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A direct composite resin stratification technique for restoration of the smile

Article in Quintessence international (Berlin, Germany: 1985) · March 2011

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Q u i n t e s s e n c e i n t e r n at i o n a l Q u i n t e s s e n c e i n t e r n at i o n a l

A direct composite resin stratification technique

for restoration of the smile
Juan Carlos Pontons-Melo, DDS, 
MSc1/ Adilson Yoshio Furuse, 
DDS, MSc, PhD2/ Jose Mondelli, 
DDS, MSc, PhD3

Composite resins can be used to improve the esthetics of the smile at a 
low cost and with relatively high clinical performance. The aim of this article was to
describe an approach to restore and enhance the esthetic appearance of the anterior
dentition through vital tooth whitening and the direct layering of composite resin during
predictable esthetic proce- dures. (Quintessence Int 2011;42:205–211)

Key words: composite restoration, dental esthetics, layering technique

Nowadays,  the  cosmetic  and  The range of composites allows the use of
esthetic parameters dictated by society different combinations of shade, hue, trans-
have com- pelled patients to seek lucency, and opacity. Thus, specific details
dentofacial harmony and improve their and aspects that exist in the patient’s
physical appearance. Additionally, the natural dentition may be obtained. This
evolution of dental materi- als has restorative approach of layering approach
increased the indication of esthet- ic has been called an “anatomic buildup tech-
restorative procedures. In this context, nique,”11 a “trendy three-layer concept,”12
composite resins occupy a paramount posi- or a “natural layering concept.”3 The goal
tion among restorative materials for anterior of these methods is to mimic the natural
teeth because they offer good predictabil- anatomy of enamel and dentin.13
ity, acceptable longevity, and the possibility The application of a layering concept
of more conservative procedures at a lower through the use of separate composite
cost than indirect restorations.1–6 resin masses that mimic the natural tooth
In addition, during the replacement of anatomy presents clear advantages for the
decayed or missing dental tissue, compos- clinician and makes the entire procedure
ite restorations allow either minimally inva- more efficient and predictable.3 When eval-
sive or no preparation. They also provide uating the polychromatic characteristics
an excellent esthetic outcome, due to the of a tooth, age should also be taken into
variety of available colors and effects.7–10
account. With increasing age, there is an
1
Professor, Department of Restorative Dentistry,
increase in chroma, a decrease in value,
School of Dentistry, San Marcos University, Lima,
Peru; Professor of Esthetic Dentistry, Spazio Oral and probably a change in hue. Actually,
Dental Education, Lima, Peruw. phenomena such as wear, acquired or dys-
2
Professor, School of Dentistry, Positivo plastic discoloration, and cracks or micro-
University, Curitiba, Brazil. fractures will require an individual
3
Professor, Department of Restorative Dentistry, approach for the restorative work.7 Thus,
Bauru School of
as is true of all art, a heightened sense of
Dentistry, University of São Paulo,
Bauru, Brazil. observation is required.14 The excellence in
Correspondence: Dr Juan Carlos Pontons-Melo, esthetic dentistry demonstrates further
Av Alberto del Campo 452 Dpto 303 San Isidro, Lima confirmation
27, Lima, Peru. Email: drjcpontons@spaziooral.com
Q u i n t e s s e n c e i n t e r n at i o n a l Q u i n t e s s e n c e i n t e r n at i o n a l

VOLUME 42  •  NUMBER  3  •  MARCH 2011 205

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Po n t o n s - M e l o e t a l

Fig 1 Preoperative photographs that show an inadequate incisal display and disharmonic relation with the
lips.

Fig 2 Initial appearance of the Fig 3 The in-office tooth bleaching

maxillary incisors. process carried out with 35%
hydrogen peroxide.

of  Leonardo  Da  Vinci’s  belief  that 

“art  and 
CASE REPORT
technology are one and the same.”
A 35-year-old woman presented for treat-
In addition to composite resin resto-
ment.  She  complained  of 
rations, vital dental bleaching may be
dissatisfaction with her smile,
employed to increase dental esthetics. Two
especially with the position of her maxillary
techniques are currently available: in-office
central incisors (Fig 1). A clinical
and  “walking”  bleaching.  Both 
examination revealed worn maxil- lary
techniques may be employed, as the
incisors and compromised color, as well
procedure is considered simple, safe, and
as old, defective composite restora-
incapable of causing major alterations of
tions  (Fig  2).  Radiographs  and 
enamel and dentin structure.15,16
diagnostic casts were taken.
The aim of this article is to describe
Vital in-office bleaching was proposed
an uncomplicated approach with which to
and conducted with 35% hydrogen perox-
restore and enhance the esthetic appear-
ance of the anterior dentition via tooth ide  (Lase  Peroxide  Sensy,  DMC) 
whitening and direct composite resin resto- (Fig  3). At the 1-week follow-up
rations with the aid of a layering technique appointment, the patient did not report
for predictable esthetic procedures. any tooth sensitivity at any point during the
bleaching treatment.
After 3 weeks, which is the recommended
 206 VOLUME 42  •  NUMBER  3  •  MARCH 2011
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 Po n t o n s - M e l o e t a l

Fig 4 The palatal silicone guide was fabricated Fig 5 Cosmetic contouring was performed to
on a study cast after optimizing the shape and better align the maxillary central incisors prior to
function of the incisors with a wax-up. starting definitive restorations.

a b
c
Fig 6 (a) After prophylaxis, modified rubber dam isolation was established. (b) Restorations were
removed with the aid of abrasive disks and diamond burs. (c) Final preparations before restorative
treatment.

a b
Fig 7 (a) Etching with phosphoric acid. (b) After rinsing and blotting with an
absorbent paper, a bonding agent was applied and light cured.

amount of time to wait before creating an incisors (Fig 5). After tooth prophylaxis,
adequate bond after the bleaching pro- modified rubber dam isolation and a retrac-
cess,17 new tooth positions and restorations tion cord were placed. The compromised
were planned with the aid of a waxed old restorations were removed, and circum-
dental cast. Enhanced predictability of the ferential chamfer bevels were created (Fig
treat- ment can be obtained with a silicone 6).  Prior  to  the  restorative 
index (Fig 4).18
procedure,  15 seconds of etching with
To avoid any interference in the chroma
37% phosphoric acid, followed by a water
and opacity evaluations due to tissue dehy-
rinse, was applied. Then,  an  adhesive 
dration, tooth shade was determined first.
system  (Adper  Single Bond  2,  3M 
Cosmetic contouring was 
ESPE)  was  applied  in  accor- dance
performed to cor-
with the manufacturer’s guidelines
rect the alignment of the maxillary central
(Fig 7). Using a composite resin instrument

VOLUME 42  •  NUMBER  3  •  MARCH 2011 207

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Po n t o n s - M e l o e t a l

Fig 8 (a) Application of

trans- lucent resin to
reproduce the palatal
portion of the teeth with
the aid of the silicone
index. (b) Application of
dentin shade to create
mamelons and reproduce
the region that corresponds
with the deepest dentin.
Dentin can be applied and
placed precisely in relation
with the future incisal
a b
edge. (c) Application of shades A1
and High Value for the layer that
corresponds to the facial surface.
(d) Artificial enamel of the final
desired shade is applied from the
cervical third to the middle and
incisal thirds.

c d

Fig 9 (left) Completed restorations

before removing rubber dam
isolation.

(IPC-T, Cosmedent), a thin layer of  Vivadent)  was  applied 

translu-
to the region of the incisal
cent enamel composite (YT, Filtek  third between the
Supreme, 
mamelon spaces (Fig 8).
3M ESPE) was spread on the 
silicone index as a lingual shelf to
establish the palatal contour and new
incisal edge. The excess material was
removed, and the composite resin was
light cured in position for 20 sec- onds.
The artificial dentin (shade A2 dentin,
4  Seasons,  Ivoclar  Vivadent)  was 
placed over the facial portion and
sculpted in the shape of mamelons. The
halo effect (ie, a thicker volume along the
incisal edge) was sculpted with 
shade A2 dentin (4 Seasons). To
mimic the opalescent effect of natural
enamel,  a  small  increment  of  Blue 
Effect  (4 Seasons,  Ivoclar 
 The final layer, which corresponded to the artificial placed interproxi- mally and pulled through
enamel, was restored with shade A2  enamel  (4  to help create a tight contact point and

Seasons)  for  the  cervical third;  shade  A1  the correct facial embrasure forms (Fig 9).
Finally, both the buccal and palatal sur-
enamel  (4  Seasons)  for  the medium  third; 
faces were light cured for 40 
and  High  Value  (4  Seasons) for the incisal third
seconds. Before polishing, excess
(Fig 8). All composites were carefully applied with a flat
material at the margins was
spatula and blended with the aid of a no. 4 flat-tipped
removed with a no. 12 surgical scalpel blade
brush (Kota). Increments of composite resin were light
cured for 20 seconds for each layer. A Mylar strip was

208 VOLUME 42  •  NUMBER  3  •  MARCH 2011

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 Po n t o n s - M e l o e t a l

a b
c

Fig 10 (a) Lines were drawn along the proximolabial regions to determine the light-reflecting and
mamelon areas of the maxillary anterior teeth. (b) The surface texture was achieved with a tapered
diamond bur. (c) In sequence, the polishing was completed with silicone rubber cups and other finishing
materials.

a b

Fig 11 Maxillary Fig 12 (a) Final outcome after recontouring and restoring the anterior
bite splint in position. teeth. (b) Patient’s smile and the new incisal edge position.

(Swann-Morton).  A  coarse-gritted  a silicone cup to eliminate some of the

disk  (Sof- Lex Pop-On, 3M ESPE)  accentuated texture (Fig 10). The final
was used to produce the primary natural gloss was achieved with Astrobrush

anatomy and achieve symme- try between (Ivoclar Vivadent), a felt wheel and an alu-

similar teeth. After the desired cervicoincisal minum oxide polishing paste (Enamelize,

and mesiodistal lengths were reached, Cosmedent), and abrasive strips 

symmetric light-reflection areas and light- for refining and polishing the
deflecting zones were outlined with pen- cil interproximal areas.
and the distance was checked with a To evaluate the occlusion, the patient
sharp-ended caliper. was placed in an upright position. The
The facial and palatal surfaces were fin- centric occlusion and the protrusive and
ished with a coarse silicone cup (Astropol, lateral movements were examined. Any
Ivoclar Vivadent) to prepare for the macro equilibration that was required to improve
surface texture. Lines along the facial sur- harmony was accomplished with a finish-
face were created with the aid of a fine-grit ing diamond bur, and the final polishing
diamond  bur  (1190F,  KG  procedures were repeated whenever nec-
Sorensen)  on a  1:4  increaser  essary. Finally, a protection bite splint was
indicated for nighttime use (Fig 11). Figure
contra-angle  (T2  REVO, Sirona) 
12 demonstrates the final result.
for  optimal  operative  control. 
The 
entire restoration was then buffed with
 VOLUME 42  •  NUMBER  3  •  MARCH 2011 209
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Po n t o n s - M e l o e t a l

DISCUSSION office bleaching treatment was performed.

When bleaching is indicated prior to adhe-
Due  to  the  evolution  of  sive restorative treatments, it is important to
composite  resins, the old concepts wait at least 24 hours before bonding to
of indication that lim- ited their use in pre- vent any negative effects of bond
several clinical situations have changed. strength of composite resin to the dental
This transformation may be attributed to structure.16
the evolution of the materials’ properties, A modified rubber dam isolation technique
such as their durability, load resistance, as well as a retraction cord were employed.
esthetics, color stability, and This technique allows clinicians to have free
predictability. The clinical performance has access to the gingival area while keeping
also yielded favorable results. These quali- the field free of saliva. Further, only
ties allow for a greater conservation of tooth compro- mised old restorations were
structure compared to indirect restorative removed. Old restorations that were not
materials.19–22 compromised by discoloration, marginal
Frequently, the dental practitioner is staining, or recur- rent caries were
challenged to modify the configuration of repaired while seeking to improve
the smile by applying an artificial mate- esthetics so that sound dental structure
rial to replace missing tooth structures or was not eliminated.
eventually rearranging the disposition of The patient should be aware that the
the teeth. A good treatment must respect shade and texture of the material will
and simulate the spatial arrangement, rela- change over time. Restorations 
tion, and appearance of natural tissues.7 also require periodic maintenance.
The success of this procedure, however, Additionally, oral hygiene protocols
depends on an understanding of the inti- should be emphasized. The color of
mate structure of natural teeth.23 esthetic restorations can be maintained
Despite  the  many  advantages  for longer periods by introduc- ing some
of  com- posite resin, there are still some restrictions on the patient’s dietary habits.19
difficulties in regard to color selection.
This aspect is considered a paramount
element for achieving esthetic success in a
restoration, but if the anatomical shape is CONCLUSION
not adequate, the result will not appear
natural and harmo- nious within the Direct composite resin 
dentofacial complex. Often, it is possible to restorations have the potential to
achieve an esthetic result, even if the color reproduce the appearance of a natural
is slightly different, as long as the shape, tooth with highly esthetic outcomes.
surface texture, and opac- ity are Additionally, this procedure is a good treat-
harmonic.24 The shade of a tooth is ment option that is less costly than other
determined by the correlation among enam- indirect approaches. Therefore, this simpli-
el, dentin, and light during the process fied approach has the potential to extend
of light refraction and reflection.11  the benefits of composite resin to a larger
Color matching is a problem, especially number of clinicians and patients.
when there is a lack of opacity in the dentin
shade of  the  material.  Such  a 
situation  decreases the value of the
restoration.25 This problem is more likely to
be noticed than a mistake in hue.26 
During  the  procedure  of  finishing 
and polishing multiple anterior restorations,
it is recommended that light reflection and
deflection areas be outlined in pencil and
checked with a sharp-ended caliper. This
procedure will enable the restorations to be
as symmetric as possible.27
Some procedures should be 
addressed. 
Before  the  restorative 
procedure,  an  in-
 210 VOLUME 42  •  NUMBER  3  •  MARCH 2011
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 Po n t o n s - M e l o e t a l

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 VOLUME 42  •  NUMBER  3  •  MARCH 2011 211
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