Table of Contents

Endodontics
Periodontics
Restorative

Inside Dentistry

May 2007, Volume 3, Issue 5
Published by AEGIS Communications

Enhancing the Polychromatic Effect of Direct Composite Anterior Restorations Using Coloring Resins

Frank J. Milnar, DDS

Albert Einstein said that after a certain high level of technical skill is achieved, science and art tend to coalesce in esthetics, plasticity, and form.1 He concluded the premise by saying that the greatest scientists are always artists as well. Today, dentists can acknowledge this phenomenon when they realize that improved composite resin materials and adhesive techniques have made it possible for them to predictably implement a conservative, practical, and esthetic approach to direct restorations.2 Once the clinical and functional parameters of a case have been identified, dentists can determine the techniques, materials, and tools that should be incorporated into the treatment plan in order to achieve the patient’s desired esthetic results, and do so in the most conservative manner possible.3 This type of systematic, evaluative process ensures that the case will be completed to the satisfaction of the patient’s esthetic needs, as well as in terms of minimizing the amount of otherwise healthy tooth structure that would be sacrificed during the restorative process.4

A variety of functionally supportive and esthetic alterations can be achieved using a category of direct composites called small-particle hybrids (Vit-l-escence™, Ultradent Products, Inc, South Jordan, UT; Point 4, Kerr/Sybron, Orange, CA; Venus™, Heraeus Kulzer, Armonk, NY; Esthet-X®, Dentsply Caulk, Milford, DE), which has been cited in the literature as demonstrating better mechanical, physical (eg, strength, wear, and handling), and optical properties than previously available composites.5,6 This bis-GMA–based fluorescent and opalescent composite system incorporates fillers with a size of 0.07 µm, according to the manufacturer, and it provides the necessary low-translucency, fluorescent dentin composites and high-translucency, opalescent/transparent enamel composites that lend themselves to a durable and natural-looking restoration.

In many instances, a natural layering concept can be used to create restorations with only dentin and enamel composites that optically mimic natural tooth structure.7 However, there are occasions when the most natural effect (ie, matching restorations to the natural characterizations observed in adjacent teeth and/or the same tooth) requires the application of tints and stains to create the intricate refinement of hue, chroma, and value necessary to produce an imperceptible restoration.8

This article presents a case in which a 49% filled, light-cured, bis-GMA composite coloring resin (Vit-l-escence Colors, Ultradent) was used to facilitate color matching and enhancement of the anatomical and morphological nuances when creating two Class IV direct composite restorations for a 20-year-old beauty pageant contestant. The pink, yellow, blue, light/dark brown, white, orange, clear, and ochre colors enabled these restorations to be completed with even polychromatic customization that ultimately contributed to a highly esthetic result.

CASE PRESENTATION

On presentation, the patient’s maxillary central incisors—teeth No. 8 and No. 9—were visibly detracting from the esthetics of her smile because the composite restorations that had been previously placed to repair Class IV fractures had become worn and discolored (Figure 1). The patient indicated that she was not interested in porcelain veneers or any treatment that would require additional removal of her remaining tooth structure. Rather, she wanted conservative yet artistically created composite restorations.

A thorough examination was performed that included radiographs and intraoral and extraoral photographs. The patient’s periodontal health and occlusion were inspected and, overall, the patient was found to be in excellent oral health. No pathologies were found that would contraindicate re-restoration and esthetic enhancement with direct composite placement.

PreoperativeTreatment Planning

The patient’s maxillary central and lateral incisors were thoroughly analyzed to determine the most appropriate composite shades necessary to affect the desired overall esthetic results. A combination of spectrophotometry (Figure 2) and visual assessment were used to record details of the appearance of the affected dentition. These details included variations in the hue, chroma, and value of the tooth structure, as well as the condition of the dentin and enamel, tooth shape, characterizations, and texture.

Initially, composite shades A1, B1, and Pearl Frost were identified as the shades for the dentin and enamel replacement composites. To ensure the esthetic success of the proposed direct composite placement treatment, an understanding of the optical characteristics of the patient’s natural teeth—and, subsequently, the optical properties of the selected restorative material—was imperative.9

A putty stent of the patient’s maxillary arch was fabricated for use as a dimensional guide during composite placement and previewed in the patient’s mouth (Figure 3).10 Class IV fractures have been successfully treated with direct resin-based composites,11 but such restorations require the development of proper and functional lingual contours, as well as an understanding of natural tooth anatomy, tooth color, and the role tooth structure plays in both.11

Composite Placement

The selected composite shades were previewed on the patient’s maxillary central incisors before tooth preparation (Figure 4). Before starting the preparation process, the patient was anesthetized; the lips and cheeks were properly retracted; and cotton rolls were placed for intraoral fluid control. The preexisting composite restorations were removed, and the preparations were refined (Figure 5 and Figure 6). The preparations were then thoroughly cleansed and scrubbed using an antibacterial agent.

The preparations for teeth No. 8 and No. 9 were etched for 20 seconds using 37% phosphoric acid (Figure 7), rinsed for 15 seconds with an air/water spray, and lightly air-dried, as was the uncut enamel of teeth No. 7 and No. 10. A single-component adhesive bonding agent (PQ1®, Ultradent) was applied to the etched enamel for 15 seconds (Figure 8), lightly air-dried for 5 seconds, and then cured with an LED curing light for 20 seconds per tooth.

Then, the first lingual/proximal layer of composite in Opaque Snow was placed on both teeth No. 8 and No. 9 to control opacity, prevent show-through, and serve as a zone of neutrality onto which the inherent hue, chroma, and value of the teeth could be built (Figure 9). Color blending using composite translucency, as well as mixing color tints to modify composite color, can produce natural-looking restorative effects.12 The material was carefully manipulated and shaped, using the putty stent as a guide to help facilitate subsequent finishing endeavors.13 This layer was cured for 10 seconds per tooth.

Then, before building up the dentin replacement layer, a combination of colored/tinted resins (Vit-l-escence Colors) (Figure 10) was applied to add warmth (chroma) to the neutral Opaque Snow layer. Specifically, a 50/50 mixture of yellow and clear-colored resin was applied (Figure 11), after which the resin was light-cured for 10 seconds per tooth. It has been suggested in the literature that opaquers, tints, and color modifiers may be extremely useful in altering the chromatic appearance of restorative substrates, contributing to predictable esthetic results.14

The dentin replacement layer composite in shade B1 was then applied to teeth No. 8 and No. 9 for mamelon development and cured for 10 seconds per tooth. To construct the incisal edge, enamel composite in Pearl Neutral was placed on both teeth and cured for 10 seconds, after which a combination of tints (30% blue, 70% clear) was applied to create the illusion of translucency along the incisal third, between the mamelons (Figure 12). This resin enhancement was also cured for 10 seconds per tooth.

Because the patient’s adjacent natural dentition also exhibited a “high-value halo” in the incisal area, this illusion was created with the application of another combination of colors—50% white and 50% clear—to both teeth No. 8 and No. 9 (Figure 13). Appropriate curing was then performed.

To complete the restorations, a final enamel layer of Pearl Frost composite was placed on each tooth, shaped, and sculpted. Each restoration was then fully light-cured for 60 seconds from multiple directions.

It is important to note that on teeth No. 7 and No. 10, incisal augmentation was completed using the Opaque Snow and Pearl Frost composites to improve the incisal silhouette.

Finishing and Polishing

Ultrafine finishing and polishing discs (VisionFlex, Brasseler USA, Savannah, GA) were used for incisal edge adjustments, as well as for opening the incisal embrasures. Initial surface texturization was completed using a green Brasseler stone. A lifelike luster was achieved using a series of high-shine polishing cups and points (Jiffy®, Ultradent) (Figure 14 and Figure 15). Tertiary anatomy (ie, surface texture and morphology) was created using the green stone (Figure 16), while final finishing was completed using burs contained in a specially designed finishing kit (New Horizon Composite Finishing System, Frank J. Milnar, DDS; #K0097, Brasseler USA).

The restorations were complete after final polishing with a goat-hair wheel and 0.5-µm diamond polishing paste (Figure 17). At that time, the final restorations on teeth No. 8 and No. 9 were verified using the putty stent (Figure 18).

CONCLUSION

More and more patients are choosing to enhance their smiles or to restore defects such as Class IV fractures in conservative ways. This is now possible in esthetic ways when today’s direct composites are skillfully and artistically applied after thoughtful consideration of the tooth’s appear-ance and characteristics (Figure 19 and Figure 20). Using an appropriately selected direct composite system that preserves and conserves the tooth restoration complex can help dentists deliver the patient’s desired esthetic results with minimal sacrifice of otherwise healthy natural tooth structures.3,15

ACKNOWLEDGMENT

The author would like to acknowledge Douglas A. Terry, DDS, a clinician and dental artist, for mentoring and encouraging other dental professionals to exercise their imaginations in the creative use and artistic placement of direct composites. By pushing the limits of color modification and composite placement, he has skillfully refined the technical process of replicating nature during the restorative protocol.

DISCLOSURE

Dr. Milnar has received financial and materials/product support from Ultradent Products, Inc, and Brasseler USA.

References

1. Discover Magazine Web site. Physics and Math Page. Available at: http://www.discovermagazine.com/2004/sep/thinktank/article_view?b_start:int=2&-C=. Accessed March 13, 2007.

2. Heymann HO, Hershey HG. Use of composite resin for restorative and orthodontic correction of anterior interdental spacing. J Prosthet Dent. 1985;53(6):766-771.

3. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132(1): 39-45.

4. Staehle HJ. Minimally invasive restorative treatment. J Adhes Dent. 1999;1(3):267-284.

5. Mopper KW. Maximizing the potential of composite artistry: three decades of direct resin bonding. Picture Perfect Aesthetics: The AACD Monograph. Vol. II. Mahwah, NJ: Montage Media Corporation; 2005:95-99.

6. Terry DA. Natural Esthetics with Composite Resin. 1st ed. Mahwah, NJ: Montage Media Corporation; 2004.

7. Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations. Quintessence Int. 2006;37(2): 91-102.

8. Fahl N Jr, Denehy GE, Jackson RD. Protocol for predictable restoration of anterior teeth with composite resins. Oral Health. 1998;88(8): 15-22.

9. Terry DA, Leinfelder KF. An integration of composite resin with natural tooth structure: the Class IV restoration. Pract Proced Aesthet Dent. 2004;16(3): 235-242.

10. Behle C. Placement of direct composite veneers utilizing a silicone buildup guide and intraoral mock-up. Pract Periodontics Aesthet Dent. 2000;12(3)259-266.

11. Felippe LA, Monteiro S Jr, De Andrada CA, Ritter AV. Clinical strategies for success in proximoincisal composite restorations. Part II. Composite application technique. J Esthet Restor Dent. 2005;17(1):11-21.

12. Chalifoux PR. Composite tints: mixing composite materials to alter color and techniques to simulate hypocalcification and craze lines. Compend Contin Educ Dent. 2004;25(8): 583-588.

13. Peyton JH. Finishing and polishing techniques: direct composite resin restorations. Pract Proced Aesthet Dent. 2004;16(4): 293-298.

14. Dias WR, Pereira PN, Swift EJ Jr. Maximizing esthetic results in posterior restorations using composite opaquers. J Esthet Restor Dent. 2001;13(4):219-227.

15. Terry DA, Geller W. Selection defines design. J Esthet Restor Dent. 2004;16(4): 213-225.

About the Author
Frank J. Milnar, DDS
Private Practice in Family
Cosmetic and Restorative Dentistry
Saint Paul, Minnesota