Anterior direct composite restorations

Introduction
Dental esthetics has become increasingly important during the last decade when considering diagnosis and treatment
planning.

Nowadays, patients seek highly aesthetic restorations especially when dealing with the smile zone requiring more
sophisticated techniques that meet with their demands.

Before you decide the treatment plan, you must have enough:

1. Knowledge about your patient

Ex: patients nowadays are more aware of what type of restorations they want because of social media, so you must know
the psychology of the patient. For example, if the patient’s teeth are stained, ask him 1st if he is satisfied with them this way
to decide if you will restore the stains in the new restoration as well or not.

2. Knowledge about material, its limitations & techniques

Ex: when to use each shade of composite and proper techniques to apply it (single shade, dual shade, polychromatic..etc)

Revision on 4th year notes: (imp for oral)

1. Non-invasive techniques: reminieralizing agent on tooth is used only

2. Microinvasive techniques: ICON (it’s called microinvasive because you use HCL prior to its application which is an aggressive acid.)
This does not mean that acid etch which you use prior to bonding a restoration is microinvasive; because the phosphoric acid that is
used during etching causes demineralization to a depth of maximum 30 microns only which if exposed to saliva will be re-
mineralized, that’s why if saliva contaminated the etched surface and changed it from chalky white to its original color, you have to
re-etch. On the other hand, HCL demineralizes to the depth of 100 microns which is beyond the capacity of natural saliva to
remineralize. You can use ICON if there’s a white patch only which means the surface is still intact; if it’s used in major surface
defects you will not restore the anatomy of the tooth.

3. Invasive techniques: restoration

Where can I use composite?

1. Preserving the original shape of the tooth (Group I):
1. Replacing hard tissue losses due to caries, trauma, erosion, abrasion, attrition
2. Correcting minor tooth dysplasias
3. Correcting the labial surfaces
4. Altering tooth color

Restoring class Vs and loss of tooth structure Replacing old class IVs that were restored by composite and Enamel hypoplasia where you will only restore the
back to its original shape became stained by aging to its original shape. defective part without changing the dimensions of the
teeth to restore it to its original shape.

Discolored tooth that failed to whiten upon internal

Class IV & diastema, but the patient wants to preserve the bleaching. You’ll remove a layer and add another to restore
diastema so you’ll restore only the class IV and preserve the its color with the adjacent tooth and preserve it original
diastema/original shape. shape.
 Restoring class IV is challenging:

 Length of bevel in Class IV cavity since it’s a stress bearing area is equal or 0.5mm more than the length of the
defect to increase retention.
(Bevel helps in color degradation and increases retention by the following: exposure of enamel rods ends rather than the sides,
increasing surface energy, removal of the acquired enamel pellicle)

Ex: if defect is 2 mm, the bevel would be 2-2.5mm

 Challenging color reproduction:

-Large defects are less challenging: Average length of central incisor is 10-12mm. If the defect in a central incisor is 4 mm, the
bevel would be 4-4.5mm, so the remaining tooth structure would be so little; in this case you will match the color and anatomy
of the restoration to the adjacent tooth. This is called inter-tooth color matching.

-Small defects are more challenging: If the defect is 2mm, the bevel would be 2.5mm, leaving sufficient tooth structure that has
to be color matched with the restoration. So in this case, intra and inter tooth color matching is required making it more
difficult that large defects.

Altering the original shape of the tooth (Group II):

1. Correcting tooth shape in cases of pronounced dental malformation
(e.g, in hypoplasia, amelogenesesis imperfecta, peg teeth)
2. Altering tooth shape in cases of transposition or other changes in position of individual teeth Peg shaped lateral
(e.g, when transporting a canine orthodontically to fill the gap due to agencies at the lateral incisor)
3. Widening a tooth in cases of migration
(“true migration” discrepancy between the widths if the dental arch and individual teeth; “apparent migration”;e.g: missing
individual teeth due to agenesis or trauma)
4. Correcting tooth position with changes in the sagittal, transverse and/or vertical position of individual teeth or
groups of teeth
(e.g: righting an inclined crown, rotating or lengthening tooth, remedying crowding in a group of teeth by interdental
stripping, and/or correcting “apparent” protrusion by using labial facing)
5. Correcting tooth shape in cases of gingival recession (reducing “black triangles”)

Bruxism leading to senile appearance. In this case, you
will alter the shape to restore youthful appearance. This
could be done by forming dentin mamelons to give a
youthful appearance which are apparent when the incisal
1/3rd of enamel is translucent.
Missing lateral so canine drifted in its place
giving a Dracula appearance. In this case, you
would change the shape of the canine to mimic
the shape of lateral without altering the
occlusion, which is challenging as canine is one of
the keys of occlusion.

Multidiastema cases are challenging because you must alter the shape and restore the shade of
the teeth. The spaces are not divided equally, they should be divided by applying the golden
ratio.
Key for success for anterior composite restoration:

1. Shape reproduction (three dimensional shape reproduction)

2. Shade reproduction (layering technique)
3. Maintenance (ex: it is the ability of maintaining the restoration the longest time possible functioning. shouldn’t break
under function after 1 week-1 year from restoring it, it should last for minimum 7 years)

Maintenance:

1. The selection of a good quality composite and proper application techniques.

2. Proper use of an appropriate bonding system
3. Use of a light curing system that is capable of delivering enough energy to properly complete the polymerization
process. Consequently, any technical error committed during one of those 3 steps, can result in clinical failure.
4. Proper cavity design (specially in class IV)