Q U I N T E S S E N C E I N T E R N AT I O N A L

RESTORATIVE DENTISTRY

Eva Wirsching

Contemporary options for restoration of

anterior teeth with composite
Eva Wirsching, Dr med dent 1
The present article gives an overview of modern adhesive restoration in the anterior area, in view of the fact that modern
dental therapy should be as minimally invasive as possible.
Illustrated with multiple cases, the article shows possible pro-

spective elds of indication. (Quintessence Int 2015;46:457463;

doi: 10.3290/j.qi.a33989; Originally published in Quintessenz
2014;65(9):10671075)

Key words: corrections of form, direct composite resin restoration, direct composite veneer, ber-reinforcedcomposite xed partial dentures (FRC-FPD), space closure

Tooth-colored restorative materials have been established in the anterior region as durable standard treatment options. Continual improvement to ceramic and
composite materials has enlarged the spectrum for
indications. To an increasing degree, esthetic motivation plays an important role in todays dentistry
because of the greater awareness of an attractive visual
appearance. Hence treatment of caries lesions is no
longer the only requirement.
Minimally invasive means a preparation that is
guided not only by cavity design. The term has to be
dened in a more complex way. Aspects such as excavation, inltration, sustainability, and reparability
should be included, and these generate the star of
minimally invasive dentistry in restorative dentistry:
composite resin.1
Todays dentistry shows a trend towards more conservative dentistry.2 Due to optimized adhesive tech-

Private Practice, Stuttgart, Germany.

Correspondence: Dr Eva Wirsching, Rotenwaldstrasse 99, 70197 Stuttgart, Germany. Email: evawirsching@gmx.de

VOLUME 46 NUMBER 6 JUNE 2015

niques it is possible to reach the boundaries of currently dened indications. However, academic research
into these additional elds of application is neglected.
Therefore, the present article depicts realistic possible
treatment options in the anterior region and illustrates
potential further options. Evidence-based data on longevity are limited, but clinical experience is promising.
In this context, treatments without data on long-term
sustainability are shown, demonstrating their practicability and feasibility.

Restoration options using direct technique

Today composite is used for direct color and shape correction of teeth. The direct build-up technique can also
be applied for layering the complete vestibular surface,
creating direct veneers. Modern composites have
proven longevity and show good consistency. In the
past, failures occurred due to discoloration of the material or excessive loss of supercial lustre. The perception of composite as a minor restorative material is now
outdated. The clinical success of this material depends
on its correct application and proper indication.

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Fig 1a Situation after orthodontic treatment with spaces remaining in the anterior region.

Fig 1b After restoration with direct composite build-ups at the

maxillary central and lateral incisors.

Fig 2a Young patient with amelogenesis

imperfecta and inadequate restoration.

Fig 2b Situation after removal of the old

composite material.

Fig 2c Situation after restorative treatment with directly made composite

veneers.

Fig 3a Situation after periodontal therapy.

Fig 3b After removal of the splinting.

Fig 3c Situation after restoration using

the direct composite layering technique.

Closing diastemas and recontouring teeth in

combination with orthodontic therapy
Figure 1 shows noninvasive treatment of anterior teeth
with asymmetric gaps and rotations. By proximally
broadening the teeth with direct composite build-ups a
harmonious situation could be created. This direct technique can also be used for distinctive shape correction of
teeth with structural malformation.3 Figure 2 shows a
young patient with amelogenesis imperfecta who was
treated in the past alio loco with partial composite restorations. After removing the old material, the teeth
could be recontoured with direct veneers using the
layering technique. The result has been stable for 2
years and the patient is undergoing orthodontic therapy.

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Harmonization after periodontal therapy

After successful periodontal therapy the outcome is
often esthetically poor. Damaged by periodontal disease, a prosthetic restoration is not possible due to the
uncertain prognosis. Restoring these teeth with direct
composite build-ups is a useful alternative for longterm provisional restoration and to create esthetically
pleasing conditions.
Figure 3 shows an adult patient after periodontal
treatment. After removing the splinting and the composite material, the restoration was made using the
direct layering technique. The result has remained stable for 5 years and the patient is still under periodontal
recall.

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Figs 4a to 4c

Fig 4a

Young patient with traumatic loss of teeth 11 and 21 and aplasia of tooth 22.

Situation at initial consultation.

Fig 4b Intraoral situation 5 years after

restoration with direct composite build-ups.

Aplasia and traumatic loss of teeth

In cases of traumatic loss of teeth and aplasia, when
treatment of gap closure is chosen, direct shape corrections are possible.
Figure 4 shows a 14-year-old boy who lost both
maxillary central incisors at the age of 9 during a car
accident. The right lateral incisor was a peg tooth and
there was an aplasia of the left lateral incisor. Orthodontic treatment was used with the aim of positioning the
canines in the region of the missing central incisors. The
peg tooth was positioned in the region of the right lateral incisor and the primary left canine persisted in the
region of the left lateral incisor, until an implantation in
adulthood is possible. To bridge the time until adulthood, direct composite build-ups of the lateral incisors
and canines were undertaken. Figure 4 shows the situation after orthodontic treatment (brackets removed)
and initial consultation. The noninvasive treatment used
the direct layering technique with composite veneers.
After 4 years a small gap was present between the central incisors due to transverse growth of the maxilla. This
gap was closed successfully using the same composite.
The young patient is now at the age of 19 and the situation has been stable for 5 years (Figs 4b and 4c).
The key advantage of this treatment is its noninvasive nature. At this young age the tooth substance
could be preserved. Initially it was clear that due to
asymmetric tooth position and unequal gaps, an
esthetically perfect result might not be possible. Therefore the treatment was intended to generate stable
conditions and to help provide the young patient with

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Fig 4c

Smile at 5 years after treatment.

a socially acceptable appearance, preserving possible

future prosthetic and implant treatment options. The
treatment was seen as a long-term provisional treatment until there is no further transverse growth of the
maxilla. In adulthood, prosthetic restoration of the
maxillary canines and right lateral incisor, as well as the
implant at the left lateral incisor, could be planned.

Esthetic shape correction in adulthood

Comprehensive shape corrections can also be performed in adult teeth with direct composite build-ups.
In these cases there is often a higher demand for a
quality result. Figure 5 shows a young woman who felt
uncomfortable with the appearance of her maxillary
teeth. Due to tooth wear, the maxillary anterior teeth
were shorter, and the lateral incisor showed rotation.
The patient did not want orthodontic treatment. The
treatment option of ceramic veneers was discussed but
the young patient wanted to be treated noninvasively.
To visualize the possible treatment outcome, the dentist can perform a direct mock-up, either via direct composite application without etching the tooth, or via waxup by the technician. Thereby the dentist plans the shape
corrections and gap closures. The restoration using direct
layered composite veneers can be seen as a long-term
provisional restoration. Only a few studies can be found
in the literature,4-6 but the published data show that
application of this type of restoration leads to promising
results. Peumans et al5 showed that 89% of the investigated esthetic shape corrections made using composite
could be graded as clinically acceptable after 5 years.

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Fig 5a Intraoral situation: excessive wear and rotation of anterior teeth.

Fig 5b Intraoral situation after directly layered composite restorations of anterior teeth.

Fig 5c

Fig 5d

Smile at initial consultation before treatment.

COMBINATION OF DIRECT AND

INDIRECT TECHNIQUES
Complete rehabilitation of teeth with
general destruction
There is a tendency in contemporary conservative dentistry to use a combination of direct and indirect techniques. Figure 6 shows a 12-year-old boy with a diagnosis of amelogenesis imperfecta (hypoplastic type) and a
loss of vertical dimension of occlusion (VDO). The treatment plan was an elevation of the bite with a new VDO
using a combination of direct composite build-ups,
indirect composite veneers, and composite crowns in a
modied three-step technique and sandwich technique.7 Owing to the use of composite, treatment could
be noninvasive. The material also requires no minimum
layer thickness.
At the initial consultation at the age of 11, orthodontic treatment proceeded to regulate the crossbite. Because of favorable temporomandibular joint
growth, the conservative therapy started at the age of

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Smile after treatment.

11. In this case the bite elevation / elevation of VDO

was dened by the pathologic bite collapse. The orthodontic treatment also had the aim of generating sufcient proximal space with interproximal gaps for further restoration. The bite was to be raised by 3 mm.
After taking an occlusal impression, a diagnostic waxup was created of the anterior and posterior teeth to
plan and control the denitive restorations. For testing
and adaptation of the new VDO, the patient had a
splint. The following restorations were planned:
posterior teeth: 16 indirect composite crowns on
teeth 14 to 17, 24 to 27, 34 to 37, and 44 to 47
(according to FDI nomenclature)
mandibular anterior teeth 33 to 43: six indirect buccal composite veneers, six direct lingual composite
veneers
maxillary anterior teeth 13 to 23: six direct buccal
composite veneers and six indirect palatal composite veneers (Fig 6c).
The laboratory-made composite crown (Fig 6c) was
made from SR Adoro (Dentin A3, Enamel TS2; Ivoclar

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Fig 6a 12-year-old boy with amelogenesis imperfect: smile

before treatment.

Fig 6b

Intraoral situation before treatment.

Fig 6d Situation after cementation of the palatal composite

veneers and posterior composite crowns.

Fig 6c Palatal composite veneers of the maxillary anterior teeth

and composite crowns of the posterior teeth.

Fig 6e Direct composite build-ups/directly made composite

veneers of the maxillary anterior teeth with Enamel Plus HFO.

Vivadent), a veneer composite with good clinical performance.8,9 The treatment was performed within 1
week. At the initial appointment, 16 posterior composite crowns were adhesively inserted (Tetric EvoFlow A3,
Ivoclar Vivadent). Due to the bite elevation there was a
temporary open bite in the anterior region. The patient
was instructed that biting in the anterior region would
not be possible for 1 week. After 1 week, at the second
appointment, insertion of the palatal composite
veneers was undertaken (Fig 6d). The vestibular aspects
of the maxillary anterior teeth were directly layered by
the dentist using composite (Enamel Plus HFO, UD3.5,

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Enamel GE2; Micerium; Fig 6e). At the third appointment 1 day later, the same procedure was performed in
the mandibular anterior region. At the control appointment 2 months later, the clinical situation showed a
natural appearance (Figs 6f to 6i).
Application of occlusal composite onlays in the posterior region for bite elevation is described in the literature within case reports. To generate a new VDO, socalled repositioning onlays are currently applied.10
These are based on a minimally invasive, defect-orientated concept. In the described case, due to the age of
the patient and the minimal available space, composite

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Figs 6f to 6i Stable situation after restorative rehabilitation. (f) Maxilla. (g) Mandible.
(h) Intraoral situation after treatment. (i) Smile after treatment.

restoration was more suitable. Further cases of patients

who were treated using this technique (eg, for molar
incisor hypomineralization) also showed good clinical
results. If chipping fractures occur at a later date due to
jaw growth or functional wear, the restorations can be
repaired intraorally. The surface lustre should be monitored to ensure it remains stable.

reported a Kaplan-Meier survival rate of 75% after 63

months, and Freilich et al12 reported a survival rate of
74% after 3.75 years. In a retrospective study by Wol
et al,13 only one of 32 examined FRC-FPDs was rated as
a failure after 18 months (USPHS/Ryge-criteria).

Replacement of missing teeth (traumatic

loss/aplasia) by fiber-reinforced composite
fixed partial denture (FRC-FPD)

The objective of the present article was to show indications for minimally invasive treatment in conservative
dentistry in addition to orthodontic, prosthetic, and
implant treatment options and to suggest future possible therapies. It has to be assumed that new forms of
therapy can always show failings because boundaries
concerning application techniques and materials were
reached. The described cases demonstrate that modern
conservative dentistry represents a wide spectrum of
indications, and that more comprehensive cases can be
treated. FRC-FPDs are an additional treatment option
for replacement of a single tooth. They can also be used
as high-quality, long-term provisional restorations in
implantology.
Modern composites seem to be benecial and full
expectations. The combination of direct and indirect
techniques when restoring anterior teeth is promising
for the future. It facilitates complex treatment steps
such as generating proper occlusion, and allows more
ecient, economical dentistry.

When single anterior teeth are missing and the gap

should be preserved, FRC-FPDs show promising clinical
results. Figure 7 demonstrates the restoration of a single tooth gap in the anterior region, where implantation was not possible due to low interradicular space.
FRC-FPDs show esthetically pleasing appearance and
they seem to be an alternative to all-ceramic xed partial dentures. Data in the literature reveal good results,
so they could be possible alternatives for implants or
prosthetic restorations in the future.
The patient in Fig 7 was referred to the orthodontic
department because of her compromised right lateral
incisor. The remaining root was aected so an orthodontic extrusion was not advisable, and the tooth was
therefore extracted. The patient declined orthodontic
treatment to widen the gap in order to facilitate
implantation, so an implant was not inserted. After
extraction a pontic was placed provisionally. The FRCFPD could then be inserted. In the literature, studies
show good long-term stability of FRC-FPDs. Vallittu11

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CONCLUSION

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Figs 7a to 7d

Restorative treatment of missing tooth 12 by ber-reinforced composite xed partial denture (FRC-FPD).

Fig 7a Situation at initial consultation: compromised tooth 12

and provisional crown.

Fig 7b Situation after extraction, forming the provisional pontic.

Fig 7c

Fig 7d

Situation before the insertion of the FRC-FPD.

ACKNOWLEDGMENT
The author thanks the technician K. Halbleib (Poliklinik fr Zahnerhaltung und Parodontolgie, Universittsklinikum Wrzburg) for the production of the indirect restorations.

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