Lessons in Layering Composites

Kit Dangler, DDS, MAGD

Growing up, I took years of art lessons. I never thought I would be using a paint brush in dentistry. But when I attended an Excellence in Composite Restoration workshop at Spear, I was taught to use a brush to layer composites. For some patients, I believe that we should consider using composites as a more affordable choice than porcelain restorations. The following case is a patient who elected composite bonding instead of porcelain veneers.

Patient presented with composite restorations on #7 and #10 done four years earlier by her previous dentist (Figure 1). During the consultation, several things were discussed about the four maxillary incisors:

  1. The incisal lengths of #7 and #10 were different from each other (Figure 2).
  2. The gingival margin on #7 does not match the gingival margin of #10 (Figure 3).
  3. The width to length ratio of #8 and #9 was around 70%, making those teeth appear narrow.
  4. The width to length ratio of #7 and #10 was around 90%, making those teeth appear wide.
  5. Papilla heights were asymmetrical on mesial of #7 and #10 (Figure 4).

The proposed treatment plan was to replace the composites on #7 and #10, laser 1 mm of the facial gingival margin on #7 and add composite to the distals of #8 and #9 to widen those teeth.

Since there were changes to the front four teeth, a diagnostic wax up of teeth #7–10 was created using gray wax (Figure 5). From the wax up, a palatal stent was fabricated using a putty material (Figure 6). This stent covers #6–11, stops at the incisal edge, and does not wrap to the facial surface (Figure 7).

Figure 8 shows the composites on #7 and #10 have been removed, a gingivectomy on #7 has been completed, and the surfaces have been roughened by particle abrasion and a diamond bur. The stent was placed on the teeth and the outline of the prepared tooth surface was scored onto the matrix (Figure 9).

After rubber dam placement, the teeth were etched with phosphoric acid, then chlorohexidine was applied, and then Scotchbond adhesive placed. A thin layer of Filtek composite A1B was placed in the stent. The composite was thinned to 0.3 mm using a #3 brush with modeling resin (Figure 10). A brush is important at this step because a composite instrument would tear the thin layer.

The next layer of composite added is to replace the dentin. It was smoothed in place with a brush and light cured. This layer of composite is under contoured to have enough room for the last layer (Figure 11 and 12).

Filtek A1E was placed on the tooth, again smoothing with a brush and light curing. The last layer was to recreate the enamel, providing a seamless transition. The restoration was completed with diamond flames, discs, and diamond paste. Figure 13 shows the before and after. Figure 14 shows the lateral views before and after.