed secondary caries below the restoration nor along its
margins (Fig. 1).
Removal of the old filling and cavity preparation
The amalgam filling was removed with diamond grinders at
high speed. This was followed by cavity preparation. The cav-
ity walls were designed perpendicular to the tooth surface
and the inner line angles were rounded. Moreover, a one-sur-
face cavity was prepared on the vestibular aspect.
Subsequently, the shade was determined with the help of the
Tetric N-Ceram shade guide. From the range of shades avail-
able, A3.5 dentin was chosen for the dentinal portion and A1
for the enamel portion. To ensure complete moisture control,
OptraDam® rubber dam was placed and solely attached to
tooth 37 with a rubber dam clamp (KSK no. 201). This was
done to protect the adjacent teeth during the procedure.
Application of the adhesive
For the etching procedure, 37% phosphoric acid was used. In
a first step, the enamel margins were etched for 30 seconds.
To condition the dentin, etching gel was applied into the cavity
for 15 seconds. Following this, the entire preparation surface
was rinsed with copious amounts of water to remove the etch-
ing gel. Subsequently, first the enamel and then the dentin
were dried with absorbent paper. This ensured better control
of the amount of moisture that remained on the dentin and
thus allowed more reliable adhesion to be achieved. The adhe-
sive used was Tetric® N-Bond. A thin coat was applied to the
entire cavity (Fig. 2). The adhesive had to be brushed into the
prepared surface for 10 seconds. Excess adhesive can be re-
moved with microbrushes or absorbent paper. The solvent was
cautiously evaporated with blown air. Following this, the adhe-
sive was light-cured for 10 seconds using bluephase® in the
Low Power mode.
 Tetric® N-Collection 13

Composite build-up
The lost dentin was replaced by applying Tetric N-Ceram Den-
tin shade A3.5 in small increments (Fig. 3). This procedure was
chosen to minimize possible negative effects due to polymeri-
zation shrinkage. Due to its high content of inorganic filler,
Tetric N-Ceram shows only low polymerization shrinkage. This
is achieved by means of the pre-polymer technology em-
ployed, which provides the material with improved properties.

Each composite increment was light-cured for 15 seconds

using the Soft Start program. Tetric N-Ceram shade A1 was
used to replace the enamel layer and reconstruct the occlusal
anatomy (Fig. 4). First the central portion and then the sides of
the cusp slopes were re-built. The main fissure was sculpted Fig. 1: Preoperative situation
using a fine probe. Throughout the entire procedure, each
new increment placed was light-cured for 15 seconds using
the Soft Start program. For characterization, Tetric® Color
Dark Brown was applied to the centre of the main fissure. If
required, Tetric Color White can be selectively placed along
the cusp slopes (Fig. 5). The stains were then light-cured for
20 seconds using the High Power program.

Prior to final polymerization, the entire restoration

was coated with a gel in order to prevent exposure of the
restoration surface to oxygen. Then the restoration was light-
cured for 40 seconds using the High Power program.
The use of high-quality materials in combination with suitable
techniques ensures predictable reconstructions which seam-
lessly blend in with the natural tooth structure (Fig. 6). Com- Fig. 2: Pre-treatment of the cavity with Tetric N-Bond
posites are the material of choice particularly for repairing
front teeth, but also for the restoration of small defects in the
posterior region.

Fig. 3: Reconstruction of the dentin layer using the incremental tech-

nique in conjunction with Tetric N-Ceram Dentin shade A3.5
14 Tetric® N-Collection

Fig. 4: The occlusal surface design was created with Fig. 5: Result after characterization with Tetric Color
Tetric N-Ceram A1.

Fig. 6: Completed restoration after final polishing

Contact details:
Dr Robert M. Yoshida Jr
R Dulcidio Pereira, 176, Jd Higienopolis
86015-170 Londrina-PR, Brazil
yoshida.roberto@yahoo.com.br
 Tetric® N-Collection 15

Esthetic posterior
restorations
Current developments in composite
resin materials and techniques Dr Cristian Higashi, Dr João Carlos Gomes,
Curitiba, Brazil

As a result of the growing demand of patients for es-

thetic restorations and the advances made in adhesive
dentistry, direct dental resins can now be used in ante-
rior and posterior teeth. These composite resins have
different compositions and classifications depending on
their indication, which influence the degree of polish
and the final quality of the restoration. The shape, type
and size of the fillers of different composite resins as
well as the filler content constitute some of the factors
that are responsible for the wide variety of mechanical
and esthetic characteristics of these materials [1]. The
findings of Arikawa et al [2] indicate that the shape and
size of the filler particles as well as the filler content sig-
nificantly affect the light transmission characteristics, in- Fig. 1: Preoperative view of tooth 36 and 37 restored with glass
cluding the diffusion properties and colour of composite ionomer cement (GIC)
resins.

The quality of composite resins is always linked to the size of

the filler particles. Hybrid resins contain a filler content of ap-
proximately 80 wt% and the average particle size is between
0.6 and 1.0 μm. Mechanical resistance is the most important
property of these resins [3]. Nevertheless, they are difficult to
polish [4]. Tetric® Ceram and its further developed successor
Tetric® N-Ceram represent examples of such composite resins.
The latter material is classified as a nano-hybrid composite
resin. It features the same high radiopacity and low sensitivity
to ambient light as the earlier material. In addition, the mate-
rial shows higher wear resistance, lower polymerization
shrinkage, better polishing properties and increased lustre
Fig. 2: Enamel etching with phosphoric acid (N-Etch) for
compared with the older version. These modifications are
30 seconds
mainly achieved by the filler particles, the high content of
which (approx. 80 wt%) has been maintained. However,
the particles are smaller and more uniform in size (40 nm –
3,000 nm) than those of the predecessor material.

Glass ionomer cements (GICs) demonstrate advantageous

properties, such as sustained fluoride release, chemical bond-
ing to the tooth substance and pulp compatibility. Neverthe-
less, these materials are not considered to possess the
mechanical properties that would qualify them for general use
as permanent restoratives in stress-bearing posterior areas
[5-8]. Many glass ionomer restorations have failed because of
bulk fractures caused by their low mechanical strength [6]. In
Brazil, therefore, these materials are mainly used as dental
cavity liners, temporary restorative materials after endodontic Fig. 3: Dentin etching with phosphoric acid (N-Etch) for 15 seconds
16 Tetric® N-Collection

treatment and restoratives for deciduous teeth [9].

The following case study shows the substitution of Class I GIC
restorations with Tetric N-Ceram (nano-hybrid composite
resin) fillings.

Clinical case
Large posterior restorations made of glass ionomer cement
(Fig. 1) should be replaced by more resistant and durable ma-
terials, such as composite resins. In this clinical case, prophy-
lactic dental treatment was provided before the old
restorations were removed. The cavity was prepared with
spherical diamond burs. The working area was isolated with a
rubber dam and the tooth was etched with 37% phosphoric
acid (N-Etch) enamel for 30 seconds; dentin for 15 seconds Fig. 4: Application of Tetric N-Bond on enamel and dentin
(Figs 2 and 3). Next, the tooth was rinsed for 30 seconds. The
enamel was dried, while the dentin tissue was kept moist.
Subsequently, the adhesive Tetric® N-Bond was applied ac-
cording to the instructions of the manufacturer (Fig. 4).

At the beginning of the restorative procedure, a small amount
of Tetric® N-Flow was placed in the deeper and more irregular
regions of the cavity (Fig. 5). In order to reproduce the high
level of chroma and opacity of the deepest areas of the poste-
rior teeth, Tetric N-Ceram A3.5 Dentin was applied as the first
restorative layer. The first increment was adapted to the buccal
cavity wall and light cured (bluephase® G2, 10 seconds high
power program). The second one was placed in the same way
on the lingual wall (Fig. 6). Next, a more translucent material
(Tetric N-Ceram A2) was applied to reproduce the natural
enamel portion (Fig. 7). This material was placed in a single in- Fig. 5: Application of a small amount of Tetric N-Flow in the deep and
crement, since the cusps were to be completely separated be- irregular areas of the cavity
fore polymerization in order to reduce the contraction stress
of the composite resin [10].

The use of stains (Tetric® Color) before the application of the

last layer of the restoration served to highlight the cusp perim-
eter and enhance the natural appearance of the restoration
(Fig. 8). These stains were individually light-cured according to
the instructions of the manufacturer.

The third and final layer of the restoration was composed of

an achromatic resin, also called Transparent or Incisal material
(for example, Tetric N-Ceram T or Tetric N-Ceram Bleach I).
This type of material allows a large amount of light to pass
into the cavity. As a result, the restorations have the appear-
Fig. 6: The first layer of the restoration is composed of two increments
ance of depth and look more natural [11]. All the cusps were
of Tetric N-Ceram A3.5 Dentin, which are individually light cured.
 Tetric® N-Collection 17

created with Tetric N-Ceram T in a third step. An increment of

this material was placed in the cavity margin (Fig. 9). It was
adapted with a burnisher to the cusp perimeter, which had
been previously defined with staining materials. Subsequently,
two secondary pits were carved into the cusps using a slender
explorer. Next, the cusps were individually light cured. The im-
mediate postoperative results are shown in Figure 10.

Then the restorations were finished. The occlusion was ad-
justed with fine diamond burs. Fine polishing was performed
with silicon carbide brushes (Astrobrush®). The outcome after
polishing is shown in Figure 11. Figure 12 shows the results
after 12 months.
Fig. 7: The second layer of the restoration is composed of
Conclusion Tetric N-Ceram A2
The correct selection and appropriate use of restorative mate-
rials has a major influence on the final results. The quality of
the restoration is not determined by the skill of the dentist
alone, but also by other factors, such as good planning, high-
quality materials and the use of an efficient technique. All
these aspects need to be taken into consideration in order to
obtain functional, esthetic and highly satisfactory results.

Acknowledgements
The authors wish to thank Rodrigo Stanislawczuk Grande for
the help provided in the clinical work. This case study was
supported by Coordenação de Aperfeiçoamento de Pessoal
de Nível Superior (CAPES, Brazil) and the doctorate program
of the University Estadual de Ponta Grossa (UEPG).
Fig. 8: Tetric Color “white” at the centre of the cusps simulates the
white spots in this area
18 Tetric® N-Collection

Fig. 9: Third and last restoration layer composed of Tetric N-Ceram T Fig. 10: Final appearance of tooth 36

Fig. 11: Final result Fig. 12: Result after 12 months at a clinical follow-up examination

Contact details: A list of literature references is available from the editors

Cristian Higashi on request.
Avenida Presidente Getulio Vargas, 1811. Apto. 42.
Rebouças. CEP: 80250-180. Curitiba, Paraná, Brazil
E-mail: cristianhigashi@gmail.com
 Tetric® N-Collection 19

The objective is
to imitate nature
Replacement of defective amalgam
restorations with composites Prof. Dr Abelardo
Báez Rosales,
Viña del Mar, Chile

Over the years, the placement of composite restorations

has developed into a routine clinical procedure that pro-
duces outstanding esthetic and functional results. The
composition and structure of dental composites has
been consistently refined in an effort to optimize them
for these applications. As a result of the growing de-
mand for esthetic solutions on the part of patients,
amalgam fillings are often replaced with composite res-
torations.

Patients believe that tooth-colored restorations improve their

sense of well-being and make them look healthy. The replace-
ment of amalgam fillings, however, is a challenging task for
the dentist. In most cases, the cavity shape is unsuitable for Fig. 1: Postoperative situation showing a defective amalgam
placing the composite material. Furthermore, contraction restoration on tooth 16
stress is more likely to build up when a restorative material is
applied in increments as is the case with composites. In the
placement of amalgam, dentists prepare the teeth in such a
way that the fillings are retained mechanically. Consequently,
an excessive amount of healthy tooth structure usually has to
be removed and accurate planimetry is requisite. In many
cases, corrosion products are found in the tooth substance
after the amalgam has been removed. These stains are very
difficult to mask and therefore compromise the final esthetic
appearance of the new restoration. The following case study
shows the outstanding results that can be achieved by replac-
ing old amalgam fillings with Tetric® N-Ceram and Tetric®
Color.
Fig. 2: Selective etching of the enamel (30 seconds)
Clinical case
Marginal defects, secondary caries and increased sensitivity to
temperature changes constituted the main reasons why this
patient wanted to have the amalgam restoration in tooth 16
replaced (Fig. 1). At the second appointment, the restoration
and the carious dental tissue were removed once the clinical
and radiographic diagnosis had been made. In order to save
as much healthy tooth structure as possible, the cavity was
not enlarged. The working field was isolated. Next, the tooth
was conditioned with a clinically proven etchant, which was
subsequently rinsed off before the adhesive was applied:
total-etch technique in conjunction with Tetric® N-Bond.
Selective acid etching is currently the most effective technique
available for conditioning tooth structure. In this technique
dental enamel is conditioned for 20 to 30 seconds and dentin Fig. 3: Etching of dentin (10 seconds)
20 Tetric® N-Collection

for 5 to 10 seconds (Figs 2 and 3). After the etching process,

the adhesive is applied and allowed to infiltrate the moist den-
tin substrate and then polymerized. It is essential that the ad-
hesive covers the entire preparation in order to ensure
hermetic sealing of the dentin tubules and the formation of
an even and sound hybrid layer. Once the tooth structure is
properly sealed, the risk of postoperative sensitivity can be ex-
cluded (Fig. 4). In the case at hand, a stabilized metal matrix
was used to create a tight proximal contact. The matrix was
adapted to the tooth with rubber wedges. Subsequently, Tet-
ric N-Ceram was placed in the proximal box (Fig. 5) and then
on the occlusal surface. A pyramid-shaped build-up scheme
was implemented in order to ensure the proper morphology
and reduce the subsequent finishing and polishing work. Fur- Fig. 4: The adhesive Tetric N-Bond completely coats the enamel and dentin.
thermore, this technique enables the unfavourable configura- The surface of the tooth structure has a homogeneous shiny appearance.
tion factor (C factor) which usually presents a problem in
posterior cavities and those that used to be restored with
amalgam in particular, to be adequately managed. It is impor-
tant to observe an increment thickness of maximum 2 mm.
Polymerization must be conducted properly to ensure a high
conversion rate in the composite and to optimize the physio-
mechanical properties. The different materials and levels of
opacity selected for this case are shown in Figure 6. It was im-
portant to use a material that exhibits a high level of opacity
and colour intensity for the first layer (Tetric N-Ceram, A3.5
Dentin). Subsequently the restoration was characterized with
Tetric Color “ochre” and “white” (Figs 7 and 8). Next, an
enamel layer was applied, with which a high level of bright-
ness was attained (Tetric N-Ceram Bleach L) (Figs 9 and 10). Fig. 5: Reconstruction of the proximal box
The esthetic result produced with this technique ensures the
predictable and precise placement of the restoration. In addi-
tion, the composite features a “chameleon effect” which en-
ables it to blend in with its surroundings to enhance the
overall esthetics.

Once the morphology of the tooth has been reconstructed, it

is advisable to coat the entire restoration surface with a water-
soluble gel and to polymerize the restoration for 60 seconds
(Fig. 11). This step removes the oxygen inhibition layer and
minimizes the finishing and polishing work. The objective is to
keep adjustments and corrective measures to a minimum and
to maintain the obtained shape if possible. Astropol® and
Astrobrush® are suitable for finishing the margins. These auxil-
iary aids help to achieve a high gloss surface finish (Figs 12 Fig. 6: The layering scheme used in this case (Tetric N-Ceram)
and 13). The quality of the finish, however, is not only based
 Tetric® N-Collection 21

on the use of a suitable polishing system, like the one em-

ployed in the present case. The size, distribution, amount and
type of composite particles also play an important role. These
factors should be in perfect equilibrium to achieve an ideal
combination of mechanics, esthetics and minimal contraction.

Conclusion
Today, the direct restoration of posterior teeth with compos-
ites is considered to be a clinically proven restorative option
which produces highly predictable results. Adhesive dentistry
offers numerous benefits which not only concern the esthetics
of teeth, but also the management of healthy teeth and opti-
mal marginal seal. Nevertheless, we must work precisely and
observe the clinical protocols to achieve the desired Fig. 7: Tetric Color “ochre” rein- Fig. 8: Tetric Color “white”
results. An important step in this process is the use of a com- forces the colour of the deepest imparts the restoration with
posite that fulfils all the prerequisites related to optimal clinical parts of the fissure to achieve a more brightness and imitates
behaviour. We chose to use Tetric N-Ceram to solve the natural-looking result. the effect of the natural
adjacent teeth.
present clinical case, because it demonstrates all the proper-
ties necessary for producing a highly esthetic and functional
restoration.

Acknowledgements
I would like to thank Dr Manuel Gajardo G. and Dr Ramón
Schlieper C. who were instrumental in compiling the pictures
and preparing the layering scheme for this clinical case.
I would like to take this opportunity to express my apprecia-
tion for their continuous support of our academic work.

Fig. 9: Palatal view of the enamel layer applied with Tetric N-Ceram
Bleach L
22 Tetric® N-Collection

Fig. 10: Occlusal view of the sculpted restoration Fig. 11: Application of a water-soluble glycerin gel on the completed
restoration surface. The restoration is subsequently polymerized for
60 seconds.

Fig. 12: Occlusal view of the completed restoration one week later. Fig. 13: Lingual view of the completed restoration made of
The esthetic integration of the composite in the tooth structure has Tetric N-Ceram
been achieved.

Contact details:
Prof. Dr Abelardo Báez Rosales
5 oriente 260 Depto, 203 Viña del Mar, Chile
abelardobaez@gmail.com, www.materialesdentales.cl
 Tetric® N-Collection

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