t.

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A disadvantage of this technique is the light-reflecting Once the composite is modeled, the palatal wall is cure
effect of the aluminum and the low contrast it provides with
the composite.

Careful foil removal. A minimum risk of having the foil Corrections are usually required at this stage, which is
heavily attached to the hardened composite is possible, easier said than done, considering the extreme precision we
especially when bonding agents are applied to the foil. want to obtain.

After milling the excess and undesired composite, some To remove the dust, bonding is applied and removed with a
dust will remain on the composite surface. .
generous air stream There is no need to cure; the buildup
can be continued from this point on.
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10. Digital index

Technology in the digital field and 3D printing are growing
at an amazing speed. Today it is very easy to obtain a very
precise intraoral scan in a few minutes and to design the
missing tooth structure in a few more.
The major drawback is the printing time, which strictly de-
pends on the resolution. On average, printing an adequate
model should take up to 45 minutes. Top printers can create
a high-resolution model in less than 6 minutes.
.\

Frontal image of the scan. An STL file Visualizing the scan from multiple Occlusal view, ready to start placing
is obtained and imported into the 3D perspectives before starting will give the digital add - ons.
design software. the designer a better sense of the
desired outcome.

Tooth 21 can be copied and mirrored to Position after cloning, completely out Positioning on the frontal plane.
the position of tooth 11. Until alignment of place.
is perfect, it might look strange.

Positioning on the occlusal plane. Rotation adjustment. Tipping from the palatal.
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3D scanning and printing have as a major advantage a min- the work considerably, a common phrase when referring to
imum loss of detail, thus allowing one to obtain a very accu- a digital workflow is “faster than plaster,” making it feasible
rate final model in a short time. Especially because there is to have an emergency wax -up on the same day.
no model development and the digital libraries abbreviate

Slight tilting from the buccal. Final adjustments from a pseudo-axial

12 o ' clock view to appreciate texture

urn
Final rendering; ready to print.
and contour. (Designer: Lenu Boca, Dentcof ,
Timisoara, Romania.)

The tooth fragment was designed in 3 Silicone index is taken from the 3D
minutes, and the model was printed in printed model. Low -resolution printing
50 minutes. Modern high-end printers helps speed up the procedure while
can do it in less than 6 minutes. still getting a quite detailed model.

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Conclusions

1
'-4

For ideal silicone indexes , guidelines and measurements

must be respected to achieve the perfect index for the most
accurate cases.

The finger index, if performed following the outlined steps and

respecting the detailed criteria, can be rather accurate.

Impressions of the natural tooth and digital impressions lose

fewer details.

Always keep tooth fragments and be ready to use them.

5
Wax-up-free techniques like the BRB matrix, finger index, and
the direct mock-up are precious resources.

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.
Andreasen JO Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to
the Teeth, ed 3. Copenhagen: Munksgaard, 1994.
Bertoldo G, Barrotte Albino LG, Ricci WA. Bertholdo-Ricci-Barrotte (BRB) matrix:
A simplified technique for obtaining a composite layering guide. Int J Braz
Dent 2014;10:24-30.
de Araujo EM Jr, Baratieri LN, Monteiro S Jr, Vieira LC, de Andrada MAC. Direct
adhesive restoration of anterior teeth: Part 3. Procedural considerations.
Pract Proced Aesthet Dent 2003;15:433-7.
Dietschi D. Layering concepts in anterior composite restorations. J Adhes Dent
2001;3:71-80.
Dietschi D. Optimizing aesthetics and facilitating clinical application of
free-hand bonding using the "natural layering concept ”. Br Dent J
2008;204:181-5.
Fahl N, Denehy GE, Jackson RD. Protocol for predictable restoration of anterior
teeth with composite resins. Pract Periodontics Aesthet Dent 1995;7:
13-22,
Magne P, Holz J. Stratification of composite restorations: Systematic and
durable replication of natural aesthetics. Pract Periodontics Aesthet Dent
1996;8:61-8.
Mendoza A, Garcia Ballesta C. Traumatologfa Oral; Diagnostico y Tratamiento
Integral, Soluciones Esteticas. Ergon, 2012:68-92.
Sapata A, Sato C. Simple: Uma Abordagem Simples em Resinas Compostas—
Anatomia, Escultura e Protocolos Clinicos. Nova Odessa, Brazil: Editora
Napoleao, 2017:86-119.
Terry DA, Geller W, Trie 0, Anderson MJ, Tourville M, Kobashigawa A. Anatomical
form defines color: Function, form, and aesthetics. Pract Proced Aesthet
Dent 2002;14:59-67.

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"Have no fear of perfection, you will never reach it.”

Salvador Dali
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CHAPTER 4

FRACTURE

Manauta •Salat •Putignano •Devoto

Interview with Walter Devoto

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WALTERMARKS

A 20-STEP QUICKSTART
GUIDE FOR CU\SS IV
RESTORATIONS

This chapter explains the step-by-step process of creating a class IV restoration (previously
.
treated fractured tooth) A class IV restoration is one of the most challenging procedures in
restorative dentistry. With so many variables, mistakes easily and often happen. When following
these 20 steps, the room for mistakes becomes dramatically lower as the clinician needs less
concentration. The name "Waltermarks" is a lecture by Dr Walter Devoto in which he explains
with hashtags and these same images, in a very didactical and amusing way, each precise step.
Dr Devoto’s ability to communicate is extraordinary, and these next pages pay homage to him,
who has inspired us since Jordi Manauta first saw him lecturing at UIC in Barcelona in 2002 and
has changed our lives forever.

THE STYLEITALIANO METHOD

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I # watch
An initial observation is essential to understand what
we are facing. If a high - quality photo can be taken, the
analysis can be much more accurate. Take an “honest
picture" (see page 482).
is strongly linked with the appearance of the tooth.
Determining the color of the material for the teeth to be
restored, regardless of the color match method, must
be done with the teeth perfectly clean and hydrated,
ideally using OptiShade Styleitaliano (Smile Line) to
get a digital recipe. The best alternative to digital is a
realistic try -in and a personalized shade guide for quick
assessment (see pages 51 and 74-75).

#preWedge
Inserting a tight wooden weoge will start creating
tooth separation and retraction of the paD>lia . giving
more room for preparation, debris removal, margin
positioning, wedge and matrix insertion and more
, delicate touches. This will allow the clinician to see how
efficient contact point achievement micro-scales of composite come off. This is not visible
with water spray. Conventional carbide caries removal
burs can be used as well.
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vJ #flattenProximal
Creation of a butt margin proximally creates
more accuracy for matrix placement and material
adaptation. We must eliminate proximal bevels as
much as possible, as they are very difficult to be
precisely filled up.
#drawTheLimit
A very delicate scratch is done in the already prepared
silicon index. This limit is extremely useful for layering
the palatal layer outside the mouth without creating an
undesired excess of material beyond the margin (see
page 162) . These excesses end up trapped between
the index and the palatal wall and create unbounded
excess and high occlusion.
vJ #longBevel
A 45 - degree bevel with approximately 2- mm width is
the perfect margin to boost the blending effect (page l
212). A red coded diamond bur or a multiblade can giv<
the final geometry of the bevel. Use high speed and
water and polish the bevel.
CJ # extendedEtch
Ideally the composite material should end where the
sound tooth starts, in other words, a perfect margin -
material interface. The experienced clinician knows that
this is completely unrealistic. There is always composite
excess over the margin at some level; this should be
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#overCure
Three cycles of 20 seconds provide enough power to
the bonding layer to achieve a much better conversion
rate, reducing dental sensitivity and increasing the
bond strength while maintaining the temperatures at
safe levels.
#misura
Misura (LM- Arte) will help not only to achieve space
for the enamel (see page 90) but also to remove the
excess material from the buccal wall and the excess
over the margin. This is very similar to the texture
transfer technique (see page 94) but on the dentin
layer. Leaving a precious space for the translucent
layer.
r !
/A
m
I U #curvyMatrix
Traditional metallic or with specially colored anatomical
matrices will provide an easy, fast , and reliable proximal
anatomy. In our experience, these matrices behave
ideally for this purpose, despite being originally
designed for posteriors. A new generation of metallic
matrices with an improved alloy, QuickmatFLEX, have
been designed by the authors and recently released by
Polydentia (see page 508).
#incisalSpace
Before curing the dentin layer, we must provide space
for the internal anatomy. This space is critical in the full
dentinal body, but after using the Misura instrument, the
focus goes directly to the incisal edge. It is time now to
create this space together with the mamelon anatomy,
removing the excess always toward the incisal to avoid
deforming the already calibrated dentin at the marginal
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Check in the occlusal view that the masses do not
occupy the space beyond the dimensions of the
tooth buccally. This, together with the correct dentin
calibration, will facilitate the finishing stage and
respect the selected color of the recipe chosen.
#slowFinishing
Composite smoothing, primary anatomy, and most of
the secondary and tertiary anatomy are achieved with
a slow- speed diamond bur (see pages 452 and 453).
For many years the selected tool for this purpose has
been the coarse- grit bur used for periodontal root
a
i ~T ffaisc
Contour, incisal shape, incisal angles, length, and
transition angles are done with only one tool (see page
446). The preferred abrasive disk is the medium-coarse
grit . Change the disk often to take advantage of the
cutting efficiency. After some use disks loose efficiency,
so change them to recover it, but also keep them on
hand for when you want a less aggressive tool.
#microFinishing
After using the coarse-grit appliances, a delicate
abrasive is used to get rid of the bur texture. These
spiral wheels are useful as well for intentionally
reducing the intensity of the tertiary anatomy (see page
453).
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About margins

There is a wide variety of margin preparation types; the most
representative are shown in the diagrams below . servative dentists. The clinical reality is that it is allowed
Geometrical color blending is the result of a gradual de-
crease of the material thickness over a substrate (see page
40), which has proven to be the most effective strategy for
increasing the blending effect in dental restorations.
As general rule: the straighter a margin is, the less blending
it will provide, and vice versa, the straighter the margin is,
the more resistance it will provide.
Margin preparation has been highly criticized by overly con-
as long as it fulfills these three requirements: respect the
enamel, improve the mechanics, and increase the esthetics,
A
Preparing perfect geometric shapes at a micrometric level,
with the inherent instability of our rotatory or ultrasonic de-
vices, bur vibrations, and margin polishing, will soften those
shapes and end up looking similar to a bevel. Our prime
choice is a medium 2-mm bevel,

Butt - joint Chamfer Bevel Softening Long chamfer Hybrid bevel Shoulder

Are bevels resistant?

All preparations that are respectful of enamel have a good r

adhesive performance. The controversial issue has been the
marginal pigmentation due to the thin material. Historical-
ly this recurrently happened with microfill and microhybrid
materials. Thus for many years bevels were not suggested,
.
even contraindicated Presently, using state-of-the-art na-
nohybrids or true nanofill materials. In other words, modern
materials are not only suitable for bevel preparations but
durable and reliable.
Long or short bevel?
Chamfers behave very similarly to bevels but require more
enamel loss during preparation. If bevels are correctly selected, they are respectful of tissue
and offer a very good boost to the blending effect.
30° 45° 55°
30-degree bevels are almost exclusively for the incisal third,
very small fractures, and favorable blending situations.

45- degree bevel are for the middle third and are used in
most situations.

55 -degree (or more) bevels are dedicated to veneering cas-

es, difficult blending situations, and volume increase. Note
1 mm 2 mm 4 mm that this is less respectful of tissue and for this reason not
Small bevel Medium bevel Long Bevel the prime choice.

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Conclusions

Protocol is essential for repeatability, speed, quality, and

success.

The realistic try-in guided with a personalized shade guide

is the best color-matching method if no digital colorimeter is
available.

Preparation and bonding stages are the essential pillars to

longevity.

It is imperative not to change the plan during the treatment;

the changes should only occur at a follow-up appointment.

5
Bevels are back for good.

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Baratieri LN, Monteiro S Jr, Spezia de MeloT. Routes for Excellence in

Restorative Dentistry: Mastery for Beginners and Experts. Berlin:
Quintessence, 2014:168-201.
.
Cerutti A, Mangani F, Putignano A Guidelines for Adhesive Dentistry: The Key to
Success. London: Quintessence, 2007.
da Costa J, Fox P, Ferracane J. Comparison of various resin composite
shades and layering technique with a shade guide. J Esthet Restor Dent.
2010:22:114-24.
Devoto W, Pansecchi D. Composite restorations in the anterior region: Clinical
and aesthetic performances. Pract Proced Aesthet Dent. 2007;19:465-70 .
Dietschi D, Fahl N Jr. Shading concepts and layering techniques to
master direct anterior composite restorations: an update. Br Dent J.
2016;221:765-71 .
Fahl N Jr. A polychromatic composite layering approach for solving a complex
Class IV/direct veneer-diastema combination: part I. Pract Proced Aesthet
Dent. 2006;18:641-5.
Kidd EA. How 'clean' must a cavity be before restoration? Caries Res.
2004;38:305-13.
Pivetta MR, Moura SK, Barroso LP, Lascala AC, Reis A, Dourado Loguercio A,
Grande RHM. Bond strength and etching pattern of adhesive systems to
enamel: Effects of conditioning time and enamel preparation. J Esthet
Restor Dent. 2008;20:322-35.
Vanini L, Mangani F, Klimovskaia 0. Conservative Restoration of Anterior Teeth.
Viterbo, Italy: Acme, 2003.
Xu H, Jiang Z, Xiao X, Fu J, Su Q. Influence of cavity design on the
biomechanics of direct composite resin restorations in Class IV
preparations. Eur J Oral Sci. 2012;120:161-7.

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4t
T
I “Always remember that you are absolutely unique.
_ i Just like everyone else.”

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— Margaret Mead
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CHAPTER 5

NECK

Manauta •Salat •Putignano •Devoto •Chiodera •Curra •Breschi

Interview with Lorenzo Breschi

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Lorenzo Breschi, DDS, PhD

Prof. Lorenzo Breschi received his DDS degree cum laude and PhD in human
morphological and molecular sciences at the University of Bologna (Italy). He is
now a full professor of restorative dentistry in the Department of Biomedical and
Neuromotor Sciences (DIBINEM) as well as chair of Restorative Dentistry and
director of the master degree in aesthetic restorative dentistry at the University of
Bologna.

Prof. Breschi has served as president of the following Academies: Italian Academy
of Conservative Dentistry (AIC), International Academy of Adhesive Dentistry (IAAD),
European Federation of Conservative Dentistry (EFCD), Dental Materials Group of
the International Association for Dental- Research (DMG -IADR), and the Academy of
Dental Materials (ADM).

Prof. Breschi is an active member of the following societies: American Academy

of Restorative Dentistry (AARD), ADM, AIC, and the Italian Society of Conservative
Dentist7 (SIDOC). Prof. Breschi is also associate editor of the Journal of Adhesive
Dentistry and a member of the editorial board of several international scientific
journals. He is actively involved in research on the ultrastructural aspects of enamel
and dentin and their interactions with dentin bonding systems and has published
more than 300 original papers and review articles in peer- reviewed journals on
different aspects of adhesion and restorative materials.

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Q: Why is it difficult to achieve long- term bonding in class V restorations ? And is there
anything
we can do to improve our chances of long- term success?

.
Let 's start from one consideration The worldwide prevalence of systems, higher restoration longevity was observed when these
cervical lesions in adults was calculated to be 46.7%, with the
most commonly associated problems being dentin hypersensitivity
.
systems were applied in selective-enamel etch mode Lastly,
universal adhesives have shown promising results in restoring
and poor esthetics related to gingival recession. First of all, these cervical lesions, with selective enamel etching being a highly
lesions have a configuration that is minimally micro-retentive recommended application mode.
with a peculiar dentin structure, which are the main reasons
why bond durability of class V composite restorations can be
.
jeopardized Dentinal tubules in cervical lesions are obliterated with
sclerotic casts, followed by a hypermineralized layer and bacterial
contamination on the lesion’s surface, all of which together make
the long-term success of this kind a treatment challenge.

With the aim of securing long-term clinical success, several dentin

pretreatments have been investigated. So far, neither dentin
pretreatment with chlorhexidine or mechanical roughening have
been shown to provide a significant improvement in terms of long-
term bonding. However the antibacterial and beneficial effects in
preserving the hybrid layer provided by chlorhexidine pretreatment
should not be overlooked.

Although composite materials are indicated for managing class V

lesions due to their excellent esthetic properties, it is interesting that
the type of composite material does not seem to significantly affect
the clinical performance of class V restorations, probably because
of the different type of stress they suffer^

As for the adhesive strategy, similar clinical performance was

observed when comparing etch-and-rinse with self -etch adhesive
systems, with etch-and-rinse adhesives showing better results in
terms of marginal discoloration. When using self-etch adhesive

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r
Working without rubber dam
As delicate as this matter is, the authors wish to express their
commitment to rubber dam use in the vast majority of cases.
This being said, there are a few situations in which it actually
cannot be placed. In particular, a fair amount of such situations
occur when dealing with cervical lesions.
In fact , when restoring class V cavities, narrow roots and
V-shaped gingival margins are common findings, which repre-
sent a contraindication to the use of a clamp, as it might easily
harm soft tissues. Concerning hard tissues, some cervical le-
sions feature sharp margins, which might be damaged by the
clamp itself .
1. Two noncarious cervical lesions, probably dueio
abfraction . showed a white line at the cervical level, which revealed
.
2 Due to the instability of the clamp, retraction cords were
used to expose the cervical margin.
3. Two increments were laid to fill each cavity, in this case
starting at the cervical.
4. Situation after finishing and polishing.
220
Moreover, cervical lesions with a flat profile (see page 230) of -
ten can’t support the clamp, which ends up sliding right back
into the cavity area. The clamp might also slide so close to the
cavity margin that etching and bonding would be incomplete,
thus constituting a major factor for debonding and infiltration.
Last but not least, when there is a free distal area, the clamp is
usually not stable enough to provide both fixation and retrac -
tion and tends to be displaced by the tension exerted by the
rubber dam.
As a result, in specific cases, alternative solutions to isolation
are used, although with the greatest care.
Limitations to the use of rubber
dam in class V lesions
• Potentially irreversible harm to
the soft tissues
• Instability of the clamp
• Impossibility of positioning
the clamp apical to the cavity
margin/area
5. The restoration on the maxillary right first premolar
immediate partial debonding of the restoration.
6. The restoration on the maxillary right canine showed
no signs of detachment, eliminating the hypothesis that
lack of isolation might be the cause for the immediate
debonding of the adjacent first premolar.
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Noncarious cervical lesions might often be smooth and

bevel-like with regard to the middle third of the crown. In
such cases, there is no need to prepare sound enamel,
as cleaning and conditioning of the contaminated
cervical hard tissues is enough if carried out properly.

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Sharp cervical lesions

It is imperative to recognize cervical cavities with high stress This attempt to immediately seal the cervical margin often
risk. Their common denominator is the presence of sharp cer- comes with the layering of a large amount of composite,
vical margins, these cavities are very susceptible to generate which is challenging to properly pack and place, creating badly
white lines (see page 220). shaped structure with, poor adaptation and strong shrinkage.

To make things worse, the classical restorative approach rec -
ommends a layering configuration from the cervical to the in-
cisal, which is supposed to achieve good dual-shade esthet -
ics and immediate resolution of the cervical margin, which is
rightfully considered to be the most delicate area in terms of
intraoperative infiltration of fluids.
Additionally, the enamel mass is often also layered in one big
single increment, which is hard to handle and creates high
stress on the previous layer, frequently detaching it from the
cervical margin. This “short blanket" effect is sometimes vis-
ible on plain sight by the appearance of a white line located at
the cervical margin.

Initial cavity with a sharp

cervical margin. A coronal
bevel is created, if indicated.

Dentin increment is placed

and adapted as best as
possible to the cervical
level.

Polymerization shrinkage is so
The enamel shade is placed strong that marginal debonding
and adapted to the buccal
-
.
occurs A thin white line in the
bevel and to the rest of the debonding area might appear.
composite inside the cavity.

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( UM
1. Two noncarious cervical lesions on the maxillary left lateral
incisor and canine. Both lesions have a peculiar geometry.
2. Retraction on the maxillary left lateral incisor was obtained
with a modified 212 clamp.
3. After the adhesive procedures, a dentin shade is placed to
seal the cervical margin.
!3
4. An enamel mass is then layered on top.
5. Flowable composite is used to correct the surface; in case
some bubbles or defects were present.
6. Situation immediately after rubber dam removal.
7. Appearance after 1 week.
8. Close up, margin behaviour is not optimal.

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r
Flat cervical lesions

Cervical lesions come in a vast variety of shapes, positions, and
types. In particular, flat lesions, which are quite common, are
most probably due to a combination of abfraction and abrasion
and/or erosion. There is one obvious, yet insidious, difference
between this kind of lesion and other class V cavities.
In fact, flat cervical lesions have neither a clear cervical margin
nor a sharp area defining the outline of the future restoration .
When restoring this kind of lesions, the polymerization shrink -
age and debonding represent a secondary issue; the main
problem in this case is caused by poor material adaptation
and overcontouring due to difficult handling and modeling of
the material.
The feather-edge-like thickness of the restoration and the ab-
sence of cavity walls suggests that this kind of lesion is safe
with regard to the short blanket effect (see page 230).
So why does adhesion failure occur in restorations with a flat
cervical profile? Well, the most logical explanation is that the
composite at the cervical level is poorly adapted and that the
restoration is often over-layered, meaning an aggressive fin-
ishing will have to be done, creating detachments and other
defects that can compromise the quality of the margins.

Example of a flat cervical lesion,

cavity configuration creates little
to none contraction stress.

Classical layering, placing the dentin first

and the enamel afterwards is difficult to
perform with high accuracy .

Restoration of class V with a flat cervical

profiles often fall dOe to bad cervical
adaptation or for overcontouring and
requiring an aggressive finishing.

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1. Two noncarious cervical lesions on the maxillary left
lateral incisor and canine. Both lesions have a peculiar
geometry.
.
2 Retraction on the maxillary left lateral incisor was obtained
with a modified 212 clamp.
3. After the adhesive procedures, a dentin shade is placed to
seal the cervical margin.
4. An enamel mass is then layered on top.
5. Flowable composite is used to correct the surface; in case
some bubbles or defects were present.
6. Situation immediately after rubber dam removal.
7. Appearance after 1 week.
8. Detail of the cervical region after 2 years. Margin behavior
is not optimal.
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r
The Closing Gap Technique

Early and late failure due to cervical debonding of a restoration
is probably the main issue associated with class V restorations,
As a matter of fact, most clinicians have experienced debond-
ing of a cervical restoration in their daily practice.
The Closing Gap Technique was developed by the authors
back in 2013, during their quest to solve this issue. This tech-
nique is aimed at reducing shrinkage-related complications,
and it is based on a reverse layering direction, ie, placing com-
posite from coronal to cervical as opposed to the traditional
approach.
In order to reduce shrinkage upon polymerization, composite
is layered in progressively smaller increments from the occlu-
sal margin to the cervical, leaving a small gap (about 1 mm).
Each layer adheres on two surfaces, of which only one is den-
tal structure.
The closing gap (most cervical increment) is filled last and cre-
ates virtually no contraction thanks to its minimal thickness,
Although the mechanism of cervical debonding is not fully clear
yet, clinical findings have shown moderate results in the long
term with regard to visible debonding lines and infiltration. Sci-
entific evidence is being gathered, and studies are in progress
due to the clinical interest shown in this technique.

Layer configuration

Besides the clear advantage of minimizing stress at the cervical 1

level, this layering configuration offers several other advantag-
es. The first significant one is it functions as a guide to buccal
shaping , as by starting from the occlusal, the buccal profile is
automatically transferred to the material. This technique helps
significantly reduce overhanging excess composite at the end
of the procedure, which also means less time is needed for
finishing procedures.
Another advantage is early shade matching. As the first incre-
ment is located at the future tooth-composite transition area,
it’s possible to detect major shade differences early on. More-
over the tooth is not yet fully dehydrated at this stage, which
makes this early checkpoint quite reliable.

J
Closing layer

Single shade strategy Progressive layer 2

Since the closing gap technique was developed, the forced Progressive layer 1
use of a single-shade approach was seen as a disadvantage.
On the contrary, after the very first few cases, it turned out to
be an incredibly reliable approach to obtain composite blend-
ing. Medium-opacity masses as body shades or low-opacity Body shade
dentin shades in fact provide optimal integration, so no at -
tempt has been made to develop a multiple -shade technique.
No need for one has emerged to this day.
•flowable
Body or

Disadvantages Advantages

• Challenging for some clinicians • Guided buccal shaping

• May cause material excess in • Early shade check
the cervical area • Minimum shrinkage
• Single mass is desirable • Full control over composite packing
• Single-mass technique

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