A clinical case by our Community member Dr. Maroun Ghaleb
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
Restoring a large cavity with direct composite has always been a debatable solution for many reasons, such as longevity, aesthetics, the risk of debonding or fracture, and many more. However, this type of treatment is required for some cases like trauma or after an endodontic treatment. In certain cases the dentist may restore the tooth by reattaching the fractured fragment using contemporary adhesive systems and composite materials. Yet, when the fragment is missing, the optimal treatment is a direct composite restoration in order to achieve a successful clinical outcome, aesthetically and functionally.
This patient reported that after falling on his upper left central incisor eighteen years earlier, he underwent a large composite restoration. Ever since, he never experienced fracture or debonding, but he was concerned about esthetics. After many years, the color of his tooth turned to be, in his words, “black”, and its shape is asymmetric in comparison to the adjacent tooth. Two years earlier, he visited a dentist just to enhance the color of the restoration and the dentist told him that he applied a “white shade of composite” to cover the black color and to minimize the color difference between the two centrals. But the patient was satisfied neither with the new color or the shape. In addition, he was complaining of frequent bleeding after brushing, and redness of his gingiva. Although the patient desired better esthetics, he wouldn’t accept a crown restoration, both because of the cost, and because he believed in the survival and the success of composite restorations in the long term. Because of an inadequate old RCT, an endodontic retreatment was suggested, together with a fiber-post and esthetic restoration.
Intra-oral picture showing:
– Gingival inflammation because of the over-hanging restoration;
– Difference between 21 and 11 (color and shape);
– Caries on tooth 11 (cervically and mesially).
Three composite shades from the CompoSite system by White Dental Beauty were used:
– Si 2, equivalent to A2, is the final shade desired by the patient.
– Si E (Si Enamel), is used to give translucency and good opalescence properties to the restoration.
– Si M (Si masque), is used to instantly have a camouflage of the underlying tooth’s shade. It is an opaque light resin considered as an ideal tool for dyschromia and for masking dark teeth with one layer.
Note the perfect adaptation of the composite to the cavity walls. Pins were used to increase the retention of the restoration.
Margins were finished with a short chamfer on the buccal aspect (to make the transition from the composite to the natural enamel invisible) and with butt-joint preparations of the proximal and the palatal aspects of the tooth. The finishing of the preparation margins should be done with great care using silicone tips to smoothen the preparation and to remove the unsupported enamel prisms. This last step is crucial to prevent these prisms from breaking by the contraction following the application of light cure, which would lead to a higher risk of infiltration.
After cleaning the caries on tooth 11, a rubber dam was placed. No additional preparation was needed on tooth 21, in order to preserve the remaining enamel substance. This enamel is crucial for high bond strength.
The additive strategy was very helpful in this case. To mask the discoloration on tooth #21 we need enough thickness of composite to:
1) Place the opaque layer, to mask the dark discoloration and give the final desired color. The thickness of this layer should be well balanced, as a layer too thin cannot mask dark substrates, while one that’s too thick would not leave the required space for the final layer of enamel composite. The total thickness of this layer should be approximately 1 mm.
2) Place the enamel composite, to give the tooth a natural appearance, especially as the adjacent teeth (12 and 22) look grayish on the proximal areas. The total thickness of this layer should be 0.5 mm.
In order to have this required space on tooth 21 while preserving as much enamel as possible, we needed to add composite on tooth 11.
A fiber-post was bonded to ensure better retention of the restoration. Moreover, the placement of the fiber-post will be useful to minimize the treatment steps later on, when the patient decides to do a full coverage restoration.
The interproximal mesial wall was built with Si2 with a total thickness of 1 mm.
Si M (Si Masque) was used at first to cover and to hide the discolored parts of tooth 21. The layering steps started with Si2.
An additional layer of Si2 was applied.
Si E (Si Enamel) was placed on top, in order to give the restorations the translucency and the opalescence properties needed.
The transition lines and the secondary anatomy were drawn with a pencil. These outlines help in attaining a proper tooth morphology during the finishing steps. The horizontal lines divide the vestibular surface into three thirds. The maximum convexity of a central incisor is located on the cervical third while the medial and the incisal thirds tend to be flat and contain the secondary anatomy. A tapered round shaped bur with an extra fine grit was used to remove the excess composite.
Discs are the best instruments to define the proximal contour, transition angles and incisal edge shape. This step is critical, especially if we have a lot of composite excess in these areas. For finishing, the coarse red grit from Sof-Lex (3M, St. Paul, MN, USA) was used. Note that the distal transition angle is more rounded than the mesial one.
The softening of the surface of the composite resin should be done with rubbers starting with the most abrasive rubber and finishing with the less abrasive one (Gazelle Polisher, Microcopy, USA).
Final restoration after 1 week. The translucency and the grayish appearance in the proximal and incisal areas were only ensured by the application of SiE (enamel).
Witnessing the survival of a large composite restoration for eighteen years without fractures or recurrent caries is spectacular, and is a great proof of the longevity of this kind of treatment. To succeed with the treatment of this case we needed to:
1) Ensure good adhesion of the composite by preserving the enamel substance as much as possible, by using properly an adequate bonding system, and by placing a fiber-post;
2) Know perfectly the composite system we are using, especially its masking capacity, the right thickness of dentin (to mask the discoloration) and enamel (to insure the translucency and the opalescence);
3) Master the finishing and the polishing steps to have the most natural and anatomical morphology as well as a stable color over time.
1. Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. The European journal of esthetic dentistry 2010;5:102-124.
2. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Publishing Co; 2012
3. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent 2008; 3(1):14-29.
5. Dietschi D, Shahidi C, Krejci I. Clinical performance of direct anterior composite restorations: a systematic literature review and critical appraisal. The International Journal of Esthetic Dentistry 2019;14:252–270.
6. Spaveras A, Vjero O, Anagnostou M, Antoniadou M. Masking the Discolored Enamel Surface with Opaquers before Direct Composite Veneering. Journal of Dentistry, Oral Disorders & Therapy 2015;3(2):1-8.
7. L.L. Miotti, I.S. Santos, G.F. Nicoloso, R.T. Pozzobon, A.H. Susin, L.B. Durand, The Use of Resin Composite Layering Technique to Mask Discolored Background: A CIELAB/CIEDE2000 Analysis, Oper. Dent. 42 (2017) 165–174.
8. S.J. Kim, H.H. Son, B.H. Cho, I.B. Lee, C.M. Um, Translucency and masking ability of various opaque-shade composite resins, J. Dent. 37 (2009) 102–107.