Creating Lifelike Aesthetics Using Direct Composites

Clinicians are often called upon to re-restore the dentition of patients who have had dental treatments in the anterior segment, where aesthetics are of paramount importance. Compounding the challenges associated with these endeavors is delivering restorations that are as minimally invasive as possible, yet equally durable, long-lasing and, perhaps most importantly, natural-looking and seamless with the adjacent natural dentition. It is therefore crucial for clinicians to consider the patient’s needs, alongside the best treatment alternatives and restorative modalities.
When direct composite resin restorations are to be placed, the illusion of the different translucencies and opacities that occur in natural dentition must be realized in order to achieve lifelike aesthetics. What is required is the careful selection of composites that inherently mimic tooth structure. In addition, the clinician must be able to build-up or layer those composites in such a way that they interplay with light to recreate the effects of natural teeth.

A NEW MICROFILLED RESIN HYBRID

Preoperative close-up view of the patient’s natural smile.

Postoperative view of the patient with her natural smile. Note the enhanced proportions and seamless blend with the adjacent dentition.

A new, microfilled resin hybrid, Kalore (GC America), has been introduced that demonstrates high chameleon effects, high flexural strength, excellent polishability and wear resistance, low shrinkage, and high radiopacity. Aspects of these critical features are possible due to the use of a new and exclusive monomer technology from DuPont. What also makes Kalore different are its 3 types of filler particles: prepolymerized fillers (eg, strontium glass, 400 nm, and lanthanoid fluoride, 100 nm that have special surface treatment for better bonding); fillers (eg, strontium glass, 700 nm and fluoroaluminum silicate glass, 700 nm); and nanosilica fillers (eg, 16 nm fillers that are dispersed throughout the composite for better wear).
This new composite resin’s high chameleon effect is critical for today’s highly sought after conservative and aesthetic restorations. This has been achieved by using many different refractive index fillers. Combined, these fillers have different light scattering properties and pick up colors from the surrounding teeth. The light is scattered inside the composite material which provides the high chameleon effects and quality of color that mimics tooth structure and enables the creation of invisible restorations.
The high-loading prepolymerized fillers have more hardness for better wear resistance, and both strontium glass and lanthanoid fluoride provide radiopacity. In particular, nanolanthanoid fluoride demonstrates high radiopacity without blocking visible light. Overall, the author has found that this composite is easy to handle and polishes easily to an exceptional luster.
Kalore is available in opaque shades that include AO2, AO3, and AO4, as well as Opaque Bleaching White (OBW), and Opaque Extra Bleaching White (OXBW). Kalore universal shades such as A1, A2, A3, A3.5, and A4; B1, B2, and B3; C2, C3, D2, and Cervical = B5, Cervical Dark = B7; and BW and XBW. Kalore Translucent shades include White Trans­lucent, Dark Translucent, Clear Translucent, Natural Translucent (NT), Gray Translucent, and Cervical Translucent.
In this article, we will demonstrate in detail how a patient’s maxillary anterior teeth were re-restored using direct composite. Previously placed Class IV composite restorations on teeth Nos. 8 and 9 were removed, and the patient’s smile was enhanced using the Kalore composite and a simplified build-up technique that is described in the following case presentation.

Figure 1. Preoperative retracted view of teeth Nos. 8 and 9 with the previously placed composite restorations clearly visible.

Figure 2. The composites were previewed on teeth Nos. 8 and 9.

Figure 3. A single-component, self-etching bonding agent (G-Bond [GC America] was applied to the preparations for 10 seconds using a brush.

Figure 4. The Bleaching White (BW) final enamel composite layer was placed on tooth No. 8.

Figure 5. The BW composite material was placed on tooth No. 9.

Figure 6. The Neutral Translucent composite layers received a final light-curing.

Figure 7. After curing and before finishing, the new composite resin restorations were assessed for color and translucency.

Figure 8. Finishing was accomplished using contouring, shaping, and shine cups and points (CLINICIAN’S CHOICE).

Figure 9. The final luster was achieved using a polishing brush (Groovy Polisher Brush [CLINICIAN’S CHOICE]).

Figure 10. Postoperative close-up retracted view of the completed composite resin restorations (Kalore [GC America]) on teeth Nos. 8 and 9.

CASE PRESENTATION
A 26-year-old female patient who would be getting married in the near future presented dissatisfied with the appearance of the 15-year-old composite restorations on her anterior maxillary teeth (Figure 1). The patient was not interested in porcelain veneers or any unnecessary removal of her existing tooth structure. Instead, she expressly requested reversible and repairable restorations.

Treatment Planning
Before the pre-existing composite restorations were removed, the patient’s occlusion was analyzed. In addition, a comprehensive intraoral examination was performed that included taking an oral history, radiographs and photographs. The patient was in good health, and nothing was found to contraindicate direct composite re-restoration of teeth Nos. 8 and 9.
The morphological, histological, and optical characteristics of the teeth were noted. To determine the appropriate composite shade for replacing the old restorations, composite materials (Kalore) in shades NT, BW, and A2 and A1 were previewed side-by-side on teeth Nos. 8 and 9. It was determined that BW composite would be ideal for the case (Figure 2), with shade A1 being the lingual enamel layer.

Preparation Protocol
Before the previous composite restorations were removed and the teeth prepared, an impression was taken for use in creating a diagnostically enhanced model. This model would also be used to fabricate a high-viscosity putty stent (Exafast [GC America]). When placed in the patient’s mouth, the putty stent would serve as a spatial reference and volumetric guide for placing the composite. It was decided that incisal length of both teeth Nos. 8 and 9 would be increased by 1.5 mm. The putty stent would also help maintain the facial-lingual line angles.
The old restorations were removed, and teeth Nos. 8 and 9 were prepared using diamond burs to create a 0.5-mm modified lingual shoulder; in addition to a 2-mm facial bevel. These preparations supported the fracture resistance and durability of the res­torations and allowed the clinician to place composite at the restorative margins.
The Class IV preparations were then verified incisally, after which the teeth were pumiced, rinsed, and dried. A single-component self-etching bonding agent (G-Bond [GC America]) was applied onto the preparations for 10 seconds using a brush (Figure 3). The bonding agent was air thinned with high pressure, and with the putty stent in place, was then light-cured for 10 seconds per tooth.
After light-curing, the Kalore composite in shade A1 was applied in a 1.5-mm thick increment to form the lingual enamel layer and block any show-through. This layer was cured for 20 seconds. In order to assess this lingual enamel layer, the putty stent was removed. Then, to simulate translucency in the middle third and incisal one-third of teeth Nos. 8 and 9, the BW layer was placed, sculpted, and light cured for 20 seconds. The final BW material was then placed (Figures 4 and 5) and light cured, after which the final NT material was applied to the anterior teeth, assessed, and light cured (Figures 6 and 7).

FINISHING AND POLISHING
After the restorations were successfully layered and anatomically constructed, they were finished and polished using a sequential series of integrated products and materials, beginning first with coarse anatomy trimmers (CONTOURS [CLINICIAN’S CHOICE]) (Figure 8), and continuing with intermediary diamond polishers (D·FINE Double Diamond Polishers for Hybrid Composites [CLINICIAN’S CHOICE]) to more refined polishers (D·FINE Shape & Shine Single Step Diamond Polishers [CLINICIAN’S CHOICE]). This helped to ensure that the restorations demonstrated a similar harmony and balance with the adjacent teeth, as well as with each other. These finishing steps also imparted life-like realism by better defining line angles (eg, second anatomy, tertiary anatomy). Surface texture was achieved using a green stone (Bras­seler USA). In order to create a natural-looking final luster a polishing brush (Groovy Polishing Brush [CLINICIAN’S CHOICE]) was used (Figure 9).

CONCLUSION
Increasingly, manufacturers are providing clinicians with the restorative tools they need to provide aesthetic dentistry that is also minimally invasive, durable, and easy to perform. The case presented here has demonstrated the manner in which an innovative direct composite resin material was used to produce seamless anterior Class IV restorations (Figure 10) shortly before the patient’s wedding. By envisioning the aesthetic outcome prior to initiating any treatment, the restorations could be placed in such a manner as to maximize the conservative nature of the direct composite modality, as well as the chameleon characteristics of the selected composite resin system.


Dr. Milnar is a graduate of the University of Minnesota School of Dentistry. He is an accredited member of the American Academy of Cosmetic Dentistry (AACD) and a board examiner for accreditation. Currently, he is the professional education committee co-chair for the AACD. He maintains a full-time practice in St. Paul, Minn, emphasizing appearance related dentistry. Dr. Milnar is co-founder of the Minnesota Academy of Cosmetic Dentistry and lectures extensively within the US Armed Forces as well as internationally on the subject of direct composite restorations, shade selection and porcelain materials. He has published numerous articles about the direct placement of composites, shade selection and porcelain materials. He can be reached at (651) 645-6111 or via email at drmilnar@stpaulsmiles.com.

 

Disclosure: Dr. Milnar lectures for GC America.