INTRODUCTION
With the advent of new composite resins and advances in adhesive dentistry, direct composite resins are the dental material of choice for conservative replacement of tooth structure. There is no longer a need to aggressively and irreversibly prepare away healthy tooth structure. There will most likely be a need for indirect restorations in the foreseeable future, but it is our charge to remain an advocate for our patients to assess every clinical need and to make recommendations based upon the current trends of responsible aesthetics.
This article will discuss how to restore a Class IV fracture (Figure 1) using conservative preparation principles and one of the latest aesthetic direct composite material options. A step-by-step procedure will be demonstrated to show how the teeth are prepared, layered with composite, contoured and polished to create a lifelike polychromatic aesthetic restoration.
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| Figure 1. The smile view shows the right central incisor (tooth No. 8) with a dark filling that has an open margin and staining. |
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| Figure 2. Side view of the color map shows the layers of composite material used in creating the restoration. | Figure 3. The frontal view of the color map shows the outline of the dentin mamelons (lobes), the clear composite layer between the lobes (Trans, short for “translucent”) the outline of the restoration, and any incisal effects added (white tint). |
Knowing and Selecting a Dental Material for the Case
When restoring anterior direct composite resins, it is crucial that the dentist possess a strong working knowledge of the fundamentals of color, tooth anatomy, and function.1,2 This appreciation of the physiology and design found in nature is what will facilitate the creation of restorations that will invisibly dissolve into the surrounding dentition. Most successful contemporary composite systems have a complete spectrum of shades, often with a special subset of materials that attempt to replicate the individual optic parameters of enamel and dentin. When critiquing the material options, it is essential that the resin has the appropriate handling properties that will enhance your predictability in creating beautiful natural results through the techniques of stratification and contouring that we will discuss3-7 (Figures 2 and 3).
Estelite Omega (Tokuyama Dental America) was selected to use on this case due to its excellent handling properties, ability to obtain a high polish, and a nice range of composite shades that allow the clinician to create a polychromatic aesthetic restoration. Estelite Omega has a great blending effect from the composite to the natural tooth structure. Due to the aforementioned characteristics found in this composite resin, it is an excellent material choice for most aesthetic anterior composite cases.
CASE REPORT
A 42-year-old female was unhappy with the old composite filling on her front tooth No. 8. The old composite filling was discolored, had open margins, and was unaesthetic. She desired to have the filling replaced with a new one that would look better. The old composite restoration was covering an existing Class IV fracture on the mesial incisal of tooth No. 8.
Clinical Protocol
The first step in the clinical appointment was shade selection. A custom shade guide was used from the Estelite Omega kit to select shade EB1. To verify that the shade was correct, the actual shade of composite was placed on the middle of the tooth (without acid etching and an adhesive) and light cured (Figures 4 and 5).
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| Figure 4. A custom shade guide was used to obtain the correct shade. | Figure 5. The actual composite material chosen for use in this case (Estelite Omega [Tokuyama Dental America]) was placed in the middle of the tooth to determine the exact shade. |
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| Figure 6. The old restoration was removed, showing the extent of the original fracture. | Figure 7. The composite layer, called the lingual shelf, was added using shade MW (Estelite Omega). This layer serves to provide the incisal edge and lingual contour. |
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| Figure 8. The dentin layer of composite was then applied using dentin shade DA2 (Estelite Omega). It was placed where the dentin of the tooth should reside. (Note the still-visible fracture line.) | Figure 9. An opaquer (Medium Chroma Opaquer; Estelite Color [Tokuyama Dental America]) was used to make the fracture area disappear. Clear incisal composite (Trans Estelite Omega) was added between the dentin mamelons. |
Since the old restoration was still in place, a putty matrix was taken directly in the patient’s mouth using a bite registration material (Blu-Mousse [Parkell]). The putty matrix was trimmed at precisely the facial-incisal line angle using a No. 12 Bard-Parker scalpel blade. This would help provide the anatomic framework of the lingual, mesial, and incisal aspects of the restoration to be placed.
Next, the patient was anesthetized with one-half cartridge (0.9 ml) of lidocaine 2% with 1/100,000 epinephrine. The old composite restoration was completely removed (Figure 6). A long bevel (1.5 mm) was placed on the facial margin, and a small chamfer was placed on the lingual margin. The long bevel on the facial helps to blend the restoration into the natural tooth structure and to mask the fracture line. The putty matrix was tried in and the lingual margin was lightly scratched to mark where the first layer of composite material was to be placed. Teflon tape was then placed on the mesial of the adjacent tooth No. 9 to protect it from the acid etchant and the bonding agent. Acid-etch gel (Ultra-Etch [Ultradent Products]) was placed on the prepared tooth, extending it slightly beyond the margin. Two applications of Prime&Bond NT (Dentsply Sirona) were placed and light cured (Valo LED Curing Light [Ultradent Products]) for 20 seconds.
The first layer of composite, shade MW (Estelite Omega) was applied to the putty matrix to create the lingual shelf. The putty matrix was placed back on the teeth, making sure that the composite contacted the tooth. This layer of composite is made very thin (approximately 0.3 mm) and thus becomes translucent and also provides a nice milky-white incisal halo (Figure 7).
The next layer of composite was the dentin shade DA2 (Estelite Omega). The dentin shade comprises the area where the dentin was formerly located prior to the fracture. Care is taken to simulate the dentin lobes. The dentin shade should also mask the fracture line. In fact, if a fracture line is evident at this stage, an opaquer should be used. The subsequent layer of enamel shade will not block out a fracture line since this material is more translucent than the dentin shade (Figure 8).
In this particular case, the fracture line was evident after the dentin shade was added and an opaquer was used. The fracture line was blocked out with Medium Chroma Opaquer (Estelite Color) by placing a thin amount of material on the tip of a small brush right on the visible fracture line, along with a little to each side. The opaquer was applied in small increments and light cured until the fracture line disappeared (Figure 9). To optically lock-in the incisal effects of the dentin mamelons, a small amount of clear composite material (Trans Estelite Omega [Tokuyama Dental America]) was sculpted in between the mamelons.
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| Figure 10. The tooth was then restored to full contour. | Figure 11. The postoperative smile photo shows sharp developmental depressions with a lack of faint white opacities. |
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| Figure 12. A thin layer of composite was removed on the facial-incisal one-third. The tooth was then microetched (MicroEtcher II [Zest Dental Solutions]). | Figure 13. A small brush (Estelite Omega’s Artist Brush [Tokuyama Dental America]) was used to apply the white tint (Estelite Color [Tokuyama Dental America]). |
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Figure 14. A surface layer of semi-translucent milky white enamel shade (MW) was placed over the entire facial surface of the restoration using a Gold Almore instrument (Almore International) to evenly spread it out. |
Figure 15. The post-op close-up view shows a nice polychromatic restoration with faint white incisal effects. The anatomy was much improved, as seen by the matching light-reflective surfaces. |
The final shade of composite used was EB1 (Estelite Omega), which is an enamel shade. The composite material was spread out over the entire area of the restoration. A mylar strip was used to pull-through the composite material from the facial to lingual to create a nice contact area and a nice facial embrasure. The large end of Estelite Omega’s Artist Brush (Tokuyama Dental America), which had been wetted with Modeling Resin (BISCO Dental Products), was used to smooth out the facial contours. The composite was then light cured for a full minute (Figure 10). Finally, the restoration was contoured using Sof-Lex XT (3M) discs. The coarse, red disc was used first to establish the primary anatomy, and the final polish was achieved using blue and pink polishing cups (FlexiCups [Cosmedent])8 (Figure 11).
The patient was seen for a one-week postoperative check and, at this appointment, the decision was made to make a few minor corrections to make the restoration ideal. The incisal edge lacked some of the faint white opacities and, in addition, the developmental depressions on the facial were too sharp. Photographs were used as a guide to make the final aesthetic corrections. There was no need to completely redo the restoration, as only a small amount of composite material (0.5 mm) was reduced on the incisal area on the facial. The restoration was then microetched (MicroEtcher II [Zest Dental Solutions]) and acid etched, and a bonding adhesive was applied (Prime&Bond NT)9 (Figure 12). A small amount of white tint (Estelite Color) was placed with the small end of Estelite Omega’s Artist Brush. Tooth No. 9 was used as a guide to replicate the pattern of diffuse opacities (Figure 13). The white tint was then light cured, and a surface layer of semi-translucent milky white enamel shade (MW [Estelite Omega]) was placed over the entire facial surface of the restoration. This composite material was evenly spread out using a Gold Almore instrument (Almore International) and then smoothed out using the large end of Estelite Omega’s Artist Brush wetted with Modeling Resin (Figure 14). The entire restoration was light cured for one minute. Once again, the restoration was contoured with the red (coarse) Sof-Lex XT disc. The primary anatomy was established, with the incisal edge and proximal line angles matching the adjacent tooth No. 9. Tooth No. 8 was polished with blue and pink polishing cups (FlexiCups). Pencil lines were drawn on teeth Nos. 8 and 9 to verify the position and shape of the line angles. The secondary anatomy was created using a flame-tip diamond (F888 012 [Kerr]), which made smooth developmental depression areas on tooth No. 8. A damp 2-x-2 gauze was wiped over the facial surfaces of teeth Nos. 8 and 9 to ensure that there was symmetry in light-reflective surfaces. The central incisors should end up being mirror images of each other in every respect. Digital photos were also taken and checked on a large monitor to verify that the contour and incisal effects were correct. The final, high-gloss polish was obtained using a FlexiBuff (Cosmedent) polisher with Enamelize (Cosmedent) paste (Figures 15 to 17).10
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| Figure 16. The final restoration can be considered to be excellent when it is difficult to tell which tooth was restored. The post-op smile view shows that it is, in fact, difficult to tell which tooth was restored. | Figure 17. This clinical protocol resulted in a very happy patient. |
CLOSING COMMENTS
A Class IV anterior direct composite resin restoration can be very aesthetic. The results can rival or exceed a porcelain veneer or crown, and it is a minimally invasive alternative. In the case demonstrated here, the extra effort in redoing the incisal area of the restoration was well worth it to improve the aesthetics in the final restoration. The final restoration looks natural, blending into the actual tooth without the restoration or fracture line showing. The first step in providing this level of care is an understanding of the possibilities, and then seeking the knowledge and clinical training to create predictable results using minimally invasive techniques.
References
- Fahl N Jr. Mastering composite artistry to create anterior masterpieces—part 1. Journal of Cosmetic Dentistry. 2010;26:56-68.
- Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.
- Crispin BJ. Contemporary Esthetic Dentistry: Practice Fundamentals. Tokyo, Japan: Quintessence Publishing; 1994:116-127.
- Terry DA. Natural Aesthetics with Composite Resin. Mahwah, NJ: Montage Media; 2004:106-114.
- Fahl N Jr. Mastering composite artistry to create anterior masterpieces—part 2. Journal of Cosmetic Dentistry. 2011;26:42-55.
- Manauta J, Salat A. Layers: An Atlas of Composite Resin Stratification. Milan, Italy: Quintessence Publishing; 2012:349-375.
- Finlay SW. Stratification: an essential principle in understanding class IV composite restorations. Journal of Cosmetic Dentistry. 2012;28:32-34.
- Peyton JH. Finishing and polishing techniques: direct composite resin restorations. Pract Proced Aesthet Dent. 2004;16:293-298.
- Baratieri LN. Esthetics: Direct Adhesive Restoration on Fractured Anterior Teeth. Carol Stream, IL: Quintessence Publishing; 1998.
- Rufenacht CR. Fundamentals of Esthetics. Chicago, IL: Quintessence Publishing; 1990:117-127.
Dr. Peyton graduated from the University of California, Los Angeles (UCLA) School of Dentistry in 1982. His private practice is located in Bakersfield, Calif, and he is also a part-time clinical instructor at the UCLA School of Dentistry. In addition, Dr. Peyton is a lecturer at Esthetic Professionals Education Center (Tarzana, Calif) and a part-time clinical instructor at the Fahl Institute in Curitiba, Brazil. He has published several articles for Practical Procedures and Aesthetic Dentistry and The Journal of the American Academy of Cosmetic Dentistry (AACD). Dr. Peyton is a Fellow, an accredited member, and an examiner for the AACD. He is also a contributing editor for the Journal of Cosmetic Dentistry. He can be reached at (661) 323-1888 or via jhpeyton21@gmail.com.
Disclosure: Dr. Peyton received payment from Tokuyama for writing this article.
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