Aesthetics With Simplicity

The development of modern composites, with a higher proportion of loading filler particles per volume and improved mechanical properties, has allowed their use not only in cavities of anterior teeth, but also in posterior teeth. Thus, considering the mechanical point of view, the current composite resins have achieved a high level of enhancement and are appropriate for most cases in which direct restorations are indicated.
By the end of the 1990s, manufacturers of composite resins began to improve their optical properties. The composite resins started to be manufactured in a greater range of shades both to enamel and to dentin, always endeavoring to provide optical properties similar to natural teeth. Currently, the composite resins can be found in a wide variety of shades, allowing the dentist to use different incremental layering techniques with different types of composite resins so as to achieve optimal clinical results. However, such a wide variety of shades can make it hard for the dentist to make an accurate shade selection during the restorative procedure. Bearing in mind that this is a crucial factor for a natural-looking restoration, in the following case report we will share a simplified technique for the selection of shades and the placement of composite resin. This technique can easily be integrated into the daily routine of most dental offices.

CASE REPORT
Diagnosis and Treatment Planning

A 12-year-old boy suffered a trauma during a soccer game on the left central and lateral incisors (Figure 1). Upon completion of the oral examination and review of the radiographs, the pulpal and gingival conditions of the teeth involved, as well as other teeth, were found to be satisfactory. The patient did not present any other oral problems. Diagnostic impressions and photographs were also taken for analysis.

Figure 1. Central and lateral left upper incisor post-trauma with a loss of enamel from the lateral incisor, and a greater loss of structure from the central incisor. Figure 2. Macro- and micro-anatomic details of adjacent teeth were visualized. The lobes, developmental grooves, and the slight translucent incisal halo found on the sound contralateral central incisor must be reproduced during the restoration. Furthermore, the microlongitudinal grooves must also be reproduced during the finishing/polishing procedure.

After the impressions were poured up, the fractured teeth were waxed-up to the desired final contours. The case would be restored using direct composite resin restorations; the occlusion of the patient was favorable for the use of these materials and direct composites represented the most conservative method of treatment for this case. The diagnostic wax-up assists in the creation of ideal and natural tooth anatomy. In addition, with the use of a lingual silicone stint (fabricated from the diagnostic wax-up), we would be able to create a restoration with a more accurate occlusion, essential for the longevity of Class IV restorations of this size.
The photo analysis enabled us to visualize macro- and micro-anatomic details of adjacent teeth to be reproduced (Figure 2). With the photos, it is possible to see the lobes and developmental grooves and even a slight translucent incisal halo, contrasting very little with the remaining enamel structure. Furthermore, it is also possible to observe the microlongitudinal grooves, which should also be reproduced in the restoration in order to obtain a final result resembling the same texture of the natural enamel of the patient.

Shade Selection and Incremental Layering
The composite system chosen was Amelogen Plus (Ultradent Products). Based on this system, the shades of the enamel and the dentin to be used were selected. The enamel of a young patient usually presents many areas in which the prisms are arranged in an irregular way. Such irregular orientation leads to an increase in the reflection of light and, therefore, a greater brightness and opalescence of the enamel. Thus, we chose to use the shade Enamel White, which is semi-translucent and of high-value (whiter). Such a shade was used both on the vestibular and the palatal surfaces, and covered all the other layers of the composite resin.
The vestibular surface of the central incisor (Figure 2) presents an A2 dentin shade on the cervical third, ranging to A1 on the incisal third. When an achromatic enamel system is used, which only regulates the luminosity of the restoration, it is recommended to start the incremental layering with a more saturated shade than the one observed on the cervical third. Thus, if the shade observed was A2, the incremental layering should start with shade A3. The visualization of the exposed dentin on the lateral incisor (shade A3) supports this assumption.
For the incisal area, the shade Trans White was selected, even more transparent than the enamel color. This shade does not contrast a lot with the selected enamel shade (Enamel White), which resulted in a slight incisal halo, just like the natural one found on the counterlateral central incisor.
An ultra-conservative bevel was prepared, merely to eliminate the weakest enamel prisms. The silicone mounting was made based on the anatomy of the contralateral teeth.
We started with the enamel layer, shade Enamel White (Figure 3). This layer is thin and fragile, so, after being light-cured for 20 seconds, and with the silicone guide in place, the next layer of composite resin was placed, now resembling dentin, shade A3. This shade was placed in a ramp shape, being thicker on the cervical area and thinner on the incisal area (Figure 4).

Figure 3. Palatal enamel layer being placed. Since this was young enamel, the prisms were generally arranged in an irregular way. This situation leads to an increase in the reflection of light and, therefore, a greater brightness and opalescence of the enamel. The chosen enamel color was Enamel White (Amelogen Plus [Ultradent Products]), a whiter, semi-translucent shade. Figure 4. When an achromatic enamel system is used (which regulates the luminosity of the restoration), it is recommended to start the incremental layering with a more saturated shade than the one observed on the cervical third. Since the observed shade was A2, the incremental layering was started with shade A3.
Figure 5. Last layer of dentin, shade A2, was placed in a way to partially cover the previous layer shade (A3) and already restoring the anatomy of the mamelons. The region between the dentin mamelons was filled with a small amount of the shade Trans White. Figure 6. A brush is a great tool when placing the last layer of enamel shade. If this step is well executed, the polishing procedure is simplified.
Figure 7. The restoration being sealed. This step was done not only to seal the restoration, but also to prevent the occurrence of stains due to microleakage in the margin between restoration and tooth. It also assists the finishing/polishing procedure. Figure 8. A layer of hydrophilic gold dust helps the clinician visualize and reproduce the vestibular superficial texture, performed with the aid of multilaminated high-speed burs.
Figure 9. One week after the composite restorations were placed, the patient returned for the final polishing. This follow-up appointment is important in order to assess the need for finishing touches of shade and/or anatomy after rehydration of the tooth and restoration has occurred. Figure 10. Completed restorations. Note the harmonious integration between the restoration and the natural teeth structures. It is paramount to identify the nuances of shape and color of the teeth. The reproduction of these in order to yield aesthetic excellence can be greatly facilitated using a composite with a simplified color system.

In Figure 5 it is possible to observe how the last layer of dentin shade A2 was placed in a way to partially cover the previous layer shade (A3), already restoring the anatomy of the mamelons. The region between the dentin mamelons was filled with a small amount of the shade Trans White.
After the individual curing of each layer, the last layer of enamel shade was placed, using a brush (Figure 6). At the end, the restoration was sealed with PermaSeal (Ultradent Products), also light-cured for 20 seconds. This step was performed aiming not only to seal the restoration but also to prevent the occurrence of stains due to microleakage in the margin between restoration and tooth. It also helps the finishing/polishing procedure (Figure 7).

Finishing and Polishing
A high-speed diamond bur (KG Diamond, KG Sorensen [model 3207FF]) was used to remove the excess composite. After using the Jiffy (Ultradent Products) composite polishing tips in the colors green and yellow, a layer of a hydrophilic gold dust was placed (Surface Texture [Hot Spot Design]). This was done to help us visualize and reproduce the vestibular superficial texture, created with the aid of multilaminated burs (Composite finishing bur, Ultradent Products [model Flame Carbide, Long, Ultra-Fine, 30-Bladed]) in high speed (Figure 8). Similar procedures of incremental layering, finishing and polishing were performed on the lateral incisor.

Follow-up Appointment: The Final Touches
One week after the procedure, the patient was scheduled for a new appointment for the final polishing. A Jiffy blue tip was used, followed by a felt disc with diamond paste. This follow-up appointment is important; it is used to observe the aesthetics after the rehydration of the tooth and restoration has occurred to assess the need for any finishing touches of shade and/or anatomy.
Figures 9 and 10 show the completed restorations. Note the harmonious integration between the restoration and the natural tooth structures.

CLOSING REMARKS
The color system of this composite system (Amelogen Plus) makes shade selection easy. With this system, the authors have found that a clinician can complete even large restorations, as demonstrated in this case report, with only 4 shades. It goes without saying that it is also extremely important to be able to identify and reproduce the nuances of shape and color of the teeth in order to yield aesthetic excellence.

Acknowledgment
The authors wish to thank Gisele Bertinato, who took all the photos.


Dr. Beolchi majored in dentistry at the University of São Paulo (USP). He has maintained a private practice since 2001, working mainly in aesthetic dentistry and oral rehabilitation. In 2009 he received his master's degree in biomaterials from the Institute of Energetic and Nuclear Research, USP. He is also a member of "Sociedade Brasileira de Odontologia Estética" (Brazilian Association of Aesthetic Dentistry). He is the teacher responsible for the continuing education course on aesthetics with direct composite resins of APCD—Atibaia Center, is an invited teacher on the specialization course of high-end asthethics of the Sanitas Institute in Bogotá, Colombia, and also provides advice on materials and aesthetic dental products. He particularly prefers direct restorations with composite resins, and has lectured several workshops addressing this topic throughout Brazil, in several countries in South America, Europe, and Asia. He can be reached at (+55) (11) 4419-6459 or at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Palo majored in dentistry at the University Paulista. He has maintained a private practice since 2001, working with endodontics. In 2009 he received his PhD from the Universidade Paulista Júlio de Mesquita Neto. He is the volunteer teacher responsible for the same institution, and also provides advice on materials and dental products. He also has lectured several workshops addressing endodontics and whitening throughout Brazil, South America, Asia, and in Europe. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosures: Drs. Beolchi and Palo are paid consultants for Ultradent Products, Inc.

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