Index-free Class IV complete step-by-step

Clinical case co-author dr Jordi Manauta

Class IV are the most challenging restorations. In this case we will review some essential steps to make this discipline more enjoyable. Let’s start with these 4 basic rules in mind:
1. We have to superimpose different materials that, instead of copying nature, blend between translucent and opaque to obtain an outcome similar to the tooth.
2. We have to prioritize management of the shape and anatomy instead of the small characterizations. Photographs, tools, matrices, and instruments are incredibly helpful in accomplishing this.
3. Finishing and polishing techniques must be easy, fast, and efficient, and it should be possible for the hygienist to replicate at check-up and maintenance appointments.
4. We have to know how to manage the restoration in the long run, i.e. how to modify and correct it in case it changes color or suffers some chipping or fracture. So this patient had suffered a class IV non complicated fracture on tooth 21. We decided to restore it immediately, thus no wax-up was available. Shade was selected before doing anything else. Shade selection will be discussed in another article.

styleitaliano style italiano direct anterior styleitaliano sequence with intensiv burs style diretto kit burs intensiv

Fig.1
Protocol contemplates all possible situations, from removing an old restoration, to restoring different types of margin. In this particular case, where no previous restoration was present, steps 1 and 2 are not necessary, while step 5 and 6 were not the chosen margins for this case. It is important to adapt the protocol to our best convenience.
Direct Anterior Styleitaliano Sequence for anterior teeth
STYD5 Margin finder
STYD2 Composite removal
STYD6 Medium-long bevel
STYD7 -or- chamfer
STYD8 Proximal margin

style italiano styleitaliano intensiv burs styleDIRETTO banner
style italiano styleitaliano intensiv burs styleDIRETTO banner
styleitaliano style italiano multigrade bur removing caries

Fig.2
The STYD3 bur was used to remove internal caries removal and debris. It’s available in 3 sizes in the Style Diretto kit, to be used according to your need.

styleitaliano style italiano fine grit flame bur creating bevel

Fig.3
If bevels are correctly selected, they are respectful of tissue and offer a very good boost to the blending effect. 45-degree bevels are for the middle third and are used in most situations. as the protocol establishes the D6 bur was used (STYD6) from the Style Diretto Kit  (Intensiv, Switzerland)

styleitaliano style italiano enamel etching

Fig.4
Selective etching of the enamel was performed for a minimum of 15 seconds and a maximum of 30 (difference between starting point and end point).

styleitaliano style italiano rinsing of etching gel

Fig.5
Thorough wash of the acid etching gel.

styleitaliano style italiano microbrush rubbing bonding agent

Fig.6
Universal bonding application scrubbing during 20 seconds.

styleitaliano style italiano light curing of bonding

Fig.7
Extended polymerization is one of the key factors in the quality of the bonding layer.

styleitaliano style italiano spatula laying composite mass on matrix

Fig.8
In order to work index-free, the goal is to obtain a manageable defect by adding up resources. We will focus on creating the proximal structures guided by the natural tooth and the neighbor teeth, and then adjust, based on said surrounding anatomical structures. An anatomical matrix was used to help develop the proximal walls.

styleitaliano style italiano compovibes vibrating composite modeling instrument

Fig.9
The material was adapted with a low frequency vibration modeling instrument (Compovibes, Smile Line, Switzerland).

style italiano styleitaliano smileline dental photography
style italiano styleitaliano smileline dental photography
styleitaliano style italiano modeling composite with compovibes

Fig.10
The material being vibrated adapts very easily thanks to its thixotropic properties. The moment the vibration is removed the composite goes back to a stiffer consistency.

styleitaliano style italiano modeling excess composite

Fig.11
Development of the marginal ridge, getting as much references as possible from the sound tissues into the restoration, this time from the buccal aspect. Same is done copying the palatal inclination.

styleitaliano style italiano holding the matrix before light curing composite

Fig.12
The composite is cured while holding the matrix with the finger to its optimal positioning, it is imperative to be delicate, and to make sure there is no deformation of the matrix.

styleitaliano style italiano intraoperative dry field corrections to composite shape

Fig.13
Correction of the generated freehand structures is mandatory. External correction is done with a disc at low speed.

styleitaliano style italiano dry correction of composite shape

Fig.14
Internal correction is done with the bur D2 (STYD2) Style Diretto Kit, no water.

styleitaliano style italiano wetting of composite powder debris

Fig.15
Milling debris is easily removed by wetting with a universal bonding agent. Air is blown afterwards to remove both bonding and the dust now embedded in it.

styleitaliano style italiano layering of composite palatal wall

Fig.16
The aim of the developed proximal structure is to create some support that will allow to determine the correct positioning of the finger to get a result that is good enough. Only then can we load a small and flat quantity of composite in the estimated position and place it in the cavity, remove the excess, and cure. When correctly done, it is possible to develop a rather good palatal wall. OA2 (Dentin A2) was used (Brilliant Everglow, Coltene Switzerland)

coltene brilliant everglow style italiano styleitaliano
coltene brilliant everglow style italiano styleitaliano
styleitaliano style italiano modeling of palatal wall with finger index

Fig.17
Composite is condensed with vibrations. Finger is held firmly in place trying not make excessive pressure. This is important not to create a subtractive defect on the palatal.

styleitaliano style italiano misura anterior instrument removing excess dentin composite

Fig.18
The Misura Instrument (LM Arte, Finland) was used on the uncured dentin, to achieve the ideal thickness of the buccal layer.

style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano lm arte anterior instrument
styleitaliano style italiano removing excess liquid from composite brush

Fig.19
Preparing the modeling brush. It is imperative, if you like to use modeling liquids, not to have excess liquid that might change, and thus jeopardize the composite’s physical properties.

styleitaliano style italiano brushing composite enamel layer

Fig.20
Compobrush Anterior (Smile Line, Switzerland). These brushes are also available for mounting onto the Compovibes instrument.

smileline compobrush banner style italiano styleitaliano
smileline compobrush banner style italiano styleitaliano
styleitaliano style italiano compovibes transferring inclination of buccal wall from tooth to restoration

Fig.21
The final enamel layer is typically placed and manually modeled. In teeth that have increased texture, this task can be challenging. By passing a composite plugger as the thin end of the LM Arte Condensa (LM, Finland) with side-to-side movements and a burnishing like pressure, the composite will adapt to the buccal depressions guided by the instrument. The bigger size can be used as well.

styleitaliano style italiano condensa instrument transferring buccal enamel texture to composite restoration

Fig.22
Texture transfer strategy.
By simply passing the information from one surface (sound tooth) to the other (uncured composite) with the help of a modeling instrument, we can precisely recreate the buccal surface. Besides being compatible with almost every layering technique, the main advantage of this strategy is that the outcome is obtained effortlessly, thus giving precision to the modeling itself, and more time to focus on other features of the restoration. Rounded instruments are preferred such as LM Arte Condensa (LM, Finland), or the same shape but in a vibrating instrument such as Compo-Vibes (Smile Line, Switzerland) would be the first choice.

styleitaliano style italiano shaping composite restoration with pop-on disc

Fig.23
The shaping protocol, which will be treated in another article, starts by defining the incisal length.

styleitaliano style italiano finishing of primary anatomy

Fig.24
Followed by primary anatomy.

styleitaliano style italiano finishing strip for proximal part of composite restoration

Fig.25
Proximal finishing with a red coded finishing strip.

styleitaliano style italiano finishing sequence and bur kit style finale intensiv

Fig.26
Finishing anteriors, Styleitaliano Sequence
STYF1 Secondary grooves depth
STYF3 Occlusion and anterior guidance
STYF4 Smoothening and tertiary anatomy
STYF5 Fine smoothening

style italiano styleitaliano intensiv burs stylefinale banner
style italiano styleitaliano intensiv burs stylefinale banner
styleitaliano style italiano finishing palatal anatomy

Fig.27
Palatal correction, reduction and smoothening is done with bur F3 (STYF3), Kit Style Finale (Intensiv, Switzerland).

styleitaliano style italiano bur for secondary anatomy

Fig.28
Secondary anatomy was then defined with the help of bur F4 (STYF4) Kit Style Finale (Intensiv, Switzerland).

styleitaliano style italiano bur smoothing composite restoration

Fig.29
Fine smoothening and advanced texture with bur F5 (STY5) Kit Style Finale (Intensiv, Switzerland).

styleitaliano style italiano spiral wheel polishing composite restoration

Fig.30
Shapeguard spiral for pre-gloss.

styleitaliano style italiano lucida star felt and paste for glossy composite

Fig.31
Lucida paste and Lucida felt (Diashine, USA) should always be used together as a final step.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
styleitaliano style italiano lucida paste for composite gloss

Fig.32
The hybrid diamond paste is a single-step, super high-gloss compound. It doesn’t come off the tooth while working, but, as it is complete hydro soluble, it is incredibly easy to remove with water only.

styleitaliano style italiano finished and polished composite restoration before rehydration

Fig.33
Final gloss, darker aspect of the restoration is expected, and the patient should be warned of this before starting.

styleitaliano style italiano composite class IV restoration after rehydration

Fig.34
Check-up appointment shows an almost perfect integration, reason why we should never improvise the use of colors under the rubber dam isolation, or correct the restoration right after finishing it.

Conclusions

Following a well established protocol with the right instruments in hand is the way to make challenging restorations, such as class IVs, predictable. A few tricks can, of course, make the difference, as long as we use them to simplify our work throughout each step of the procedure.

Bibliography

1. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: a new concept in composite layering – Part I. Odontostomatol Trop. 2014 Jun;37(146):5-16.
2. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS., Stratification in anterior teeth using one den- tine shade and a predefined thickness of enamel: A new concept in composite layering – Part 2. Tropical Dental Journal vol. 37, n°147
3. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Books, 2012.
4. Mendoza A. García Ballesta C.Traumatología Oral; Diagnostico y Tratamiento integral, soluciones estéticas. ERGON, 2012 p. 68-92
5. Terry DA, Geller W, Tric O, et al. Anatomical form defines color: function, form, and aesthetics. Pract Proced Aesthet Dent 2002;14(1):59–67.
6. Kataoka S, Yoshimi N. Nature’s Morphology: An Atlas of Tooth Shape and Form. Chicago: Quintessence Publishing, 2002.
7. Afif Elossais A. Desenvolvimento e avaliação da efetividade de duas pastas polidoras empregadas a materiais restauradores estéticos. Análise comparativa por perfilometria digital e microscopia de força atômica. Araraquara : [s.n.], 2008. 198 f. ; 30 cm. (Doctoral Thesis In Portuguese).

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