Using a Universal Composite to Create Natural-Looking Anterior Restorations
Marcos Vargas, DDS, BDS, MS
When it comes to esthetically restoring the anterior maxillary teeth, a variety of direct and indirect techniques are available.1 However, there are times when patients cannot afford indirect porcelain restorations, or they prefer more conservative options such as those involving direct composite resin.
Direct resin restorations have historically challenged clinicians in terms of ensuring esthetic predictability, strength, durability, and wear rates, among other factors. Fortunately, as a result of manufacturers’ development of new products, clinicians now have enhanced direct restorative options available to provide their patients with more esthetic, long-lasting, and conservative treatments.
When placing composite restorations in the anterior region, ensuring optimal beauty and strength as well as polishability and wear resistance are important considerations when choosing a direct restorative. So is ease of placement in the production of an esthetically superior restoration. This article highlights the clinical protocol involved with using resin composite for the restoration of two fractured central incisors. The author details the necessary clinical protocol involved with precisely placing the composite, contouring and finishing the restorations for anatomically accurate morphology, and then polishing to create a life-like luster.
Case Presentation
A female patient presented with a Class IV fracture on tooth No. 8 that she sustained during a fall (Figure 1). She had an unfortunate history of falling and, as a result, the mesial aspect of tooth No. 9 also was chipped, indicating a history of fracture and restorative work. Although the dentin was exposed, there was no pulpal involvement. However, although the patient felt no pain, the pulp tested positive for both teeth. Dissatisfied with the appearance of tooth No. 9, the patient requested that the restoration on that tooth be replaced while treating tooth No. 8. Although a variety of options were presented to the patient—including a crown or other type of porcelain restoration—the patient indicated that she preferred the most conservative treatment option. Additionally, since finances were a concern, she decided on direct composite resin build-ups.
Matrix Development and Preparations
Upper and lower alginate impressions were made and poured, the casts were mounted in a semi-adjustable articulator, and a wax-up was performed to contour the patient’s teeth and to verify the occlusion. A matrix was then fabricated from the wax-up that would guide the composite build-ups. Shade selection was completed before any isolation and after the teeth had been cleaned with pumice. The shade was taken from the middle third of the lateral incisors. The central incisors were not used because the presence of resin composite could affect the shade. The enamel replacement material was of the selected shade. A darker and opaque shade was selected as a dentin replacement.
Once the patient was anesthetized, a rubber dam was placed for isolation.2 Other alternatives for isolation are available, but the rubber dam provided the best isolation results, in this author’s opinion.
In this specific case, no caries were present, but the old restoration on tooth No. 9 required removal using a diamond bur. To prepare teeth Nos. 8 and 9, bevels (of which there are two types) were made. The first type is a facial bevel, which is longer and extends 2 mm or 3 mm toward the facial aspect of the teeth and starts in dentin inside the dentinoenamel junction. Additionally, this is a festooned or scalloped bevel to allow a better blending of the resin composite over tooth structure. The second type of bevel is the lingual bevel, which is limited to a 45° angle starting in the enamel junction.
To round the edges so that the margin of the bevels would become imperceptible, a Sof-LexTM disc (3M™ ESPE™, St. Paul, MN) or any contouring disc could be used. In this case, rounding the edges made it impossible to detect where the bevel ended, especially in the facial aspect. Note that it is necessary to pay attention to the proximal areas and ensure that they have been beveled. These areas frequently are not beveled, allowing visibility of where the restoration finishes and where the tooth begins.
Overall, the preparation for this specific case required only a very conservative approach. The only tooth structure removed was a small amount of enamel for the bevels.3
The matrix was then tried in to verify the fit, which should be comfortable with the rubber dam in place. Note that at this point the matrix may need to be cut back to ensure that it fits nicely with the rubber dam.
Adhesive Protocol and Incremental Build-Up
The adhesive procedure consisted of applying a three-step, total-etch adhesive (OptiBond FL®, Kerr Corporation, Orange, CA) according to the manufacturer’s directions on the entire facial surface of each tooth.
The material selected for this case was Premise™ (Kerr Corporation). This material provides a large range of shades and translucencies for anterior esthetic build-ups. This is a fine-particle resin composite that has good handling properties, can be polished to a high luster, and has adequate physical properties to withstand the occlusal forces in the anterior area of the mouth.
The direct composite build-up started with the placement of the lingual layer using an enamel-type or translucent-type material based on previous shade selection.2 This lingual increment of composite can be placed in three ways. First, the matrix can be placed into the mouth after the adhesive has been polymerized, and composite can be applied into the matrix to ensure that it reaches the adhesive side of the bevel. Another way to place the lingual increment is to add a layer of composite to the matrix before placing it in the mouth. Then, once the composite has been patted into the matrix, the matrix can be set into the patient’s mouth, the lingual portion of composite adapted, and then light-cured. The third way to create this increment that is preferable is to place the composite on the teeth and adapt it immediately to the bevels. The matrix can then be placed in the mouth, and a thick increment of 1 mm or less can be spread over the lingual matrix (Figure 2). The lingual increments are then formed and light-cured from the facial aspect with the matrix in place and then after without the matrix from the lingual aspect.
Mylar strips were placed in the mesial and distal aspects to build up the proximal enamel (Figure 3). After the build-up using an increment of composite, this aspect was shaped, the matrix was returned to the mouth for verification, and the composite was further adapted to the tooth. The mesial aspect, if needed, could then be built up.
While pushing the composite into the matrix, be sure to brush and smooth the composite into place. Once the lingual increment and proximal enamel aspects are complete, it is essential to keep building up the restorations toward the facial. Dentin layers of composite tend to be a shade that is slightly darker than the lingual shade, but will still fall in the A range. Once this composite increment is placed, it should be adapted using a brush (Figure 4). It is crucial that the dentin increment cover the dentin of the natural tooth. In particular, the dentin increment should extend beyond the bevel so it can hide the demarcation between tooth structure and restoration. This composite layer is then light-cured also.
In this particular case, to create the halo effect or characterization around the teeth, a Color Plus White stain and a #2 brush were used to impart a white rim around the incisal edges. This colorized resin was then light-cured, after which a layer of clear translucent material (Premise), was applied to ensure that the restoration would demonstrate natural light reflecting and optical properties (Figure 5). The translucent material was placed onto teeth Nos. 8 and 9 simultaneously (Figure 6) and then light-cured.
After the lingual enamel, dentin, translucent shade, and halo characterization were applied, the final enamel increment could be placed. This composite layer enables clinicians to impart natural contours and anatomy to the restorations. While placing the increments at the same time using a thin-bladed instrument and a brush, it will be necessary to contour and blend the material in a cervical direction, moving the excess toward the incisal. This layer of composite was then also light-cured.
Contouring
Creating contour involves following a step-by-step procedure.4 The matrix is used as a guide for the incisal edge length. Once the length has been established, the Sof-Lex disc can be used to contour the interproximal areas. An alternative is a #12 finishing blade used for opening the embrasures. Once the embrasures are opened, they can be contoured (Figure 7). Microanatomy can be imparted using a medium diamond bur (Brasseler USA, Savannah, GA). In this case, developmental grooves and indentations were required.
To contour the proximal areas, VisonFlex Strips (Brasseler) (Figure 8) were used remove any excess. To finish these proximal areas, a sequence of colored strips (Epitex Strips, GC America, Alsip, IL) was used. Note that the proximal area should be smooth upon completion as well. Check with floss to ensure that the patient does not have anything caught in between.
Finishing and Polishing
Finishing and polishing also followed a specific protocol.2,4,5 The final contour and initial polishing was completed using an abrasive quartz cup (Ultradent, South Jordan, UT) (Figure 9). Medium polishers were used first and then fine polishers were used to achieve a lifelike shine and luster.
Upon removal of the rubber dam, the restoration was complete (Figure 10). The patient was appointed for a follow-up visit to verify the occlusion and ensure the satisfactory condition of the composite restoration.
Conclusion
Recent advancements in composite formulations have helped to alleviate clinicians’ concerns regarding shrinkage and filler size and their effects on the predictability and esthetics of composite restorations.6 Innovative composite material offers clinical advantages such as smoother, more consistent handling properties, long-lasting esthetics, and high sculptability. As demonstrated in the preceding case, its easy polishability and handling allows dentists to work with popular shades and create durable restorations with enhanced physical properties.
Disclosure
The author has no financial interest in any product or companies mentioned in this article.
References
1. Vargas H. Conservative aesthetic enhancement of the anterior dentition using a predictable direct resin protocol. Pract Proced Aesthet Dent. 2006;18(8):501-507.
2. Fortin D, Vargas MA. The spectrum of composites: new techniques and materials. J Am Dent Assoc. 2000;131: 26S-30S.
3. Ozel E, Kazandag MK, Soyman M, Bayirli G. Two-year follow-up of fractured anterior teeth restored with direct composite resin: report of three cases. Dent Traumatol. 2008;24(5):589-592.
4. Peyton JH. Direct restoration of anterior teeth: review of the clinical technique and case presentation. Pract Proced Aesthet Dent. 2002;14(3):203-210.
5. Peyton JH. Finishing and polishing techniques: direct composite resin restorations. Pract Proced Aesthet Dent. 2004;16(4):293-298.
6. Yesil ZD, Alapati S, Johnston W, et al. Evaluation of the wear resistance of new nanocomposite resin restorative materials. J Prosthet Dent. 2008;99(6): 435-443.
About the Author
Marcos Vargas, DDS, BDS, MS
Department of Family Dentistry
University of Iowa
Iowa City, Iowa
