Vanini described an anatomical stratification technique that goes beyond the typical three dimensions (hue, chroma, value) of color. The technique, especially useful when esthetic demands are high, enables dentists to predictably create life-like esthetic restorations that are indistinguishable from natural teeth. [1, 2]
Introduction
A 10-year-old male patient reported with a complaint of trauma to the upper left central and lateral incisors, involving the enamel and dentin. Direct composite was used in multi-layers and the smile was restored. This article explains detailed steps in the polychromatic layering technique with special emphasis on the finishing and polishing protocol. 3M Espe Filtex Z350 Xt was used with a universal bonding agent.
Fig 1-7: Evaluation and mock up
Fig 1: Intraoral view of the initial situation (class IV fracture with 11 and 12).
Fig 2: A close-up smile view.
Fig 3: Shade was evaluated with the “Button technique”. A2 Dentin was used for inner layer and incisal halo, A2 Body for mid layer, Clear Translucent for opalescence and A2 Enamel for outer layer.
Fig 4: A monochrome picture helps evaluate the Value. A2 Enamel was chosen for this case.
Fig 5: Quick intra-oral mock-up was performed without etching and bonding. This can also be done with the chosen shades of composite to roughly evaluate the selected shade.
Fig 6: Occlusion was checked and adjusted accordingly.
Fig 7: Once verified, a putty index was made with A-Silicone to record the palatal surface.
Fig 8-18: Bonding and palatal shell
Fig 8: After thorough prophylaxis, the concerned site was isolated with a rubber dam and further retraction of gingiva was achieved with the help of floss ties.
Fig 9: Using fine grit bur all unsupported enamel was removed and 2mm short bevel was given.
Fig 10: The bevel allows better integration between the composite restoration and the remaining dental tissue.
Fig 11: Selective etching with 37% Phosphoric acid was used to etch the enamel for 20 seconds.
Fig 12: After thoroughly rinsing for 20 seconds the tooth was dried completely.
Fig 13: A single bond universal from 3M was used as the adhesive. The bond was applied in scrubbing motion for 10 seconds and the excess was removed with a fresh applicator tip and light cured.
Fig 14: The silicone index was then used to build the palatal shell which served as the base to further layer composite.
Fig 15: The extent of the palatal surface was marked using a probe.
Fig 16: Clear translucent shade was used to build the palatal surface.
Fig 18: With the final palatal shape it is easy to foresee the final shape for the final composite resin restoration.
Fig 19-24: Contact build-up with band and wedge
Fig 19 and Fig 20: The sectional matrix for posterior teeth was used in a vertical direction and stabilized with wedge on both mesial and distal side.
Fig 19 and Fig 20: The sectional matrix for posterior teeth was used in a vertical direction and stabilized with wedge on both mesial and distal side.
Fig 21: Mesial wall was built with A2 body shade.
Fig 22: Distal wall was built with A2 body shade.
Fig 23: Interproximal build-up was done on both mesial and distal side.
Fig 24: After interproximal build-up, the band and wedge were removed, leaving behind the scaffold for further layering.
Fig 25-30: Layering protocol step by step
Fig 25: A2 Dentin was used for the inner layer and dentinal structures were created using 3 well-defined lobes.
Fig 26: It was bulked up till the start of the bevel slightly covering the bevel.
Fig 27: A2 Body was used to build the mid layer and multiple lobes were created to mimic the adjacent tooth.
Fig 28: A2 Dentin which is opaque was used at the incisal edge to create an incisal halo.
Fig 29: Clear Translucent was used to fill the space between the incisal edge and the mamelons in order to increase the translucency at the incisal third.
Fig 30: Final A2 Enamel was used for outer layer giving it proper contour and final form.
Fig 31-41: Polishing protocol and post-op
Fig 31: Primary anatomy was marked using a lead pencil.
Fig 32: Sof-Lex finishing coarse disc was used to define the mesial and distal line angle at slow speed without irrigation.
Fig 33: Sof-Lex finishing medium disc was used to reduce the surface roughness at a slow speed without irrigation.
Fig 34: Sof-Lex finishing fine disc was used to smoothen the surface at high speed with irrigation.
Fig 35: Sof-Lex finishing super fine disc was used for final finish and shine at high speed with irrigation.
Fig 36: The secondary anatomy was obtained using Shofu white finishing stone to create undulation often referred to as the “Eiffel Tower”. It is always important to evaluate the depth and the extension in the neighboring tooth so as not to exaggerate its presence.
Fig 37: Diamond-impregnated polisher was used for surface refinement at high speed with irrigation.
Fig 38: Buff was used for the final glass-like finish and polished at high speed with irrigation.
Fig 39: Final composite resin restoration immediately after the polishing procedure.
Fig 40: Life-like appeal to final restoration.
Fig 41: Note the natural integration of the composite resin with the dental tissue.
Conclusion
The article demonstrates how using the right protocols and armamentarium for composite materials can give life-like results in a short time in a minimally invasive way. No single layering technique can ensure a 100% success rate. Regardless of the technique, establishing good secondary and tertiary anatomy and thorough polishing are the key steps that make a restoration look more natural. Composite is the perfect material for allowing correction of mistakes or improvement.
References
- Vanini L. Conservative composite restorations that mimic nature. A step–by-step anatomical stratification technique. J Cosmet Dent 2010; 26(3): 80–98
- Vanini L, Mangani FM. Determination and communication of color using the five color dimensions of teeth. Pract Proced Aesthet Dent. 2001 Jan-Feb;13(1):19-26; quiz 28. PMID: 11301528.
Custom shield Technique
An idea of Gaetano Paolone and Salvatore Scolavino and the style italiano team, is the "Custom Shield technique”. In this technique the height and the ...
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Prof. Penny Hatzimanolakis:sharpen(level=0):output(format=png)/up/dt/2011/07/fdi.png "FDI World Dental Federation")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/ROOTS-SUMMIT-2024_Dr-Antonis-Chaniotis.jpg "“The concept of the root canal blockage course was born out of the desire to teach and practise different techniques”")
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:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/ROOTS-SUMMIT-2024_Dr-Antonis-Chaniotis.jpg "“The concept of the root canal blockage course was born out of the desire to teach and practise different techniques”")
:sharpen(level=0):output(format=png)/up/dt/2023/09/Neha-Gupta-300x300.png "Dr. Neha Gupta")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig1.jpg "Fig 1: Intraoral view of the initial situation (class IV fracture with 11 and 12).")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig2.jpg "Fig 2: A close-up smile view.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig3.jpg "Fig 3: Shade was evaluated with the “Button technique”. A2 Dentin was used for inner layer and incisal halo, A2 Body for mid layer, Clear Translucent for opalescence and A2 Enamel for outer layer.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig4.jpg "Fig 4: A monochrome picture helps evaluate the Value. A2 Enamel was chosen for this case.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig5.jpg "Fig 5: Quick intra-oral mock-up was performed without etching and bonding. This can also be done with the chosen shades of composite to roughly evaluate the selected shade.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig6.jpg "Fig 6: Occlusion was checked and adjusted accordingly.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig7.jpg "Fig 7: Once verified, a putty index was made with A-Silicone to record the palatal surface.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig8.jpg "Fig 8: After thorough prophylaxis, the concerned site was isolated with a rubber dam and further retraction of gingiva was achieved with the help of floss ties.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig9.jpg "Fig 9: Using fine grit bur all unsupported enamel was removed and 2mm short bevel was given.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig10.jpg "Fig 10: The bevel allows better integration between the composite restoration and the remaining dental tissue.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig11.jpg "Fig 11: Selective etching with 37% Phosphoric acid was used to etch the enamel for 20 seconds.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig12.jpg "Fig 12: After thoroughly rinsing for 20 seconds the tooth was dried completely.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig13.jpg "Fig 13: A single bond universal from 3M was used as the adhesive. The bond was applied in scrubbing motion for 10 seconds and the excess was removed with a fresh applicator tip and light cured.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig14.jpg "Fig 14: The silicone index was then used to build the palatal shell which served as the base to further layer composite.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig15.jpg "Fig 15: The extent of the palatal surface was marked using a probe.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig16.jpg "Fig 16: Clear translucent shade was used to build the palatal surface.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig17.jpg "Fig 17: Light cured")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig18.jpg "Fig 18: With the final palatal shape it is easy to foresee the final shape for the final composite resin restoration.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig19.jpg "Fig 19 and Fig 20: The sectional matrix for posterior teeth was used in a vertical direction and stabilized with wedge on both mesial and distal side.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig20.jpg "Fig 19 and Fig 20: The sectional matrix for posterior teeth was used in a vertical direction and stabilized with wedge on both mesial and distal side.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig21.jpg "Fig 21: Mesial wall was built with A2 body shade.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig22.jpg "Fig 22: Distal wall was built with A2 body shade.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig23.jpg "Fig 23: Interproximal build-up was done on both mesial and distal side.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig24.jpg "Fig 24: After interproximal build-up, the band and wedge were removed, leaving behind the scaffold for further layering.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig25.jpg "Fig 25: A2 Dentin was used for the inner layer and dentinal structures were created using 3 well-defined lobes.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig26.jpg "Fig 26: It was bulked up till the start of the bevel slightly covering the bevel.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig27.jpg "Fig 27: A2 Body was used to build the mid layer and multiple lobes were created to mimic the adjacent tooth.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig28.jpg "Fig 28: A2 Dentin which is opaque was used at the incisal edge to create an incisal halo.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig29.jpg "Fig 29: Clear Translucent was used to fill the space between the incisal edge and the mamelons in order to increase the translucency at the incisal third.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig30.jpg "Fig 30: Final A2 Enamel was used for outer layer giving it proper contour and final form.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig31.jpg "Fig 31: Primary anatomy was marked using a lead pencil.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig32.jpg "Fig 32: Sof-Lex finishing coarse disc was used to define the mesial and distal line angle at slow speed without irrigation.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig33.jpg "Fig 33: Sof-Lex finishing medium disc was used to reduce the surface roughness at a slow speed without irrigation.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig34.jpg "Fig 34: Sof-Lex finishing fine disc was used to smoothen the surface at high speed with irrigation.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig35.jpg "Fig 35: Sof-Lex finishing super fine disc was used for final finish and shine at high speed with irrigation.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig36.jpg "Fig 36: The secondary anatomy was obtained using Shofu white finishing stone to create undulation often referred to as the “Eiffel Tower”. It is always important to evaluate the depth and the extension in the neighboring tooth so as not to exaggerate its presence.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig37.jpg "Fig 37: Diamond-impregnated polisher was used for surface refinement at high speed with irrigation.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig38.jpg "Fig 38: Buff was used for the final glass-like finish and polished at high speed with irrigation.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig39.jpg "Fig 39: Final composite resin restoration immediately after the polishing procedure.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig40.jpg "Fig 40: Life-like appeal to final restoration.")
:sharpen(level=0):output(format=jpeg)/up/dt/2023/09/fig41.jpg "Fig 41: Note the natural integration of the composite resin with the dental tissue.")
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