Layering Concepts in Anterior Composite Restorations Didier Dietschi? ‘Summary: With increasing patient demands for esthetic dentition, composite resin restorations enjoy great popularity due to excellent esthetics, acceptable longevity, and relatively low costs. Shading con- cepts used by manufacturers, however, may be confusing to many clinicians. Purpos fo review and describe the current main shading concepts, evaluate their potential for creating natural esthetics, and provide guidelines for application. J Adhesive Dent 2001;3:71-80. he occidental culture increasingly emphasizes the importance of physical appearance. As a consequence, a young and beautiful, therefore ap- pealing smile is considered a major advantage for professional and social achievement. This logically leads esthetic and adhesive dentistry to the front of the stage. On the other hand, income levels may limit many of our potential patients in the quest of their “dental dreams”. Actually, it seems that the concern for a beautiful smile is most common among the so-called Baby Boomers, and less so ‘among the older age categories, who generally have the more comfortable incomes.° For these reasons, composite resins nowadays occupy a paramount position among restorative materials because they offer excellent esthetic potential and acceptable longevity, with a much lower cost than equivalent ceramic restorations for the treatment of anterior teeth. In addition, composite restorations allow for minimally invasive preparations or no preparation at all, to assume the replacement of the decayed or missing tissues (Fig 4). ® ‘Senior Lecturer, Department of Cariology, Endodontics and Pe- odintics, Schoo! of Dentistry, University of Geneva, Switzerland. Reprint requests: D. D. Dietschi, Department of Carlology, Endodon tics and Pedodontics, School of Dentistry, University of Geneva, 19 Rue Barthélémy Menn, 1205 Geneva, Switzerland, Tel: + 41-22. 3829-165/150, Fax: +41-22.3829-990. e-mail: Didier.Dietschi @medecine.unige.ch Vol 3, No 4, 2004 ‘Submitted for publication:08, 10.00; accepted for publication:01.01.01. However, the many shading concepts which guide manufacturers in the development of their materials are confusing for the clinician and might prevent a correct application of the different com- ponents of the composite system. This is likely to be the case when trying out a new system. The aim of the present paper is then to review and describe the main shading concepts available on the market, to evaluate their potential to copy natural esthetics, and provide guidelines for their application. OPTICAL PROPERTIES OF NATURAL TISSUES AS A REFERENCE FOR COMPOSITE EVALUATION The identification of respective dentin and enamel optical characteristics is of considerable interest for the development of tooth colored materials.118 Masters ceramists and manufacturers of dental porcelains expend great efforts in developing spe- cific powders which mimic the two main consti- tuents of natural teeth.14 For porcelain restora- tions, other masses also are available to modify or implement the basic dentin and enamel materials, in order to cover the entire “color” spectrum and peculiarities of real teeth. Unlike composite resins available for a free-hand application, ceramics are mainly to be used for the veneering of a metal or ceramic framework in thin layers and configurations which do not necessarily mimic the arrangement of caDietschi Fig da init central incisors, made with the former composite generation, View of large direct composite filings on both fear and discolora Fig 4e Two additional layers of enamel and incisal materials om ration, according to the so-called classical Stayer concept. View of the restorations after anatomical fin ishing and polishing. leted the rest natural tissues. Therefore, ceramic powders are de- signed to give the restoration its color and to create an apparent “depth”, together with some light ef fects within a rather limited thickness. Therefore, unlike many methods, it is necessary to use the natural tooth as a model for analyzing or developing a composite system (Fig 2 The optical attributes of importance are the color (hue, chroma and lightness), opacity-translucency, opalescence, and fluorescence. Color and Translucency The literature provides abundant information on tooth color.2.8:14.13.15.16 However, most authors at- 72 Fig 1b The first restoration step consisted in the dentin re placement with a high chroma, rather opaque composite Fig 1d Same restorations after 4 years of clinical function, Form, color, and translucency remain stable; the esthetic ben. efit of a multilayer, polychromatic technique is evident terial: Herculite XRV. Restorative tempted to measure the whole tooth instead of ana: lyzing dentin and enamel separately. Actually, the objective of such evaluations was chiefly to develop a scientific approach to the evaluation of natural tooth shades and then to transfer the information to the lab for a precise and predictable ceramic powder selection. The information is, however, of imited value for the manufacturers when having to develop separate masses. Colorimetric and opacity measurements of human natural tissues lus L*a*b* color measures; contrast ratio = CR)#10 were also performed on pure dentin and ename disks.2.7 Despite their sparsity, these data are of critical importance as they serve as a reference for ing existing materials as well as to develop new composite systems. ristimu: evaluat rhe Journal of Adhesive DentistryDietschi Fig 2a and b Sets of teeth showing the variation in dentin chroma and enamel tint and translucency, among young (a) and adult teeth (b). Composite materials have to provide components which allow the replication of natural esthetics. The analysis of natural tissue colorimetric mea- sures (according to the CIE L*a*b* measuring sys- tem: L* is the lightness, a* values correspond to the red-green axis, b* values correspond to the yel- low-blue axis; a positive or negative “a*” value means that the color contains red or green, resp; a positive or negative “b*” value means that the color contains yellow or blue, resp) led to the following conclusions: Dentin: - There is only a slight difference between the av. erage and distribution of L*a*b* values between A and B as defined in the Vita shading system (Vita Zahnfabrik; Bad Sackingen, Germany). - There is a clear decrease in the L* values when increasing the chroma for the same shade (ie. from A1 to Ad). - The a* values are negative in all teeth; there is a slight shift toward green, at least when measur. ing extracted teeth. The b* values are positive; the amount of yellow increases with increasing chroma. Some composites adequately cover the shade range of natural teeth”? but only a few of them perfectly match the opacity of natural dentin It has to be pointed out that in a natural environ- ment, soft tissues and the presence of a living pulp can produce a color shift toward more positive a* values. Dentin sclerosis might also turn the color to ward red tints. Vol 3, No 4, 2001. Enamel: - Very few composites perfectly match natural ‘enamel translucence. - So-called enamel shades often are more opaque than natural enamel - Incisal or transparent shades are usually more translucent than natural enamel. In vivo, enamel has several effects on the per- ceived color of dentin, the most evident influence being a decrease of the apparent dentin chroma. This of course is modulated by intrinsic enamel translucence and thickness. Opalescence effects are also likely to modify the assessment of enamel translucence and dentin hue. Moreover, changes in light conditions can influence the visible amount of blue and orange; this calls for a standardization of illumination conditions in order to facilitate shade selection.23 Fluorescence The natural fluorescence of dental tissues was rec ognized early as critical for the development of highly esthetic ceramics, and is now also consid- ered an important issue for composite restorations (Fig 3).642.17 Actually, this property is fundamental to give the restoration some “vitality” and con- tributes to giving it a correct value. When a nonfluo- rescent material is used, it tends to have a grayish appearance and will appear as a “black hole” when 73Dietschi Fig 3. Natural tissues show a typi e in the blue under ultraviolet illumination. Modern materials usually ex nibit an appropriate fluorescence. Left si ws the dentin core, right sample shows the full tooth fe bulk of the restoration is monochromatic (B = ered by an incisal-transparent r rent materials), representation of the classical 2ayer concept. ly material) and is ial (/T= incisal or tran seen under ultraviolet illumination, such as the ones used in nightclubs. Opalescence The ability of enamel to preferentially reflect the blue waves and allow transmission of the orange aves of visible light bestows it with opalescent properties (Fig 4). When translucent enough, mod: ern incisal composite masses also exhibit opales cencedike effects, which are essential to reproduce 74 Fig 4 Bluish reflections can be seen on this section of nat el, which is typical of this tissue’s natural opales- cence. With most composite materials, this critical optical property is not adequately reproduced. rammatic represent. Fig 6 Dia ion of the classical Slayer concept. The bulk of the restoration is made of 2 separate colored masses of different opacity, the first one being the nore opaque and having the higher chroma (D = dentin, E enamel materials). The surface is covered by an incisal-trans nt material ((/T). Check irregularities at incisal edge bor- ders. the bluish reflections typical of the incisal third This effect is predominant in young patients.62, LAYERING CONCEPTS A comprehensive understanding of the aforemen- tioned parameters and knowledge of composite op. tical properties are necessary for the correct application of the different masses available in system, in order to achieve natural looking restorations. This information is directed to the olin: ea The Journal of Adhesive DentistryDietschi ician as a “layering concept”, specific to some groups of products and related to the number of composite masses available. We basically distin- guish between 2- and 3-layer techniques, according to the number of layers that should normally be ap: plied in a Class IV restoration. The ideal and also simpler technique is the 2-layer approach; however, it requires dentin and enamel masses to optimally imitate natural enamel and dentin, which unfortu- nately is rarely the case. Classical 2-layer Concept It comprises one set of body masses, usually follow- ing the VITA shade guide (Vita), with different hues (A to D) in varying chroma (1 to 4, according to the shade group). Body materials exhibit an intermedi ate opacity (between natural dentin and enamel values). A few “opaque” and “incisal” materials (re- ferring to manufacturer's material designation) usually complete the system. Typical brand names are Silux and Z250 (3M, St Paul, MN, USA), Re- namel micro or hybrid systems (Cosmedent, Chicago, IL, USA) and Prodigy (Kerr; Orange, CA, USA) (Figs 5). This concept is based on a monochro- matic buildup of the restoration and its blending with surrounding tooth structure by the so-called chameleon effect. Incisals (often named “transpar- ent’) can help in achieving a better esthetic result in Class IV cavities or incisal buildup. Although it is a simple layering technique, the restoration esthetic quality might be restrained by an oversimplified shading concept. Classical 3-layer Concept It comprises two sets of dentin (or opaque) and enamel (or body) masses, following the VITA shade Buide, providing different hues (A to D) in varying chroma (1 to 4, according to the shade group) Dentin masses exhibit an opacity close to or higher than natural dentin, while enamels show an inter: mediate opacity, intermediate values of natural dentin and enamel. One or several incisal transpar- ents complete the system. Typical brand names are Herculite XRV (Kerr) and Brillant (Coltene, Altstat- ten, Switzerland) (Fig 1). This concept implies a polychromatic buildup of the restoration, with varying opacity and chroma from the inside to the surface of the restoration (Fig, Vol 3, No 4, 2004 Fig 7 Diagrammatic representation of the modern 2-layer concept. The dentin (D) and enamel (E) are selectively re: placed by 2 distinct masses, which closely reproduce the opt cal properties of natural tissues. 6). However, because the different masses do not match the optical properties of natural tissues, 2 different arrangement and relation of the 3 differ ent materials is required. While the esthetic poten- tial of the restoration is improved by the application of this method, it does however mandate a long learning curve. Modern 2-layer Concept This concept actually relies on the application of 2 basic masses which rather closely replicate the op- tical properties of natural tissues and then allow for a spatial arrangement which is identical to the tooth structure. Dentins are available in different hues (Vita A to D shades) with varying chroma, ex- hibiting an opacity close to the one of natural dentin. Enamels were developed according to the concept of “natural layering”5 which implies the use of 3 different basic materials: white opalescent, neutral/ivory, and gray translucent enamels, for young, adult, and old patients, resp. A typical brand name is Point 4 (Kerr) or Esthet-x (Dentsply) (Fig 8). The latter system includes additional opaque shades, which should be used only in deep cavities. This approach is not only clinically appropriate but also has great esthetic potential. However, the use of intensive tints might be necessary to repli- cate or better match some specific anatomical pe culiarities.Dietschi Fig 8a Preoperative view showing deficient restorations and" Fig 8b Nonvital (tooth 14) and vital bleaching (tooth both central incisors. Tooth 11 is nonvital; tooth 21 has been _ performed to obtain a uniform shade. traumatized and is discolored, 1) were Fig 8c A remodeling of the restoration on tooth 11 was per- _Fig'8d_ The silicone key fixes the newly established spatial in formed, as well as an addition of material on tooth 21. formation. Fig 8e The first increment was applied directly on the matrix . Fig 8f The second layer consists of a body shade, whose and established the lingual restoration profile. color and opacity is very clase to natural dentin, 76 The Journal of Adhesive DentistryDietschi Fig 8g After the placement of some intensive color (white opaque), the final enamel layer was added to finalize the tooth form. Fig 9 Diagrammatic representation of the trendy S-layer con- cept. As for the modern 2-layer concept, the bulk of the restoration is made of 2 separate colored masses of different opacity (D= dentin, E= enamel). Effect materials (EM) to be placed between dentin and enamel masses complete the sys tem for improved esthetics. Trendy 3-layer Concept This concept relies on the application of the same basic masses found in a modern 2-Iayer system, but with the addition of effect materials to repro- duce fine anatomical details (Fig 9). These effect materials usually have to be placed between dentin and enamel layers, like tints, and therefore are not to be systematically applied. For instance, one can highlight areas of high translucency-opalescence or chroma with blue or yellow tinted composites. This approach is not only clinically uncomplicated, but has also has the greater esthetic potential because the effect materials make individual characteriza- tion easier and more predictable. Typical brand names are HFO (Micerium, Avegno, Italy), Vitales- cence (Ultradent, Salt Lake City, USA), and Mira (Colténe) (Fig 10). In this latter set, additional dentin shades are available with a higher chroma Vol 3, No 4, 2001 Fig 8h The final view shows the potential of modem material to replicate tooth color and other optical properties (Restora tive material: Esthet) than the usual Vita shade range, which proved very useful when treating older patients. Intensive Colors Their use has often been dictated by the deficien cies of former generations of composite materials It is a means to give the illusion of a polychromatic restoration buildup and help simulate areas of high chroma, opacity (like white spots), or high translu: cency and opalescence such as observed in the in- cisal third of front teeth. It has to be pointed out that these materials are still of use, as even many of the most modern composites do not fully repli- cate or imitate the richness of light effects found in natural tissues.Dietschi Fig 10a Fractured maxillary central incisors immediate restoration. which require an Fig 10¢ The first increment is the palatinal wall, made di rectly on the silicone key with an enamel mass (according to the trendy 3layer technique) Fig 40b A silicon key shows the final tooth form and incisal edge position, as previously established by a composite mock-up" made chairside ig 20d A dentin material replaces the dentin structure; note the configuration of this increment, with lobes, which repli: cates the internal 3-D structure of the tooth. ct material) si Fig 10e A translucent the natural translucency and opalescence of the incisal 738 lates Fig 20f The surface was completed with a more translucent, enamel” material. The postoperative view after 2 years demonstrates a satisfactory result (Restorative material Enamel Plus HFO, Micerium The Journal of Adhesive DentistryDietschi Fig 44a to © Representation showing the arrangement of natural tissues in a central incisor for young, adult, and old teeth; note that the dentin chroma as well as enamel tint and translucency evolve di to physiological maturation of tissue. Fig 41a Dentin lobes are fully covered with thick enamel, in cluding at the incisal edge. Fig 1:1¢ Dentin lobes have almost fully disappeared due to function. The thickness of enamel has also diminished all lover the tooth, CLINICAL APPLICATION The sophistication of the restorative work in terms of layering depends on the cavity configuration, the simplest one being the Class V and the most chal: lenging one the Class IV. In the latter situation, the full range of dentin, enamel or incisal masses with occasional effect materials, opaque or intensive color tints must be employed Special attention has to be paid to some tooth characteristics which are related to the patient's age and degree of tooth wear. Significant changes ‘occur over time in the incisal third which alter the spatial relations between dentin and enamel, and necessitate an adaptation of the basic layering Vol 3, No 4, 2003 Fig 11b Dentin lobes are partly exposed; the thickness of enamel covering this structure has been reduced by func tional wear. technique. Figure 11 depicts the specific relation between both tissues and proposes a strategy for composite layering according to the tooth’s age and extent of wear. Young Teeth The internal dentin structure is unaltered and the developmental lobes are fully intact. Dentin is en- tirely covered by enamel, including the incisal edge (Fig 14a). Enamel usually has a white tint, with pro- nounced opalescent effects. The surface is tex: tured, which increases surface reflection and reinforces the impression of relative opacity.Dietschi Adult Teeth The internal dentin structure is globally unaltered, but developmental lobe tops might be exposed in the incisal edge area. Enamel almost entirely cov- ers dentin, with the previously mentioned exception (Fig 14b). Enamel normally has a more neutral ap- pearance, with less pronounced opalescent effects. The surface texture is more discrete because of wear, which also occurs on nonfunctional surfaces. Old Teeth The dentin structure is altered, not only by function in the incisal edge, but also internally by different stimuli and aggressions, such as trauma, thermal shocks and infiltration, which stimulate the forma- tion of tertiary dentin or provoke discoloration. De- velopmental lobes have usually disappeared and dentin looks like a “flat” wall, underneath a thinner enamel shell (Fig 11c). Enamel mostly shows a re- duced thickness, minimal or no surface texture and, also due to an increase of its mineral content, a higher translucency. As a result, enamel and the whole tooth look more gray than adult or young teeth. CONCLUSIONS The traditional restorative objectives have not changed over time; they have simply been imple- mented according to the esthetic demands of an in- creasing number of patients. Composite resins then became the materials of choice for young patients and less privileged people, or for any case which re- quires a strictly conservative approach. The con- temporary practitioner is ultimately challenged to replace the missing tissues or perhaps modify their configuration by applying an artificial material to the patients’ teeth; these materials must respect or simulate the spatial arrangement, relations and ap- pearance of natural tissues. This objective can be achieved in a more pre- dictable way, first by selecting a restorative compos- ite which exhibits an appropriate fluorescence and opalescence, in addition to offering a suitable range of shades and opacities. The second step is the application of the correct and product-specific shading-layering technique. Today, an esthetically 80 satisfactory and natural-looking restoration primar ily results from a systematic and comprehensive ‘treatment sequence, rather than only being an ex pression of the practitioner's artistic sense and ability. REFERENCES 1. Chiche G, Pinault A. Aesthetics of anterior fixed prosthodon- ties. Chicago: Quintessence, 1994, 2. Clarke FJ. Measurement of colour of human teeth. In: Me Lean JW (ed). Dental ceramics: Proceedings ofthe fist inter rational symposium on ceramics. Chicago: Quintessence, 1983:441-488, 3. Cook WD, McAree DC. Optical properties of esthetic restora: tive materials and natural dentition, J Biomed Mater Res 1985;19:469.488. 4. Crisp S, Abel G, Wilson A. The quantitative measurement of the opacity of dental filling materials. J Dent Res 1979; 58:1585-1596, 5. Dietschi D. Free-hand bonding in the esthetic treatment of anterior teeth: creating the illusion. J Esthet Dent 19975 156-164. 6. Dietschi D. Free-nand composite resin restorations: a key to anterior aesthetics. Pract Periodont Aesthetic Dent 1995 71525, 7. Dietschi D, Ardu , Krejci |. Exploring the layering concepts: for anterior teeth. In: Roulet JF, Degrange M (eds). Adhesion - The silent revolution in Dentistry. Berlin: Quintessence, 2000:235-251, 8 Goodkind RJ, Schwabacher WB. Use of a fiber-optic colorime- ter for in vivo color measurements of 2830 anterior teeth. J Prosthet Dent 1987;58:535-542, 9. Golstein RE, Garber DA. A gap In our understanding - Why those who can don't seek aesthetic treatment. J Esthet Dent 1996;8:99. 410. Inokoshi S, Kataumi M, Pereira PNR, Yamada 7, Tagami J. Ap- Pearance of composite resins in posterior teeth. In: Dondi dall'Orologio G, Prati C (eds). Factors influencing the quality of composite restorations: theory and practice, Nov 22-23, 1995, Bologna, Italy. Haarlem NL: Cavex publishing,1995: ppi4i154, 11. Macentee M, Lakowski R. Intrumental color measurement of vital and extracted human teeth. J Oral Rehabil 1981:8:203. 208, 412. Magne P, Holz J. Stratification of composite restorations: sys- tematic and durable replication of natural aesthetics. Pract, Periodont Aesthetic Dent 1996;8:61.68, 13. Miller L. Shade matching. J Esthet Dent 1993:5:143-152. 414, Sieber C. Voyage. Chicago: Quintessence, 1994. 15, Sproull RC. Color matching in dentistry. Part I: The three-di- ‘mensional nature of color, Prosthet Dent 1973;29:416-424, 16, Sproul! RC. Color matching in dentistry. Part I: Practical appll- Cations of the organization of color. J Prosthet Dent 197329: 556-566. 47. Vanini L. Light and color in anterior composite restorations. Pract Periodont Aesthetic Dent 1996;8:673-682. 18, Winter R. Visualizing the natural dentition. J Esthet Dent 1993:5:103-117. The Journal of Adhesive Dentistry