The power of the Shape

With the Style Italiano recipes and rules to handle the power of the shape in anterior composite restorations, any dentist is able to learn how to create direct restorations that fulfill high aesthetic demands of the patients. The procedure is easily taught and learnt and prevents unpleasant surprises, as the case of a young female patient is here shown.
The patient had beautiful teeth, but the aesthetics of her smile were somewhat negatively affected by a small, discolored composite restoration and incorrect shape on her upper right central incisor. The character of the teeth was analyzed closely using images taken under different light conditions, including one made with a polarizing filter (Smile Lite MDP by Dr. Louis Hardan and powered by Style Italiano). The image shows that it is relatively easy to read the inside of the tooth, which has varying opacities and a clearly visible mamelon structure, but no intensive intrinsic colors. Therefore, it was decided to restore the tooth using a dual-layer technique with one dentin and one enamel shade of Filtek Supreme XTE (3M). The use of additional stains included in the restoration was not necessary.

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Fig.1
Initial situation. Female patient wants to improve the aesthetic of the central incisor, with a old restoration and a inadequate shape.

style italiano styleitaliano dentistry

Fig.2
Intra-oral view of the initial situation. Internal details of the anatomy of the natural tooth are visible.

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Fig.3
A close-up view of the transition lines of the two central incisors makes it easy to understand the importance de shape correction, in order to achieve a natural aesthetic outcome.

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Fig.4
Shade selection with a Vita Classical shade guide (A1 Vita shade).

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Fig.5
After shade selection, a diagnostic restoration was done to give the desired final shape, in order to fabricate a palatal silicone index with a putty silicone material.

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Fig.6
Removing the old restoration and anterior bevel execution.

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Fig.7
The bevel allows a better integration between the composite restoration and the remaining dental tissue. A 3 mm minimum bevel extension should be executed. To make a more conservative bevel and polish the angles, a hard grain disk is recommended.

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Fig.8
Silicone index try-in.

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Fig.9
Enamel etching.

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Fig.10
Bonding procedure was carried out using Sctochbond Universal (3M), rubbed on the surface for a minimum of 10 seconds.

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Fig.11
Composite resin layering steps used in this clinical case. The artificial palatal enamel was made with a translucent composite resin (Filtek Supreme XTE CT effect, 3M), the artificial dentin was made with an opaque mass (Filtek Supreme XTE A1 dentin, 3M) and the buccal enamel was made with the Filtek Supreme XTE A3 enamel (3M), following the Style Italiano recipe for the Vita shade A1.

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Fig.12
Palatal enamel built with the palatal silicone index.

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Fig.13
With the final palatal shape it is easy to foresee the final shape for the final composite resin restoration.

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Fig.14
The thin proximal enamel was built with the same enamel used in the buccal surface (Filtek Supreme XTE enamel A3).

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Fig.15
The thin proximal enamel (less then 0,5mm) can be shaped using a sectional posterior matrix (ex. Garisson) in order to easily get a convex contour.

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Fig.16
Interproximal enamel done on the mesial and distal surfaces.

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Fig.17
The incisal halo was made with an opaque flowable composite resin (Filtek Supreme XTE flowable dentin, 3M).

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Fig.18
For the dentin control and calibration of the space for the buccal enamel (0,5 mm) the LMArte Misura was used.

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Fig.19
After calibration with the Misura instrument, the dentin was shaped in a similar shape to that of the natural tooth. The LM Arte Fissura was then used for the dentinal anatomy reproduction.

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Fig.20
Between the dentin mamelons and the incisal halo was applied a translucent enamel (Filtek Supreme XTE CT effect, 3M) in order to increase the translucence in this incisal area.

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Fig.21
To smoothen the dentin and enamel with a better and faster composite resin modeling phase a CompoBrush (Smile Line powered by Style Italiano) was used.

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Fig.22
Buccal enamel placed after light-curing.

style italiano styleitaliano dentistry

Fig.23
Grain discs used for the polishing and finishing procedures and tooth contouring (Sof-Lex discs, 3M).

style italiano styleitaliano dentistry

Fig.24
Polishing the buccal surface with a light orange Sof-Lex disc.

style italiano styleitaliano dentistry

Fig.25
Smoothen the composite resin surface with a Sof-Lex Spiral weel (3M)

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Fig.26
Polishing the composite resin surface with a Sof-Lex Spiral Diamond (3M). In order to have the best shining surface we should use this disc under water.

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Fig.27
To get a final enamel-like surface, we recommend the use of a small grain polishing paste (Diashine, US) with a smoothening felt.

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Fig.28
Final composite resin restoration immediately after the polishing procedure.

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Fig.29
Final composite resin restoration.

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Fig.30
Difference between the shape in the initial situation and the final restoration. A natural outcome was achieved.

Conclusions

The described technique is easily taught and learnt. It enables every dentist to obtain highly aesthetic results through a highly efficient procedure. However, these results are only achieved if high-quality materials are used and if the practitioner has developed a thorough understanding of the employed materials. Instead of magic, it is precise preparation and careful planning that leads to the desired, repeatable and therefore predictable outcomes.

Bibliography

Vanini L (1996). Light and color in anterior composite restorations. Pract Periodont Aesthet Dent 8:673-682. Duarte S, Perdigão J, Lopes M (2003). Composite resin restorations – Natural aesthetics and dynamics of light. Pract Proced Aesthet Dent 15:A-H.
Perdigão J (2010). Dentin/Enamel bonding. J Esthet Restor Dent 22:82-85.
Devoto W, Saracinelli M, Manauta J. (2010). Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur J Esthet Dent Spring;5(1):102-24.
Perdigão J, Sezinando A, Monteiro PC. (2012). Laboratory bonding ability of a multi-purpose dentin adhesive. Am J Dent Jun;25(3):153-8.
Paolone G, Orsini G, Manauta J, Devoto W, Putignano A. (2014). Composite shade guides and color matching. Int J Esthet Dent Summer;9(2):164-82.
Manauta J, Salat A, Layers, an Atlas of composite resin stratification, Quintessence 2012.
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 II. Odontostomatol Trop. 2014 Sep;37(147):5-13.
Betrisey E, Krejci I, Di Bella E, Ardu S. The influence of stratification on color and appearance of resin composites. Odontology. 2015 Feb 5
Gönülol N, Yilmaz F. J. The effects of finishing and polishing techniques on surface roughness and color stability of nanocomposites. Dent. 2012 Dec;40 Suppl 2:e64-70

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