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Special Issues
July/August 2021
Volume 42, Issue 1

Isolating, Bonding, and Creating Composite Artistry

Adamo E. Notarantonio, DDS, FICOI, FAACD

A patient presented with a significant dental history regarding teeth Nos. 8 and 9 dating back to age 8. Most recently she had had a traumatic experience when the resin restorations were replaced. The material was overbulked interproximally, causing the papilla to recede and resulting in a black triangle. After removal of the existing resin, periodontal treatment, and replacement of the bonding, the soft tissue returned to normal, but the patient was unhappy with the esthetics of the bonding. After multiple referrals, the patient was sent to the author for Class IV resins on Nos. 8 and 9. She wanted assurance that her papilla would be protected, and that the composite restorations would match the translucency of her other teeth. The author informed her that isolation of individual teeth would be accomplished using a heavy-gauge rubber dam to retract and protect the tissue and establish an ideal field for bonding and restoring. The bonding agent of choice was All-Bond Universal® (BISCO, bisco.com), and a total-etch protocol was used. Multiple shades of resin were utilized to mimic the natural colors and effects present in the patient's dentition. Meticulously combined, these techniques allowed for delivery of high-quality esthetic restorations that will stand the test of time.

Key Takeaways

Use of a rubber dam for closing diastemas and/or Class IV fractures with composite resin helps prevent moisture contamination and enable sufficient gingival retraction.

All-Bond Universal provides clinicians the versatility to bond via self-etch, selective-etch, or total-etch depending on the preparation design and amount of dentin exposed during preparation.

Understanding the colors in a resin system, along with using a systematic approach to layering resin, allows maximum esthetic results to be achieved.

About the Author

Adamo E. Notarantonio, DDS, FICOI, FAACD
Clinical Instructor, Honors Aesthetic Program, New York University College of Dentistry, New York, New York; Private Practice, Huntington, New York

Fig 1. Photograph sent to the author displaying the overcontoured resin on the mesial of tooth No. 9, long contact, and inflamed papilla between the two central incisors.

Fig 1

Fig 2. Preoperative full smile of the patient after the resin in Fig 1 was replaced and periodontal treatment was completed to repair the damaged tissue between the central incisors.

Fig 2

Fig 3. Preoperative close-up, 1:1.5 magnification ratio, retracted view with black contraster.

Fig 3

Fig 4. Absolute isolation was achieved with a heavy-gauge 6-in x 6-in rubber dam (Nic Tone, nictone.ro) from teeth Nos. 6 through 11 with primary W2 clamps (Hu-Friedy, hu friedy.com) placed over the rubber dam and on the first bicuspids.

Fig 4

Fig 5. All existing resin was removed under a microscope (PromiseVision 3D™, Seiler, seilermicro.com). A “starburst” bevel was placed in enamel. The surfaces to be restored were air-abraded with 50-μm aluminum oxide via an air-abrasion system.

Fig 5

Fig 6. The lingual matrix, used to build-up the lingual shelf in achromatic enamel, was tried in after rubber dam placement to ensure proper seating before starting the final restorations.

Fig 6

Fig 7. Tooth No. 8 is shown after the etching and bonding protocol. Because this case was entirely in enamel, a total-etch technique was used. After being washed with water spray, the enamel was etched with Select HV Etch w/BAC (BISCO) for 15 seconds and then rinsed thoroughly. Excess water was removed by blotting the surface with an absorbent pellet for 1 to 2 seconds, leaving the preparation visibly moist. One to two drops of All-Bond Universal dental adhesive was dispensed into a clean well, and the cap on the bottle was replaced promptly to avoid evaporation of solvent. Two separate coats of All-Bond Universal were applied, with the preparation being scrubbed with a microbrush for 10 to 15 seconds per coat. The adhesive was not light-cured between coats. Excess solvent was evaporated by thoroughly air-drying with an air syringe for at least 10 seconds; there should be no visible movement of the adhesive. The second coat of All-Bond Universal was applied in the same manner as the first, followed by a 10-second light-cure.

Fig 7

Fig 8. The completed resin on tooth No. 8 prior to final polish. The tooth was shaped and contoured with flexible discs (FlexiDiscs , Cosmedent, cosmedent.com).

Fig 8

Fig 9. Tooth No. 9 was prepared for its final restoration with the bonding technique utilized for tooth No. 8 described in Fig 7.

Fig 9

Fig 10. The lingual shelf shown here was created using a putty matrix built off of the original teeth. The resin used for this was an achromatic enamel in Milky White shade (Estelite Omega, Tokuyama, tokuyama-us.com).

Fig 10

Fig 11. Final layer of resin (Estelite Omega) was placed. For this, EB1 shade was chosen. This photograph was taken prior to any finishing or shaping

Fig 11

Fig 12. Completed Class IV resin restoration prior to removal of rubber dam, final polish, and occlusal adjustments. Shaping was completed in the same manner as described in Fig 8.

Fig 12

Fig 13. Final postoperative smile.

Fig 13

Fig 14. Final close-up, 1:1.5 magnification ratio, retracted view with black contraster.

Fig 14

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