8

DIRECT RESTORATION OF ANTERIOR TEETH:

REVIEW OF THE CLINICAL TECHNIQUE
AND C ASE P RESENTATION
James H. Peyton, DDS*

Direct composite resin bonding procedures are growing

Composite resins can be used in direct procedures to

in popularity as conservative and predictable restora-

successfully restore function and aesthetics, and they are

tive treatment alternatives. An understanding of the

often less abrasive on opposing teeth than porcelain.6 -9

fundamental layering, contouring, and polishing prin-

Direct resin veneers are recommended as an immedi-

ciples is paramount to the success of any direct compos-

ate treatment option for patients who will eventually

ite restoration; this awareness can be subsequently

require extensive restoration (eg, orthodontic procedures).

applied to indirect restorations and significantly enhance

Since preparation for direct veneers is often conserva-

laboratory/clinician communication. This article presents

tive, and minimal if any tooth structure is removed,

a clinical technique that describes the incremental place-

these materials can often be used to augment the exist-

ment of direct resin veneers on a typodont and demon-

ing tooth structure with clinically reversible results. Missing

strates the application of these procedures on an actual

tooth structure can be corrected with direct resin, and

clinical case.

incisal edge length can be easily added or reduced.

Key Words: composite, incremental, direct, resin

The use of composite restorations is also indicated for

the treatment of younger patients with immature gingival crests. Utilization of this treatment modality eliminates

n recent years, significant improvements in compos-

laboratory fees from the overall cost of restorative treat-

ite resin technology have occurred. Various new

ment, and patient expenditures are further reduced by

composite resin systems (eg, Esthet-X, Dentsply/Caulk,

the clinicians ability to (potentially) complete restora-

Milford, DE; Point 4, Kerr/Sybron, Orange, CA; Renamel,

tions in one visit. Limitations associated with direct resin

Cosmedent, Chicago, IL) have been developed in

veneer restorations include increased chairtime and the

response to clinicians increasing demand for materials

with enhanced physical properties and aesthetics.1 These
contemporary material formulations contain more diverse
ranges of shades with greater mechanical properties.2-4
The development of these composite materials has
provided clinicians with the ability to directly restore frac-

Darker
Cervical
Area

tured and misshapen teeth and to repair defective enamel.5

*Clinical Instructor, UCLA Center for Esthetic Dentistry, Los Angeles,

California; private practice, Bakersfield, California.
James H. Peyton, DDS
2005 19th Street
Bakersfield, CA 93301
Tel:
661-323-1888
Fax: 661-323-0188
E-mail: [email protected]

Pract Proced Aesthet Dent 2002;14(3):203-210

Incisal
Translucent
Area
Dentinal Lobes
Figure 1. Illustration demonstrates the various composite layers
used in this laboratory exercise.

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necessity for a high-quality aesthetic composite resin

system.2 A comprehensive understanding of material
strengths and characteristics is required for successful
application, and the oral habits (ie, bruxism or similar
parafunctional habit) of the patient must be identified
prior to treatment.
Using a typodont, this article reviews a basic technique for sculpting direct resin veneers. A step-by-step
incremental buildup technique is used to demonstrate
the composite layering procedures. A clinical case of
10 direct resin veneers is also presented to demonstrate
the application of this technique for aesthetic and funcFigure 3. A model is used to illustrate the preparation of typodont
teeth #9, #10, and #11 for subsequent placement of direct
resin veneers.

tional results.

Composite Resin Selection

Hybrid Composites
In extensive restorations, the hybrid composite is the first
layer that contacts the natural tooth structure (ie, Renew,
Bisco, Schaumburg, IL; Charisma, Hereaus Kulzer,
Armonk, NY; Filtek Z250, 3M ESPE, St. Paul, MN). This
material is highly filled with ground particles (ie, quartz,
strontium, heavy metal glasses that contain barium).10
This is the material of choice for posterior restorations,
and it provides an excellent underlying layer when a
microfill is used as the surface layer on anterior restorations.11 Hybrid composite materials can be successfully
used for the restoration of Class IV anterior restorations
and any restoration where a high amount of stress is anticipated.12 The radiopacity of hybrid materials is particu-

Figure 4. A cylinder of hybrid composite is placed over the facial

surface following placement of the adhesive agent.

larly important during the placement of Class II posterior

restorations to radiographically determine if the margin
is sealed or becomes decayed in the future. These restorations are contraindicated, however, for the treatment of
Class III and Class V defects and in labial veneers that
require a high surface polish.
0.75 to 1 mm
Facial Reduction
Half-way Into
Contact Area

Hybrids have high compressive strength, tensile

strength, and reasonable polishability. Inorganic filler
materials vary widely between different composite systems. These materials are composed of the resin binding matrix and two different types of inorganic filler

1.5 to 2 mm
Incisal Reduction
Figure 2. Approximately 1 mm was removed from the facial
aspect and 1.5 mm was reduced off the incisal edge for
instructional purposes.

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particles: microparticles (0.04 m) and macroparticles

1 m to 15 m. They are heavy-loaded inorganically
(ie, 76% to 80% more by weight).12 Hybrid composites
are available in opaque and translucent shades. Translucent materials are ideal for the restoration of incisal

Peyton

Microfills tend to be less highly filled, have smaller particle size, and are less fracture resistant. The inorganic
filler of most microfilled composite systems is colloidal
silica with a particle size of approximately 0.04 m.
Microfill composites are generally loaded with inorganic
filler materials at approximately 50% by weight.12
Microfills are also more translucent and polishable.
Incisal shades of microfill resin should be selected if
incisal translucency is required to replicate natural tooth
structure. These resin formulations are indicated for anterior restorations that require a high polish (ie, Class III,
Class V, small Class IV, and labial veneers); they should
Figure 5. The hybrid composite is evenly placed over the entire
facial surface. Incisal dentinal lobes are established and facial
surface is contoured.

not be used for restorations that undergo heavy loading (ie, large Class IV composites, posterior restorations,
core buildups).
Tints and Opaquers
Tints and opaquers are used for intrinsic staining and
characterization of the composite restoration (ie, Creative
Color, Cosmedent, Chicago, IL; Kolor + Plus, Kerr/
Sybron, Orange, CA; Tetric Color, Ivoclar Vivadent,
Amherst, NY). Opaquers are highly pigmented, lightcured liquids that can be used to conceal dark tooth
structure, translucency, and metal, and to change color.
Incisal translucency is simulated using violet, gray, and
blue tints. Slight gingival shade change can be accomplished with brown, orange, or honey-yellow tints. The

Figure 6. A brown or yellow tint is added to the cervical area to

provide a more natural appearance. A translucent hybrid should
also be added to the incisal region.

use of tints and opaquers should be subtle, and these

materials must always be overlaid with a microfill or
hybrid resins. A complete composite restorative system

edges, and opaque hybrid composites have the ability

to mask darkness in the underlying tooth structure. This
opaque material effectively restores the dentin layer of
the tooth. If the enamel layer is the only aspect that
requires restoration, however, the hybrid layer may not
be necessary. If no color change is required and the
incisal edge remains intact, a microfill can be used alone
with predictable and aesthetic results.
Microfill Composites
The microfill composite is used as the surface layer for
anterior restorations (ie, Micronew, Bisco, Schaumburg, IL;
Matrixx, Discus Dental, Culver City, CA; Durafil, Heraeus
Kulzer, Armonk, NY; Helimolar RO, Ivoclar Vivadent,
Amherst, NY; Filtek A110, 3M ESPE, St. Paul, MN).

Figure 7. A cylinder of microfill composite is added to the facial

surface. The placement of excess composite limits the creation of
voids and pits in deficient areas.

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should include an enamel replacement (translucent microfill shades that are highly polishable), dentin replacement (opaque hybrid shades), tints, and opaquers.12

Clinical Technique
In a clinical case, the first step is to determine the shade(s)
of the teeth. A color map should be made to indicate
the intended shade of the gingiva, middle, and incisal
thirds. The clinician should then decide the amount of
incisal translucency, opacities, stains, and additional optical features necessary to provide a natural, aesthetic
result (Figure 1). A preliminary veneer preparation is

Figure 9. It is necessary to wet the incisal

area with unfilled resin or flowable incisal
microfill during placement of the translucent
incisal microfill composite.

advised if significant color change is anticipated. This

enables the application of an opaque hybrid layer, opaquers, and the overlaying microfill layer. An advance
mockup of the intended final contour may also be performed, and a silicone matrix may be fabricated to guide
the establishment of the incisal contours.13
Tooth Preparation
For the purpose of this exercise, no attempt has been made
to match the shade of the adjacent teeth in the typodont.
A deep facial reduction (0.75 mm to 1 mm) should be

Figure 10. The final contour of tooth #9 is

demonstrated prior to finishing.

performed to simulate deficient clinical teeth and enable

subsequent restoration with the hybrid and microfill composite layering technique. The incisal edge can also be
reduced by 1.5 mm to simulate a deficient incisal aspect
and demonstrate the creation of proper translucency.

Full veneer preparations are performed on teeth

#9(12) through #11(23) to provide adequate space for
the use of a hybrid (opaque dentin) and microfill (enamel/
translucent) layer (Figure 2). For the purpose of the
typodont exercise, a full 1- mm reduction was performed
at the facial aspect, and 1.5 mm was removed from the
incisal edge. The preparation should extend halfway into
the contact area (Figure 3). While all veneer preparations do not require incisal reduction or as deep a facial
reduction, this example is used to simulate a more complex situation and demonstrate the incisal effects of
composite materials.
Direct Resin Buildup
Restoring one tooth at a time allows the clinician to
develop a more ideal interproximal contact area and
overall shape and contour. The indicated tooth should be
isolated using a matrix band or plastic strip and then be

Figure 8. The incisal region should subsequently be intersculpted to

characterize the tooth and provide a more natural effect.

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acid-etched; an adhesive agent should subsequently

be applied. A cylinder of hybrid composite is then added

Peyton

The composite material should be directly applied

to the adjacent tooth without the use of a plastic strip.
If the adjacent tooth is highly polished, the composite
material should not adhere to this region, and a very
tight and natural contact will be achieved. If the restorations are not highly polished interproximally, the composite material will stick together and result in chipping
or a poor contact area. While a smooth surface is desirable, a thin plastic strip can be used to provide sufficient
Figure 11. The lingual excess is trimmed with
a high-speed football-shaped diamond bur.

surface smoothness if a rough or unpolished surface exists.

The body microfill must be thinned and sculpted at the
incisal one third to provide space for the incisal layer
(Figure 8). A thin coat of unfilled resin can subsequently
be placed, and the translucent incisal microfill can then
be added (Figure 9). Care should be taken to push the
incisal microfill into the grooves to again avoid pits in
the final restoration. While a flowable incisal microfill
can also be used, bubbles in the material must be
removed prior to polymerization.
Although the presence of excess material incisally
and facially is acceptable, the interproximal contours
must remain as close as possible to the final contours

Figure 12. The width of the veneer on tooth #9

should be compared to the width of tooth #8
using dividers or calipers.

(Figure 10). The restoration must be completely light

cured from all directions prior to contouring, finishing,
and polishing.

to the tooth and evenly distributed (Figure 4). Care must

Contouring

be taken not to overcontour the interproximal areas. This

A football-shaped carbide bur should first be used to con-

hybrid layer is applied using a composite instrument, and

tour the lingual aspect (Figure 11). A coarse finishing

dentinal lobes are established (Figure 5). The mamelon

anatomy (incisal aspect of dentinal lobes) can be
enhanced through the placement of ochre tint on tips
of the lobes. The violet tint can be added to the lobe
concavities and interproximal region to provide a more
translucent effect prior to polymerization.
Sufficient space should be left on the facial aspect
for subsequent placement of the microfill layer following
application of a translucent hybrid on the incisal region.
The body and incisal regions of the hybrid layers are light
cured for 20 seconds; a brown or yellow tint may be
added to the cervical one third to provide a more natural
appearance (Figure 6). A cylinder of body -shaded microfill resin can then be placed over the entire facial surface
(Figure 7). The material should be placed in one increment and evenly spread out to avoid air entrapment that
may result in white lines and pits on the final surface.

Figure 13. The line angles and heights of contour can be drawn in
pencil to match those of the adjacent tooth.

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disc can be used to ensure that the incisal edge of #9

remains level with #8. The facial contours are subsequently created with a flame-tipped carbide bur and
the coarse finishing disc, which can also facilitate even
reduction of the composite surface. The tooth thickness
and the position of the incisal edge are then established.
The tooth should be viewed incisally to verify the
accuracy of the three planes of facial contour. The width
of tooth #9 should also be verified with a divider to
ensure its congruency with tooth #8 (Figure 12).
Finishing
Once the basic tooth shape is established, the line angles
and heights of contour should be created. It is often help-

Figure 14. Facial view of the direct resin veneer after finishing
and polishing.

ful to actually draw these characterizations in pencil on

the tooth (Figure 13). If present, the contralateral tooth
may provide the necessary details and/or guidance.
The incisal embrasures should be equivalent from right
to left, and a successively larger incisal embrasure space
from the central incisors that increases in size to the premolar region should be evident. The gingival embrasures
should also be symmetrical. In order to maintain the contours during the polishing process, a smooth facial surface should be created prior to the establishment of facial
dentinal lobes or developmental depressions.14
Polishing
The coarse polishing disc should be used to initiate the
polishing sequence, followed by the medium, fine, extrafine, and superfine polishing discs. A successive series of

Figure 15. Postoperative view of the direct resin veneer restorations

placed on the typodont model.

smaller and smaller scratches should be created until they

finally disappear and leave a highly polished surface.
Since use of polishing discs enables composite removal,
they should be used to establish the initial contours.
The subtle surface characterizations should be evaluated, and a high polish should be established on the
final surface layer. Horizontal perikymata can be placed
using a coarse diamond bur with a feather-touch from
the mesial to distal aspects. Irregularities in surface
character can also be placed. The final surface polish
and luster is placed with a flexible buff wheel and polishing paste (Flexibuff and Enamelize, Cosmedent, Chicago,
IL), which spreads out over the tooth surface and evenly
polishes the composite (Figure 14).
Once this restoration is completed, the same process
would be followed for the adjacent tooth. Note that if

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Figure 16. Preoperative facial view demonstrates the presence of

extensive abrasion, erosion, and worn incisal edges.

Peyton

there is a dark stained area, an opaquer is used to

conceal the darker area until it matches the rest of the
tooth. Once the subsequent restoration is finished and
polished, the other teeth can be restored (Figure 15).
Hybrid, microfill, tint, and incisal composites are placed
so the layers would overlap to enable refined blending
and gradation of colors and materials.

Case Presentation
A 43-year-old male patient presented with extensive
abrasion and erosion of the maxillary dentition (Figure 16).
Direct composite resin restorations were selected to
Figure 17. Once tooth #8 was etched and bonded, a hybrid
composite was added to the facial aspect.

enable immediate modification of length and contour. A

direct intraoral mockup was prepared to determine the
incisal length and assess aesthetics, phonetics, and lip
support.13 Once patient approval was obtained, the
length of the anterior teeth was determined, and the
mockup was sectioned to guide the establishment of
incisal length.
Teeth #6(13) through #11(23) were planned for
direct bonding procedures, and the patient declined
anesthetic treatment. The shade was determined with a
color-corrected light. A diagnostic waxup was completed
on mounted study models to facilitate determination of
anterior guidance, clinical crown length, and the amount
of bite opening required (approximately 4.5 mm). An
intraoral mockup was fabricated to evaluate aesthetics
and phonetics. Anterior guidance was established directly

Figure 18. Upon completion of direct resin veneers for the six
anterior dentition, teeth #4, #5, #12, and #13 were subsequently
restored to fill the dark buccal corridors.

with composite resin and verified with articulating paper.

Teeth #8 and #9 were prepared on the facial aspect
with a technique similar to that used for porcelain veneer
preparations. Since a significant color change was
required, control over the tooth shade was very important. The central incisors were built up using the aforementioned technique, and centric stops were established
on the lingual surface (Figure 17). A hybrid layer that
included the dentinal lobes was added. Correct color,
length, width, and contours of the central incisors had
to be established prior to proceeding any further with
the direct resin veneers.15
The lateral incisors and canines were subsequently
built up, and the centric stops were established harmoniously with those of the central incisors. Excursive
contacts were verified to provide canine guidance. The

Figure 19. Postoperative facial view demonstrates the aesthetic

integration of the definitive restorations.

protrusive contacts were noted on the lingual surface of

the central incisor and interferences were removed. The

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anterior segment of the mandibular splint was removed

and polishing protocols. Direct resin restoration may

as each tooth was restored. Use of the composite resin

be difficult and frustrating without practice. The principles

material enabled direct manipulation against the adja-

of contouring and polishing are critical to the success of

cent dentition for the best possible contour and contact,

direct and indirect restorations, and this understanding

and the restorations were polished to establish balance.

will significantly improve laboratory/clinician communica-

The maxillary premolars were restored at a subsequent

tion.16 The aforementioned exercise can also enable the

visit to close the dark buccal corridor, and the mandibu-

clinician to fabricate improved direct veneer provisional

lar splint was removed to allow each new restoration to

restorations, particularly for the demanding patient. While

function in harmony. The absence of any joint pain and

this article described the direct layering process with

no further occlusal wear indicated that proper guidance

composite hybrid and microfill materials, this concept

and function had been achieved. A dramatic aesthetic

can be applied to all systems, including contemporary

modification was evident upon completion and the patient

microhybrid composites that contain opaque and dentin

was pleased with the definitive result (Figure 18).

layers as well as a wide range of enamel shades.

Occlusal Analysis

Acknowledgment

The first phase consisted of opening the bite with a full-

The author mentions his gratitude to Dr. Bruce Crispin,

time mandibular splint. The anterior segment was opened

Woodland Hills, CA, for his assistance in developing

3 mm to 4 mm in composite resin and canine guidance

this presentation. The author declares no financial inter-

was established. The treatment plan for the posterior

est in any of the products cited herein.

reconstruction included porcelain onlays and crowns on

teeth #3(16) through #5(14), #12(24) through #14(26),
#18(37) through #21(34), and #28(44) through
#31(47). This treatment has not yet been commenced.
A diagnostic waxup was completed, and temporary
restorations (BioTemps, Glidewell Laboratories, Newport
Beach, CA) have been fabricated. Fixed prosthodontic
consultation was performed for proper occlusal analysis, to verify anterior guidance, and to review the overall treatment plan.
Upon reevaluation 4 years postoperatively, the direct
resin veneers demonstrated strength against the forces of
mastication, clenching, and staining (Figure 19). The
patient wore through his original splint and the direct
veneers have been in complete function for two years.
A new nightguard was advised to protect against wear
and potential fracture.

Conclusion
This article demonstrates a clinical workshop technique
for placing direct composite resins with a layering
protocol that incorporates successive application of
dentin, enamel, and incisal composite to achieve aesthetic restorations. Optimal clinical success can be
accomplished once the clinician has an adequate understanding of preparation and composite layering techniques, the use of tints and opaquers, and contouring

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References
1. Dietschi D. Freehand composite resin restorations: A key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7(7):15-25.
2. Baratieri LN. Aesthetics: Direct Adhesive Restoration on Fractured
Anterior Teeth. Carol Stream, IL: Quintessence Publishing, 1998.
3. Fahl N Jr. Trans-surgical restoration of extensive Class IV defects
in the anterior dentition. Pract Periodont Aesthet Dent
1997;9(7):709-720.
4. Bowen RL, Eichmiller FC, Marjenhoff WA. Gazing into the future
of aesthetic restorative materials. J Am Dent Assoc 1992;123(5):
32-39.
5. Fahl N J Jr. Achieving ultimate anterior aesthetics with a new
microhybrid composite. Compend 2000;21(suppl No. 26):
4 -13.
6. Vanini L. Light and color in anterior composite restorations. Pract
Periodont Aesthet Dent 1996;8(7):673-682.
7.

Fahl N Jr. The direct/indirect composite resin veneers: A case

report. Pract Periodont Aesthet Dent 1996;8(7):627-638.

8. Nash RW. Freehand composite veneering The direct option.

Pract Periodont Aesthet Dent 1994;6(3):89-94.
9. Christensen GJ. Veneering of teeth. State of the art. Dent Clin
North Am 1985;29(2):373-391.
10. Albers HF. Tooth-Colored Restoratives. Santa Rosa, CA: Alto
Books; 1996:6a1- 6a9.
11. Miller MB, ed. Reality. Volume 13. Houston, TX: Reality
Publishing, 1999.
12. Jordan RE. Esthetic Composite Bonding: Techniques and
Materials. St. Louis, MO: Mosby; 1993:163-173.
13. Behle C. Placement of direct composite veneers utilizing a silicone buildup guide and intraoral mock-up. Pract Periodont
Aesthet Dent 2000;12(3):259-266.
14. Rufenacht C. Fundamentals of Aesthetics. Carol Stream, IL:
Quintessence Publishing; 1990:137-145.
15. Spear F. The maxillary central incisal edge: A key to aesthetic
and functional treatment planning. Compend Contin Educ Dent
1999;20(6):512-516.
16. Crispin, B J. Contemporary Esthetic Dentistry: Practice Fundamentals. Carol Stream, IL: Quintessence Publishing; 1994:
241-266.

CONTINUING EDUCATION
(CE) EXERCISE NO. 8

CE
8

CONTINUING EDUCATION

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:
1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail
it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article Direct restoration of anterior teeth:
Review of the clinical technique and case presentation by James H. Peyton, DDS. This article is on Pages 203-210.

Learning Objectives:
This article describes a laboratory workshop technique and clinical case for the placement of direct resin veneer restorations. Upon reading this article and completing this exercise, the reader should:
Have an increased awareness of the layering technique for composite resins.
Know the various applications for tints and opaquers.
Understand how to obtain an enamel-like finish for composite restorations.

1. Polychromatic aesthetic direct resin veneers result from:

a. Continual reduction of the incisal edge.
b. Use of a hybrid resin for the surface layer.
c. Placement of tints and opaquers on the surface layer.
d. Use of a layering technique for hybrid and microfill
composite materials.
2. Which of the following is a feature of microfill
composite materials?
a. Opaque quality.
b. Highly polishable.
c. Large particle size.
d. High compressive strength.
3. Which of the following is a feature of hybrid
composite materials?
a. Highly polishable.
b. Small particle size.
c. Low compressive strength.
d. Applicable for posterior restorations.
4. The purpose of an intraoral mockup is to determine
all of the following EXCEPT:
a. Phonetics.
b. Lip support.
c. Incisal length.
d. Tooth preparation.
5. In the use of a typodont, it is important to:
a. Create subgingival margins.
b. Match the color of the plastic teeth.
c. Follow the contours of the adjacent teeth.
d. Use a plastic matrix strip throughout the entire procedure.

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6. Why must the facial-incisal layer of body microfill

be thinned?
a. To increase the opacity.
b. To provide a thin incisal edge.
c. To provide room for the incisal microfill.
d. To increase the strength of the restoration.
7. One reason to restore one tooth at a time would be to:
a. Increase the length of the tooth.
b. Create a more translucent restoration.
c. Idealize the interproximal contact area.
d. Minimize the use of the hybrid composite material.
8. In the composite layering process, dentinal lobes are
created by:
a. A strong dentinal bond.
b. Contouring the hybrid composite.
c. The use of a yellow-tinted opaquer.
d. The application of rounded incisal edges.
9. Why must composite layers be added in one large
piece at a time?
a. To increase the bond strength.
b. To distribute composite in an even thickness.
c. To minimize expenditure for restorative materials.
d. To increase the translucency of the restored tooth.
10. Why is a flexible polishing disc required during
the finishing process?
a. It does not scratch the surface of the tooth.
b. The device avoids heat buildup during rapid reduction.
c. The device is rigid and quickly cuts the composite
material.
d. The device spreads out over the tooth surface and
evenly reduces the composite.