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

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.

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)

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).

Fig.5
Thorough wash of the acid etching gel.

Fig.6
Universal bonding application scrubbing during 20 seconds.

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

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.

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

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.

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.

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.

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

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

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.

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)

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.

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

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.

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

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.

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.

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

Fig.24
Followed by primary anatomy.

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

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

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

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

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

Fig.30
Shapeguard spiral for pre-gloss.

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

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.

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

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).