t.

me/Dr_Mouayyad_AlbtousH

After the left central incisor was After evening out the incisal edges with A spiral wheel was used with an up-
layered completely, the adjacent a disc, a perio diamond bur was used and-down motion for polishing,
lateral incisor also was restored with at low speed to create the secondary
the same body shade. anatomy.

to
. T
*

#
A felt disk and hybrid diamond paste
1 The final aspect of the restorations,
was then used for final gloss (page 456 The single-shade restorations
Four- year follow- up of the restorations;
no re-polishing had been done yet.
and 471). seem to integrate well regardless of
dehydration.
 t.me/Dr_Mouayyad_AlbtousH
Monochromatic tooth
One of the most important indications for using a sin -
gle-shade strategy is when a tooth lacks characterizations,
In other words, when it is relatively monochromatic. Several
times we have failed trying to do multi-layer techniques in
A
Tooth fracture at on the maxillary left central incisor with
severe discoloration. After endodontic retreatment, internal
bleaching was carried out.
Bleaching is immediately neutralized with sodium
ascorbate. The polarized image shows the desired degree
of bleaching was reached during one session.
H
The mesial protective matrix is removed, and the distal one
is rotated to guide the distal buildup.
186
this kind of teeth, getting an unpleasant outcome. The most
important thing to assess first is that the material matches
the opacity of the tooth. If the user lacks a digital colorime-
ter, this can be done by a realistic try - in (see page 51).
Following in - office internal bleaching. The whitening
gel is removed once the tooth is slightly over-bleached.
Assessment is done without rubber dam.
The field is isolated. To prevent the most coronal gutta-
percha from influencing the restoration, a fiber post is
placed.
i
The same strategy was used for the mesial wall. A no- prep
adhesive post is an excellent way to make sure there is no
gutta-percha in the coronal portion.
 t.me/Dr_Mouayyad_AlbtousH

The composite layer is placed directly intraorally, and After light curing, the outline of the restoration is ready to be
raw excess material is removed from the sides with a thin corrected.
spatula (see page 188).

Final aspect of the restoration after finishing and polishing. Polarized image shows perfect integration of the
The surface could be improved. restoration.

The finger index is useful to minimize palatal

finishing, even without a wax -up (see page 188).
 t.me/Dr_Mouayyad_AlbtousH
Modified single shade
The modified single shade offers the advantages of using only
one color but with incisal modifications that allow rich charac-
terization and inconspicuous integration.
When correctly selected, a single shade can perfectly mimic
the opacity and color of a tooth. While shade selection is thus
simplified, the choice range among available colors may be
strongly limited.
110
As opacity and color selection are limited to the composites
that are commercially produced, we wanted to make the ad-
vantages of the single shade merge with those of a multiple
shade approach, but we did not want to compromise on the
predictability. ,\
As the name of this technique bluntly declares, it is a du-
al-shade modification of the single-shade approach. In fact ,
the majority of the restoration still brings in all the advantages
of a medium-opacity composite, with the addition of some life-
like characterization in the incisal area.
 t.me/Dr_Mouayyad_AlbtousH

4
\

Advantages Disadvantages

• Extreme simplicity • Requires intraoperative

• Color predictability volume control
• Opacity accuracy • Very translucent in certain
• Wide adaptability cases
• Possibility of adding
characterizations

The direct approach in veneering is often the standard when
it comes to young patients and well-preserved teeth. In fact,
young patients seem to be facing the need for social ac -
ceptance and attractiveness sooner as time goes by and
present asking for shape modifications, diastema closures,
and other smile enhancements.
Well -preserved enamel, or the illusion of it, is every dentist ’s
dream, but when the structure to restore, or build, is large,
it may become very challenging to achieve optimum results
with multiple layers.
Despite what one might think, the worst thing that could
happen when working at the incisal aspect is to create all
the beautiful characterizations and then end up removing
the most buccal portion during finishing procedures,
That being said, the modified single shade is simple enough
to allow full control over the buccal thickness and anatomy,
guide the final incisal layering, and leave minimum to no
room for last -minute failure. In fact, corrections may be car-
ried out right to the end of body modeling to preserve the
artistic work that will go into the incisal characterizations.

Moreover, when incisal lengthening is involved, using a den-

tin mass in a nearly incisal area may result in excessively
strong chromaticity. On the other hand, this area deserves
some internal characterization for a satisfying outcome.
 t.me/Dr_Mouayyad_AlbtousH

1. Practice class IV defect to be restored.

2. Based on the desired incisal translucency, either body or enamel may be used to build
the palatal wall.
3. The proximal wall is built with the chosen body mass.
4. Then the whole area is filled with the same body composite.
5. The Condensa instrument is used to copy the buccal anatomy on the restoration (see
page 94).
6. Excess composite is pushed toward the incisal.

112
 t.me/Dr_Mouayyad_AlbtousH

7. txcess material is removed.

8. The body mass is modeled in order to create the most appropriate internal features.
9. The chosen enamel composite is used to fill the incisal spacing and to complete the
buccal surface.
10. After brushing the buccal composite and light curing, the restoration is almost
complete.
11. Secondary and tertiary anatomy are defined, and the restoration is polished.
12. Gloss is achieved with the Lucida system (DiaShine; see page 457).
 t.me/Dr_Mouayyad_AlbtousH

A young patient presented with a fractured maxillary The field was isolated with rubber dam. The medium bevel
right central incisor and an incongruous restoration on will help integration of the future modified single-shade
the left central incisor. We decided to do a single -shade restorations (see page 212).
restoration, adding only opalescence to the incisal edge.

After the internal anatomy was built on both incisors, an Proximal walls were restored with matrices. In a case with a
opalescent composite was used to enhance the incisal wax -up or finger index, walls would have been created first.
third. Present only in the right incisor in this picture.

The body composite was used to finish the buccal surface Appearance of the restorations after finishing and polishing.
and light cured. The patient did not appear for the follow -up appointment .

m
 t.me/Dr_Mouayyad_AlbtousH

After 1 year, the patient fell again and fractured the The field was isolated. The buccal surface of the
maxillary right central incisor. Note that the composite of restorations was removed. As this is basically a single-
the original restoration is still bonded to the margins. shade strategy, it was easier to redo the entire surface of
both centrals rather than integrate a small restoration.

Palatal and proximal enamel composite layering. The Checking the shape symmetry. If required, changes should
lateral view shows the nice contrast provided by the black be made at this time,
anatomical matrices, allowing the composite to be easily
detected.

WW) EiEresfsn
EE] Ol'KIO 9K
 t.me/Dr_Mouayyad_AlbtousH

Some translucent composite was used in the incisal Finishing procedures were carried out under rubber dam
spacing to make the restorations look more natural. isolation. Only the occlusion check and final gloss were
done without rubber dam.

Finished restorations before rehydration. The patient again Unfortunately, the maxillary right central incisor was
missed the follow -up appointment . broken again, this time in a less destructive way. Note the
aggressiveness of the young patient ’s occlusion.

Again, thanks to a known, repeatable recipe, we were able Detail of the surface and the critical finishing area of the
to fix the restoration with minimal intervention. composite (see page 460).
 t.me/Dr_Mouayyad_AlbtousH

From the first fracture of an old restoration placed in another office, these teeth have suf -
fered twice again some traumatic events, partially losing the restoration. Having an easy- to-
repair material avoids substituting the whole restoration every time. Having a sandblaster
is imperative when practicing adhesive dentistry. Wet sandblasting units (Aquacare) are
suggested.

Image Gallery 2

Virtual image gallery with long-term photographic follow -up and

. updates as they occur
 t.me/Dr_Mouayyad_AlbtousH

A young patient presented with a fractured maxillary left Isolation was particularly challenging as all teeth except the
central incisor. Color was assessed with a personalized incisors were partially erupted or unerupted.
shade guide as described on pages 44 and 45.

Isolation was done only on the four incisors, and the The rest of the quadrant remained under rubber dam; this
anchorage teeth were the erupted first molars. gave a cleaner aspect, a more comfortable view, and better
isolation.

Having diastemata on both sides of the tooth is one of the The full anatomy, including the marginal closure, is done
few exceptions where the finger index is not followed step with the same body shade; only space for incisal masses
by step. Buildup is started with a body shade following the is left ,
palatal anatomy.

1
 t.me/Dr_Mouayyad_AlbtousH

Opalescent mass was added below the body and in Incisal halo was created with a roll of A 2 dentin.
between the mamelons.

The small space left between the halo and the body was After the finishing stage, which is done with abrasive low-
covered with enamel. speed discs and diamond burs, the polishing is done with a
spiral wheel and Lucida felt and paste.

Final appearance after 1 month. The shape could be Details of the texture achieved in very little clinical time.
improved, but we decided to leave it as it was.

TI9
 t.me/Dr_Mouayyad_AlbtousH
Body screen
As seen before, a thick body layer integrates nicely and
easily in a single-shade and a modified single-shade res-
toration. Nevertheless, this approach has some limitations,
especially regarding opacity.
When dealing specifically with class IV restorations, using
a single body shade in some situations can result in an un-
pleasant translucent restoration, with a gray color or low val-
ue as a result of the unwanted blending effect (see page 39).
When trying to work over thin teeth, translucent masses
and high blending materials have little to no masking effect
of the black background; thus deep opaque layers may be
needed.
120
The use of some commercially available dentins with high
opacity, on the other hand, can be dangerous, as they easily
look unnatural when used in combination with a thin enamel
(±0 5 mm) as in the CBT technique.
^
With low-translucency teeth, a thick opaque dentin layer
can save the day if placed in the palatal-most portion of the
restoration to screen the black background, thus providing
the buccal body layer with the needed opacity without be-
coming translucent, as the stock shade guides that are ca-
pable of displaying a good opacity/ translucency, in almost
every situation thanks to the screening opaque layer and its
thick body shade (see page 28).
It is especially indicated for the new-generation "one-
shade” materials.
 t.me/Dr_Mouayyad_AlbtousH

Indications Advantages Disadvantages

• Class IV • Versatility • Difficult to produce a

• Large restorations • Reasonably simple custom shade guide
• Shape modification • Natural high opacity • Thorough knowledge of the
• Suitable for semi-direct • Forgives mistakes material advised
approach • Possible to characterize
• Suitable for mimetic
materials

The real advantage of this technique is that it is the trick up
our sleeve. In fact, the body screen technique is actually
very forgiving, which makes it ideal when no other approach
seems to fit the case.
There is always going to be one case that is not very trans-
lucent, that is missing a lot of structure, or that requires you
to cover discolored tissues. One day, you also could find
that none of the samples from your custom shade guide
matches the color you need.
So the usefulness of a forgiving technique is undeniable as,
with some training and experience, most dentists can ob -
tain very pleasant results. This is true in terms of thickness
and in terms of shade mismatch tolerance thanks to the
optical properties of body shades and some of the recent -
ly developed high-blending materials in combination with
opaque masses,
As this technique allows for a 0.7- to 1.5 -mm range as a
margin of error, a direct mock-up before isolation (realistic
try- in; see page 51) increases accuracy.

121
 t.me/Dr_Mouayyad_AlbtousH

1. A practice class IV defect to be restored.

2. Palatal wall can be layered with either body or enamel shades.
3. The proximal walls also are layered with the same composite.
4. Dentin mass is placed below the bevel, leaving 1 to 1.5 mm for the surface body layer.
5. Lateral view shows how the dentin mass is placed on the sagittal plane.
6. Body increment is layered to fill the entire cavity.

122
 t.me/Dr_Mouayyad_AlbtousH

4
\

7. Texture transfer with a Condensa instrument is used to ensure no buccal excess is left
(see page 94).
8. If no incisal characterization is needed this would be the aspect of the final layer.
9. Body is removed from the incisal only when an incisal characterization is needed.
10. Enamel is placed on top, just on the incisal edge to finish the restoration.
11. Finishing procedures are carried out to create secondary and tertiary anatomical
features.
12. Details of the micro-anatomy and polishing.

123
 t.me/Dr_Mouayyad_AlbtousH

Patient presented asking us to fix the discoloration of these Before starting, shade matching was done with the Vita
two restorations. We decided to correct them and enhance Classical shade guide (page 48).
the esthetics.

A special bur was used to eliminate the buccal part of the restorations without removing sound enamel.

After having removed the buccal composite, the Enamel was then etched up to the cervical portion to avoid
restorations were sandblasted. Note the opaque dentin of the risk of debonding areas,
the previous restoration.
 t.me/Dr_Mouayyad_AlbtousH

Two sectional matrices were inserted to build the proximal The proximal walls and incisal halo were built using a white
walls. They were removed one at a time to ensure a body composite.
tight contact point. These black matrices (LumiContrast,
Polydentia) are no longer used in favor of the new
QuickmatFLEX (Polydentia).

A1 composite body was used for the whole layering, closing the margin, but leaving space for incisal characterizations in
order to ensure a bright and natural- looking outcome.

Some translucent composite was layered in the incisal third Some white and opalescent masses were used to
to increase optical depth of the restorations. selectively enhance the incisal areas.
 t.me/Dr_Mouayyad_AlbtousH

A final check showed that a little volume was missing on Some anatomical details were added to the shape during
the buccal aspect; some body composite was added. finishing.

Finished rough restorations right after rubber dam removal; occlusion was checked, and afterwards gloss was applied.

After polishing, the characterizations at the incisal look very High gloss strongly contributes to the final esthetic
natural, and color integration is good in the middle third. outcome, especially with low - translucency restorations.

126
t.me/Dr_Mouayyad_AlbtousH
 t.me/Dr_Mouayyad_AlbtousH
If you can’t beat them... veneer them
Matching a single restoration, even with an accurate color
reading and a digital recipe, requires high precision. Dif-
ferent defect types require different material selection, ac -
curate planning of the margins, and specific construction
strategies.
After a patient has received several restorations, in different
time intervals, it is normal to see an esthetic incongruence
accepted by both the patient and the clinician, that at some
point in time becomes evident.
If teeth lack uniformity or several restorations are already
evident, it is extremely difficult to plan a single treatment for
every single restoration,
With these difficulties in mind, many of our cases that pos-
sess multiple restorations that have to be replaced or im-
proved are not to be solved by individual planning but by
a simpler and more user- friendly full composite veneering
strategy. This gives the patient a better outcome in less
time, with the advantage of reinforcing the teeth by thick -
ening them.
 t.me/Dr_Mouayyad_AlbtousH
Erosion
0 Fracture
0 Old restoration
After 12 years, a patient ’s teeth that have undergone several
treatments in the office no longer have a pleasant appear-
ance, in spite of periodic maintenance, due to restoration
degradation and aging. Teeth lose substance both buccally
and the lingually due to the combination of erosion, abra-
sion, and attrition.
Making a material match with the untouched natural tissue
is more difficult than doing full coverage. This is a perfect
case for enhancing the esthetics while thickening the teeth
and reinforcing the tooth structure,
After removing the surface of the old restorations with a bur,
a small amount of buccal preparation was done at the incisal
angle to optimize the shape and thickness of the composite
in the incisal area without entirely removing the enamel (see
page 519). The old composite was sandblasted with 53 pm
aluminum oxide (Aquacare), a mandatory step for bonding
over the old composite.
t.me/Dr_Mouayyad_AlbtousH
 t.me/Dr_Mouayyad_AlbtousH

Unica matrix

Two of the most desired features when doing direct veneering is full
cervical access and anatomical proximal walls.

Besides complete isolation, setting up a tooth for direct composite

veneering requires a retraction clamp such as a B4 or 212A (see pag -
es 486, 487) and two anatomical matrices, intervening several times
to perform the Synchro matrix strategy (see page 254), and significant
efforts to obtain good contours.

The idea of obtaining a mild cervical retraction by slipping the ma-

trices subgingivally is not new. This concept comes from products
such as Margin Perfect Matrix (MPM Products) and the Contour-Strip
(Ivoclar-Vivadent); for this same purpose, several clinicians make their
own matrices with metal strips and scissors. Ail of these matrices,
including the homemade version, did not provide anatomical proximal
walls, but were mainly focused on class V defects and composite
veneering that required a lot of finishing.

The Unica matrix (Polydentia) was designed for direct veneering,

which performs extremely efficiently the two specific veneer features:
cervical retraction and simultaneous proximal anatomical walls. In ad-
dition, it has a palatal portion specifically projected for strong insertion
without ruining the anatomical areas. In 2021 a version for deep mar-
gins and small teeth was released (Unica Minideep).

There are four ways of fixing the Unica matrix in position:

1. Wedging.
2. Custom resin (liquid dam or flow).
3. Contact point friction.
4. Finger pressure.

131
 t.me/Dr_Mouayyad_AlbtousH

1. After sandblasting the old composite restorations, the two Unica matrices are inserted into place. This is done
in order to avoid sandblasting the matrices, which would cause an undesirable situation.

The palatal extremities, long and flat (not visible in the picture), allow the placement of each matrix without harming
the anatomical proximal portion.
Normally, these matrices are placed manually, and time is taken to ensure the positioning is perfect. What seems
to take extra time (a little more than a classical matrix) then saves much time in the construction steps.

When positioning is achieved, if the matrix reveals some undercuts between the matrix and teeth, especially in
triangular teeth, it is suggested to fill them to improve anatomy and eliminate black triangles (see page 520).

132
 t.me/Dr_Mouayyad_AlbtousH

2. Aspect after buildup of proximal walls and cervical area of the maxillary left central incisor.
3. After building up the essential structures, we can form the palatal walls with finger index technique. If you
have a wax - up, we recommend exploiting the benefits of it .
4. Buildup of the internal anatomy with dentin and an opalescent mass on top of it in the incisal region.
5. Final enamel layer application. It should be applied only after being sure that both dentinal structures have
similar thickness.
6. Detail of a Unica matrix on a lateral incisor. In this case it was too wide; we opted for the Unica Minideep,
which has better adaptation to small and triangular teeth.
7. After precontouring the central incisors with abrasive disks, the lateral incisors were constructed with the
same procedure described above.

133
 t.me/Dr_Mouayyad_AlbtousH

* *

Image Gallery 4 Postoperative surface appearance.

134
 t.me/Dr_Mouayyad_AlbtousH

1
I

Situation immediately after rubber dam removal. Note how

little the gingiva is bleeding; little to no trauma was caused. It is
important to point out that the restorations were highly polished
but not texturized. For the next 7 to 10 days, the patient would
test the new restorations esthetically and functionally.

After 10 days, the patient was highly satisfied. The situation

was ideal, so it was decided to create the secondary and
tertiary anatomy (see page 470), which took barely 12 minutes.
In the virtual gallery, long-term follow-up of this case is updated
frequently.
I
Four-year follow-up. The situation was found to be extremely
favorable, and the surface of the composite was almost the
same as on day 1. The ease of corrections and repairs makes
these kind of treatments very reliable and convenient. Surface appearance at 4-year follow-up.
 t.me/Dr_Mouayyad_AlbtousH

Cutback

As described in some of the previous cases, composite cor-
rections are an essential strategy for our restorative routine.
Corrections are not only aimed at defective restorations but are
often used for improvements during layering. As classical com-
posite layering requires precision and refinement when adding
layers, after modeling a structure, such as the proximal wall, if
the shape obtained is slightly different than the desired one, a
correction is done in the middle of the procedure.
For this reason and more, a correction in composite can be
the key to a perfectly planned and successful restoration. If this
correction is planned, we will call it a cutback, which has been
used mainly in the laboratory for a wide variety of materials,
suck as wax, acrylic, composite, and ceramics.
In many situations it is necessary to model a specific mass or
inject a composite and then cutback to add a translucent layer
or some characterizations.

Nowadays with the introduction of digital colorimetry, layering

predictions, and digital recipes that require very specific meas-
urements (see page 75), the cutback is an essential tool for
achieving high accuracy and can even determine its feasibility.

Indications Advantages

• Precise thickness required • Simple

• Difficult internal anatomy • Color predictability
• Uniform color
Suitable for flowable com-
posites
• Digital recipes

136