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Inside Dentistry
January 2024
Volume 20, Issue 1
Peer-Reviewed

Streamlining Layered Composite Veneer Procedures

Enhance efficiency while maintaining impeccable esthetics by incorporating transparent matrices

Sandra Hulac, DDS

The delivery of no-preparation direct composite veneers is an immensely popular treatment approach in everyday dental practice. For younger patients, they often constitute the most singularly prudent choice to achieve an esthetic outcome. Moreover, an increasing number of adult patients are gravitating toward this noninvasive treatment, which may be a result of cautionary tales circulating online about mishaps involving porcelain veneers with excessive tooth preparations and subsequent costly corrective measures.

The execution of layered composite veneers that demonstrate the highest esthetic value demands a substantial amount of practice. Even seasoned practitioners of the technique acknowledge that, despite years of experience, a case involving ten units can still occupy a significant portion of their workday. As an alternative, a method of placing direct composite veneers using an injection molding technique with flowable composite has gained notable popularity. This approach markedly reduces the chairside time required for composite veneer procedures. Unfortunately, although the esthetic outcomes of injection-molded composite veneers are commendable, they lack the nuanced color variations exhibited by layered composite veneers. Furthermore, some practitioners have noted that certain flowable composites exhibit low color value when used in the injection molding method.

By beginning with a traditional composite layering technique and then applying the final layer to multiple teeth at once with the aid of a transparent matrix derived from a wax-up, the composite veneering process can be significantly expedited without any compromise to the esthetic result. This approach can modify zones of light reflection, manipulate and highlight lengths or widths, and ultimately yield a transformed perception of the appearance of the teeth. It is particularly advantageous in cases with difficult space distribution, where the precise placement of line angles and secondary anatomy is of paramount importance. In addition, another advantage of the procedure is the reduction of surface irregularities that often result from the freehand application of the final layer and require time-consuming corrections.

Ideally, the wax-up is created by the dentist to ensure comprehensive control over the outcome; however, a dental technician can also carry out this task using analog or digital methods. Similar to the injection molding technique, two matrices are fabricated per arch to enable a time-efficient "alternating tooth" strategy. In this strategy, the first matrix is loaded with composite to simultaneously apply the final layers to half of the treated teeth (ie, every other tooth), and then the second matrix is used to apply the final layers to the remaining teeth. These matrices are cut to permit greater ease in the "pressing on phase," facilitate easier removal of any excess composite, and to permit the placement of a split dam for moisture control.

This case demonstrates the esthetics that can be achieved using this technique, which, based on the practitioner's experience, can reduce chairside time by approximately 40%.

Sandra Hulac, DDS
Fellow
American Academy of Cosmetic Dentistry
Private Practice
Hong Kong, China

(1.) Pretreatment smile photograph demonstrating failing composite veneers on teeth Nos. 6 through 11.

Figure 1

(2.) Pretreatment left lateral photograph showing the large diastema between teeth Nos. 10 and 11 that had not been fully closed despite the substantial addition of material to tooth No. 11.

Figure 2

(3.) View of the smile design, which included lengthening in order to achieve the correct proportions and close the diastemas.

Figure 3

(4.) A wax-up based on the smile design was carried out by the practitioner.

Figure 4

(5.) The wax-up was duplicated, and then every other tooth was removed from it. Similar to the injection molding technique, these two models would enable the fabrication of two sequential matrices—an initial one to place the final composite layer on the first half of the teeth and a secondary one to place the final composite layer on the second half.

Figure 5

(6.) Intaglio view of the transparent matrices (Finopaste Crystal, Fino GmbH) that were produced. Note that these are open on the palatal aspect in order to facilitate the removal of excess composite and have no holes in the incisal aspects, which is different from the matrices used in the injection molding technique.

Figure 6

(7.) The matrices were placed on the cast and cut in order to facilitate the placement of rubber dam clamps.

Figure 7

(8.) After a split dam (Isodam®, Sigma Dental Systems) and retraction cord were placed, the previously placed composite restorations were removed and a lingual matrix (Lab Putty, Coltene) was tried in.

Figure 8

(9.) View of the lingual shelves (IPS Empress® Direct [Trans 30], Ivoclar) that were placed every other tooth for the teeth to be treated using the first transparent matrix. Dentin and side layers (inspiro® [Bi 1 and Bi 2], Edelweisss DR; IPS Empress® Direct Flow [Trans Opal], Ivoclar)were then applied using a conventional layering technique. After layering, it is recommended to smooth out the entire facial surface with a finishing diamond bur and reapply the bonding agent. This will ensure that the teeth have smooth surfaces to press the final layer of composite onto, which will help to avoid trapping air bubbles. Isolating the teeth that aren’t being treated using PTFE tape is optional during this “first round.”

Figure 9

(10.) A more transparent shade of composite (IPS Empress Direct [Trans 30], Ivoclar) was placed into the incisal part of the first matrix, followed by an enamel shade (IPS Empress Direct [B1 Enamel], Ivoclar) in the middle and cervical third. The matrix was then placed onto the teeth, and the final composite layers were light cured through it.

Figure 10

(11.) View of the completed first round of composite veneers. Any excess composite was easily removed with a No. 12 scalpel blade.

Figure 11

(12.) All of the teeth treated during the first round were isolated with PTFE tape to protect them during the second round, in which all of the remaining teeth were treated using the same protocol and materials.

Figure 12

(13.) Intraoperative view following placement of the second round of composite veneers. The primary anatomy would require very little correction.

Figure 13

(14.) Postoperative full smile photograph demonstrating the improved lengths and proportions of the teeth.

Figure 14

(15.) Postoperative left lateral photograph showing that the diastema between teeth Nos. 10 and 11 is fully closed.

Figure 15

(16.) Postoperative close-up maxillary view showing the internal characterization of the veneers achieved using this technique.

Figure 16

Sandra Hulac, DDS

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