Eur J Esthet Dent 2010 Devoto PDF

CLINICAL APPLICATION pyrig
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Composite in Everyday Practice: esse nc e n
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How to Choose the Right Material

and Simplify Application Techniques
in the Anterior Teeth
Walter Devoto, DDS

Clinical Lecturer, Department of Restorative Dentistry, University of Siena, Italy
Visiting Professor, University of Marseille, France
Private and referral practice, Sestri Levante, Italy
Monaldo Saracinelli, DDS

Grosseto, Italy
Jordi Manauta, DDS

Barcelona, Spain
Correspondence to: Dr Walter Devoto

Via E. Fico 106/8; 16039 Sestri Levante, Italy
e-mail: dewal@tele2.it; www.italianshadeguides.com
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 5 • NUMBER 1 • SPRING 2010
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Abstract te ot
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In daily practice, composites are the mate- to make the right color choice. Paradoxical-
rials most commonly used for restorative ly, they say that the appearance on the
dentistry. They are used for preventive market of sophisticated materials, de-
seals, microinvasive restorations, build-ups signed to give ever better results in the
and complex direct and indirect restora- medium and long term, only makes it more
tions in posterior sections. difficult to make the correct decision.
Indeed, it is in the anterior sections that Indeed, many of these colleagues, after
composites have traditionally been used to the first buzz of enthusiasm, give up on
the greatest effect, enabling clinicians to the layering technique and opt for mate-
carry out complex restorations using direct rials which they say are more simple or
techniques with notable esthetic and clini- “mimetic.”
cal results. In the present article, the authors will
Recent product developments com- discuss these topics and make sugges-
bined with clinical research on stratification tions on how to acheive high quality results
make it now possible to utilize new com- every day, both from an esthetic and clin-
posites that have excellent opalescence ical point of view. However, predictability of
and fluorescence characteristics and pro- the results is more important, as pre-
vide an excellent color range to choose dictability provides advantages in terms of
from.1,2 the quality of work and economy for clini-
It is however, a common complaint cians and patients.
among clinicians that the layering tech-
niques are rather complex and it is difficult (Eur J Esthet Dent 2010;5:102–124)
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Introduction te n
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Adhesive dentistry has made it possible to
restore teeth to their full functionality by cre-
ating a bond with the hard tissues, while
preserving, as much as possible, healthy
tissues of the teeth (Figs 1 to 3).
Prior to the introduction of adhesive sys-
tems, clinicians needed to create mechan-
ical retentions for the materials. When that
was not possible, prosthetic solutions
Fig 1 Patient, 16 years old, with incongruous restora- rather than conservative procedures were
tion on tooth 11 and evident passive eruption. resorted to.
From a practical point of view, compos-
ite resins and adhesive systems have
made it possible to use less invasive pro-
cedures to treat clinical cases that at one
time would have required a significant
sacrifice of dental structure. This means
that today, clinicians can propose individ-
ually tailored treatment plans characterized
by considerable biological and financial
savings (Figs 4 to 13).
Fig 2 Gingivectomy to redefine the length of the

teeth.
Fig 3 The finished case after composite reconstruc- Fig 4 Patient, 33 years old, was not satisfied with her
tion, which was carried out after gingival healing. smile but had limited financial options.
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Fig 5 Once the old restorations had been removed Fig 6 After the build up of the cavities, impressions
it was clear that it would not be possible to restore the are taken to plan the indirect vestibular additive restora-
anterior sector directly in composite within a reason- tion: diagnostic waxup and silicone stents are funda-
able amount of chair time and to a high standard. mental to an individual treatment plan.
Fig 7 With the aid of the silicone stent, the planned Fig 8 The patient can now evaluate the esthetic and
project is transferred to the mouth of the patient using phonetic impact of the new project and the clinician can
flowable composite. prepare the required space directly on the mockup.
Fig 9 Impressions are transferred to the laboratory: Fig 10 The photograph highlights the new dimen-
the veneers are made from the waxup with transparent sions on the additive composite veneers: the sound tis-
silicone and a flask. This method makes it possible to sue in the six anterior teeth remains practically un-
realize reconstructions simply and quickly. touched.
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Fig 11 The finished case with good esthetic integration achieved at relatively low biological and financial cost.
a b
Fig 12a and b The situation before and after the intervention: the additive solution allows for re-intervention
without dental sacrifice should the patient subsequently decide to resort to other restoration solutions, or require
root canal treatment in the future.
In recent years, there has been a break-

through not only in the use of composite
resin, but also in the way it is being manip-
ulated. Initially, the materials were seen as
nothing more than an esthetically agree-
able way of filling cavities.3 Only later did
clinicians begin to layer predetermined
thicknesses of dentin and enamel to build
up a natural looking restoration.4-8 This
technique, known as stratification, has its
origins in the way ceramicists operate and
Fig 13 The patient’s smile. has led to the development of composites
especially designed for this purpose.9
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a b
Fig 14a The color of the tooth is derived from the Fig 14b By carefully adjusting the thickness of the
dentin, but the role of the enamel is of fundamental im- enamel on the incisors, it is possible to reproduce the
portance as can be seen from these specially con- natural opalescence without the addition of transparent
structed composite samples. It is the thickness of the composite and changing the “age” of the tooth as well.
enamel that determines the different dental ages.
Within the range of resin composites on the Colors and form

market, there is a continual quest to find
dentin and enamel materials with optical The choice of color has for decades been
and mechanical properties similar to natu- debated by clinicians for whom it repre-
ral tissues. sents a challenging decision.15 Literature
In the course of its evolution, composite published today provides various sugges-
is no longer considered only an “esthetic” tions, as does observation of nature and
alternative to materials which are not ac- clinical experience.16
ceptable in the anterior, but rather a mate- Until a few years ago, it would have been
rial with its own unique properties that unthinkable not to refer to virtual color
combines esthetics with function.10 guides, which gave only an approximate
These properties are, in fact, what has idea of the color in which to construct a
made it possible to apply composite in restoration. Since a universal color con-
both direct and indirect solutions and in the cept was introduced, many materials have
anterior and posterior sections. Its extreme been simplified.
versatility allows for a wide variety of appli- Today, it is universally known that the
cations.11-14 base color is derived from the dentinal
Not only have composites replaced ma- body and that enamel works as a modifi-
terials of the past, but they have also pro- er of the dentin color. It is the thickness of
vided, due to their unique characteristics, the enamel which is decisive for the color
additional value to clinical practice. of the tooth, and this changes over time
(Fig 14).17
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te is now on
Consequently, the choice of dentin ot
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focused on a single base hue with different
chromatic shades, and an accompanying
system of enamel to modify the color.
However, many clinicians remain in
some doubt regarding the choice of chro-
matic shade and the number of different
dentin chromas to use when creating a
restoration. In the present study, we have
attempted to simplify the matter by creat-
ing disks of composite of the same chro-
Fig 15 Uniform layers of A3 dentin with increasing matic value (A3) but of variable thickness.
thickness: increasing the thickness increases the satu- This visual analysis demonstrates how a
ration of the color (chromaticity).
different thickness corresponds to different
chromatic results (Fig 15).
As a dental restoration is created in var-
ious thicknesses (Fig 16) from the cervical
to the incisor area, clinical experience sug-
gests using a minimum number of dentin
colors and varying the chromatic inci-
dence by adjusting thickness and use of
enamel to modify the base color.
For this type of restoration, it is of the ut-
most importance to correctly manage the
Fig 16 The correct reproduction of the layers of
dentin in a young tooth. space dedicated for each material. Any
casual application is an irrational choice
(Figs 17 to 19).18
Saving chair time in reconstructive den-
tistry means the precise management of
the quantities of composite applied. A
small excess or under-application could
determine esthetic failure and the need to
repeat the restoration, in other words, a sig-
nificant waste of time.
Clinicians should not, therefore seek
esthetic success solely in the brand name
of a particular composite material or in the
use of a large number of syringes on a
single tooth. Rather, they should look for
the methods and the guides which aid the
Fig 17 Patient, 8 years old, with traumatic fracture of correct management of space to ensure an
teeth 11 and 21. adequate overlay of materials of different
translucency. The management of the form
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of a restoration would therefore appear to be
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the fundamental topic in this discussion.19 ss e n c e
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In order to optimize chair time, as well as
the results, it is necessary to begin to think
about how to apply the reconstruction ma-
terials even before removing the caries or
the old reconstruction, so as to avoid los-
ing all information on the dimensions to re-
produce.
It is crucial to have an efficient and sta-
ble guide for the buildup, and this is pro- a
vided by the rigid silicone matrix. This

guide can be obtained from the old
restoration before removing it, from a pre-
restoration, or from a waxup.20
In addition, the authors suggest apply-
ing preformed sectional guides with multi-
ple convexities in the anterior sections to
facilitate a natural emergence profile and
to optimize the position of the interproximal
contact point (see clinical case).
b
Three-dimensional Fig 18a and b For an esthetically pleasing restora-
thickness tion, it is important to obsessively control the layers of
dentin and enamel.
Utilization of the silicone guide and inter-
proximal matrix allows one to manage the
two dimensions of the restoration’s space:
height and width. The greatest difficulty
remains managing the third dimension—
thickness of the tooth—and this, in the au-
thors' experience, is the primary cause of
esthetic failure.
The correct calculation of the thickness
of the alternating opaque and translucent
materials is a crucial step when recon-
structing a tooth using composite materi-
als. It is well known that enamel materials
tend to increase the “grayish effect” the
thicker they are, and thus dull the underly- Fig 19 The case after a 1-year checkup.
ing color of the dentin as can be seen in
the samples in Figure 20.
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How to resolve this problemte n ot
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In the most complex cases, authors rec-
ommend preparing an ample silicone
stent, which also reproduces the vestibu-
lar portion of the teeth. This can then be cut
in different planes, frontally or sagittally.
This application, which has already
been used in prosthetic dentistry, allows
the clinician to adequately control the
thickness of the two materials. It also
Fig 20 In the center, a sample of A3 dentin on which makes it possible to decide how much
increased thicknesses of enamel are overlapped. The space should be left for the chosen enam-
thicker the enamel the greater the cover effect on the
el, after evaluating the opacity of the pa-
color of the dentin with a consequent tendency to re-
sult in a grayish color. tient’s natural enamel as well as the choice
of composite to use (see clinical case).
As a general rule, authors advise leav-
ing space no larger than a half of a natu-
ral enamel thickness.
One of the more interesting innovations
in the world of composites is the recent in-
troduction of high refractive enamel that
has a refractive index very close to that of
natural enamel. As can be seen in the ex-
ample in Figure 21, the use of this kind of
enamel increases the thickness without in-
creasing the graying effect; on the contrary,
Fig 21 In the center a sample of A3 dentin onto the luminosity is increased.
which increasing thicknesses of new generation enam- This can be of great help to a clinician
el (HRI) are overlapped (clockwise). By increasing the during the difficult management of a cru-
thicknesses, the dentin is covered but the undesirable
cial part of the tooth such as the vestibular
gray effect does not result.
enamel.
The choice of materials

The type of composite material used is an
important choice for a clinician. How can
one identify the best choice?
Fig 22 Teeth reconstructed with nine different com- Sometimes, recommendations are giv-
posites using A3 dentin with the same thickness and a
en by a senior practitioner who takes the
medium value enamel of 0.5 modulated thickness. It is
clear that, on final inspection, the restorations appear role of advisor, or by a trusted speaker at
completely different from each other. a conference. The risk in such cases is
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that sometimes the abilities of a colleague Nanofillers deserve a separate discussion.
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or famous speaker can affect the intrinsic ss e n c e
Composites made of these materials were
fo r
characteristics of the material itself. created using a complex industrial techno-
On other occasions, the choice can be logical process and have the advantage of
influenced by the sales team of a compa- being extremely homogenous and com-
ny who demonstrate the latest materials posed of particles on a nanometer scale.
on the market, the “wonder product” with Today, there are very few composites on
miraculous mechanical and esthetic the market made of pure nanofillers. Sev-
properties, new chemical formulas, and eral companies have adopted the philos-
chameleonic properties. ophy of combining different percentages
In yet other cases, clinicians trust the of nano- and micro-hybrids.
best known brands of composites and, The disadvantages of these materials
paradoxically, as statistical studies and regard their manipulation. High viscosity
classifications of the most requested prod- renders the composite difficult to layer, es-
ucts have demonstrated, some countries pecially in the anterior region which, as has
still have materials which are notoriously already been discussed, requires scrupu-
obsolete yet remain in use. lous control of the layer thickness.
From a physical and chemical point of Another difficulty concerns poor esthet-
view, materials have undergone many ic results. The materials' micromechanical
changes over the course of time as has optimization (surface hardness) was at the
been highlighted above. Following the cost of the esthetic results, probably due to
evolution of industrial systems, companies the lack of knowledge concerning the re-
have been trying to find a stable material lationship such fine particles have with
from both a micro-mechanic and esthetic light. Mixing nanocomposites with different
point of view. Nowadays, they use a variety percentages of microfiller composites
of fillers in different dimensions in order to seems to have optimized the esthetic re-
optimize the amalgam with a percentage sult, similar to the quality of the latest gen-
of resin. eration of pure hybrids.
Today, hybrid composites are the most
widely used. This material contains parti-
cles of different dimensions which fit to- How to evaluate composite
gether like a puzzle, thus reducing the
materials from an esthetic
percentage of resin to a minimum. Al-
point of view
though resin is essential for binding the
fillers, it is in fact the weak link in the final Composite manufacturers usually design
product as it deteriorates in a damp envi- kits made up of a number of syringes that
ronment. contain dentin and enamel materials. The
One of the advantages of this family of dentin materials are divided into groups of
hybrid composites is the high level of me- color (A, B, C, and D) and different chro-
chanical stability, although it is sometimes mas according to the color saturation. The
difficult to obtain a highly polished surface different chromas are then indicated by
immediately. They also require continual numbers, the highest number correspon-
maintenance to sustain the final result. ding to the darkest dentin color.
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There are two trends on the market at pres- te which on
thickness of the residual enamel, ot
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ent. Some manufacturers simplify their ss e n c e
physiologically loses value or whiteness
fo r
systems, as described above, and elimi- over the passage of time, allowing the
nate all dentin hues except A. In the light base color of the dentin to show through.
of previous literature21 and the authors' In addition, almost all of the manufacturers
clinical experience, this would appear to offer “special effect” enamels for the repro-
be a wise decision. duction of highly translucent layers, such
Several systems recommend linking as the orange or blue opalescence of the
enamel and dentin materials of the same incisal third of the natural tooth.
type (eg, dentin A2 with enamel A2, etc.). Certain conclusions may be drawn from
This choice seems to based mainly on the this general analysis:
desire to simplify the manipulation and I manufacturers have a tendency to offer
legibility of the system rather than on sci- systems that are, at least theoretically, in-
entific research. In reality, as has already creasingly simplified to speed up and
been highlighted, enamel modifies the optimize the final result
base color of dentin and its influence is di- I “globalization” in dentistry leads manu-
rectly linked to the thickness of natural facturers to develop products that can
enamel—the thicker it is, the whiter and be accepted by different markets with
more opaque is the tooth.22 diverse needs and operational philoso-
Presumably, the above mentioned phies.
products are characterized by a chromat-
ic contrast between dentin and enamel, The American market and its demands
which have less saturation of color as if can be a principal example of this phe-
enamel was diluted dentin, in order to ap- nomenon. Composites are widely viewed
pear more translucent. Some manufactur- as a material for only small to medium
ers include in their systems a product restorations in anterior teeth, while more
called “body.” According to the instruc- complex restorations are preferably re-
tions, a layer of rather opaque missing solved using ceramic materials. It should
dental tissue should be built up with a cor- also be noted that American patients favor
responding layer of body material and lat- uniformity and brilliance, obtained by the
er covered by a layer of enamel. This body use of shiny white materials. The American
seems to be a material of intermediate market focuses its attention on chromati-
translucency, sometimes known as “uni- cally “simple” materials such as low satu-
versal” (a single product used to realize a ration dentins (sometimes less than A1)
restoration). and enamels that are suitable for post-
Yet other manufacturers propose sys- bleaching restorations.
tems which contain only general dentin The European market, on the other
and enamel materials. Usually, dentin in hand, tends to be more conservative and
these systems is very intense and the endeavours to integrate a restoration with
enamel modifies the base color with white the patient’s natural smile. Clinicians work-
or amber nuances. These manufacturers ing in Europe are more attentive to detail
suggest identifying the required enamel and to the nuances of color and effects that
according to the age of the patient and the are obtainable with modern composites.23
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There is, therefore, much opportunity for
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confusion. Experience shows that the in- ss e n c e
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structions that come with products are of-
ten of little use (Fig 22). What is more, cli-
nicians often fall into the trap of dividing
materials into those considered “simple”
and those designed for the “esthetically
obsessed,” as if there might be patients or
dentists interested in esthetically displeas-
ing restorations. Moreover, clinicians re-
quest materials with chameleonic proper-
ties, as if a syringe could possibly contain Fig 23 It is possible to find tools to modulate the
such a miracle product. thickness of the material and create individual shade
guides.
How to overcome these difficulties
To be perfectly clear, the miracle product

does not exist. If used badly, even the most
esthetically favorable material can give
terrible results, just as the worst material in
the right hands can give satisfactory re-
Fig 24 Sample of A3 of equal thickness of nine differ-
sults. Consequently, continual practice
ent brands compared to one another; note the difference
with the material of choice, constructing in color and translucency. Which of these is really A3?
various samples, and applying different
stratification techniques is the path to suc-
cess.
Another very interesting exercise is to try to
Is it possible to objectively judge decide whether a tube contains dentin or
a composite material? enamel without looking at the label. Some

syringes turn out to be of little use, and oth-
The first thing to suggest is to construct a ers have the possibility of integrating very
personalized color chart. Too often, color well into different systems. Naturally, this
guides presented by a manufacturer are experiment does not cover everything, but
unrealistic and often made of a different it is a good beginning for a critical and an-
material such as plastic or card, or is even alytical evaluation.
missing completely. Objectively however, it is clear that when
There are many instruments on the comparing samples of an even thickness
market that can be used to create disks of and the same color but of different brands,
the material in various even thicknesses, the chroma and translucence are com-
and this can give a clear idea to the prac- pletely different. This accounts for the need
titioner of the properties such as opacity, to create an individual color scale, espe-
translucency, and pigment saturation in cially if one uses different composite sys-
the composite (Fig 23). tems (Fig 24).
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Table 1 Suggested key parameters for evaluating the ideal choice of material.
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Composite Enamel Dentin Opalescence Intensity Dark Light Deep dentin Mamelon
features stains stains masses
Fluorescence 2 5 1 4 4 4 5 5
Hybrid 4 5 4 4 4 4 5 5
Opalescence 4 1 5 1 1 1 1 1
Nanofill 3 3 3 1 1 1 0 0
Microfill 1 0 1 1 1 1 0 0
Flowable 1 4 1 1 4 4 3 0
Opacity 3 5 0 4 5 2 5 5
Translucency 4 2 5 3 1 4 1 0
Chroma 1 5 3 0 5 3 5 5
Value 4 2 2 5 0 3 2 4
0: not desirable, 1: not appealing, 2: somewhat appealing, 3: appealing, 4: very appealing, 5: desirable
Next is to focus on the physical character-

istics and optical properties of composites
in order to create a scale of general prior-
ities. As shown in Table 1, some mechani-
cal and esthetic properties, in relation to
the necessity of the restoration, are seen to
be absolutely necessary, while others are
appealing or useless, if not damaging.
Based on the recent literature,24 but
above all on clinical experience and pas-
sion for the field, authors have attempted
Fig 25 A composite tooth reconstructed in two lay- to set up a system for evaluating the com-
ers of dentin and a layer of palatine and vestibular posite materials present on the market.
enamel in different sizes. This is the model chosen to
While concentrating on the anatomical
analyze the materials on the market.
form of the natural teeth, it is possible to
make some suggestions on the thickness
of the layers (Fig 25). It is in fact dentin that
makes up the most important layer from a
volumetric and chromatic point of view,
and represents the crucial layer for the fi-
nal restoration for integration with the rest
of the teeth.
At this point, it is possible to model the
dentinal body three dimensionally, as has
been shown above, limiting masses of
dentin to two at most and exploiting the
Fig 26 A composite copy of a natural tooth to man- thickness variation of the tooth. A rigid sili-
age the spaces of dentin and enamel. cone impression, taken from an integral
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natural incisor, allowed the reproduction of
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a copy in composite (Fig 26). Using this ss e n c e
fo r
copy, the tooth was divided into three lay-
ers: dentinal body, dentin (creates internal
anatomy like mamelon and opalescence),
and the vestibular surface enamel (Fig 27).
With the aid of calibration and a thickness
gauge, three types of samples were me-
chanically prepared:
I type one was made only of dentinal
body Fig 27 The rigid silicone guides for the preparation
of dentinal masses and the pre-constructed dentinal
I type two was made of the base dentin
masses. From the left: the base dentin followed by the
together with dentin that had been second dentin to simulate the different anatomies of
anatomically modeled to reproduce the opalescence in a young, adult, and old tooth.
incisor opalescence of a young tooth
(three mamelons), adult (horizontal win-
dow), and elderly
I type three was made of a dentinal body,
described above, with three different
free spaces of 0.3, 0.5, and 0.7 mm in
order to be able to uniformly reproduce
the surface enamel of three different val-
ues (Fig 28).
Fig 28 Samples for the construction of dentins of dif-
ferent thicknesses (0.3, 0.5, and 0.7 mm) to simulate the
Serial impressions were taken from these loss of enamel as the tooth gets older.
models that could be inserted in a special-
ly created laboratory flask using a trans-
parent silicone guide (Fig 29).
By analyzing the color samples on the
prefabricated scale, two colors of dentin
and three different types of enamel were
identified for each composite system avail-
able on the market. The choice of samples
was based on the analysis of two expert
clinicians, one newly graduated dentist
and a dental technician, who analyzed the
color scales without knowing the product
brand or the masses. The panel was asked
to identify masses and base their deci-
sions on knowledge and clinical experi-
Fig 29 The flask is used to form the enamel, curing
ence, with the aim of selecting three den- the material through the transparent silicone in order to
tal ages. obtain a sample with an even thickness.
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Fig 30 The excess composite enamel is now re- Fig 31 The finished and polished samples are ready
moved mechanically. to be examined under different light sources for the fi-
nal evaluation.
Three composite teeth were reproduced I Clinicians and specialized dental tech-
with evenly distributed thicknesses of ma- nicians possess an extraordinary
terial for each brand of composite and amount of knowledge and expertise
thus, the final results were easy to compare concerning the problems linked to re-
(Figs 30 and 31). The data acquired by the producing the color of natural teeth
authors during this experience was cer- and the suitable materials.
tainly empirical, but very close to the clini- I By listening to their suggestions and
cal reality of everyday dentistry. Therefore, analyzing materials using color-
it was considered to add value to the as- measuring instruments that are avail-
sertions above. able today (spectrophotometer), the
I Every composite system on the market manufacturers could further simplify
can be reduced to a limited number of their systems, which would be ex-
syringes that are useful in reconstruct- tremely advantageous for everyday
ing all natural teeth. Any exceptions can dentistry practice. Indeed, it was found
be dealt with by using special effect that the best clinical performance was
masses and super colors, which are provided by products produced in this
suitable for emphasizing particular spirit of collaboration.
translucencies and individual features.
I For the majority of materials analyzed,
the clinician’s choices appeared to be in
disagreement with the manufacturers
suggested use. When it is desirable to
optimize work with the chosen compos-
ite, it is imperative to construct a person-
alized color scale made of samples of
even thickness in order to identify the
correct mass.
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Clinical case te ot
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The patient was a 32-year-old female with
high esthetic demands who came to the
clinic requiring emergency treatment, hav-
ing herself glued on a fragment of com-
posite to a pre-existing restoration on tooth
11 using cyanoacrylic glue. She reported
no pain or thermal sensitivity, but com-
plained about a slight sporadic bleeding of
the gums. A clinical examination (Fig 32)
revealed a number of resin restorations on Fig 32 Pre-surgical image showing the patient’s at-
teeth 11, 21 and 22, which were incon- tempt to glue on a broken fragment of composite on tooth
11. Alterations to the pre-existing restorations and evi-
gruous for emergence profile, color, and dence of the degree of contamination by bacterial plaque.
degree of finish, with discolored margins
infiltrated by secondary caries. More im-
portantly however, restorations were es-
thetically and anatomically inadequate. An
examination of gingival tissues revealed
marginal gingivitis caused by the patient’s
poor hygiene and a large accumulation of
bacterial plaque. However, the periodontal
area appeared to be in good condition.
Radiographic examination not only
confirmed the areas of carious infiltration,
but also revealed an inadequate root canal
treatment on tooth 22, which had been ex- Fig 33 Radiograph of endodontic treatment of tooth
clusively accessed via the mesial inter- 22 with access through the mesial cavity of the 3rd
class cavity with perio-apical lesions.
proximal 3rd class cavity, with a conse-
quent periapical asymptomatic lesion
(Fig 33).
After careful cleaning and a motivating
oral hygiene session (Fig 34), the treat-
ment plan proceeded with an accurate
cleaning of the cavity to eliminate the car-
ious infiltrations. The margins were pol-
ished to eliminate areas which could retain
bacterial plaque and the root canals were
then correctly re-treated.
Fig 34 View of incisor group after oral hygiene, mo-

tivational talk to patient, and cleaning of provisional
restorations.
117
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Only at this point did research begin ot
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form of the teeth, and the first step swas ce
s e nto
fo r
ask the patient to provide photographs tak-
en before the restoration work was carried
out. A diagnostic waxup was made on ex-
tra hard plaster casts (Fig 35). These plas-
ter models were used to create a series of
Fig 35 Laboratory-created silicone stent based on laboratory-made rigid silicone guides for
the waxup. palatal support, and sectioned in a saggi-
tal plane in a vestibular-palatal direction as
well. These guides are indispensable in de-
termining palatal walls and controlling the
thickness of the composite during the strat-
ification technique, as well as acting as a
matrix for the final form of the restorations.
In addition, a personalized color chart
was compiled, subsequent to careful
analysis of the teeth under a light source of
5500 K (Trueshade Lamp, Optident, Ilkley,
UK). After carefully isolating the operative
field from tooth 14 to 24 with a medium
weight rubber dam (Nic Tone, Cooley &
Cooley, Houston, TX, USA) and W2 clamps
(Hu-Friedy, Rotterdam, The Netherlands)
and checking the rigid silicone matrix guide
to fit perfectly by trimming it with number 15
Fig 36 Isolation of the field with rubber dam and scalpel blade where necessary, the provi-
cavity preparations (palatal view)
sional composite fillings were removed us-
ing a medium grain cylindrical diamond
bur (Fig 36).
The preparation of the enamel was lim-
ited to clean, well-finished margins and a
chamfer on the vestibular finishing line to
render the transition from composite to
natural enamel invisible. Great care was
taken to finish the preparation margins us-
ing silicone points mounted on a blue ring
counter-angled hand piece, at a low
speed, to carefully smooth the preparation
and eliminate the prisms of unsupported
enamel which would break off during poly-
Fig 37 Finishing cavity margins step.
merization contraction and lead to discol-
oring and infiltration of the restoration. This
118
DEVOTO ET ALpyr
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operation was carried out under a constant
ion
te ot
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cooling spray (Fig 37). ss e n c e
fo r
Once the cavity preparation was fin-
ished, a silicone stent made it possible to
visualize form, thickness, future dimen-
sions, and correct interproximal relation-
ships. This is of significant help as it ren-
ders the work predictable, allowing for
time management and limiting chair time.
Also, sectional transparent matrixes with
multiple convexities (KerrHawe, Bioggio,
Switzerland) are a useful aid for time man- Fig 38 Use of a sectional transparent matrix to restore
agement as they allow the clinician to re- the correct emergence profiles and contact points.
alize and simply and intuitively correct

emergence profiles. These are the tools to
correctly manage the build up of restora-
tions, eliminating any excess of material
which otherwise would demand laborious
and difficult remodelling interventions that
risk damage to the adjacent teeth and los-
ing contact points. A sectional matrix is a
useful means for restoring interproximal
anatomy due to its intrinsic elasticity,
which makes it highly adaptable to a large
number of dental morphologies (Figs 38
and 39). Furthermore, it also helps to
avoid accidental contamination of adja- Fig 39 Layering step, 3rd class cavity on tooth 22.
cent teeth during the phases of etching

and adhesion (Fig 40). The combined ap-
plication of a stable stent and sectional
matrices allows the clinician to simply and
intuitively manage even the most com-
plex dental forms in a single step, thus op-
timizing both operative time and the final
result (Figs 41 to 44).
Once the cavity’s solid geometry has
been limited by interproximal well-defined
margins and incisal angles, it is possible to
focus on building up the dentinal body
(Enamel plus HFO, Micerium, Avegno,
Italy). This involves desaturating the color
Fig 40 Use of the sectional matrix during the cavity
in a cervical-incisal direction with two differ- etching phase to avoid contaminating the contiguous
ent layers of dentin and gradually covering elements.
119
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Fig 41 Combined use of the silicone stent and sec- Fig 42 Silicone stent in the vestibular/palatal section
tional matrix to contemporarily “box up” palatally and on a waxup.
interproximally.
Fig 43 Layering phase. Distribution and thickness of Fig 44 Combined use of silicone stent and the sec-
the different masses are controlled in the vestibular/ tional matrix for the control and stratification of the
palatal section through the use of the sectional silicone emergence profile and mesial contact point.
stent.
Fig 45 Reconstruction step of the dentinal body us- Fig 46 Realization of the incisal opalescence and in-
ing the color desaturation technique working in a ternal features.
palatal-to-vestibular direction.
120
DEVOTO ET ALpyr
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the preparation almost completely from
ion
te ot
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the vestibular margin in order to render the ss e n c e
fo r
meeting point between the enamel and
composite almost invisible. The dental
body on the incisor was modeled leaving
enough space to add the specific features
and opalescence taken from the color
scheme compiled in the preliminary inves-
tigative phase.
Management of the internal compos-
ite thickness is controlled using another
laboratory-produced rigid silicone matrix Fig 47 Vestibular composite enamel and final step of
sectioned in the sagittal plane (Fig 42). curing using glycerine gel.
This makes it possible to control the

quantity and distribution of the composite
dentin in section, in order to leave just the
right space for the enamel and not to low-
er the value of the restoration (Fig 43).
Layering finishes with a very thin layer of
composite enamel (Enamel plus HFO),
no thicker than 0.3 to 0.4 mm. A final 60
second curing is performed under glyc-
erine, which eliminates oxygen access to
the surface. This prevents the composite’s
complete polymerization and reduces the
surface resistance of the material (Figs 45
Fig 48 Search for macro- and micro-surface texture
to 48).
before final polishing.
Fig 49 View of reconstructions and rehydrated ele- Fig 50 Good esthetic integration of restorations and
ments after 72 hours. health of the periodontal tissues 30 days after treatment.
121
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ss e n c e
fo r
a b
Fig 51 Radiographic check of restorations and root Fig 52 Two-year follow-up.

canal treatment (a) and radiographic check of restora-
tions 2 years after treatment (b) with resolution of api-
cal radiolucency.
Final polishing is fundamental to the es- servative and financial advantages for pa-
thetic success of the restorations, as a tients.
shiny smooth surface reduces plaque ac- Doubts that clinicians may have are
cumulation and prevents the teeth from usually associated with the amount of chair
discoloring (Shiny System, Micerium). In time required as well as the difficulty in
the end, the polished restoration had a achieving good esthetic results every day.
surface very similar to that of a natural As a consequence, more invasive tech-
tooth (Figs 49 and 50). However, this lev- niques such as ceramic restorations are
el of clinical result obtained with a direct favored.
technique is possible only with correct The authors believe that operation
and accurate management of form and times are inevitably linked to certain oblig-
buildup. These parameters must be deter- atory steps (preparation, adhesion phase,
mined before clinical procedures are car- buildup with limited quantities of compos-
ried out (Figs 51 and 52). ite in order to reduce contraction, correct
curing times for each layer of material).
Nevertheless, with the instruments and
Conclusions guides that have been analyzed in the
present article, the stratification technique
Today, composite materials allow clini- can be key to the long-term success of the
cians to realize restorations on a high es- restoration from both a clinical and esthet-
thetic level while being minimally invasive, ic point of view. This enables the clinician
affordable to patients, and long lasting.26 In to avoid short-term disappointments that
addition, the associated risk level over time require re-facing and a waste of time.
is low and manageable. Re-intervention is It is crucial to understand that a suc-
relatively easy and cheap, and fractures or cessful restoration begins with the correct
defects that may appear in time are re- choice of a base material. However, there
pairable without the necessity to remake is no miracle material on the market and
the whole restoration, which provides con- the final result is fundamentally linked to the
122
DEVOTO ET ALpyr
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ion
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Fig 53 Constant practice and a good knowledge of the materials allow clinicians to reproduce every detail,
even serious esthetic defects such as a tooth which has been discolored by antibiotics
clinician's manual skills and, what is more, Acknowledgements

to skills in choosing the correct techniques
The authors wish to express their heartfelt gratitude to
that simplify everyday work (Fig 53). the following people: Dr G Paolone (Rome) for his help
In this profession, success should not in compiling the bibliography, Dr F Menghetti (Grosset-
be measured solely by exceptional results, to) for the root canal and surgical treatment of the clin-
ical case, and Mr D Rondoni (Savona) for his precious
but rather by a good everyday standard
collaboration in analyzing the composite.
with regard to time management and lim-
iting long-term risk.
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CLINICAL APPLICATION pyrig

How to Choose the Right Material

Walter Devoto, DDS

Monaldo Saracinelli, DDS

Jordi Manauta, DDS

Correspondence to: Dr Walter Devoto

Fig 2 Gingivectomy to redefine the length of the

In recent years, there has been a break-

Within the range of resin composites on the Colors and form

vided by the rigid silicone matrix. This

The choice of materials

How to overcome these difficulties

To be perfectly clear, the miracle product

a composite material? enamel without looking at the label. Some

Next is to focus on the physical character-

Fig 34 View of incisor group after oral hygiene, mo-

alize and simply and intuitively correct

cent teeth during the phases of etching

This makes it possible to control the

Fig 51 Radiographic check of restorations and root Fig 52 Two-year follow-up.

clinician's manual skills and, what is more, Acknowledgements

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