Clinical Strategies for Success in Proximoincisal Composite Restorations.

Part II: Composite Application Technique

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A/STRACT

Repro0ucing the form% function% an0 optical characteristics of natural 0ental structures 1ith 0irect composites in large an0 mo0eratel2 large proximoincisal 3Class I*4 restorations represent a great challenge for clinicians in general. Un0erstan0ing color is fun0amental to achie5ing success 1hen restoring these 0efects% as 1as 0iscusse0 in Part I of this t1o6part article 3*olume 78% um9er 84. The proper restoration of the functional lingual contour is also a challenge that cannot 9e o5ercome 1ithout close attention to the restorati5e technique. In this secon0 article% the composite application technique is 0iscusse0 an0 presente0 in 0etail. Clinical photographs illustrate the propose0 technique. The propose0 clinical protocol% inclu0ing a tr26in of the sha0es in a moc;6up restoration to more accuratel2 0efine color an0 shape% an0 a silicone gui0e to transfer the lingual an0 proximoincisal contour of the moc;6up to the final restoration is of great help to successfull2 restore proximo6 incisal 0efects. fication to mas; the intraoral 9ac;6 estoring the natural optical an0 functional characteristics of teeth pre0icta9l2 an0 relia9l2 has 9een an important goal for clini6 cians 1hen using 0irect composites on anterior teeth 1ith proximo6 incisal 0efects. The challenges to 9e face0 1hen executing proximo6 incisal restorations inclu0e the crea6 tion of 374 a natural color transition from tooth to restoration% 3<4 opaci6 groun0% 3=4 a translucent incisal e0ge 3in 2oung teeth4% an0 3>4 natural surface texture% as 1ell as a goo0 o5erall sha0e match or ??9len06in@@ 1ith the a0Aacent structures. Rarel2 can the clinician achie5e excellent esthetic results in proximoincisal restorations 1ith a single sha0e of composite. This can onl2 9e achie5e0 1hen the tooth is relati5el2 mono6 chromatic an0 the selecte0 composite material ??pic;s up@@ the tooth color
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3+ $sthet Restor &ent 7B:7E7C% <CCD4 0uring 9oth refraction an0 reflection of inci0ent light. ,o1e5er% goo0 results can

9e often o9taine0 using a la2ering technique 1hen the clinician un0erstan0s 9asic concepts of light an0 color% as 1ell as applies a pro6 tocol supporte0 92 a

moc;6up resto6 ration an0 a custom lingual matrix. This article is the secon0 of a series of t1o that aims to present clini6 cal strategies for optimal success

(Assistant professor% &epartment of Stomatolog2% !perati5e &entistr2 Section% #e0eral Uni5ersit2 of Santa Catarina% Santa Catarina% /raFil
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Professor% &epartment of Stomatolog2% !perati5e &entistr2 Section% #e0eral Uni5ersit2 of Santa Catarina% #loriano polis% Santa Catarina% /raFil . Assistant professor% &epartment of !perati5e &entistr2% Uni5ersit2 of orth Carolina at Chapel ,ill%
Chapel ,ill% C% USA

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1hen 0irect resin69ase0 composites are use0 for the restoration of mo0erate to large proximoincisal 0efects. In the first article% 1e 0is6 cusse0 concepts of natural anat6 om2% color as it relates to 0ental structures% an0 composite selection for the restoration of proximo6 incisal 0efects. This current article presents a clinical protocol for tooth preparation% matrix selection% inser6 tion% surface characteriFation% fin6 ishing% polishing% an0 maintenance of mo0erate an0 large proximo6 incisal composite restorations. A 9rief 0iscussion of the a5aila9le matrix metho0s is presente0 prior to a step6926step pictorial 0escrip6 tion of the clinical protocol.
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&ifferent t2pes of matrices an0 insertion techniques ha5e 9een propose0 o5er the 2ears for the restoration of mo0eratel2 large incisoproximal 0efects 1ith com6 posites% such as the use of pol26 ester film strips 3'2lar% &uPont% Hilmington% &$% USA4% precon6 toure0 pol2ester cro1ns% an0 free6 han0ing techniques. Use of a contoure0% clear '2lar strip is the most popular matrix technique for proximoincisal 0efects. The strip% 1hich can 9e slightl2 0e6 forme0 to 9etter fit the proximal contour% is secure0 in place 1ith an interproximal 1e0ge an0 lingual finger pressure. Hhen the composite is inserte0% the strip is close0 o5er

the facial surface of the tooth an0 maintaine0 until the composite is cure0. The '2lar strip technique originate0 1ith silicate69ase0 an0 autocure0 3paste6paste4 composite restorations% in 1hich the material ha0 to 9e inserte0 in one large in6 crement 9ecause of the short 1or;6 ing time an0 lac; of a0hesion 9et1een increments. Hith the in6 tro0uction of light curing% clinicians experience0 more control o5er 1or;6 ing time allo1ing the insertion technique to 9e mo0ifie0. Certainl2 simplicit2 an0 spee0 are the main a05antages of using the '2lar strip% 9ul; increment technique% 9ut there are man2 0isa05antages% such as the 0ifficult2 to o9tain goo0 anat6 omic form an0 proper color. A00i6 tionall2% the amount of composite excess in 9oth incisal an0 gingi5al areas is greater than in the incre6 mental technique% requiring more time for finishing an0 polishing. Preforme0 pol2ester cro1ns ha5e also 9een use0 as semicustomiFe0 matrices for incisoproximal 0efects. In this technique a hollo1 preforme0 pol2ester cro1n 1ith similar 0imen6 sions to the tooth to 9e restore0 is selecte0 an0 mo0ifie0 to fit the con6 0ition. This technique can 9e applie0 in t1o 0ifferent 1a2s. In the first technique% once the clear cro1n shell is cut to fit the preparation% the composite is place0 on the insi0e of the cro1n% transporte0 to the pre6 pare0 tooth% an0 a0Auste0% after 1hich excess composite is remo5e0 an0 it is light cure0. In the secon0 technique% a 1in0o1 is cut on the

la9ial surface through 1hich the composite is incrementall2 inserte0. This secon0 technique permits the 0esire0 shape to 9e o9taine0 in a more con5enient 1a2% 1ithout the amount of excess generate0 92 the 9ul;6fill technique. ,o1e5er% the shape is not perfect as it still results in some excess composite an0 has some limitations on the insertion of the composite. The interproximal contact ten0s not to 9e proper o1ing to the thic;ness of the pol2ester cro1n. The lingual contour has a pre0etermine0 anatom2 an0 nee0s su9stantial contouring to achie5e a0equate results as that surface is not full2 customiFe0.7 The 0ifficulties associate0 1ith the use of a preforme0 matrix can to some extent 9e surpasse0 92 the use of a free6han0 technique% in 1hich the composite is inserte0 an0 light cure0 incrementall2 1ithout the use of a matrix. ,o1e5er% this technique can 9e more 0ifficult to execute% especiall2 for the untraine0 opera6 tor% 0eman0ing more training. To facilitate the proce0ure% the use of a silicone gui0e has 9een propose0% cop2ing the preoperati5e lingual con6 tour 3in the case of restoration re6 placement4 or the lingual contour of a 0iagnostic 1ax6up or restorati5e moc;6up.<%= !nce o9taine0% the

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cone gui0e is use0 as a custom ma6 trix that% associate0 1ith the free6 han0 insertion technique% generates the final restoration. The anatomic form% inclu0ing incisal length% height of contour of the lingual em9ra6 sure3s4% an0 e5en occlusal stops an0

excursi5e contacts% can 9e chec;e0 in the 1ax6up or moc;6up stage an0 copie0 1ith the silicone matrix. As mentione0% the silicone gui0e can 9e o9taine0 from a 1ax6up or from a moc;6up restoration place0 in situ. The latter metho0 helps to select the color of the restoration as the light con0itions for the moc;6up are the same as those for the final restora6 tion. If the clinician notices that the composites selecte0 0o not pro0uce a goo0 tonalit2% he or she can fine tune the selections. Consequentl2% the tr26 in or moc;6up restoration 1ith the selecte0 composites is an important step for color an0 shape selection. This extra step might% at first% seem li;e a 1aste of time% 9ut actuall2 much more time is 1aste0 if the final restoration 0oes not present a goo0 sha0e match. Part I of this series 0escri9e0 color an0 composite selec6 tion in great 0etail.>
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#igure 7. Initial 5ie1 of the maxillar2 central incisors 1ith 0eficient composite restorations. $sthetic anal2sis re5eale0 that the tooth length 1as the same as the 1i0th. A small increase in length 1as planne0.

#igure <. Tooth preparation 1ith empha6 sis to the 7 mm 9e5el. This conser5ati5e 9e5el 1as possi9le 9ecause 9oth central incisors are 9eing restore0. Small com6 posite excess 9e2on0 the 9e5el is allo1e0.

The follo1ing case report is use0 to illustrate the propose0 protocol. A health2% <C62ear6ol0 female pre6 sente0 to our clinic 1ith a 0esire to mo0if2 or replace the restorations of her maxillar2 central incisors o1ing to esthetics 3#igure 74. Ca5it2 Preparation After an intraoral e5aluation% sha0e selection% an0 mapping of the 0e6 tails present in the neigh9oring teeth 1hile the2 1ere still moist% the patient 1as anesthetiFe0 an0 the 0efecti5e restorations 1ere carefull2 remo5e0. The tooth preparation for

a proximoincisal 0efect shoul0 9e as conser5ati5e as possi9le% con6 sisting in exca5ating an2 existing carious 0entin an0Ior enamel% re6 mo5ing existing un0esire0 restor6 ati5e material an0Ior 9ase% an0 a00ing a facial enamel 9e5el to 9etter mas; the facial interface as 0iscusse0 9elo1. In this case a 7 mm roun0 9e5el 1as place0 3#igure <4. The preparation is not exten0e0 for retention an0Ior resistance form to a5oi0 1ea;ening the tooth an0 exposing the restoration to more lingual functional contacts than is a9solutel2 necessar2. The stan0ar0 preparation 0esign for a proximo6 incisal restoration in5ol5es the place6 ment of a 7 to < mm >DA 9e5el on the facial enamel for esthetics.D

tional >DA angle flat 9e5el can 9e replace0 92 a roun0 9e5el configu6 ration% 9ut there is no conclusi5e e5i0ence that fa5ors a single69e5el

An extension of the opaque 0entin o5er the 9e5el helps to mas; the interface% as is 0escri9e0 9elo1.B #or esthetic reasons the 9e5el is more important in the la6 9ial an0 proximal aspects than
metho0.K%7C in the lingual aspect% since the latter is not 5isi9le. The 9e5el coul0 9e re0uce0 or eliminate0 1hen the aim of the restoration is to 0iscreetl2 realign the tooth or teeth. If a 9ase material is use0 for pulp cap6 ping or pulp protection% the 9e5el shoul0 9e place0 after the 9ase to a5oi0 contamination of the margin 1hen placing the 9ase. Restoration margins place0 at the mi00le thir0 of the cro1n are easil2 notice0 o1ing to its importance in 0eter6 mining the tooth@s 5alue. These cases might require a 1i0er% more pronounce0 9e5el to 9etter hi0e the restoration@s margin. Inci0entall2% the cer5ical thir0 of a tooth pla2s a maAor role in 0etermining the tooth@s

The length of the 9e5el as 1ell as its 0epth t2picall2 respects the amount an0 thic;ness of the resi0ual natu6 ral enamel. Impro5ements in a06 hesi5e s2stems re0uce0 the nee0 of the 9e5el to achie5e retention%8 9ut 9e5els are still use0 to allo1 for a natural color transition from tooth to the restoration.B%J The tra0i6

chroma% the mi00le thir0 0etermines the tooth@s 5alue% an0 the incisal thir0 0etermines the tooth@s translu6 cenc2 characteristics.77 Restorati5e Tr26In an0 Silicone :ui0e Imme0iatel2 after the 9e5el prepa6 ration% a quic; restorati5e tr26in is performe0 to chec; the final to6 nalit2 of the pre5iousl2 selecte0

case presente0% the restorati5e tr26in 1as conclu0e0 successfull2 3#igure =4. A small increase in the tooth length 1as accomplishe0. The restorati5e tr26in 1as a0Auste0 in

#igure =. The tr26in restoration 0efines the anatomic form of the restorations an0 the composite sha0e an0 thic;ness for each increment. These tr26in restorations 1ere ma0e 1ith a free6han0 technique% 1ithout a0hesi5e proce0ures. Small shape corrections 1ere ma0e 1ith san0paper 0is;s an0 0iamon0 points. The lingual surface an0 the incisal e0ge recei5e special attention once the2 are copie0.

The tr26in also 0etermines the 9est anatomic form for the res6 toration to 9e copie0 on the silicone gui0e. It coul0 9e performe0 0irectl2 on the tooth or pre5iousl2 1axe0
resins.<E> in a stone mo0el. If ma0e intra6 orall2% the tooth shoul0 9e main6 taine0 h20rate0. The restorati5e tr26in shoul0 9e ma0e soon after the ca5it2 preparation% simulating the exact con0ition of the composite thic;ness. In Part I of this series% the relationship 9et1een tonalit2% thic;ness% an0 composite t2pe an0 the lac; of precision offere0 92 the commerciall2 a5aila9le sha0e gui0es 1as 0iscusse0%> as

the patient@s maximum inter6 cuspation position. The time in5este0 in generating a proper tr26in an0 custom matrix is later sa5e0 at con6 touring% finishing% an0 polishing. The restorati5e tr26in is impresse0 1ith a goo06qualit2% fast6setting sil6 icone putt2 material 3#igure >4. The impression shoul0 9e precise in the lingual surface an0 incisal 9or0er of the affecte0 teethLfree of 9u99les% fol0ings% or fissures. Hith a surgical 9la0e% the impression is sectione0 at a9out half the thic;ness of the

#igure D. The silicone gui0e is trimme0 at the incisal 9or0er. !nl2 the lingual half is use0 in this technique.

1as the change in tonalit2 that can happen after com6 posite curing.7<%7= The final restora6 tion can ha5e 0ifferences in tonalit2 if the restorati5e tr26 in has a 0if6 ferent thic;ness from the final res6 toration. !ther metho0s of sha0e selection ha5e 9een 0escri9e0 9ut are not totall2 appropriate for es6 thetic an0 0eman0ing situations such as the one 0escri9e0 here. In the

#igure >. A fast6setting silicone putt2 material is use0 to cop2 the lingual surface an0 incisal e0ge. This impression 9ecomes the silicone gui0e 3or ;e24.

incisal 9or0er% as sho1n in #igures D an0 8. !nl2 the lingual half of the gui0e is use0 in this technique. #igure B sho1s that the cut gui0e still maintains half the thic;ness of the incisal 9or0er% 1hich 1as slightl2 re0uce0 3#igure J4. !nce the custom matrix is o9taine0% it is set asi0e for a later use.

#igure 8. Lateral 5ie1 of the silicone gui0e re0uce0 in the correct place.

#igure B. The gui0e can 9e teste0 until full2 a0apte0. This photograph sho1s that the matrix nee0s re0uction at the incisal 9or0er.

#igure J. After a0Austment the entire facial surface can 9e 5isualiFe0.

#igure K. *ie1 of the teeth isolate0 an0 9on0e0.

/on0ing The teeth 1ere isolate0 1ith ru99er 0am for 9etter 5isualiFation of the composite la2ers% not 9eing man0a6 tor2 in this t2pe of restoration. The restorati5e tr26in 1as remo5e0% an0 the enamel an0 0entin 1ere etche0 an0 9on0e0 follo1ing current tech6 niques 3#igure K4. The silicone gui0e 1as seate0 an0 its a0aptation con6 firme0 3#igure 7C4. Insertion of the Translucent Lingual $namel A microh29ri0 composite 3Charisma I% ,eraeus MulFer% Armon;% )%

USA 4 1as selecte0 for the lingual enamel% ha5ing a 1hitish translucent tonalit2. A small amount of the composite 1as sprea0 across the correspon0ing lingual surface of the silicone gui0e 3#igure 774. Hith the composite still uncure0% the gui0e 1as seate0 on the teeth. Hhen o9ser5ing the profile of the tooth% an2 excess composite in the 0entin area shoul0 9e re0istri9ute0 or elimi6 nate0. The translucent resin cannot in5a0e the 0entin area 3#igure 7<4. After curing the lingual composite la2er for <C secon0s 1ith the gui0e firml2 ;ept in place% the gui0e is

remo5e0 3#igure 7=4N the lingual surface of the tooth is no1 esta96 lishe0 3#igures 7> to 784. These illustrations sho1 that the translu6 cent lingual enamel composite 0oes not in5a0e the 0entin area. Insertion of the Internal La2er of !paque &entin The internal la2er of opaque 0entin 0efines the chroma an0 opacit2 of

In our case the pa6 tient@s smile re5eale0 teeth 1ith

the restoration.7> lo1 chroma 39et1een A7 an0 A< in the *ita gui0e O*ita Pahnfa9ri;% /a0 Sac;ingen% :erman2Q4. Accor0ingl2%

#igure 7C. The gui0e is teste0 again to 5erif2 the a0aptation after the ru99er 0am insertion. The space that 1ill 9e fille0 1ith the restoration can 9e seen.

#igure 77. The composite correspon0ing to the lingual surface is place0 insi0e the gui0e 1ith silicone points an0 paint6 9rushes. $nough composite to fill the restoration area is place0% 1ithout too much excess. A translucent 1hitish resin 3Charisma Incisal4 1as chosen% simu6 lating the lingual enamel la2er.

#igure 7<. The gui0e is ta;en to the patient@s teeth prior to curing the com6 posite. Hith the composite a0aptation on the lingual margin% excess composite in5a0ing the 0entin area or lac; of composite are 5erifie0. The composite is pol2meriFe0 for <C secon0s.

#igure 7=. The gui0e is remo5e0 from the teeth% an0 the restoring space is 0efine0 3height an0 1i0th4 for the composite plate correspon0ing to the lingual surface.

#igure 7>. *ie1 of composite plate on the lingual surface. ote the excellent composite a0aptation to the 9e5el mar6 gins% re0ucing the finishing proce0ures in this area.

#igure 7D. Incisal 5ie1 of the lingual resin plate.

the opaque 0entin nee0e0 to 9e !/< or !A< 3Charisma !/<N $sthet6G !A<% &entspl2ICaul;% 'ilfor0% &$% USA4. ext% the composite is inserte0 against the lingual surface that is alrea02 cure0 3#igures 7B an0 7J4. The 0entin la2er shoul0 co5er Aust a part of the 9e5el% not exten0ing until its en0. This helps mas; the interface% resulting in an impercep6 ti9le composite6tooth transition. The

#igure 78. Proximal 5ie1 of the lingual resin plate. The proximal 5ie1 is use0 to o9ser5e 1hether the translucent composite in5a0e0 the 0entin area of the restoration.

0entin composite increment is mo06 ele0 similarl2 to the initial 0ra1n plan 3#igure 7K4. Such a 0ra1ing or map can 9e helpful in 0etermin6 ing 1ith more precision ho1 much of each sha0e is necessar2 in each location. #igure <C 0emonstrates se5eral forms that the 0entin mamelons can assume in the incisal thir0 of teeth. The larger the ma6 melon contrast is in the incisal thir0% the larger the opaque 0entin exten6 sion is to the incisal 9or0er. ot all patients require 5isi9le mame6 lons% 9ut 1hene5er necessar2% these opaque 0entin extensions shoul0

9e co5ere0 92 a high translucent enamel composite to increase its 5i6 sualiFation 3eg% #ilte; Supreme )T or :T% =' $SP$% St. Paul% ' % USAN $sthet6G )$% &entspl2ICaul;4. The composite la2ers are cure0 using a pulse60ela2 or soft6start metho0 to minimiFe shrin;age.7D Insertion of the Translucent &entin La2er This la2er complements the inner% more opaque 0entin. A translu6 cent 0entin la2er pro5i0es optical 5italit2 to the 0entin stratum. If onl2 opaque 0entin is use0% the resto6

#igure 7B. Composites correspon0ing to the 0entin are applie0 to the resin lingual plate. The placement of these increments is facilitate0 92 the cure0 lingual increment.

#igure 7J. The opaque 0entin shoul0 repro0uce the 0entin mamelons.

#igure 7K. Schematic 0ra1ing sho1ing the location an0 thic;nesses of the la2ers of composites 0rafte0 for the restora6 tion of the teeth. Hhen the mamelons nee0 to 9e more e5i0ent% the opaque 0entin shoul0 9e exten0e0 to the incisal 9or0er% creating a larger contrast 1ith the translucent enamel.

ration loo;s 0ull% matt% an0 too opaque. Some composites offer great 5ariation among the opaque an0 regular 0entin pastes. In the proxi6 mal areas an0 mamelons en0s% an A7 composite 3Charisma4 1as applie0. 'as;ing of the Composite6Tooth +unction To ensure that the composite6tooth Aunction is not noticea9le% this area is co5ere0 1ith a thin la2er of opaque microfill composite.B If the

use0 3eg% &urafill SL!% ,eraeus MulFer4. If the final 9asic sha0e is uni5ersal 3A<4% an opaque !A< or !/< is use0. This la2er shoul0 9e thin to not result in an opaque strip in the surface of the final restora6 tion. A microfill composite is the material of choice for this area o1ing to its 9rightness an0 polisha9ilit2 3#igure <74. Insertion of the Incisal !paque /or0er Hhen an incisal ??halo@@ effect is 0e6 sire0% an opaque h29ri0 or microfill composite shoul0 9e applie0 as a thin line across the incisal 9or0er 3#igure <<4. This optical phenome6 non is note0 especiall2 in 2oung natural teeth an0 can 9e repro0uce0 1ith composites.78%7B Insertion of the $namel La2er Proximoincisal restorations are lo6 cate0 1here the natural enamel is the thic;est. The enamel composite la2er fills the spaces 9et1een the mamelons an0 0efines the final res6 toration shape 3#igures <= an0 <>4. The thic;ness an0 0egree of trans6 lucenc2 of the composite use0 in this

#igure <7. A small amount of opaque microfill composite is 0istri9ute0 in a strip form follo1ing the resin6tooth Aunction o5er the 9e5el. This resin is alrea02 positione0 in the surface of the restoration. The finish an0 0istri9ution of this resin la2er shoul0 9e the 9est possi9le% emphasiFing the goo0 restoration shape.

la2er is 0irectl2 proportional to the translucenc2 characteristics of the a0Aacent natural enamel an0Ior teeth. Li;e1ise% the tone of the composite shoul0 follo1 the selec6 tion of the enamel tonalit2 of the patient@s teeth. #inal Coating 1ith 'icrofill Composite The long6lasting% high surface gloss an0 texture are o9taine0 1ith micro6 fill composites% pro0ucing a natural aspect. :loss an0 texture shoul0 repro0uce the existing characteris6

0esire0 final 9asic sha0e is /7 or /C% a lighter opaque resin shoul0 9e

#igure <C. A% Schematic sho1ing the most classic appearance of the incisal 9or0er. This format can 9e calle0 tri0igital 9ecause it presents three 0efine0 mamelons. /% This illustration in0icates another 1a2 of sho1ing the 0entin mamelons. The 0igital format comes 9ipartite3it occurs 1hen a single 0igit 0i5i0es in t1o an0s4% creating 0entin fillets that are proAecte0 in the 0irection of the incisal 9or0er. C% The form of the incisal mamelons sho1n here is more 0ifficult to recogniFe an0 repro0uce. !ften it is necessar2 to create internal paintings in this restoration area to e5i0ence these fine proAections of the 0entin in the 0irection of the incisal 9or0er.

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#igure <<. After the opaque microfill resin is applie0% it is possi9le to notice larger softness in the sha0e transition from resin to the tooth 3in the area of the 9e5el4.

#igure <=. *ie1 of the facial enamel la2er placement. A thin la2er of Cha6 risma Incisal 1as 0istri9ute0 in the facial area of the restoration% 1ith limits among the incisal 9or0er an0 the la2er of the opaque microfill resin an0 proximal areas. The interproximal contact 1as not 2et esta9lishe0% an0 care 1as require0 to a5oi0 gluing one tooth to another. #ine paint9rushes an0 fine metallic spatulas 1ere use0 to mo0el the resin in the proximal areas.

#igure <>. #lat paint9rushes a9out = to D mm 1i0e are use0 to mo0el the facial composite. At this time the shape is practicall2 conclu0e0% 9ut a small space exists for the microfill coating.

tics of the a0Aa cent ena mel an0I or teet h.7J

The col or sele ctio n sho ul0 9e sim ilar to the ena mel la2e r% an0 usu all2

A u s t o n e c o l o r i s u s e 0 9 e 6 c a u s e t h

e 0e sir e0 to na lit 2 ha s al 6 re a0 2 9e en in se rt e0 . T he pr o xi m al

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area has a 0ou9l e con5 exit2% facial to lingu al an0 cer5i cal to incis al. $xce ss comp osite is remo 5e0 an0 paint 9rus hes help to 0istri 9ute an0 plane the comp

os ite in th e su rf ac e. T he ap pl ic ati o n of thi s la 2e r sh o ul 0 no t re qu ire m or

e tha n thre e inc re6 me nts% alth oug h the nu m9 er of inc re6 me nts 0ep en0 s on the ext ens ion of the 0ef ect. If

mo re tha n one inc re6 me nt is use 0% car e sho ul0 9e ta; en to a5 oi0 the 0e5 elo pm ent of un 0es ir6
a9l e co mp

o s i t e i n t e r f a c e s . # i n a l $ 5 a l u a t i o n o f t h e S h

a p e a n 0 P o l i s h i n g T h e fi n al s h a p e is c h e c ; e 0 fr o m a l l a n

gle s to cert if2 that no exc ess or lac ; of co mp osit e is pre sen t

3#igures <DE<B4. If an excess is note0% a cur5e0 scalpel 9la0e an0Ior san0pap er 0is;s are use0 to contour the restorati on. Care shoul0 9e ta;en 1hen appl2ing the composit e la2ers 9ecause too much excess can result in the operator remo5ing the character iFation o9taine0 from the la2ering technique

upon a0Austing the restoratio n contour 3#igure <J4. As the restoration @s contours are esta9lishe0 0uring the insertion of

#igure <D. The cer5icoi ncisal 5ie1 is use0 to 0etermi ne 0eficien cies in the facial contour .

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the composite la2ers% the nee0 for gross re0uction an0 contouring 1ith rotar2 instruments is greatl2 mini6 miFe0. If anatomic form a0Austments are 0eeme0 necessar2 after all com6 posite has 9een place0 an0 cure0% fine

0iamon0s or spiral6 cut multi6 9la0e0 9urs can 9e use0. Roun0 an0 o5al instrumen ts are use0 on the lingual surface% an0 flame6 shape0 instrumen ts are use0 on the facial

surface an0 proximal em9rasure s.

#igure <8. Incisal 5ie1. Loo;ing ??up@@ from the incisal e0ge% the clinician shoul0 0etermine at this point 1hether more composite is necessar2.

#igure <B. #rontal 5ie1 9efore remo5al of the ru99er 0am.

#igure <J. #rontal 5ie1 after the ru99er 0am has 9een remo5e0 an0 9efore polishing. ote the minimal excess composite present.

#igure <K. #rontal 5ie1 after polishing an0 reh20ration of the teeth.

Polishing resulting in a high gloss can 9e o9taine0 in se5eral 1a2s an0 1ith 0ifferent polishing instruments. Surface smoothness generall2 is pro0uce0 1ith lo16spee0% ru99er6 9ase0 0is;s or cups 3eg% +iff2 Polishers% Ultra0ent Pro0ucts Inc.% South +or0an% UT% USAN Po:o% &entspl2ICaul;N Contour an0 &6#ine% Clinician@s Choice4. A paste is t2picall2 use0 for polishing 3eg% !pal no. D<C6CCC% Renfert% ,ilFingen% :erman2 4. ,igh gloss is o9taine0 1ith a 9rush of natural 9ris6 tles rotating on the resin 3#igure <K4. The surface of anterior composite

restorations is sometimes flat% some6 times roun0e0% so the goal of fin6 ishingIpolishing is to generate a composite surface that mimics the a0Aacent natural tooth surface not onl2 in optical properties 9ut also in surface texture. Care shoul0 9e ta;en not to eliminate the natural enamel surface texture a0Aacent to the restoration 0uring the finishingI polishing process.
&I SCUSSI !

0ifficult2 encountere0 92 man2 cli6 nicians. A 0ar;62ello1 or gra2ish line at that interface ma2 occur after the complete h20ration of the tooth% 1hich is not noticea9le until hours after the completion of the restoration. The 0ar; line can 9e cause0 92 sclerotic 0entin in the interface in6 creasing the opacit2 an0 chroma 3#igure =CA an0 /4. Hhen the tooth6 restoration is o9ser5e0 in a frontal 5ie1% the inner 0ar; tonalit2 appears in the surface as a gra2 or 9ro1n line. #or recentl2 fracture0 teeth in

!9taining an in5isi9le composite6 tooth interface 1hen restoring anterior teeth 1ith composites is a

#igure =C. Replacement of a 0eficient proximoincisal restoration on a maxillar2 central incisor. A% Preoperati5e 5ie1. Sha0e selection for this tooth nee0s a clear an0 lo1 translucenc2 enamel in the incisal thir0. &entin mamelons are not 5isi9le. The opaque 0entin shoul0 9e light in tone. /% After remo5ing the unsatisfactor2 restoration% it is possi9le to notice the opaque an0 0ar; sclerotic 0entin. To mas; such 0entin% a less conser5ati5e 9e5el is necessar2. A = mm 9e5el 1as ma0e to increase the material thic;ness almost simulating the o5erla2 or composite 5eneer technique. C% Postoperati5e 5ie1 of the restoration after polishing an0 h20ration of the tooth.

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1hich sclerotic 0entin has not 2et forme0% the interface ten0s to 9e less 5isi9le. ,o1e5er% the 0ar; line can 9ecome 5isi9le o5er time. The 0ar; line can 9e also cause0 92 light inter6 action 1ith the interfaces of the composite% a0hesi5e% an0 tooth o1ing to more light penetration in this area. If the light is not reflecte0 similarl2 to the tooth 9ut is rather a9sor9e0% a slight re0uction in 5alue is notice0% resulting in the 0ar; color. An a9rupt 0ifference in 5alue an0 translucenc2 of the 0entin com6 posite in comparison 1ith the tooth can also ren0er the restora6 tion noticea9le. Mno1le0ge of the tooth structure optical properties an0 correlation 1ith the composites is necessar2. The central area of the tooth is crucial for the 5isual im6 pression of its 5alue 3#igure =CC4. The 0entin composite la2er shoul0 react to the inci0ent light 30iffusion% reflection% an0 refraction4 similarl2 to the 1a2 natural 0entin reacts. If the light penetrates into the com6 posite more than into the tooth% it means that the composite is more translucent than the tooth% 1hich 1ill ma;e it appear too gra2. #inall2% it shoul0 9e note0 that restorations place0 in relati5el2 translucent areas of teeth% such as proximoincisal composite restora6 tions% e5en 1hen perfectl2 matche0 in the imme0iate postoperati5e perio0% might 9ecome 5isi9le o5er time o1ing to changes in 9oth the natural tooth an0 in the com6 posite material.

C!

CLUSI!

Hith the impro5ement experience0 on composite technolog2% more an0 larger anterior 0ental 0efects can 9e restore0 successfull2 1ith 0irect composite resins as oppose0 to more in5asi5e ceramic restorations. This is particularl2 true 1ith 2oung patients in 1hom ceramics might not 2et 9e in0icate0. The restoration of proximoincisal 0efects 1ith com6 posite requires attention to 0etail% a goo0 un0erstan0ing of color an0 sha0e selection% an0 the use of correct composite materials an0 sha0e3s4% as 1ell as the application of a protocol compose0 of logical steps that ena9le the clinician to o9tain satisfactor2 esthetic results 1ith less guess1or;.
&IS C L!SUR$

8. 'eer9ee; /*% Per0igaR o +% Lam9rechts P% *anherle :. Clinical performance of a0he6 si5es. + &ent 7KKJN <8:7E<C. B. #ahl . !ptimaiFing the esthetics results of Class I* restorations 1ith composite resins. + Can &ent Assoc 7KKBN 8=: 7CJE77D. J. #ree0man :. Color communication. + $sthet &ent 7KK>N 8C:8KDE8KK. K. :ol0stein R$. $sthetics in 0entistr2. <n0 $0. ,amilton% ! : /C &ec;er Inc% 7KKJ. 7C. :ol0stein R$% #einman RA% :ar9er &A. $sthetic consi0erations in the selection an0 use of restorati5e materials. &ent Clin orth Am 7KJ=N <B:B<=EB=7. 77. #elippe LA% 'onteiro S +r% /aratieri L % An0ra0a CAC% Ritter A*. Using opaquers un0er 0irect composite resin 5eneers: an illustrate0 re5ie1 of the technique. + $sthet Restor &ent 7KK=N 7D: =<BE==8. 7<. S1ift $+ +r% ,ammel AS% Lun0 PS. Colori6 metric e5aluation of *ita sha0e resin composites. Int + Prosthet &ent 7KK>N B: =D8E=87. 7=. Segui RR% :ritF '&% Mim +. Colorimetric changes in composites resulting from light initiate0 pol2meriFation. &ent 'ater 7KKCN 8:7==E7=B.

The authors 0o not ha5e an2 finan6 cial interest in the companies 1hose materials are 0iscusse0 in this article.
R$#$R$ C $S

7>. !@/rien H+. &ou9le la2er effect an0 other optical phenomena relate0 to esthetics. &ent Clin orth Am 7KJDN <K:88BE8B<. 7D. Hatts &C% ,in0i AA. Intrinsic ??soft6start@@ polimerisation shrin;age6;inetics in an acr2late69ase0 resin6composite. &ent 'ater 7KKKN 7D:=KE >D. 78. U9ass2 :. Shape an0 color: the ;e2 to successful ceramic restoration. /erlin: Suintessence Pu9lishing Co% 7KK<. 7B. *anini L% 'angani #'. &etermination an0 communication of color using the fi5e color 0imensions of teeth. Pract Proce0 Aesthet &ent <CC7N 7=:7KE<8. 7J. /aratieri L % 'onteiro S +r% An0ra0a 'AC% et al. $sthetic60irect a0hesi5e resto6 rations of fracture0 anterior teeth. Chicago: Suintessence% 7KKD.

7. Croll TP% /ulloc; :A. /on0e0 resin69ase0 composite cro1n restoration of 0iminuti5e lateral incisors. Comp Contin $0uc &ent <CC<N <=:DDCEDDK. <. &ietschi &. #ree6han0 composite resin restorations: a ;e2 to anterior aesthetics. Pract Perio0ontics Aesthet &ent 7KKDN B:7DE<D. =. *anini L. Light an0 color in anterior composite restorations. Pract Perio0ontics Aesthet &ent 7KK8N J:8B=E8J<. >. #elippe LA% 'onteiro S +r% An0ra0a CAC% Cerqueira A&% Ritter A*. Clinical strategies for success in Class I* composite restora6 tions. Part I: un0erstan0ing color an0 composite selection. + $sthet Restor &ent <CC>N 78:==8E=>B. D. ,e2mann ,!. 'o0ifie0 ca5it2 prepara6 tions for composite resins. + Tenn &ent Assoc 7KJ=N 8=:>8E>K.

Reprint requests: LuTs Anto" nio #elippe% &&S% 'S&% Rua Lauro Linhares 7CBD% Sala /% Trin0a0e% #loriano polis% SC JJC=86CC7% /raFilN e6mail: proffelUterra.com.9r n<CCD /C &ec;er Inc