RestorativeDentistry
Hannah P Beddis
Peter J Nixon
Layering Composites for Ultimate
Aesthetics in Direct Restorations
Abstract: A number of modern materials are available which allow placement of highly aesthetic anterior restorations. However, some
systems are complex and technique sensitive. The authors describe a layering technique for the provision of direct aesthetic anterior
composite restorations suitable for a general practice setting.
Clinical Relevance: Aesthetic restorations can be provided directly and in a conservative manner using composite resin, often avoiding the
need for more destructive indirect techniques.
Dent Update 2012; 39: 630–636
Resin composite provides the most aesthetic
direct restorative material for restoring teeth.
Composites offer the opportunity for minimal
preparation compared to more destructive
indirect alternatives. Some composite
materials are specifically intended to be
used to build layered restorations, eg Miris
(Coltène/Whaledent, AG, Feldwiesenstrasse
20, 9450 Altstätten, Switzerland), Ceram X
Duo (Dentsply, York, PA, USA), Enamel HFO
(Micerium SpA, 16036 Avegno (Ge) Italy).
Such composite systems differ from other
composites in that they have different
characteristics between the enamel and
dentine composite shades.
Composite resins are available
with a range of optical characteristics, having
a range of translucencies and colours. Whilst
Hannah P Beddis, BChD(Hons),
MJDF RCS(Eng), Specialty Registrar in
Restorative Dentistry and Acute Dental
Care and Peter J Nixon, BChD(Hons),
MFDS RCS(Ed), MDentSci, FDS(Rest Dent)
RCS(Ed), NHS Consultant in Restorative
Dentistry, Specialist in Restorative
Dentistry, Periodontics, Endodontics and
Prosthodontics, Restorative Department,
Level 5, Leeds Dental Institute,
Clarendon Way, Leeds, LS2 9JT.
630 DentalUpdate November 2012
in certain situations it may be feasible to
create an adequate appearance by using a
single composite shade, composite systems
intended for layered restorations are
composed of distinct enamel and dentine
shades. The difference between the enamel
and dentine composite is marked with a high
opacity and chroma for dentine shades and
high translucency and low chroma for enamel
(Tables 1 and 2).
Such composite systems allow
aesthetically superior restorations to be
created provided that each shade is used in
the correct position and quantity. Errors in the
quantity or position of each shade can result
in poor results. Excessive enamel composite
tends to lead to restorations that are too
translucent and greyish in appearance. Excess
dentine composite leads to a restoration
that is too yellow and opaque in appearance.
Achieving restorations that are optimally
Hue The basic colour, eg
red/yellow/blue
Value The brightness of the colour
Chroma The amount of hue in a
colour, eg dark vs light blue
Table 1. Definitions of hue, value, chroma.
Vita Classic Hue
Shade
A Red-brown
B Red-yellow
C Grey
D Red-grey
Table 2. Hues of Vita Classic shades.
aesthetic can be technique sensitive, but
rewarding with practice. Some previous
guidelines on building layered composite
restorations have been complex and included
suggestions to mix several shades and
materials of varying consistency. Below is
a description of a relatively simple layering
technique that can lead to optimally aesthetic
restorations.
Indications
Composite can potentially be
used for a variety of restorations, in anterior
and posterior teeth. Wear and strength
properties of the material are now adequate
for acceptable longevity of restorations, in the
majority of situations. In addition to standard
cavity preparations, direct composite can also

be used in a number of situations where
indirect restorations have typically been
employed. Such indications include:
 Discoloration/hypoplastic defects;1
 Fractured teeth;
 Management of toothwear;2,3,4
 Correction of tooth size/shape
discrepancies.
The use of composite in preference to
indirect restorations in such circumstances
has a number of advantages:
 Conservation of tooth tissue;
 Ease of adjustment at placement or at a
later date;
 Immediate check of shade matching and
modification, if necessary;
 Opportunity to include effect shades to
match dentition;
 Allows blending of supragingival
restoration margins.
Direct composite veneers
are particularly useful in young patients
in preference to porcelain, if gingival
maturation is not complete. This is because
margins for direct composite veneers can
be blended into natural tooth structure
better than indirect veneers, meaning
that supragingival margins are not visibly
apparent as they often are with indirect
veneers.1
Composite is also increasingly
being used in the treatment of toothwear,
for optimal aesthetics and maximum
conservation of tooth structure. By layering
such restorations appearance can be
optimized.
Longevity
There is not a great deal of
research into the longevity of anterior
composite restorations. A study investigating
the treatment provided in general practice
by VDPs and their trainers found a 4.5 year
mean survival of composite restorations, but
this did not distinguish between posterior
and anterior restorations.5 Other research
by the same author found a 4.7–7.4 year
mean survival age, but again this includes
posterior restorations.6 A review article in
2006 found that 5-year survival rate of Class
III and V composite restorations is 60–80%.7
This paper noted that Class IV composite
restorations have a higher, but unquantified,
failure rate; particularly in traumatically
injured teeth. This was attributed to
increased stresses during occlusal function.
November 2012 DentalUpdate 631
Procedure
Pre-operative requirements
Good oral hygiene and
periodontal health should be established
prior to restoration placement. Poor gingival
health will increase the risk of surface
contamination via blood or crevicular fluid,
leading to reduced bond strength and
increased microleakage.
Shade-taking
Prior to placing composite
restorations, it is helpful to record
the desired shade at the start of the
appointment while the natural tooth
structure is hydrated. Dehydration of
tooth tissue causes an 82% reduction in
translucency;8 therefore, the tooth will
appear lighter and more opaque if allowed
to dry out.
The hue of a tooth progressively
reduces from cervical to incisal aspects,
and from inside to the outside of a tooth.9
Correspondingly, a more opaque composite
should be used in the cervical third and
inner portion of the tooth.
It is useful to observe the
contour and texture of the tooth (or teeth)
to be restored and the adjacent dentition.
For complex layering or special effects,
it may be useful to take a pre-operative
photograph of the contralateral or adjacent
teeth for reference during the procedure,
if the reference teeth are to be covered by
rubber dam.
Surface preparation
Polishing teeth to be restored
using a slurry of pumice is helpful to
remove the salivary pellicle, plaque and
surface debris, ensuring that the tooth
surface is not contaminated in any way that
may interfere with bonding. Removal of old
restorations is required to improve bond
strength.
After polishing, some form
of preparation is usually required. At the
margins of preparations a bevel may be
useful to help blend the composite into
the remaining tooth structure to help
disguise the edge of the restoration.
Preparation at the margins of the intended
restoration can also expose a larger surface
area for bonding and there is evidence to
suggest that the bond to prepared enamel
is improved compared to unprepared
enamel.10,11
RestorativeDentistry
Bonding technique and moisture control
Moisture control may be
satisfactorily obtained in anterior regions via
isolation with cotton wool rolls and use of a
saliva ejector. However, rubber dam may be
necessary, particularly for posterior teeth and,
on occasion, lower anterior teeth.
Use of an appropriate dentine
bonding agent is mandatory, paying close
attention to the manufacturers’ directions for
use, to ensure that maximal bond strengths
are achieved. Dentine should be dry but
not desiccated for optimal bond strength;
although it is essential that the surface is
free from contamination, eg by saliva, blood,
crevicular fluid, handpiece oil.12 Desiccation
of the dentinal surface tends to flatten the
collagen network left after etching, reducing
penetration of the bonding agent and leading
to absence of a hybrid layer.13 However,
excessive moisture leads to increased
microleakage14 and poor bond strength.
The use of cotton wool pledgets to blot the
surface has a risk of leaving fibres on the
dentine surface to interfere with bonding
(although this would achieve the correct level
of drying); so the surface should be gently
dried using the 3-in-1 syringe.
There is evidence that rubbing
the bonding agent into the dentinal surface
improves bond strength and allows time for
the bond to permeate.15
Light-curing
The light-curing unit should
be well maintained, and the curing tip free
from debris and scratches, in order to ensure
maximum output (Figure 1). A reduced output
will decrease the depth of composite cured.16
It is recommended that the bulb is changed
every 3–6 months for conventional light-
curing units.17
Pre-warming composite
Composite resin can be pre-
warmed to increase its flow18 and therefore
improve ease of placement. This may be
done by placing the compule in a warm
place or by the use of a specially-designed
composite warmer (Figure 2). Warming hybrid
composites to 54 °C prior to placement has
been shown to reduce microleakage,19 and
results in more complete curing.20 It should
be borne in mind that this completeness
of curing could lead to increased residual
stress21 and therefore shrinkage,20 so it may be
 RestorativeDentistry
Figure 1. Poorly maintained light-curing tip – the
presence of damage and debris will reduce the
output.
Figure 2. Composite warming device.
prudent to place smaller increments.
Placement of resin
In order to help with the
placement of resin, a palatal silicone matrix (or
index) is a useful tool.
The matrix can be created in a
number of ways:
 An index of a previous restoration with
acceptable contour;
 From an approximate intra-oral
build-up;
 From a model wax-up (Figure 3a).
The matrix may be fabricated chairside, using
silicone putty, or in the laboratory, using for
example Memosil (Heraeus Kulzer, Newbury,
Berks); a clear silicone material (Figures 3b and
c).22
The palatal matrix allows the
operator to place the first increment against
it, providing a guide to placing the correct
thickness of material. Once the palatal wall
has been completed, this initial increment acts
as a guide to the positioning of subsequent
increments. Figure 4 shows the placement of
composite restorations on the central incisors
of the case in Figures 3 a–c. The canines and
lateral incisors have already been restored. The
pre-existing restorations were retained as a
base, having been slightly reduced.
Layering may be done with
632 DentalUpdate November 2012
dentine palatally followed by enamel labially
and incisally (2-layer technique), or with
enamel palatally, dentine centrally, followed
by enamel labially (3-layer technique). The
principle of the 3-layer technique is to mimic
the position of natural dentine and enamel
within a tooth and has hence been termed
‘the natural layering concept’.23 The argument
for two layers is that restorations are viewed
from labially and hence there is no need for
enamel shade on the palatal aspect of the
restoration.
In the authors’ experience, it
is easier and quicker to provide 3-layer
restorations rather than 2-layer. By placing the
initial enamel shade on the palatal aspect, the
increment can be built-up to the full incisal
length of the tooth, including the incisal
edge, providing a guide to the placement of
further increments without the further need
for the palatal matrix. The use of clear matrix
strips interdentally will allow contact point
formation whilst preventing bonding to the
adjacent teeth.
Special effects
Special effect shades such as
brown, white and opalescent blue resins
can be incorporated into restorations to
help blend them into the surrounding
natural dentition (Figure 5). Such effect
resins can greatly enhance the appearance
of restorations, helping to form a seamless
transition at restoration margins. Crack-lines,
areas of localized hypomineralization and
fissure patterns can all be incorporated to
enhance the final appearance and disguise
the restoration (Figure 6 a–h). However,
incorrect placement or over-use of effects can
have a detrimental effect on the restoration
(Figure 7).
Finishing
Attempts should be made during
resin placement to attain, as far as possible,
the desired shape of the final restoration.
Should gross adjustment be required, it is best
achieved through the use of diamond burs or
stones. Contouring the restoration to mimic
the adjacent teeth is important in creating
an aesthetic restoration. Both the form of the
tooth and the patterns of light reflection from
the surface should be taken into account and
reproduced as far as possible. Appropriate
labial contour (which may involve multiple
planes) and mamelons can be created. This
may be done using finishing burs.
Use of carbide burs for fine
finishing is not recommended as, despite
providing a smoother surface than diamond
burs,24 they have an adverse effect on the
restoration marginal integrity.25 Both types of
bur provide a poorer marginal integrity than
the use of a grit paper. Finishing and polishing
can be initiated with the use of abrasive discs,
eg Sof-lex™ discs (3M ESPE, St Paul, Minn, USA)
and rubber points (Diatech Charleston, SC
29413), or Enhance polishing points, cups or
discs (Denstply, York, PA, USA), (Figures 4 j–l).
Final polishing can be completed
using polishing brushes, eg Occlubrush
(Hawe Neos-Kerr, Via Strecce 4, 6934 Bioggio,
Switzerland) or diamond/polishing paste, eg
Prisma Gloss (Dentsply, York, Pa, USA) (Figure 8).
Conclusions
The range of indications for
direct composite restorations is increasing
as materials improve. When reconciling the
conservation of tooth tissue with the desired
outcome of treatment, direct composite is
increasingly the option of choice ahead of
indirect restorations.
References
1. Nixon PJ. Conservative aesthetic
techniques for discoloured teeth: 2.
Micro-abrasion and composite. Dent
Update 2007; 34: 160–166.
2. Robinson S, Nixon PJ, Gahan MJ, Chan
MFW-Y. Techniques for restoring worn
anterior teeth with direct composite
resin. Dent Update 2008; 35: 551–558.
3. Hemmings KW, Darbar UR, Vaughan S.
Toothwear treated with direct composite
restorations at an increased vertical
dimension: results at 30 months. J Prosthet
Dent 2000; 83: 287–293.
4. Poyser NJ, Porter RW, Briggs PF et al. The
Dahl concept: past, present and future. Br
Dent J 2005; 198: 669–676.
5. Burke FJT, Cheung SW, Mjör IA, Wilson
NHF. Restoration longevity and analysis
of reasons for the placement and
replacement of restorations provided
by VDPs and their trainers in the UK.
Quintessence Int 1999; 30: 234–242.
6. Burke FJT, Wilson NHF, Cheung SW, Mjör
IA. Influence of the method of funding on
the age of failed restorations in general
dental practice in the UK. Br Dent J 2002;
192: 699–702.
7. Macedo G, Raj V, Ritter A. Longevity of
anterior composite restorations. J Esthet
Restor Dent 2006; 18: 310–311.
 RestorativeDentistry

a b c

Figure 3. (a) Diagnostic wax-up. (b) Memosil matrix made in the laboratory on the wax-up. (c) Memosil matrix in the mouth pre-operatively.

a b c

d e f

g h i

j k l

Figure 4. The procedure for placement of an anterior composite restoration: (a) pre-operative appearance; (b) following isolation with cotton wool rolls, the
teeth are etched with 37% phosphoric acid; (c) application of a dentine-bonding agent using a microbrush; (d) insertion of matrix taken from diagnostic
wax-up; (e) placement of the palatal increment of composite resin (enamel shade). Note that the composite is placed up to the correct incisal level; (f)
removal of matrix and restoration of dentinal area using appropriate dentine shade; (g) build-up of mamelons in incisal third; (h) placement of translucent
composite shade and restoration of interproximal areas. The use of matrix strips interdentally at this stage will prevent bonding to the adjacent teeth; (i)
placement of overlying enamel shade; (j) polishing using Sof-lex™ disc. Note the anatomical contouring of the labial surface; (k) polishing using rubber
point; (l) final result.

634 DentalUpdate November 2012

 RestorativeDentistry

a b

Figure 5. Kolor + Plus (Kerr, 1717 West Collins,

Orange, CA 92867). Composite tint.

c d e

f g h

Figure 6. Composite restorations as treatment of toothwear, incorporating special effects: (a) pre-operative smile; (b) post-operative smile with composite
restorations on UR123, UL123; (c) pre-operative intra-oral anterior view; (d) post-operative intra-oral anterior view; (e) pre-operative UR123; (f) post-
operative UR123 showing the use of translucent and opaque shades with incorporation of crack-lines; (g) pre-operative UR1; (h) post-operative UR1
showing light reflection and appropriate labial contour.

Figure 8. Armamentarium for finishing and polishing restorations: Sof-lex™ discs, rubber points,
Figure 7. Excessive use of translucent composite Occlubrush polishing brush, Prisma Gloss polishing paste, Enhance polishing disc, point and pop-on
leading to adverse aesthetics. polishing cup.

November 2012 DentalUpdate 635

 RestorativeDentistry
8. Brodbelt RH, O’Brien WJ, Fan PL.
Translucency of dental porcelains.
J Dent Res 1980; 59: 70–75.
9. Franco EB, Francischone CE, Medina-
Valdivia JR, Baseggio W. Reproducing the
natural aspects of dental tissues with resin
composites in proximoincisal restorations.
Quintessence Int 2007; 38: 505–510.
10. Perdiago J, Geraldeli S. Bonding
characteristics of self-etching adhesives to
intact versus prepared enamel.
J Esthet Restor Dent 2003; 15: 32–41.
11. Schneider PM, Messer LB, Douglas WH. The
effect of enamel surface reduction in vitro
on the enamel bonding of composite resin
to permanent human enamel. J Dent Res
1981; 60: 895–900.
12. Burke FJT, Combe EC, Douglas WH. Dentine
bonding systems: 1. Mode of action. Dent
Update 2000; 27: 85–93.
13. Ferrari M, Tay FR. Technique sensitivity in
bonding to vital, acid-etched dentin. Oper
Dent 2003; 28: 3–8.
14. Carpena LG, Colle ZA. Microleakage of
occlusoproximal adhesive restorations,
effect of dentin moisture after acid
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636 DentalUpdate November 2012
etching. Minerva Stomatologica 2009; 58:
593–600.
15. Reis A, Pellizzaro A, Dal-Bianco K, Gones
OM, Patzlaff R, Loguercio AD. Impact of
adhesive application to wet and dry dentin
on long-term resin-dentin bond strengths.
Oper Dent 2007; 32: 380–387.
16. Dunne SM, Davies BR, Millar BJ. A survey
of the effectiveness of dental light-curing
units and a comparison of light testing
devices. Br Dent J 1996; 180: 411–416.
17. Mitton BA, Wilson NHF. The use and
maintenance of visible light activating
units in general practice. Br Dent J 2001;
191: 82–86.
18. Knight JS, Fraughn R, Norrington D. Effect
of temperature on the flow properties of
resin composite. Gen Dent 2006; 54: 14–16.
19. Wagner WC, Aksu MN, Neme AM, Linger
JB, Pink FE, Walker S. Effect of pre-
heating resin composite on restoration
microleakage. Oper Dent 2008; 33: 72–78.
20. El-Korashy D. Post-gel shrinkage strain and
degree of conversion of preheated resin
composite cured using different regimens.
Oper Dent 2010; 35: 725–731.
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21. Prasanna N, Pallavi Reddy Y, Kavitha
S, Lakshmi Narayanan L. Degree of
conversion and residual stress of preheated
and room-temperature composites. Ind J
Dent Res 2007; 18: 173–176.
22. Mizrahi B. A technique for simple and
aesthetic treatment of anterior toothwear.
Dent Update 2004; 31:
109–114.
23. Dietschi D. Optimising aesthetics and
facilitating clinical application of free-
hand bonding using the ‘natural layering
concept.’ Br Dent J 2008; 204: 181–185.
24. Botta AC, Duarte S Jr, Paulin Filho PI, Gheno
SM. Effect of dental finishing instruments
on the surface roughness of composite
resins as elucidated by atomic force
microscopy. Microscop Microanal 2008; 14:
380–386.
25. Maresca C, Pimenta LA, Heymann HO,
Ziemecki TL, Ritter AV. Effect of finishing
instrumentation on the marginal integrity
of resin-based composite restorations.
J Esthet Restor Dent (Official Publication
of the American Academy of Esthetic
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