CASE REPORT

The injectable composite resin

technique: biocopy of a natural
tooth – advantages of digital
planning

David Geštakovski, Dr med dent

Private Practice, Zagreb, Croatia

Correspondence to: Dr D. Geštakovski,

Bukovačka 1, 10000 Zagreb, Croatia; Tel: +38598314436; Email: david.gestakovski@hotmail.com

280 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021

Abstract
The injectable composite resin technique is a minim-
ally invasive and purely additive procedure that uses
a transparent silicone index and flowable composite
resin to translate the restorative plan from the wax-
up to the final restoration. Its minimally invasive nature
means that it can preserve tooth structure as it may
not require hard tissue reduction. It is also an indirect/
direct molding technique that allows the clinician to
perform a direct restoration based on a proper analys-
is and planning. This case report describes a simple
case of reshaping the maxillary lateral incisor and max-
illary first premolar of a 25-year-old female patient to
close the buccal corridor and restore smile symmetry.
Digital planning was used to make a biocopy of the
contralateral incisor to mimic the restoration. A print-
ed model was prepared based on the design of the
The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
GEŠTAKOVSKI
digital wax-up, followed by an analog protocol. Shade
selection was challenging due to the high translucen-
cy of the incisal edges. This article is a step-by-step de-
scription of the injectable composite resin technique.
It also compares this technique with other treatment
options such as ceramic veneers, prefabricated com-
posite veneers, different molding techniques, and
freehand bonding. The significant advantages of the
injectable composite resin technique include its pre-
dictability, repeatability, simplicity, minimal invasive-
ness, and financial affordability for patients. Recent
studies demonstrate significant improvements in
physical, mechanical, and optical properties of specif-
ic flowable composite resins, which reinforces the jus-
tification for implementing them in different restora-
tive procedures.
(Int J Esthet Dent 2021;16:280–299)
| 281
CASE REPORT
Introduction
In recent years, dental esthetics has evolved
into a principal aspect of restorative dentistry
due to the increase in the esthetic demands
of patients seeking to improve their smile.1
This has led to the continual development
of dental esthetics, where various treatment
options, materials, and techniques can pro-
vide the clinician with a myriad of treatment
possibilities to meet patient expectations.
The development of highly filled flowable
composite resins and their mechanical and
esthetic properties has led to various new
clinical procedures.2-5
Ceramic veneers and the protocol of ad-
hesive preparation design and cementation
have been described in the literature for over
four decades.6-9 It was the concept of bond-
ing composite resin to acid-etched porce-
lain that allowed the successful fabrication
and placement of porcelain veneers.10,11 Due
to high success rates, optimal esthetics, and
good biomechanical behavior, ceramic ve-
neers are still considered the gold standard
in many clinical situations.12-14 Furthermore,
it has been demonstrated that freehand
bonding using composite resin restorations
offers excellent esthetic results with long-
term clinical success while providing a less
expensive and minimally invasive alternative
therapy.15-18 This procedure involves layering
composite materials with different opaci-
ties and shades to create natural esthetic
results. However, this technique requires an
extensive knowledge of dental morpholo-
gy, material, and techniques, and it is nec-
essary for the clinician to have significant
experience and advanced clinical skills.18
One disadvantage of this direct chairside
procedure is that it requires extensive chair
time. Currently, composite restorations are
most frequently utilized for applications in
operative prosthetic and esthetic dentist-
ry.19 In the past, it was difficult to define the
longevity of composite restorations in the
282 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
anterior and posterior region; however, re-
cent systematic reviews provide promising
results for these restorations as a reliable
treatment.20-22 In addition, prefabricated
composite veneers have been established
as another modern method and one pos-
sible solution for esthetic treatment.23
Various techniques based on injection
molding have been described in the lit-
erature24 to reduce chair time and avoid
complex intraoral techniques that require
advanced clinical skills. Although prefabri-
cated templates for vestibular surfaces have
certain advantages and disadvantages, they
can lead to the desired results.25 On the oth-
er hand, the ‘index technique’ described by
Dr Ammannato offers a more individualized
approach for each patient and includes the
treatment of occlusal tooth wear with a
composite resin material utilizing a wax-up,
which improves esthetics and function.26,27
The main question clinicians ask them-
selves when restoring a smile is whether to
utilize a direct or indirect technique, while
preserving as much healthy tooth structure
as possible. With the improvement of den-
tal materials such as flowable composite
resins, new techniques have been intro-
duced. Clinicians should consider direct/in-
direct techniques performed intraorally but
executed based on an extraoral plan. This
process could decrease chair time, while
allowing the clinician to perform a proper
analysis, along with detailed planning and a
3D prototype (wax-up/mock-up) of the fu-
ture restoration, which can then be convert-
ed into the final treatment result.28
Terry described the ‘inverse injection
layering technique,’29-32 a noninvasive tech-
nique in which the wax-up is transferred
directly onto the teeth, injecting a flowable
composite through a transparent silicone
index. A significant advantage of this tech-
nique, in addition to the aforementioned
ones, is the predictability and repeatability
of the final result. The planned prototype

(wax-up) can be inspected intraorally
(mock-up), followed by the final restoration.
Furthermore, the technique does not rely as
much on the clinician’s skills as it does on
proper planning and material selection. It
can be used to change the morphology of
the teeth and can also be used in challeng-
ing esthetic cases that require changes to
function and the vertical dimension of oc-
clusion (VDO), as described by the present
author.33,34
In the past decade, digital dentistry has
become very popular and widely used
among clinicians and dental technicians.
Nowadays, 3D-printed models that show
satisfactory precision for everyday prac-
tice can be manufactured at an acceptable
price.35-39
In this article, the full protocol from plan-
ning to final restoration of a simple case uti-
lizing the injection technique using flowable
composite resin material is described in de-
tail. A comparison is also undertaken with
this and other techniques, and the advan-
tages of a digital workflow are described.40
Case presentation
A 25-year-old female non-smoker patient
presented with a complaint about the shape
of her maxillary left lateral incisor (tooth
22) and the little gaps within the adjacent
teeth (Figs 1a and 2a). Tooth 22 was slight-
ly smaller compared with the contralateral
tooth, which caused the diastemas. This is
not unusual for a maxillary lateral incisor,
which can show variation in shape and
morphology.41 The patient also wanted her
teeth bleached. After intraoral and extraoral
photos, videos, and impressions were tak-
en to prepare a detailed study of the case,
different therapeutic approaches were sug-
gested. The first option, which included the
preprosthetic correction of the posterior
crossbite through orthodontic therapy, was
refused. Treatment options for restoring the
GEŠTAKOVSKI
smile included three different types of res-
torations: ceramic veneers, composite ve-
neers using the injectable technique, and
freehand bonding. All the advantages and
disadvantages of these alternatives were pre-
sented to the patient, who chose compos-
ite veneers using the injectable technique.
Changes were planned not only to tooth 22
but also to the maxillary right first premolar
(tooth 14). Due to the posterior crossbite,
a large buccal corridor existed distal to the
maxillary right canine, causing asymmetry
in the smile (Figs 3a and 4a). By adding ma-
terial to the vestibular surface of tooth 14,
a smooth transition from the canine to the
second premolar could be achieved, redu-
cing the buccal corridor and improving the
appearance of the smile (Figs 5 and 6). Since
the procedure and protocol for the veneer
on tooth 14 were identical to that of tooth
22, only the procedure for the lateral incisor
is explained below, step by step with clinical
photography. Note that a perfect esthetic
result for tooth 14 could not be achieved
due to the malocclusion and the limitation
of the functional mandibular movements.
At the first appointment, the teeth were
professionally cleaned and the calculus
was removed. As there were no contra-
indications present, the patient’s desire to
bleach the teeth was carried out as home
bleaching, performed with 16% carbamide
peroxide (Opalescence PF; Opalescence)
four times for 4 hours (every second day).
A 2-week break was taken after the last
bleaching and before the final treatment to
allow for shade stabilization.
As the main aim of treatment was to
copy the natural morphology of the right
maxillary lateral incisor (tooth 12) to the left
side, it was decided to take advantage of
the digital workflow. Casts were scanned
and a digital wax-up performed on digital
models. Tooth 12 was copied, flipped, and
positioned in place of tooth 22 (Fig 7). With
this simple trick, a symmetric biocopy of the
The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 283
CASE REPORT

a a

b b

Fig 1 Intraoral side view. (a) Before. (b) After. Fig 2 Side view of the full dentition. (a) Before. (b)
After (matching the shade of the restoration with the
adjacent teeth).

a a

b b

Fig 3 Fig 4 Intraoral view, full bite. (a) Before. (b) After.
dentition).

284 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
 GEŠTAKOVSKI

a b

Fig 5 Natural smile. (a) Before. (b) After.

a b

Fig 6 Frontal view. (a) Before. (b) After.

The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 285
CASE REPORT

a b

Fig 7a and b Digital wax-up and biocopy of the maxillary right lateral incisor to the contralateral side.

a b

Fig 8 (a) Printed model of wax-up. (b) Prepared transparent silicone indices with channels made with the syringe
of the flowable composite.

Fig 9 Polyvinyl siloxane

(PVS) putty silicone index for
the mock-up and transparent
silicone indices for the
injectable technique.

existing tooth was obtained. It is advisable
to instruct the dental technician to place the
margin of the wax-up equigingivally to pre-
vent periodontal problems.
The digital wax-up was printed out as
an analog model, which served for the lat-
er procedure (Fig 8a). To double-check the
plan intraorally, a silicone index of this mod-
el was made from polyvinyl siloxane (PVS)
putty silicone (Exaflex; GC) to produce the
mock-up (Fig 9). For this purpose, a resin-
based material (Protemp; 3M) was used
(Fig 10). The mock-up is a powerful tool that
allows the clinician to check the functional,
phonetic, and esthetic parameters.42,43 After
the patient had agreed to the therapy plan, a
transparent silicone index was made for the
final procedure.

286 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
 GEŠTAKOVSKI

a b

Fig 10 (a) PVS putty silicone index for the production of the mock-up. (b) Mock-up.

a b

Fig 11 Production of the transparent silicone index. (a) Two putty silicone stoppers. (b) Printed model in place in a
non-perforated tray filled with a transparent silicone.

Firstly, the model was stabilized in a
non-perforated tray using two stoppers
made of putty silicone (Exaflex), enabling
enough space in the vestibular and incis-
al area for the transparent silicone index
(Fig 11), which should be thick enough to
prevent any deformation during the injec-
tion of the flowable composite. Afterwards,
the transparent silicone (Exaclear; GC) was
placed over the wax-up tooth and the adja-
cent teeth that would serve as a stabilization
for the future index. This was done carefully
to avoid air being trapped between the sili-
cone and the model (Fig 12). The tray was
also filled with the transparent silicone, and
the model was placed within the tray in a
stable position determined by the stoppers.
The tray and model were then placed in a

The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 287
CASE REPORT
high-pressure pot set on 2 bars for 7 min
(regular setting time of the material). It is
crucial to use a high-pressure pot while pro-
ducing the transparent silicone index over
a printed model to prevent bubbles from
forming on the inner surface of the silicone,
which renders the index useless (Fig 13).
Once out of the pot, the excess material was
cut out with a scalpel. The index was also
cut, following the sulcular line on tooth 22,
to enable the removal of the excess flow-
able composite directly after the intraoral
injection and before the final polymeriza-
tion, avoiding time-consuming procedures
to remove the polymerized composite from
this area.33 In the transparent silicone index,
a channel was made for the insertion of a
syringe containing the flowable composite,
in the position of the incisal edge of tooth 22.
This channel was made with the same metal
syringe holding the flowable composite that
would be used later on (G-ænial Universal
Injectable; GC; see Fig 8b). Compared with
drilling holes using a bur, which creates sili-
cone dust within the channel, using the tip
of the syringe creates a clean, sharp-edged
channel of the exact size needed.
Two weeks after the last home bleaching
session, the treatment continued to the final
phase. It is important to wait long enough
because the tensile bonding strength values
are decreased in the teeth immediately af-
ter bleaching; in addition, time is needed for
shade stabilization.44
288 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
Fig 12 The transparent
silicone was placed carefully
in an attempt to avoid any air
being trapped between the
silicone and the model.
Selection of the correct material shade
is crucial for the future esthetic result and a
major challenge, especially when trying to
mimic adjacent teeth and fit the restoration
into the existing dental arch.45 Choosing the
correct shade was difficult in this case. Usu-
ally, universal shades are preferable for this
technique, but in this case, due to the age
of the patient and the bleaching process,
the incisal edges of the anterior teeth be-
came very translucent (see Figs 1b and 3b).
It was decided to use the transparent shade
AE (G-ænial Universal Injectable) in order
to mimic the incisal edges of the adjacent
teeth. Although the shade of the other inci-
sors was B1, universal B1 shade would have
given too opaque a result in this case.
Teeth 21 and 23 were isolated using
polytetrafluorethylene (PTFE) tape, and the
stability of the silicone index in the correct
position was checked. The whole vestib-
ular surface of tooth 22 was etched with
35% phosphoric acid (Ultra-Etch; Ultradent)
for 60 s (Fig 14). After rinsing and drying, a
size 0 dental cord (Ultrapak; Ultradent) was
placed in the initial part of the sulcus (Fig 15).
The aim of this cord placement was not to
retract the gingiva but to create a mechani-
cal barrier and to prevent the fluctuation of
the flowable composite in the subgingival
area, which can cause inflammation and bi-
ologic problems over time. It also prevents
the flow of the sulcular liquid to the field of
work (Fig 16).39 When the cord was in place,
 GEŠTAKOVSKI

Fig 13 Transparent
silicone indices.
(a) Index made
without the use of a
high-pressure pot
(bubbles are visible
on the surface). (b)
Index polymerized in
a high-pressure pot
(no bubbles).
a b

Fig 14 Etching of
the whole tooth
surface.

Fig 15 Packing
dental cord in the
initial part of the
sulcus.

Fig 16 Working field

isolated with
dental adhesive (G-Premio BOND; GC) was polytetrafluoroethyl-
applied on the etched enamel surface, left ene (PTFE) tape and a
undisturbed for 10 s, air dried, and then light dental cord (tooth
cured for 10 s. After the polymerization, the surface is etched).

cord becomes rigid and serves as a barrier.

The transparent silicone index was placed
in position and held still for the stabiliza-
tion. The syringe of the flowable composite
(G-ænial Universal Injectable) was pushed
through the channel on the incisal edge,
and the flowable composite injected into
the free space of the mold (Fig 17a). To pre-
vent air being trapped, and to ensure that all
the voids at the interproximal and marginal
areas were filled with the material, a small
amount of overflow in the gingival area is
needed (Fig 17b). This excess was light cured
for 3 s. In that incompletely polymerized
form, it was removed easily using a dental
probe (Fig 17c). Next, the composite mater-
ial was light cured for a further 40 s from
the vestibular and incisal directions (Fig 18).
With the injectable technique it is advisable
to prolong the light-cured polymerization
due to the physical barrier and the distance
between the source of the polymerization
light and the material.26 The silicone index
was then removed, and a glycerin gel was
placed over the composite surface for the
final polymerization of the oxygen-inhibited
layer, which can cause discoloration of the
restoration after a while.46,47 The PTFE tape,
the dental cord, and the glycerin gel were
removed before the finishing and polishing
of the restoration (Fig 19). For this purpose,

The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 289
CASE REPORT

a b

Fig 17 (a) Injection of the flowable composite. (b) Excess material

overflows the margins of the index. (c) Removing material excess
after the flash polymerization.

Fig 18 Polymerization of the flowable composite through the Fig 19 Restoration after the final polymerization and before the
transparent silicone index. removal of the dental cord, the PTFE tape, and the finishing and
polishing processes. Primary and secondary morphology is already
present (printing layers are also visible).

290 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021

a no. 12 blade was used to cut out the small
excess on the edge of the restoration. The
interproximal sites were polished with sti-
pes (Epitex; GC). The cervical part was fin-
ished with diamond finishing burs and EVA
handpiece burs, and polished with polishing
rubbers (Fig 20). Due to the precision of the
transparent silicone index, the vestibular
surface already had a primary morpholo-
gy. The roughness copied from the printed
model (layers from the printing process)
was smoothened and polished with pol-
ishing rubbers (Fig 19). Horizontal grooves
were made to mimic the natural surface of
the perikymata through the use of a flame-
shaped carbide bur on low RPM in an elec-
tric handpiece (Fig 20). The tooth was later
polished with polishing spirals (Sof-Lex; 3M),
a silicone polishing brush, and diamond pol-
ishing paste (DiaPolisher Paste; GC) on low
RPM and with low pressure to enhance the
gloss while preserving the texture (Fig 21).
Note that after all this manipulation around
the soft tissue, some superficial capillary
bleeding is possible. This bleeding should
stop quickly, during the treatment, and
should have no detrimental effect. For the
health of the periodontal soft tissue, the
margins of composite restorations need to
be well polished, with no overhangs.
The same protocol as described above
was followed for tooth 14. In case of multi-
ple restorations, it is necessary to isolate the
adjacent teeth to preserve normal free in-
terproximal contacts. A few teeth can be re-
stored at the same time, providing the adja-
cent teeth are properly isolated. The patient
was recalled after 3 days for a final checkup.
The diastemas were closed, the lateral in-
cisor was reshaped to mimic the contralat-
eral side, the shade of the restoration fitted
in perfectly, and, by enlarging tooth 14, the
size of the buccal corridor was reduced on
the right side and made symmetrical with
the patient’s smile (Figs 22 to 24; also see
Figs 1b, 2b, 3b, 4b, 5b, and 6b).
GEŠTAKOVSKI
b
b
a c
Fig 20a to c Finishing process using EVA handpiece burs, finishing bur, and
polishing rubber.
The patient was recalled 10 months af-
ter the treatment. No wear, discoloration or
periodontal problems were found (Fig 25).
Discussion
The concept of reshaping teeth and chang-
ing smiles with ceramic veneers was intro-
duced many years ago following the devel-
opment of adhesive technology in dentistry.
It was guided by a minimally invasive ap-
proach, preparing teeth within the enamel
whenever possible for a higher adhesive
strength.48 Although non-prep ceramic ve-
neers were also described, their protocol of
cementation, production, and manipulation
is more difficult, and they are also not as fre-
quently indicated.49,50 Although they are still
an invasive treatment, ceramic veneers can
be considered minimally invasive and are
the gold standard for a long-lasting restor-
ation in an esthetic area.6-14
The improvement of composite resin
materials gave clinicians the opportunity to
reshape teeth directly and intraorally using a
The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 291
CASE REPORT

a b c

Fig 21a to c Polishing of the surface with interdental stripes, polishing spirals, a silicone brush, and polishing paste.

Fig 22 12 o’clock
view showing the
excellent matching of
shade and shape with
the existing dental
arch.

freehand bonding technique, with or with- a significant advantage of composite restor-

out a silicone index for a palatal shell, de-
pending on the protocol followed.15,16 For
many years, this technique worked well
and was a lower-cost alternative to ce-
ramic veneers, with acceptable longevity
that was widely spread among dental clin-
icians.19,21 Compared with ceramic veneers,
ations is that they are much easier to ad-
just or repair if needed after the end of the
procedure.
Due to the high complexity of the tech-
nique, which includes layering of various
shades and opacities, a good result de-
pends on a very knowledgable and skilled

292 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
 GEŠTAKOVSKI

a b

Fig 23a and b Natural appearance of the maxillary left lateral incisor compared with the one on the right.

a b

Fig 24a and b Left and right lateral views of the patient after the treatment.

The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 293
CASE REPORT
Fig 25 Side view at the 10-month follow-up in the laterotrusive movement
(before it was repolished).
clinician. For this reason, other simplified
molding techniques were described. Good
results were seen from the technique that
uses prefabricated vestibular templates, but
there was a lack of control regarding the
thickness of the restoration,25 which could
result in a prolonged process of finishing
and polishing and lead to a dissatisfactory
longer-term result. In other described mold-
ing techniques, such as the index technique,
an individualized mold is used that is made
of a transparent silicone based on the wax-
up. The mold is separated into single teeth
indices, which can compromise the stabili-
zation on the tooth structure.26,27 Due to the
consistency of the heated composite, and
the small indices, clinicians need to exert
substantial external pressure on the index
while molding, which can lead to a distor-
tion and destabilization of the index, conse-
quently producing an unsatisfactory result
in terms of the shape and position of the ve-
neers. The advantages of these techniques
compared with freehand bonding are that
they take less time, and the molding process
results in a smooth and precise morphology
294 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
of the vestibular surface. A disadvantage is
that the 3D position of this surface is not
constant. This is due to various factors such
as questionable stabilization, which is relat-
ed to the small size of the molds, and the
need for strong external pressure on the
mold due to the consistency of the heated
composite material.
On the other hand, the injectable mold-
ing technique involves an injection of flow-
able composite in a well-stabilized transpar-
ent silicone index that serves as a mold.29-33
In this case, external pressure is exerted on
the flowable composite while injecting,
and not on the index itself, which passive-
ly serves as a mold with no possibility of a
distortion. This is the key point that makes
the injectable technique repeatable and
consistent for different operators, and is its
main advantage compared with the previ-
ously mentioned techniques. Due to the vis-
cosity of the flowable composite material, it
fills the mold perfectly with a nice transition
to the tooth structure. It can therefore be
molded in a very thin layer so that, in most
cases, tooth preparation is not needed and
the whole healthy tooth structure can be
preserved, as in the presented case. To be
more precise, for an effective adhesion,
only the etch-and-rinse protocol is required
because, in most cases, it is a completely
additive technique.51
When comparing the procedural costs
of the injectable technique with the most
common and popular treatment options
(direct freehand bonding and indirect ce-
ramic veneers), some main differences
need to be considered. With direct freehand
bonding, depending on whether or not the
palatal shell is produced based on the wax-
up, the procedure can be completed in one
or two appointments. The dental technician
costs and the time spent for the full proced-
ure are the lowest. For the injectable tech-
nique, at least three appointments are need-
ed. More thorough planning is done with a

more precise wax-up, which raises the den-
tal technician costs. Although patient chair
time may be lower compared with the free-
hand layering technique, time consumption
of the full treatment with all appointments is
slightly higher in the case of the injectable
technique compared with freehand bond-
ing. Indirect ceramic veneers, on the other
hand, involve the highest dental technician
costs and more of the clinician’s time. This
is true too of the injectable technique be-
cause a detailed plan is required involving
a mock-up, and tooth preparation is an ex-
tra step, as is the production of the veneers
in the laboratory. Taking these differences
into account, a time-consumption price ra-
tio can be presented, as follows: treatment
with ceramic veneers is the most expensive,
followed by the injectable technique at half
that price, and then freehand bonding at
half the price of the injectable technique.
These parameters depend, of course, on
the country where the treatment is taking
place because the cost of laboratory work
differs, as does the ratio of the mentioned
techniques.
A good case selection is also crucial. Fa-
vorable cases for the injectable technique
are those with few or small diastemas,
retruded teeth, or, as in the present case,
an irregular tooth size and morphology. A
perfect indication is one where an additive,
noninvasive approach is possible. Also, in
comparison with ceramic veneers, the in-
jectable technique has the major advantage
of requiring no minimal material thickness,
as is the case for the former.
Until recently, it would have been contro-
versial to use a flowable composite for the
production of composite veneers because
the mechanical and esthetic properties of
these composites were not as dependable
as paste composites. Wear resistance was
a major concern with older composite re-
storative materials. Problems due to abra-
sion as a result of toothbrushing, which led
GEŠTAKOVSKI
to a rough surface and loss of the gloss,
were apparent with the older generations
of flowable composites. Their mechanical
properties in general were not on the same
level as paste composites, so they were not
recommended for use in areas of higher
stress.52-54
As Baroudi and Rodrigues55 pointed out:
“[...] different flowable composites exhibit a
variable composition and consequently var-
iable mechanical properties. Clinicians must
be aware of this aspect to make a proper
material selection based on specific prop-
erties and indications of each material rele-
vant to a particular clinical situation.”
Nowadays, highly filled flowable
composites with a small nano filler size
(< 200 nm) have improved mechanical
properties and better esthetics.56 The lat-
est findings show no statistical or clinical
differences in any outcome assessed be-
tween conventional composites and flow-
able ones. A recent study by Kitasako et
al5 showed that the “clinical assessment of
the conventional and highly filled flowable
composite materials in direct restorations
revealed good outcomes, with predomi-
nantly clinically acceptable scores after 36
months. It demonstrated that the highly
filled flowable composite had a low volume
loss. It also produced a much smoother sur-
face after the wear test compared with the
other flowable and conventional compos-
ites.” Although tested in posterior direct res-
torations, the highly filled flowable compos-
ite, with its fine filler distribution, had good
wear resistance that was comparable with
conventional composite materials, which is
also promising from the point of view of the
injectable technique.5
Similar results were found by Hirata-
Tsuchiya et al57 in a 2-year clinical com-
parison of flowable and paste compos-
ites. As other recent studies have shown,
“new flowable composite resins have the
potential for use in high stress-bearing
The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 295
CASE REPORT
areas because of the enhanced mechan-
ical properties and wear resistance.”2 Not
only the mechanical properties but also the
esthetics of those materials are on a high
level. Recent studies of highly filled flowa-
ble composites have shown excellent sur-
face properties after toothbrush abrasion,
and they can obtain similar or even better
surface polish than their paste composite
counterparts.58,59 The clinical studies men-
tioned here tested short-term follow-ups,
and long-term results are yet to be inves-
tigated. To date, there is no clinical evi-
dence in the literature regarding long-term
follow-up of composite veneers. There-
fore, when it comes to veneers, ceramic
materials are at present more suitable for
long-lasting results (> 10 years).60
Due to the progress in the development
of dental materials, including flowable com-
posites, the injectable technique has taken
its place as one of the superior treatment
options in esthetic cases. As a result of the
latest improvement in physical properties
such as flexural strength and wear resist-
ance, following by esthetic properties such
as polishability, gloss retention, and higher
resistance to discoloration, the highly filled
flowable composite, G-ænial Universal In-
jectable, was chosen in this case for this
purpose because durability and esthetics
were very important.2-5,57-59
To avoid any biologic complications
and inflammation of the soft tissue, which
can be caused by the interference of the
restoration when it is too deep in terms of
biologic width, the wax-up was made with
a thin epigingival margin.22 During the iso-
lation protocol, a dental cord was placed in
the initial part of the sulcus to prevent the
fluctuation of the flowable composite sub-
gingivally. The transparent silicone was cut
following the sulcular line to gain perfect
control of the excess material in the gingi-
val area so that it could be easily removed
after the flash polymerization, as described
296 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
in the present author’s previous publication
on this theme.33
In the present case, digital planning was
performed. Compared with an analog pro-
cedure, the digital one made it much easier
to biocopy the morphology of the natural
existing contralateral tooth 12 by rotating
it and positioning its copy in the place of
tooth 22. This is the reason it should be
considered an option, together with the
other advantages of digital planning such as
combining it with the DSD software and the
access to a natural tooth-shape library.36,40
There are certain disadvantages of print-
ed models compared with analog ones. Al-
though dental 3D printers are highly precise,
layers of printed sequences are present on
the model and will be reproduced in the
composite veneer if they are not printed
in super-fine printing mode (see Fig 19).37-39
Furthermore, during the polymerization of
the transparent silicone while in contact
with a printed model, a gas is produced that
will form bubbles on the inner surface of
the index. To prevent this from happening,
the polymerization process must be carried
out under high pressure, as in the presented
case (see Fig 13), which is not the case in an
analog wax-up procedure. When modeling
digital wax-ups, margins should be checked
in the software before the printing process
because, later on, the clinician cannot see
the thickness of the added material. If it is
not ideally planned, it can cause overhangs
in the marginal area, which can cause later
inflammation of the surrounding soft tissue
if it is not spotted on time and smoothened
out.
The present case is a simple one pre-
senting a single tooth restoration. The aim
was to describe every single step of the pro-
cedure, which can serve as an example of
what can be done in more difficult cases. In
this case, the shade selection of the restora-
tive material was difficult. After the bleach-
ing process, the incisal parts of the adjacent

natural teeth that were not restored became
more translucent. In such cases, universal
shades do not have an ideal fit. In this case,
an AE (adult enamel) transparent enamel
shade was chosen. In the present author’s
experience, the best results in regular cases
are achievable with universal shades, and it
is much easier to obtain a good result when
multiple restorations are performed simulta-
neously. In challenging cases, the clinician
needs to be prepared with various shades
and opacities of the flowable composite.44
In the presented case, although tooth 22
was restored with only a single translucent
shade, a very natural result was achieved,
and there was no need for a polychromatic
restoration because the space that was re-
stored was tiny and it matched the natural
layer of the enamel. In cases where veneers
are planned to be thicker or larger, it is pos-
sible to obtain a polychromatic restoration
with the goal of a more natural lookalike
veneer. One option for this purpose would
be to inject and mix two shades before light
curing; firstly, the darker and more opaque
shade in the cervical area, and afterwards the
lighter and more translucent shade, which
is injected to mimic the incisal part of the
tooth.29 This process should be undertaken
with high precision to avoid air becoming
trapped within the material. Another option
would be to employ the cutback technique
after the polymerization of the base shade in
the full contour. If necessary, some tint can
be placed on the composite surface, and af-
terwards the enamel shade can be injected
through the same transparent silicone index
to obtain a more natural appearance.33
It is possible with the injectable tech-
nique to perform a more substantial recon-
struction of esthetics as well as function.
To restore a fractured tooth or worn den-
tition, one can change the protrusive and
laterotrusive guidance and the VDO.33 In
such cases, it is advisable to make a hard,
acrylic Michigan splint for the patient to
GEŠTAKOVSKI
wear at night to protect the veneers from
possible parafunctional habits. It has been
shown that the survival of an anterior restor-
ation depends more on the patient’s caries
risk and parafunctional habits than on the
choice of composite material.20 In the pres-
ent case, there was no need for a splint as
there were no strong occlusal interferences
found in this patient, and no change made
in terms of function (see Fig 25).
Conclusion
Through proper case selection and a careful
workflow, stable and predictable results can
be achieved using an injectable composite
resin technique. In comparison with ceram-
ic veneer preparation and placement, this
technique can be more financially accept-
able for patients, less invasive, and with the
possibility of reparability. Furthermore, it is
less complicated, more predictable, and re-
peatable compared with freehand bonding.
Depending on the clinical situation, dig-
ital planning is possible, and the implemen-
tation of the digital workflow can provide
the clinician and technician with certain
technical advantages.
As this is a single case report, specific
conclusions about the longevity of this type
of restoration cannot be deduced. There
is, however, supporting clinical evidence
to show that long-term maintenance of
these composite resin restorations can in-
crease the longevity of the restorations and
improve the natural esthetics.61 Since only
time can tell, future clinical trials are re-
quired to determine the long-term material
success and benefits of this new compos-
ite resin formulation and technique; how-
ever, promising results have been reported
in the experience of the author of the orig-
inal technique.31 Although recent studies
indicate improvement in the physical and
mechanical properties of flowable com-
posite materials, which in turn supports the
The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021 | 297
CASE REPORT

implementation of this technique in every- Acknowledgment

day practice for cases with limited time lon-
gevity,2-5 there are still no clinical studies to
support a claim about the mechanical suita-
bility of the chosen material for these tech-
niques over a longer period of time. Clinical
studies show that ceramic veneers perform
superiorly to composites over 10 years, me-
chanically and esthetically in terms of color
match, surface roughness, fracture of the
restoration, and wear of the restoration.60
The clinical postoperative results in the
present case reflect the degree of integra-
tion that can be achieved between biomat-
erials and tooth structure utilizing these re-
storative techniques.
The author expresses his gratitude to DT
Petra Kolenić and the Rudić Dental Labora-
tory for the cooperation on this case. Also,
big thanks to Douglas A. Terry, DMD, for
clinical advice. For the review of the Eng-
lish manuscript, thank you to Andoni Jones,
DMD (private clinic, Dublin, Ireland), and
Nora Magdalena Tomić, DMD.
Disclaimer
The author declares that there are no con-
flicts of interest regarding the publication of
this article.

References
1. Tin-Oo MM, Saddki N, Hassan N. Factors
influencing patient satisfaction with dental
appearance and treatments they desire
to improve aesthetics. BMC Oral Health
2011;11:6.
2. Imai A, Takamizawa T, Sugimura R, et al.
Interrelation among the handling, mechan-
ical, and wear properties of the newly de-
veloped flowable resin composites. J Mech
Behav Biomed Mater 2019;89:72–80.
3. Sumino N, Tsubota K, Takamizawa T,
Shiratsuchi K, Miyazaki M, Latta MA. Compar-
ison of the wear and flexural characteristics
of flowable resin composites for posterior le-
sions. Acta Odontol Scand 2013;71:820–827.
4. Ujiie M, Tsujimoto A, Barkmeier WW,
et al. Comparison of occlusal wear between
bulk-fill and conventional flowable resin
composites. Am J Dent 2020;33:74–78.
5. Kitasako Y, Sadr A, Burrow MF, Tagami J.
Thirty-six month clinical evaluation of a highly
filled flowable composite for direct posterior
restorations. Aust Dent J 2016;61:366–373.
6. Gürel G. Predictable, precise, and
repeatable tooth preparation for porcelain
laminate veneers. Pract Proced Aesthet
Dent 2003;15:17–24.
7. Gürel G. The Science and Art of Porcelain
Laminate Veneers. London: Quintessence,
2003.
8. Magne P P, Belser UC. Novel porcelain
laminate preparation approach driven by a
diagnostic mock-up. J Esthet Restor Dent
2004;16:7–16.
9. Magne P P, Magne M. Use of additive
waxup and direct intraoral mock-up for
enamel preservation with porcelain laminate
veneers. Eur J Esthet Dent 2006;1:10–19.
10. Simonsen RJ, Calamia JR. Tensile bond
strength of etched porcelain. J Dent Res
1983;62(special issue):297.
11. Horn HR. Porcelain laminate veneers
bonded to etched enamel. Dent Clin North
Am 1983;27:671–684.
12. Calamia JR, Calamia CS. Porcelain lam-
inate veneers: reasons for 25 years of suc-
cess. Dent Clin North Am 2007;51;399–417.
13. Beier US, Dumfahrt H. Longevity of
silicate ceramic restorations. Quintessence
Int 2014;45:637–644.
14. Turgut S, Bagis B. Colour stability of
laminate veneers: an in vitro study. J Dent
2011;39(suppl 3):e57–e64.
15. Dietschi D. Free-hand composite resin
restorations: a key to anterior aesthetics.
Pract Periodontics Aesthet Dent 1995;7:15–
25.
16. Dietschi D. Free-hand bonding in the
esthetic treatment of anterior teeth: creating
the illusion. J Esthet Dent 1997;9:156–164.
17. Pontons-Melo JC, Atzeri G, Collares
FM, Hirata R. Cosmetic recontouring for
achieving anterior esthetics. Int J Esthet
Dent 2019;14:134–146.
18. Pontons-Melo JC, Pizzatto E, Furuse
AY, Mondelli J. A conservative approach for
restoring anterior guidance: a case report. J.
Esthet Restor Dent 2012;24:171–182.
19. Demarco FF, Collares K, Correa MB,
Cenci MS, Moraes RR, Opdam NJ. Should
my composite restorations last forev-
er? Why are they failing? Braz Oral Res
2017;31(suppl 1):e56.
20. Demarco FF, Collares K, Coelho-de-
Souza FH, et al. Anterior composite restor-
ations: a systematic review on long-term
survival and reasons for failure. Dent Mater
2015;31:1214–1224.
21. Peumans M, Van Meerbeek B, Lambre-
chts P
P, Vanherle G. The 5-year clinical per-
formance of direct composite additions to
correct tooth form and position. II. Marginal
qualities. Clin Oral Investig 1997;1:19–26.
22. Dietschi D, Shahidi C, Krejci I. Clinical
performance of direct anterior composite
restorations: a systematic literature review
and critical appraisal. Int J Esthet Dent
2019;14:252–270.
23. Dietschi D, Devigus A. Prefabricated
composite veneers: historical perspectives,

298 | The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021

indications and clinical application. Eur J
Esthet Dent 2011;6:178–187.
24. Musella V. The inverse layering technique.
Quintessence Dent Technol 2013;36:97–106.
25. Dávila-Sánchez A, Pulido C, Monte-
negro-Arana AF, Martins G, Arrais CAG,
Loguercio A. Optimizing the composite
resin stratification technique with prefabri-
cated templates: a case report. Int J Esthet
Dent 2019;14:420–432.
26. Ammannato R, Ferraris F, Marchesi G.
The “index technique” in worn dentition: a
new and conservative approach. Int J Esthet
Dent 2015;10:68–99.
27. Ammannato R, Rondoni D, Ferraris F.
Update on the ‘index technique’ in worn
dentition: a no-prep restorative approach
with a digital workflow. Int J Esthet Dent
2018;13:516–537.
28. Terry DA. Developing a functional com-
posite resin provisional. Am J Esthet Dent
2012;2:56–66.
29. Terry DA, Powers JM. Using injectable
resin composite: part one. Int Dent Afr
2014;5:52–62.
30. Terry DA, Powers JM. Using injectable
resin composite: part two. Int Dent Afr
2014;5:64–72.
31. Terry D. Restoring with Flowables. Han-
over Park, IL: Quintessence, 2017.
32. Terry DA, Powers JM, Blatz MB. The
inverse injection layering technique. J Cos-
met Dent 2018;34:48–62.
33. Geštakovski D. The injectable com-
posite resin technique: minimally invasive
reconstruction of esthetics and function.
Clinical case report with 2-year follow-up.
Quintessence Int 2019;50:712–719.
34. Salehi A. Injection moulding with
composite to obtain a predictable aesthetic
outcome. Int Dent Afr 2019;9:60–68.
35. Dawood A, Marti Marti B, Sauret-Jack-
son V, Darwood A. 3D printing in dentistry.
Br Dent J 2015;219:521–529.
36. Kessler A, Hickel R, Reymus M. 3D print-
ing in dentistry – state of the art. Oper Dent
2020;45:30–40.
37. Abduo J, Bennamoun M, Tennant M. In-
fluence of conventional and digital wax-ups
on axial tooth contour. Int J Periodontics
Restorative Dent 2015;35:e50–e59.
38. Abduo J. Morphological symmetry of
maxillary anterior teeth before and after
prosthodontic planning: comparison be-
tween conventional and digital diagnostic
wax-ups. Med Princ Pract 2016;25:276–281.
39. Brown GB, Currier GF, Kadioglu O,
Kierl JP. Accuracy of 3-dimensional printed
dental models reconstructed from digital
intraoral impressions. Am J Orthod Dentofa-
cial Orthop 2018;154:733–739.
40. Coachman C, De Arbeloa L, Mahn G,
Sulaiman TA, Mahn E. An improved direct in-
jection technique with flowable composites.
A digital workflow case report. Oper Dent
2020;45:235–242.
41. Kondo S, Townsend G, Matsuno M. Mor-
phological variation of the maxillary lateral
incisor. Jpn Dent Sci Rev 2014;50:100–107.
42. Fabbri G, Cannistraro G, Pulcini C,
Sorrentino R. The full-mouth mock-up: a
dynamic diagnostic approach (DDA) to test
function and esthetics in complex rehabilita-
tions with increased vertical dimension of oc-
clusion. Int J Esthet Dent 2018;13:460–474.
43. Fradeani M, Barducci G. Esthetic Re-
habilitation in Fixed Prosthodontics, vol 2.
Chicago: Quintessence, 2008.
44. Cavalli V, Reis AF, Giannini M, Ambrosa-
no GM. The effect of elapsed time following
bleaching on enamel bond strength of resin
composite. Oper Dent 2001;26:597–602.
45. Babina K, Turkina A, Sokhova I, Budina
T, Makeeva M. Comparative assessment of
various composite materials and natural
tooth tissue translucencies. Int J Esthet
Dent 2019;14:406–419.
46. Park HH, Lee IB. Effect of glycerin
on the surface hardness of composites
after curing. J Korean Acad Conserv Dent
2011;36:483–489.
47. Gauthier MA, Stangel I, Ellis TH, Zhu XX.
Oxygen inhibition in dental resins. J Dent
Res 2005;84:725–729.
48. Morita RK, Hayashida MF, Pupo YM,
Berger G, Reggiani RD, Betiol EA. Mini-
mally invasive laminate veneers: clinical
aspects in treatment planning and ce-
mentation procedures. Case Rep Dent
2016;2016:1839793.
49. Farias-Neto A, Gomes EM, Sánchez-Ay-
ala A, Sánchez-Ayala A, Vilanova LS. Esthetic
rehabilitation of the smile with no-prep por-
celain laminates and partial veneers. Case
Rep Dent 2015;2015:452765.
50. Mozayek RS, Allaf M, Dayoub S. Porce-
The International Journal of Esthetic Dentistry | Volume 16 | Number 3 | Autumn 2021
GEŠTAKOVSKI
lain sectional veneers, an ultra-conservative
technique for diastema closure (three-di-
mensional finite element stress analysis).
Dent Med Probl 2019;56:179–183.
51. Loguercio AD, Moura SK, Pellizzaro A, et
al. Durability of enamel bonding using two-
step self-etch systems on ground and un-
ground enamel. Oper Dent 2008;33:79–88.
52. Baynes SC, Thompson JY, Swift EJ Jr,
Stamatiades P P, Wilkerson M. A characteriza-
tion of first-generation flowable composites.
J Am Dent Assoc 1998;129:567–577.
53. Clelland NL, Pagnotto MP, P Kerby RE,
Seghi RR. Relative wear of flowable and
highly filled composite. J Prosthet Dent
2005;93:153–157.
54. Garcia FC, Wang L, D’Alpino PH, Souza
JB, Araújo PA, Mondelli RF. Evaluation of the
roughness and mass loss of the flowable
composites after simulated toothbrushing
abrasion. Braz Oral Res 2004;18:156–161.
55. Baroudi K, Rodrigues JC. Flowable
resin composites: a systematic review and
clinical considerations. J Clin Diagn Res
2015;9:ZE18–ZE24.
56. Shinkai K, Taira Y, Suzuki S, Kawashima S,
Suzuki M. Effect of filler size and filler loading
on wear of experimental flowable resin com-
posites. J App Oral Sci 2018;26: e20160652.
57. Hirata-Tsuchiya S, Yoshii S, Ichimaru-Sue-
matsu M, et al. Two-year clinical comparison
of a flowable-type nano-hybrid composite
and a paste-type composite in posterior res-
toration. J Investig Clin Dent 2017;8:e12227.
58. Lai G, Zhao L, Wang J, Kunzelmann
KH. Surface properties and color stability
of dental flowable composites influenced
by simulated toothbrushing. Dent Mater J
2018;37:717–724.
59. Wang RL, Yuan CY, Pan, YX, Tian FC,
Wang ZH, Wang XY. Surface roughness and
gloss of novel flowable composites after
polishing and simulated brushing wear [in
Chinese]. Zhonghua Kou Qiang Yi Xue Za
Zhi 2017;52:243–247.
60. Gresnigt MMM, Cune MS, Jansen K,
van der Made SAM, Özcan M. Randomized
clinical trial on indirect resin composite
and ceramic laminate veneers: Up to
10-year findings. J Dent 2019;86:102–109.
61. Terry DA, Geller W. Esthetic and Restora-
tive Dentistry: Material Selection and Tech-
nique, ed 3. Chicago: Quintessence, 2018.
| 299
Copyright of International Journal of Esthetic Dentistry is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.