Fig.1
Frontal view retracted: single shade restoration on central right maxillary incisor can be noted. The patient had approximately one month earlier finished the orthodontic treatment. She wanted a more natural looking restoration as her natural dentition was full of color and opacity differentiation.

Fig.2
Left lateral retracted view. The surface structure of the restoration in situ did not match with the left central incisor. Also was taken note that the angulation of the incisal third, bending slightly towards the palatal on tooth #21, was absent.

Fig.3
Right lateral view. Apparently a diastema of 1mm in between tooth #12 en tooth #11 had developed in that period.

Fig.4
In both upper and lower jaw throughout the whole dentition white spots and striations can be noted. Especially in the incisal third area.

Fig.5
A fixed retainer was in place at the first consultation. The bar was removed in order close the diastema by wearing a clear overlay retainer. Removal of the wire also created an ideal restoration site for both good possibility to place the rubber dam and proper access during treatment.

Fig.6
After taking preoperative photographs impressions were made in order to make a wax-up of tooth #11. The wax-up shows proper form and shape with the desired slightly palatal angulation of the incisal third and small nodges in the incisal edge. If doing a multilayered restoration the exact right placement of the different color, opaque and translucent composites is of the greatest importance. The wax-up serves to make a silicone index to transfer the result intraorally during the stratification treatment ensuring a more spot on layering in the sagittal and vertical plane.

Fig.7
A close-up was altered by raising contrast and lowering the brightness. This puts the emphasis on the internal color build-up of the tooth making it easier to read. The first color selection was made.

Fig.8
The preliminary selection was put on the neighboring tooth #21 and light cured. If the rubber dam is in place you have to do this prepared within minutes because of very rapidly dehydration of the tooth occurs resulting in loss of true color character. Tooth structure becomes more opaque because of the blocked passage of light. The color analysis has to be trusted throughout the whole further treatment. An A2 dentin and body composite was chosen, a white enamel, a clear translucent enamel and amber enamel.

Fig.9
The rubber dam isolation in perfectly place because of the absence of the fixed retainer .

Fig.10
The silicone index checked intra-orally for perfect seating and absence of rubber dam interference before starting treatment.

Fig.11
Close-up of the silicon index shows the mesial and incisal edge will look different after treatment. The index ensures the edge does not need to be altered afterwards keeping the dynamic incisal third color pattern intact.

Fig.12
After removal of the old composite restoration, all sharp edges were rounded up and a 2-2,5 mm bevel was placed.

Fig.13
After 35% phosphoric acid etching for the enamel for max. 30 seconds and the dentin for 15 seconds, rinsing, applying primer and bonding and light curing, the silicone index was checked again for accurate seating.

Fig.14
With the LM-Arte instrument Fissura the transition line was marked in the putty. Any caused debris was blown away before applying composite in the shell. The transition line prevents over-applying composite reducing the finishing time on the palatal later.

Fig.15
After placing a white enamel composite in the matrix, the matrix was seated and by instrument and brush shape and perfect adaptation to the bonded tooth structure was assured. On the palatal no bevel was made to avoid possible air voids.

Fig.16
Extra light curing on the palatal after light curing from the buccal first before removing the putty.

Fig.17
In both mesial and distal corner application of white color effect using LM Arte Fissura instrument. A rounded very small brush can also be used in a tapping motion to distribute and absorb a possible overdose.

Fig.18
Mamelon base was created using the dentin composite.

Fig.19
An A2 body composite was placed in mamelon shape over those already formed in dentin composite in order to make the dentin less prominent in the final result.
Perikymata were made with a #06 endodontic file before light curing the composite.

Fig.20
THE MAIN TIP OF THE ARTICLE
Comparing white opaque shade mixed with sculpting/composite instrument wetting resin on the left, and the original white opaque shade on the right. Note the intensity of the color level dropping down creating a distinct difference. Opening up a larger array of indication of use for the white color effect. The use of bonding should be avoided because of the presence of the hydrophilic monomer HEMA in most adhesives.

Fig.21
Applying the altered, moderated color effect to create the striations. Diffuse slightly by brush before light curing.

Fig.22
Clear translucent enamel composite is packed in between the mamelons with a dash of amber composite on the mid incisal edge. Using a spatula instrument to check the already defined incisal egde shape not being surpassed before curing. Finally the last layer of white enamel was placed.

Fig.23
After application of the last layer of enamel composite further adjustments were made according to the last article The Power of Pencil.

Fig.24
Surface structure of the neighboring central incisor was identified by carbon paper and copied using a diamond bur at very low speed without water.

Fig.25
A white stone was moved manually in a horizontal way to create the illusion of perikymata.

Fig.26
Carefully accentuating the little incisal notches.

Fig.27
Polishing was carried out after creating the surface structure and consisted of multiple steps to achieve a low surface roughness. Only when polished the effects put in the restoration can fully come to life. This will give the restoration shine and luster and the smoothness of the composite will help prevent future unwanted staining.
The multistep polishing procedure starts with the beige Sof-Lex spiral elastomer wheel.

Fig.28
Followed by the white one.

Fig.29
Last step is to use an aluminum oxide paste together with a felt coated disc for final gloss.

Fig.30
Directly after rubber dam isolation removal.

Fig.31
Shortly after rubber dam removal.

Fig.32
Final result: two days after rubber dam removal. To assess the final outcome in treatments using white color effects besides polishing, rehydration is key. Dehydration is a matter of minutes, complete rehydration is a matter of day(s).

Fig.33
Final result right retracted view. Note that the use of the modified white color effect makes the striations in the restoration much more subtle.

Fig.34
Final result left retracted view. Surface structure of the restoration corresponds to tooth #21.

Fig.35
The fixed retention bar put back in place again with the initial 1mm diastema #11-#12 still nicely closed.

Fig.36
Close-up of the incisal third area shows an invisible transition of the restoration to the tooth and a vivid display of color and variation of opacities.

Fig.37
Final result lip framed by the wonderful patients smile at the end of the treatment. Form, color and surface structure in complete harmony with the neighboring teeth creating a harmonious overall appearance.
The vivid display works best in this dynamic dentition

Conclusions

What often happens is the white effect being too much in the end result. On the one hand because there is no possibility for the operator to really see and judge the final outcome before the polishing procedure. Polishing makes the creation come to life and only then the effects become truly visible. On the other hand most white effects are so immensely intense, that applying a moderate amount is difficult, even when using delicate tools. The use of white color effect mixed together with a moderate or large amount of sculpting/composite instrument wetting resin mixed to a desired level of intensity can make the effect more subtle and less tricky in its application technique.

Bibliography

1. Villarroel M1, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent. 2011 Apr;23(2):73-87.
2. Gönülol N1, Yilmaz F. The effects of finishing and polishing techniques on surface roughness and color stability of nanocomposites. J Dent. 2012 Dec;40 Suppl 2:e64-70.
3. Takahashi M1, Nakajima M, Hosaka K, Ikeda M, Foxton RM, Tagami J. Long-term evaluation of water sorption and ultimate tensile strength of HEMA-containing/-free one-step self-etch adhesives. J Dent. 2011 Jul;39(7):506-12.
4. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 4 Mid and chapter 10 Surface and polishing Quintessence Books, 2012