Esthetics with Predictability
Simplifying incremental composite layering using a novel material
Rafael Beolchi, DDS, MSc
A challenge of modern dentistry is to promote function and esthetics while still respecting tooth conservation. Minimally invasive techniques are preferred, especially in cases of extensive rehabilitation.1 This report presents a clinical case in which direct composite veneers were applied to six upper anterior teeth using a minimally invasive procedure.
A 19-year-old man presented with both deciduous upper canines in place and many anterior diastemas (Figure 1.) At the request of the patient and his family, the original treatment plan of extraction of the deciduous teeth, orthodontic treatment, and dental implants was rejected in favor of a more conservative, faster, cheaper, and above all, reversible treatment.
A diagnostic wax-up was created with the aid of the Uveneer™ direct composite template system (Ultradent Products, Inc.) (Figure 2). This wax-up was created in a semi-adjustable articulator in which the excursive movements were simulated in order to respect the patient’s occlusion.
Treatment Plan Presentation
A silicone guide was constructed based on the wax-up. This guide was trimmed along the gingival lines, and a bis-acryl composite (ExperTemp® material, Ultradent Products, Inc.) was expressed inside (Figure 3). The guide was immediately put into position intraorally, and following the required setting time, it was removed along with any excess resin (Figure 4). After seeing a mock-up of the final result, the patient accepted the treatment plan (Figure 5).
Before the restoration process began, the patient whitened his teeth with the use of pre-fabricated trays containing 10% hydrogen peroxide (Opalescence Go® trays, Ultradent Products, Inc.). In order to avoid any potential interaction between the peroxide and composite, the patient waited two weeks before proceeding to the next step of the process.
Shade Selection and Layering
The direct composite veneers were created with the new Mosaic® universal composite (Ultradent Products, Inc.). This system follows the achromatic enamel concept, in which the enamel layering is determined by the translucency and luminosity of the patient’s teeth.2
The semi-translucent shade Enamel White was the best match based on the patient’s age and the results of the tooth whitening (Figure 6). This shade was used both on the vestibular and the palatal surfaces and covered all of the other layers of the composite resin.
After the working field was isolated with a modified rubber dam technique (Figure 6), the enamel was etched using UltraEtch® etchant, then Peak® Universal Bond adhesive (Ultradent Products, Inc.) was applied.
The palatal shell was placed with the aid of another silicone guide. With the anatomical outline of the final restoration in place, dentin shade A3 was layered on the cervical third and shade A2 was layered on the remaining buccal aspect (Figure 7). The composite was brought 1 mm shy of the incisal edge.
To mimic the rich information contained in the incisal region, two small dots of Opaque White composite were placed on the incisal border of the restoration and combined with the color Enamel Trans to result in a discreet and natural incisal halo (Figure 8).
The last layer of enamel shade was placed with greater thickness in proximity to the incisal edge and thinner close to the gingival third. Throughout the process, each layer was individually cured with the aid of the VALO® curing light (Ultradent Products, Inc.).
After all six anterior teeth were restored, the restorations were sealed with PermaSeal® composite sealer (Ultradent Products, Inc.), which also was light cured for 20 seconds per tooth.
Finishing and Polishing
The excess composite was removed using a series of polishing disks at low speed, then the restorations were finished using Jiffy® composite polishing tips (Ultradent Products, Inc.) in the colors green, yellow, and white.
Final polishing was completed two weeks after the procedure. This waiting period allowed for the rehydration of the tooth and restoration so adjustments to the shade or anatomy could be made as needed. In addition, it is easier to perform the final polishing procedure on a composite that is more hydrated and has undergone the final curing process. In some cases, this can increase the conversion rate by up to 20%.3
A Jiffy® HiShine polishing tip (Ultradent Products, Inc.) was used first, followed by a felt disc with diamond paste (Diamond Polish Mint, Ultradent Products, Inc.). Multi-laminated burs were employed at high speed to reproduce the vestibular superficial texture.
Figure 9 shows the completed restorations of all six upper anterior teeth. On the extraoral photo (Figure 10), it is easy to see the integration between the restoration and the natural tooth structures, resulting in a more harmonic and balanced smile.
Dr. Rafael Beolchi received material and financial support from Ultradent Products, Inc., for the writing of this article.
1. Dietschi D, Devigus, A. Prefabricated composite veneers: historical perspectives, indications and clinical application. Eur J Esthet Dent. 2011;6(2):178–187.
2. Vanini L. Light and color in anterior composite restorations. Pract Periodontics Aesthet Dent. 1996;8(7):673-682.
3. Boaro LC, Gonçalves F, Guimarães TC, Ferracane JL, Pfeifer CS, Braga RR. Sorption, solubility, shrinkage and mechanical properties of “low-shrinkage” commercial resin composites. Dent Mater. 2013;29(4):398-404.
About the Author
Rafael Beolchi, DDS, MSc
São Paulo, Brazil
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