The Composite Ball Technique 2.0. Improving the rigidity of transparent silicone with the “Stiff Index Technique”

Let us recommend reading the first “Composite Ball Technique” article describing the possibility of rehabilitating worn dentition with a simplified technique and without tooth preparation before reading this one.
Said article presented a clinical case involving a new method, where more predictable stability was achieved by a “composite ball technique”.
Some clinicians who have been using the technique have reported difficulties with replicating a correct premolar anatomy due to the flexibility of the transparent silicone, leading to possible anatomical discrepancies as a result of pressing the heated composite resin material. The smaller dimensions of premolars compared to molars makes the silicone index much more susceptible to discrepancy during the restoration process.

style italiano styleitaliano cut silicone indices for vdo augmentation

This photo illustrates the wax up with the precut silicone index.

style italiano styleitaliano anterior silicone index

This photo illustrates the lower anterior wax-up with the precut silicone index.

style italiano styleitaliano silicone index in composite ball technique

The index was also scalloped with a no. 10 blade, in order to establish the reference point at the “composite ball” that was temporarily positioned in the cervical third of the buccal surface (that should be obtained before taking impressions in order to fabricate the wax up with the “composite ball” in place).

style italiano styleitaliano checking the occlusal chimney of silicone index

Then, in each silicone block, the occlusal chimney was created and the passage was evaluated with the Fissura instrument (LM).

style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano pattern resin reinforcement of silicone index

Pattern resin was mixed according to the manufacturer’s instructions and placed onto the index surface in order to make it more rigid and less susceptible for the volume distortion. Prior to applying the pattern resin, the occlusal surface of the index was covered by a layer of universal tray adhesive.

style italiano styleitaliano resin reinforced silicone indices

Precut silicone blocks, reinforced with the pattern resin – ready to use for direct restorations.

style italiano styleitaliano positioned stiff index with silicone and pattern resin

Heated composite resin was pressed with the cut and stiffened silicone index.

style italiano styleitaliano occlusal procured composite with chimney excess

The direct composite restoration after a 3-second occlusal pre-polymerization. As you can see, resin excess flowed through the chimney. This pre-polymerization enables easy and predictable excess removal (with a cutting motion of blade no 12) before final curing.

style italiano styleitaliano occlusal injected composite after excess removal

The clinical situation after removing composite excess and curing, before finishing and polishing.

style italiano styleitaliano Direct restorations of lower, right premolars with the rigid silicone index

Direct restorations of lower, right premolars with the rigid silicone index.

style italiano styleitaliano injected and finished occlusal restorations for vdo augmentation

The posteriors were restored with cut transparent silicone index, while a conventional layered technique based on hard, laboratory silicone index (as described in the previous article) was used for the anteriors.

style italiano styleitaliano implant and screw retained crown

In case of indirect restorations are needed (35, indirect onlay; 36, screw retained FPD), they are obtained after VDO augmentation with direct restorations and adequate balancing.

style italiano styleitaliano lower anteriors at 3 months recall

Recall at 3 months.


  1. The Full Occlusal Rehabilitation with direct composite restorations is a conservative no-prep option that can be widely applied to our clinical practice today.
  2. The index technique can be the recommended method of transferring the occlusal anatomy from the wax up, especially when structural loss does not severely compromise the proximal walls.
  3. “The composite ball” technique seems to be an accurate solution in order to facilitate the stable position of the index and to avoid the index displacement.
  4. “The Stiff index” technique prevents discrepancies in the final restoration anatomy.
  5. “The Stiff index” technique allows for a more secure handling of the index blocks during the restoration process.
  6. “The Stiff Index” technique is easy to replicate in every clinical practice.


1. Zarow M: “The Composite Ball Technique” and “Pre-Polymerisation Procedure” – the Simplification in VDO increase with direct composite. 2022
2. Terry DA, Powers JM. Using injectable resin composite: part one. Int Dent Afr 2014; 5:52–62.
3. Terry DA, Powers JM. Using injectable resin composite: part two. Int Dent Afr 2014; 5:64–72.
4. Ammannato R, Ferraris F, Marchesi G. The “index technique” in worn dentition: a new and conservative approach. Int J Esthet Dent 2015; 10:68–99.
5. Kois J. 2019 Symposium July 18-20, Kois Centre, Seattle, USA
6 Kim JL, Karastathis D. Dental Hygiene Theory and Practice. 3rd ed. St. Louis, MO: Saunders-Elsevier; 2010. Dentinal hypersensitivity management. In: Darby ML, Walsh MM; pp. 726–35.
7. Calamita M, Coachman C, Sesma N, Kois J. Occlusal vertical dimension: treatment planning decisions and management considerations. Int J Esthet Dent. 2019;14(2):166-181.
8. Zarow M. Finding the Centric Relation – The Kois Deprogrammer. 2018
9. 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.
10. Hardan L, Mancino D, Bourgi R, Cuevas-Suárez CE, Lukomska-Szymanska M, Zarow M, Jakubowicz N, Zamarripa-Calderón JE, Kafa L, Etienne O, Reitzer F, Kharouf N, Haïkel Y. Treatment of Tooth Wear Using Direct or Indirect Restorations: A Systematic Review of Clinical Studies. Bioengineering (Basel). 2022 Jul 27;9(8):346.

style italiano styleitaliano Essential Dentistry kit online on demand course
style italiano styleitaliano Essential Dentistry kit online on demand course


styleitaliano style italiano smile proximal composite restoration technique cavity design polishing proximal walls

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