Aesthetic and Cosmetic Dentistry Made Easy, 1ed (2008) PDF

Aesthetic and Cosmetic
Dentistry Made Easy
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DVD CONTENTS
Smear layer
Composite fillings (Including an easy way to
remember points in chronological order)
Lamination and fractured corner repairs of front teeth
by direct bonding
Fluorosis treated by lamination/bonding
Diastema closure
Crowns and bridges
Bleaching of teeth
End of the slide show
DISCLAIMER
The Medicine and Dentistry is changing rapidly resulting in
changes regarding concepts, techniques, treatments, drugs,
etc. The readers are advised to update their knowledge by
the product information and data (most recent codes of
conduct and safety regulations, etc). The authors do not accept
any responsibility or legal liabilities for any error in text or
misuse or misapplication of material in this book.
Aesthetic and Cosmetic
Dentistry Made Easy
Pramod Bansi Mathur

Junior Specialist (Dental) Rtd.
Bikaner, Rajasthan (India)
Sanjay Bansi Mathur

Dental Surgeon
Bikaner, Rajasthan (India)
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Aesthetic and Cosmetic Dentistry Made Easy

2008, Pramod Bansi Mathur, Sanjay Bansi Mathur
All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a
retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the authors and the publisher.
This book has been published in good faith that the material provided by authors is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and authors will
not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are
to be settled under Delhi jurisdiction only.
First Edition: 2008
ISBN 978-81-8448-385-7
Typeset at JPBMP typesetting unit
Printed at Ajanta
Dedicated to
My Naniji Smt. Phool from whom I learnt devotion and parity

(non-partiality).
My Mother Smt. Gur Peari (Kailash) from whom I learnt
discipline and punctuality.
My Father Dr. Brij Bansi Lal from whom I learnt lesson of
contentment and simplicity.
My Mausi Smt. Kiran (Kinno) and Dr. PC Tawakli from
whom I learnt the lesson of laugh and gratification.
My Brother Ashok Kumar from whom I learnt the lesson of
hard working and how to win friends.
My Teachers from whom I learnt the perfect art and science of
dentistry.
My Idol A. Prasad from whom I learnt elegance and grace.
My Chum S.K. Bisaria from whom I learnt consistency and
dignity of labour.
My Mother-in-law Smt. Rukmani from whom I learnt
meaning of affection and blessings.
My Wife Dr. Smt. Nirmala Mathur who filled my life with
care and comfort.
My Patients from whom I learnt the lesson of faith and trust.
(All these lessons made me, what I am today).
PB Mathur
PREFACE
Aesthetic and Cosmetic Dentistry Made Easy is written for

practising dental surgeons and students.
The authors are very experienced clinicians having a
vast experience of dental practice and have highlighted in
this book, the common procedural mistakes, which
ultimately result in failures leading to frustrations both
for the patients and the dentists.
First chapter is about the origin and scope of Aesthetic
and Cosmetic Dentistry. Next four ones give briefings
about the Materials used in aesthetic and cosmetic
dentistry (along with their commercial/brand names and
names of the companies that manufacture them). Bonding
generation chart is a special feature explaining names/
brands/flaws/benefits/date of invention and relative
information about the Bonding materials (generally we
say 1st, 3rd and 4th generations, etc. You will know the
exact meaning of these terms from this chart).
Remaining chapters explain what you ought to know
about a successful practice of aesthetic and cosmetic
dentistry. In accompanying audio-visual DVD, we have
given actual working movie films of different procedures
of Aesthetic Dentistry on patients, models, etc.
Hope and wish this book would help you in your day-
to-day successful practice of aesthetic and cosmetic
dentistry.
Pramod Bansi Mathur

Sanjay Bansi Mathur
CONTENTS
Chapter 1 Introduction --------------------------------------- 1

1. Scope of Aesthetic and Cosmetic Dentistry
2. History of Bonding
3. Smear
4. Conditioning of Enamel and Dentine and
What Actually Bonding Is?
Chapter 2 Recent Advances in the Improvement of

Materials Used in Aesthetic Dentistry --- 11
1. Bonding Material
2. Bonding Materials Generation Chart
3. Microfiller like Hybrid Composite
4. PRG Technique
Chapter 3 Compomers -------------------------------------- 17

1. Introduction
2. Brands
3. Indications
4. Contraindications
Chapter 4 Non-rinse Conditioners (NRC)/

Self-etching Primers -------------------------- 21
1. Advantages and Disadvantages
Chapter 5 Flowable Composites and Compomers - 23

1. Why Needed
2. Composition
3. Indications and Contraindications
x Aesthetic and Cosmetic Dentistry Made Easy
Chapter 6 Composite for Posterior Teeth (Molars) - 27

1. Contents
2. Indications and Contraindications
Chapter 7 Compulsory Steps in Successful

Bonding ------------------------------------------ 29
1. Mandatory Steps in Successful Bonding
2. Techniques for Polishing the
Composite Fillings
3. Summary of Filling Steps
4. Pit and Fissure Sealing
Chapter 8 Restoration of a Fractured Incisor

(Class IV Defect) ------------------------------- 57
1. Methods Available
2. Steps in Bonding
3. Diagrammatic Representation of How to
Convert a 13 into Missing 12
4. Diagrammatic Representation of
Incisal Edge Repair
5. Diagrammatic Representation of
Laminating Heavy Fluorosis Cases
Chapter 9 Diastema Closure ------------------------------ 71

1. Length and Breadth Ratio of Incisors
2. Simple Diastema
3. Complex Diastema
4. Steps in Closing Diastema
Chapter 10 Bleaching of the Teeth ----------------------- 81

1. Material
2. In Office Bleaching
3. At Home Bleaching
4. Types of Stains that can be Bleached
and ADAs Recommendations
Contents xi
Chapter 11 Indirect Metal Free Restorations (MFR) - 87

1. Pressable Ceramics
2. Selection of Dental Adhesive and
Resin Cements
3. Impression Taking
4. Bonding of the MFR to prepared Tooth
5. Direct Provisional Crown and
Bridge Material
6. Metallic Crown with Acrylic Facing
7. Dowel Pin Crown Fitted on 12
Index ----------------------------------------------- 97
CHAPTER 1
Introduction
2 Aesthetic and Cosmetic Dentistry Made Easy
SCOPE
In recent years the maximum, ever possible progress was
made in the field of Aesthetic/adhesive dentistry
because this branch of dentistry has made it possible to
retain natural teeth, which were aesthetically ugly looking.
For example, broken/chipped corner teeth, teeth with
spacing (diastema) stains, dark-shaded teeth (deep
coloured) and specially in older persons where spacing,
sensitive teeth due to attrition, abrasion and abfraction
lesions, dark-shaded teeth which were unacceptable,
aesthetic and cosmetic dentistry proved a boom in
retaining these defective unacceptable teeth into acceptable
and aesthetically beautiful looking natural teeth. In all
discoloured, broken, chipped, abraded, abfraction lesioned
and periodontally involved loose teeth, light-cure bonding,
capping, crown and bridge techniques have proved very
helpful.
HISTORY OF BONDING MATERIALS

In 1954 Buonocore demonstrated that after etching the
tooth with phosphoric acid, which made microspores in
enamel, it was possible to bond self-cure acrylic resin
on this etched surface of enamel.
But, however, this bond was too weak to stand the
loading materials heavy shrinkage forces during
polymerization and the material used to detach, hence his
concept did not get momentum.
But experimenting on these lines in 1960 Bowen
introduced Bis-GMA resin with fillers. With the
introduction of his invention Aesthetic and cosmetic
dentistry came to real existence and success.
Due to the merits of the result of these experiments
both the dentists and the manufacturers of adhesive
Introduction 3
dentistry materials, became interested in this branch and

the adhesive dentistry marched ahead in leaps and bounds.
It was soon realized that inspite of good retention
properties, Bis GMA caused postoperative sensitivity
and pulpal damage which leads to pulpal death. It was
soon found that the defect was in the adhesion to dentine
by hydrophobic resins of that time.
SMEAR
The smear layer that formed over the cut dentinal surface
consists of hydroxylapatite crystals and denatured collagen
fibres of dentine. This smear layer tends to seal the open
dentinal tubules and act like a lid preventing the
penetration of bonding fluids into the cut dentinal tubules.
The earlier adhesives materials used to bond to this dry
smear layer and this smear layer itself was loosely attached
to the underlying dentine, hence the material bonding to
this smear layer was not very strong (2-6 MPa) and used
to detach under stresses of polymerization shrinkages of
the loading composite materials.
CONDITIONING
This defect, however, was overcome by either removal
(total etch conditioning) or by penetration of the smear
layer. The bonding strength of 22 MPa (megapascals) or
above could be achieved and is satisfactory. However, in
abfraction lesions at cervical position of the teeth of older
patients, where due to less periodontal support of the tooth
and comparatively thinner (without prisms) layer of
enamel and peritubular dentine structure and shallow
saucer-shaped lesions, all these factors make important
contribution in debonding of the material in the cervical
restorations. Because any bonding agent will be influenced
by the properties of the composite to which it is attached,

polymerization shrinkage, moisture absorption and
coefficient of thermal expansion and contraction of the
loading composite shall influence the load stress on the
bonding agent through which it is attached to enamel
and dentine of the tooth.
Recent generations dentine bonding materials either
remove, penetrate or solubilise the smear layer and wet
the underlying dentine with its hydrophilic monomers
(liquid). The smear layer can be removed by total etch
with 34 to 37 per cent ortho-phosphoric acid for not more
than 15 to 20 seconds (otherwise it will denature the
collagen network of dentine and dentine will collapse).
This process will condition the enamel and dentine
which can then be washed with air-water spray for 5 to 10
sec. After this conditioning, hydrophilic monomer in
alcohol/acetone base can penetrate the decalcified
intertublar dentine upto 1-5 microns. This zone of
penetration of monomer is called the hybrid zone
interpenetration or interdiffusion zone. This is the main
site for enamel and dentine adhesion. After light-cure for
10 seconds these millions of threads/tentacles have
physical catchment with resultant bonding strength of
more than 22 megapascals (MPa). However, penetration
of these bonding materials into the dentinal tubules does
not seems to increase its bonding strength. It is the collagen
fibres of the dentine which gives strength to the attached
tentacles.
WHAT IS BONDING
Thirty-seven per cent phosphoric acid after application for
15 seconds on enamel and dentine will dissolve the
inorganic rods of enamel and tubules of dentine
sparing the organic matrix intact.
Introduction 5
The pressure spray of water and air will remove the

etchant gel along with residue of dissolved enamel rods
and dentinal tubules leaving behind millions of spores
(1-5 microns deep) which were previously occupied by
inorganic enamel rods and dentinal tubules when the area
is blot dried and water is withdrawn from them they
become hollow tubes. Now when the Primer is applied
for 20 seconds over them the liquid infiltrates into these
hollow tubes by osmosis and fill them. After 20 seconds
the excess Primer (solvent base Alcohol/Acetone) is
blown (Air thinned) by air blasts for 1 to 2 seconds leaving
behind thin surface of Primer. Then it is light-cured for
10 seconds. The liquid which had infiltrated inside the
hollowed tubes along with the surface layer will get cured
and shall get physically attached (Bonded) to enamel
and dentine of the tooth. The surface layer of primer is
now loaded with flowable/regular filled composite and
light-cured, so this layer shall get Bonded to surface layer
of Primer.
Hence the regular composite material will get attached
(bonded) to surface layer of Primer which in turn is
attached to tooth (enamel and dentine) by millions of
tentacles. This is the integral part of the so-called term
Bonding. This mechanism should be crystal clear in the
mind of operator (See Figs 1.1 to 1.8). Worth mentioning
here is that if phosphoric acid concentration is high or if it
is applied for a longer duration than 15 seconds or if more
penetrating (corrosive) acids like hydrochloric acid/
sulphuric acid, etc. are used, they will attack the organic
matrix of dentine denaturing the collagen fibres after
which the dentine shall collapse and shall not be left
suitable for bonding. Enamel, however, can tolerate acid
better than dentine because of its compact and hard matrix,
hence can be etched a little longer than dentine (see Fig.
7.7).
Fig. 1.1: A smear layer forms on the dentine during tooth preparation,
the smear layer which covers the surface of the dentine and plugs the
tubules, requires conditioning to prepare the tooth for bonding
Fig. 1.2: The total-etch technique uses phosphoric acid to condition the
dentine, subjecting both the enamel and the dentine to acid, which must
then be properly rinsed and dried. Doing so removes the smear layer
and the dentine plugs entirely and prepares a hybrid zone for resin
infiltration to support bonding. It also exposes the dentine and dentine
tubules to air, oral fluids and bacteria. That coupled with the chance of
over drying increases the possibility of postoperative sensitivity and poor
bond strength
Introduction 7
Fig. 1.3: Rather than removing the smear layer and exposing the dentine
and dentine tubules, self-etch materials incorporate into the hybrid zone.
Adhesive resin can then infiltrate the hybrid zone and penetrate the
tubules, preparing the dentine for bonding. In this way, self-etch materials
help control sensitivity as well as eliminate technique-sensitive steps
associated with total etch, which makes bonding more efficient
Fig. 1.4: Ground dentine

Fig. 1.5: Dentine with FL-bond/Primer
Fig. 1.6: Fluoride release into dentine

Introduction 9
Fig. 1.7: The above scanning electron microscope image shows an

intimate bonding interface (H and R) between nano bonding material
and dentine
Fig. 1.8: This SEM shows the effective penetration of OptiBond Solo
Plus when used with its Self-Etch Primer. The result is excellent infiltration
into the hybrid zone and the dentinal tubules, forming deep resin tags
We are now entering the post-amalgam age of operative

dentistry with an increasing trend toward the use of tooth
coloured amalgam substitutes and alternatives.
CHAPTER 2
Recent Advances in
the Improvement of
Materials Used in
Aesthetic Dentistry
BONDING MATERIALS FILLED DENTAL PRIMERS

Recently addition of fillers in the dentine bonding materials
have immensely increased the bonding strength and
marginal integrity. But unfortunately addition of fillers
makes the bonding material more viscous and the resultant
film thickness exceeding 15 microns shall make them
unsuitable for bonding indirect restorations.
The latest introduction is Nano-scale size fillers which
are almost 100 times smaller than regular micron fillers.
The nano fillers have revolutionized adhesive bonding
with deeper penetration of resin liquid into hybrid area
along with fillers which result into increased strength and
better seal of the cavo surface margins and less setting
shrinkage due to presence of more particles/fillers.
The following nano filled dentine adhesives are
available commercially.
i. Prime and bond NTTM (Dentsply)
ii. Opti-bond solo plusTM (Kerr)
iii. Excite (Ivoclar)
Table 2.1: Bonding generation chart

Bonding When Characteristics Bonding Examples Compo-
gene- Invented strength nents
ration to dentine
7th Recent Single component 18-25 MPa iBOND 1

Desensitizing
Self-etching
Self-priming
No mixing
Moisture
independent
Bonds to metal
Very little-no
sensitivity
Contd....
Recent Advances in Aesthetic Dentistry Materials 13
Contd....
Bonding When Characteristics Bonding Examples Compo-

gene- Invented strength nents
ration to dentine
6th Recent Multi-component 18-23 MPa Prompt-L-Pop 2-3
Multi-step SE Bond
Self-etching Liner Bond ll
(enamel?)
Self-priming
Hybridization
Very little sensitivity
5th 2000s Single component 20-24 MPa Gluma 1
Moist bonding Comfort Bond
Hybridization Prime &
No mixing Bond NT
Little sensitivity Single Bond
Excite
One Step
Bond 1
4th Early Hybridization 17-25 MPa All Bond ll 2-5
90s Total etch Pro Bond
Little sensitivity Scotchbond MP
Tenure
Bond it
Syntac
3th Late 2 component primer 8-15 MPa Prisma 2-3
80s and adhesive system Universal
Bonding to metals Bond
Reduced sensitivity Scotchbond ll
Tenure
Gluma
X-R Bond
2nd Early Weak adhesives 2-8 MPa Bond lite 2
80s requiring Scotchbond
retentive preps Dentine
Prone to water Adhesit
degradation/
1st Late Very weak bond 2 MPa Cervident 1
70s to dentine Cosmic Bond
MICROFILL LIKE HYBRID COMPOSITE

Hybrid composites have proved their worth in even stress
bearing areas of class II and class IV cavities, but the major
disadvantage is that they are difficult to polish because of
the size of the fillers which leaves ditches when these fillers
get dislodged. This defect of the material can be overcome
to some extent by better polishing technique available
(EnhanceTM, Dentsply) but this polish also gives way
against abrasion and the restoration looks rough and
stained. Hence periodic maintenance becomes mandatory.
The best example for composite that can be given is by
comparing it with mosaic floor in buildings and houses, Bis-
GMA is like cement base and fillers are like stone pieces
incorporated into the cement. More the stone pieces more the
hardness, when the cement along with incorporated stone pieces
in the floor sets, it is polished by surface grinding to result into
a smooth, hard and shiny floor, exactly like this Bis-GMA
base with fillers after light-curing become hard and its polishing
results into shiny and hard surface of the fillings, much harder
than Bis-GMA alone.
The recent introduction of improved hybrids have
fluoride glass fillers (0.6 m to 0.8 m) and a narrow
particle size distribution. This results in less viscous,
sculptable, non-sticky, superior polish attaining, long
lasting and better polishable material with of course very
low polymerization shrinkage (Because of reduced
quantity amount of base material (Bis-GMA) which can
shrink, but the fillers cannot shrink by polymerization
process).
The examples are :
i. Esthet-XTM (Dentsply) with 31 body shades, 3 opacities
and 5 translucent enamels to replicate any tooth colour.
ii. Point-4TM (Kerr)
Recent Advances in Aesthetic Dentistry Materials 15
iii. RenewTM (Bisco)

iv. VitalescenceTM (Ultradent).
PREREACTED GLASS (PRG) IONOMER TECHNIQUE

The PRG is a new technology from Shofu Inc to form a
stable phase of glass ionomer through advance reaction of
acid active fluoride containing glass and polyacid under
the presence of water. This technology can be further
classified into two categories F-PRG (Reaction of entire
glass) and S-PRG (Reaction of only the glass surface). These
SPRG fillers plus resin forms Gio-mer is commercially
called BeautifilTM (Shofu Inc) (See fillings with BeautifilTM
in Figs 7.26 to 7.31).
Fig. 2.1: A nano-composite is combination of Nano-particles (shown by

yellow arrow) and nano-clusters (shown by green arrow). A nanometer is
1/1000 of a micron. This type of composite is perfect both for anterior
and posterior fillings
CHAPTER 3
Compomers
Compomer was first introduced in 1993 by Dentsply when

their product DyractTM was launched. It was invented
by the research team of Dentsply and was adopted by rest
of the manufacturers. Compomer is derived from two
words Compo-Site and Iono-Mer and is the
combination of composite and ionomer technologies.
Compomer is a laymans term, better scientific version
should be Poly acid modified composite. Since it is a
composite which inherits the properties of glass-ionomer
such as self adhesion and fluoride ions release.
In case of ionomer cements, water which is essential
for acid-base reaction, is derived from the water available
in glass-ionomer liquid and therefore the acid-base reaction
starts as soon as dry powder is mixed with water
containing liquid. But in the case of compomer which is
anhydrous the acid-base reaction starts only when the
light-cured compomer is exposed to moisture in the oral
cavity. This reaction is possible due to polymerizable acidic
monomers present in compomers.
The older version of DyrectTM has been recently
improved by reducing the size of the particle of the filters.
The original matrix has also been modified by adding cross-
link monomers. These modifications in new product
Dyract APTM gives greater strength, increased wear
resistance and higher fluoride release. The compressive,
tensile strength and wear resistance of Dyract APTM is
similar to small particle hybrid composite, which makes it
suitable for all types of restorations specially to suit high
caries risk patients and children.
BRANDS
The brands of compomers available are:
i. CompoglassTM (Ivoclar)
ii. HiytacTM (Esp)
Compomers 19
iii. F-2000 (3M Corp)

iv. Elan (Kerr)
v. Dyract APTM (Dentsply).
All restorative materials which are cured by
polymerization, shrink during curing process. Average
filled composite shrink on an average of 2 to 4 per cent,
packable composites, however, shrink about 1.8 to 2.2 per
cent because of their higher filler contents. Studies done
on improved compomers show that the polymerization
shrinkage is compensated by the hydrophilic expansion
of the compomer through water uptake from the saliva.
The net volume change in Dyract APTM was found after
3 months to be equal to 0.5 per cent as compared to 2 per
cent shrinkage in an average composite material.
Doubtlessly, the water is absorbed by compomers, but
there is, however, no loss of its mechanical properties,
because of the continuous acid-base reaction. This increases
marginal integrity of the product and it is probably the
reason for less postoperative sensitivity and reduced
secondary caries due to continuous release of Fluoride.
INDICATIONS
Compomers are indicated especially in class V cervical
cavities. All types of restorations in children, class III
cavities, small class I and class II cavities, root caries, high
caries risk patients and where fluoride release property of
compomer would be beneficial.
CONTRAINDICATIONS
It is contraindicated in high stress bearing situation like
large class II and IV restorations, where composite is still a
better choice, inspite of all the improved properties of
compomer.
CHAPTER 4
Non-rinse
Conditioners (NRC)
Self-etching Primers
No doubt compomers can be used directly only after

applying the primer/adhesive but when it is to be bonded
to enamel especially in stress bearing areas of class I, II
and class IV situations, conditioning of the enamel should
be done by total etch technique. This conditioning is done
with 37 per cent phosphoric acid etchant gel, which must
be rinsed off by air-water jet. This area then requires re-
isolation of the tooth without saliva contamination. This
re-isolation should be performed under high speed suction.
To reduce this time consuming and technique sensitive
method of air-water jet washing and then re-drying the
tooth and again re-isolation of tooth without being
contaminated, to avoid all these procedures a new method
of non-rinse conditioner (NRC) similar to self etching
primer has been developed.
The NRC is applied to both the enamel and dentine
surfaces and left undisturbed for 20 seconds. After 20
second the excess of NRC is removed by air syringing
without desiccating the tooth. After application the NRC
penetrates and incorporates into the smear layer, rather
than removing it completely as in total etch technique. At
present NRC is used only with compomers. This is very
useful technique for children where rinsing and changing
of cotton rolls is difficult and chance of saliva
contamination is greater.
CHAPTER 5
Flowable
Composites and
Compomers
In restorative dentistry it was realized that a less viscous

material should also be available, which could flow easily
into nooks, corners and angles of the cavity without
creating any voids, air bubbles, etc. and should thoroughly
wet the cavity floor. The material should also seal small
class I, class II, and class V cavities efficiently in contrast
to normal viscous material.
Kerr was first to develop a flowable composite and
marketed it under the brand name RevolutionTM. Soon
many other manufacturers developed flowable composite
as under:
i. Tetric FlowR (Ivoclar, vivadent)
ii. Renamel FlowTM (Cosmodent)
iii. Aclit flowTM (Bisco).
COMPOSITION
In all of them basically monomer matrix contains Bis-GMA,
urethane dimethylacrylate and triethylene glycol
dimethacryate. The inorganic filler particles are barium
glass ytterbium trifluoride, Ba-Al fluorosilicate glass,
highly dispersed silicon dioxide and spheriod mixed oxide
(68% by wt.) catalysts, stabilizers and pigments are
additional contents (0.4% by wt.).
The filler quantity is 64 to 68 per cent by wt. and 40 to
44 per cent by vol. with particle size between 0.04 and 3.0
m (mean particle size is 0.7 m). The major use of flowable
resin would be to form a good marginal seal at the gingival
box of class II restoration. A flowable compomer with
properties of self adhesion and continuous fluoride release
would be a preferred advantage as compared to composite.
Its fluoride release property will be a boom in children
and high caries risk individuals. The following product of
flowable compomer are commercially available.
Flowable Composites and Compomers 25
i. Dyract flowTM (Dentsply)

ii. Compoglass flowTM (Ivoclar).
Tuberculin syringe delivery and better curing without
porosity is an edge of Dyract flowTM over Compoglass
flowTM.
INDICATIONS
The indications for the use of flowable materials are:
i. Class V restorations (cervical caries/root erosions)
ii. Sealing proximal box of class II cavities near gingiva.
iii. Small class III restorations.
iv. Small class I cavities as sealant.
v. Blocking undercuts in inlay, onlay and crown
preparations.
vi. As first increment in all deep restorations to avoid
voids/porosities and to obtain a good seal to prevent
post-filling sensitivity.
vii. Preventive resin restorations in premolars and molars.
viii. Adhesive cementation of composite/ceramic veneer.
ix. Repairs of composite/ceramic veneers.
x. Adhesive cementation of ceramic and composite
restorations.
CONTRAINDICATIONS
i. Covering of surface of large restorations because of its
less wear resistance.
ii. Where dry field is not possible to achieve.
iii. Where patient is allergic to any of the ingredients of
the material.
CHAPTER 6
Composite for
Posterior Teeth
(Molars)
The advancement in the field of submicron hybrid

composites, e.g. TPH spectrum TM or much better
packable composites like surefilTM with increased wear
resistance and greater comprehensive and tensile strength,
along with the introduction of nano-scale filled hydrophilic
dentine bonding agents like Prime and Bond NTTM, this
combination has made posterior teeth (molars) filling very
popular because of technically acceptability and matching
colour.
INDICATIONS FOR POSTERIOR TEETH (MOLARS)

FILLINGS BY COMPOSITE
1. All class I and class II cavities.
2. Patients sensitive or allergic to mercury.
3. Patients demanding aesthetics even in posterior teeth.
4. Patients who are afraid of mercury toxicity.
CONTRAINDICATIONS
1. Where moisture control is not possible.
2. Where proximal step of class II cavity is below gingival
margin. In such condition it is not only difficult to
manipulate placement of composite, but also moisture
from gingival tissue is difficult to control.
3. If lack of time is a factor.
4. If cost of the filling is a factor.
CHAPTER 7
Compulsory Steps in
Successful Bonding
1. Shade determination: Clean the tooth before determining

the shade. The tooth should be still moist for shade
determination.
2. Cavity preparation: Prepare the cavity according to the
principles of the adhesive technique, i.e. gentle
treatment of the tooth structure. In class II gingival
box area do not injure gingiva otherwise it may bleed
or ooze which will be difficult to control. Do not
prepare any sharp internal edges or additional
undercuts in caries free area, i.e. it is not mandatory to
follow G.V. Blacks principles as in cavity preparation
for amalgam. In anterior regions, bevel the enamel
edges. Caries free cervical defects are not prepared,
but merely cleaned with pumice and a suitable clearing
paste or water using a rubber cup or a rotary brush.
After that, remove possible residue with waterspray
and clean the cavity. No oil or oily material should
ever be used, because no bonding material, bond to oily
or dirty plaqued surface of the tooth.
3. Isolation: Appropriate isolation of the tooth with cotton
rolls with heavy suction or ideally with a rubber-dam
is required.
4. Base/pulp protection: If an enamel/dentine bonding
agent is used, a base material is not required. Cover
the areas close to the pulp in floor of the cavity in dots
like fashion with a calcium hydroxide material. And
in very deep cavities calcium hydroxide layer should
be covered with a pressure resistant cement, e.g. a glass
ionomer cement or a zinc phosphate cement. Do not
cover the remaining cavity walls, use these surfaces
for bonding with an enamel/dentine adhesive. Do not
use oil based cements like zinc-oxide, eugenol, etc. as
no bonding is ever possible on any oily surface.
Compulsory Steps in Successful Bonding 31
5. Fix the matrix/inter-dental wedge: Use a transparent

matrix band preferably without a clamp for cavities
affecting the proximal areas.
6. Conditioning/application of bonding agent: Condition the
cavity/tooth with Total etch technique using 34 to
37 per cent phosphoric acid etchant gel as per
recommendations of the manufacturer. Normally it is
applied for 15 seconds (not more than 20 seconds) lest
it should denature the surface dentine causing a
collapse of its collagen fibres resulting in a week
bonding to the dentine.
7. Wash off the etchant gel: With an air/water pressure
spray for about 5 to 10 seconds.
8. Remove the excess water: From the tooth surface with
an air syringe for 1 second/ or blot dry with an
applicator tip or cotton pellet taking care that you do
not desiccate (dry) the surface. It is essential to keep
the dentine slightly moist. Moisture is required for
diffusion of the hydrophilic resin of the primer into
the collagen fibres. Moisture also saves collagen fibres
against collapse.
Note: It is sometimes better to first apply the etchant
gel to only enamel part of the cavity in the first
installment sparing the deeper dentine part, leave it
for 15 seconds undisturbed and then spread afresh
etchant gel into the whole cavity including dentine for
another 15 seconds. Reason being that enamel tolerates
etchant better than dentine.
But in no case dentine should be etched for more than
15 seconds.
9. Researches have proved: that the results of one bottle
adhesive is as good as primer and bonding materials
in two separate bottles.
a. Take the Prime and Bond NT TM/Optibond

soloplus directly on applicator tip or put two
drops of prime and bond in a dappen dish and
apply the adhesive freely over the cavity area
with a small brush wetting the surfaces
thoroughly well.
b. Leave undisturbed for 20 seconds.
c. After 20 seconds remove excess solvent by air
syringing for a second or two (Air thinning).
d. Light-cure by good reliable light for 10 to 20
seconds. Inspect for perfect glossy base and
walls. If matt, i.e. hazy like areas are present it
indicates insufficient application of adhesive,
repeat the application of the adhesive and cure
all the matt, i.e. hazy areas till they also become
glossy and no matt areas are left. This step shall
give perfect sealed interface between loading
composite and bonding material and thus shall
avoid any future development of pulp
sensitivity.
10. Use incremental technique: for placement of composite
each increment of about 2 mm (except in case of
SurefilTM where increment may be of 5 mm because
SurefilTM can be cured upto a depth of 5 mm at a time).
Light-cure each increment separately for 40 seconds
keeping the light-cure machines light emersion
window as close to the restorative material as possible.
The first increment may be of Compomer or better
with a flowable compomer or composite for release of
fluoride and a better flow to avoid voids, air bubbles
and better adaptation in nooks and corners of the
cavity. It will also act as stress breaker for the normal
filled rigid loading composite layers above it. Keep in
mind that this layer of flowable material should not
be of more than 0.5 mm or so and of course it should

also be thoroughly light-cured for 60 seconds (See figs
7 to 21). The flowable material in a restoration
occupies the total base area of the cavity, whereas the
regular filled material is filled over this layer, taking
its bonding strength from flowable material base and
bonding tentacles from the inner walls of the cavity.
Now, if a thin layer of flowable material is applied
then it will just allow very little elastic compression
space under the occlusal stresses on the regular filled
material over it and shall act as favourable Stress
breaker. But if a thick layer (more than 0.5 mm or so)
of the flowable material is applied, then it will have
more elastic compression space (spring action) under
the regular filled material, which in turn shall break
its only weak tentacle support of the sides and shall
collapse over the base of the flowable material to
which it is bonded below and the filling will break
and come out.
That is why it is very important to give only 0.5
mm or so (thin) base layer of flowable material, so
that restoration may not collapse under occlusal
stresses.
11. In the last occlusal layers: contour the increment, when
it is still copious to maintain the occlusal and cuspal
anatomy and then light-cure it for 50 to 60 seconds.
The first deeper layer near the floor of the cavity should
be light-cured a little longer, i.e. 50 to 60 seconds for
complete/better polymerization of the martial to avoid
development of any future sensitivity of the pulp.
Also the last increment near the occlusal surface
should also be light-cured for 50 to 60 seconds for better
curing resulting into a better wear resistance.
12. After correcting: the filling for any excess and also
checking the proximal contacts rubber-dam or cotton
rolls should be removed. The occlusal relationship
with the opposite teeth should be corrected next with
the help of articulating papers and grinding of the
excess material by appropriate finishing diamond
under low speed and light pressure to avoid
overheating/charring of the composite. After attaining
perfect occlusion in centric occlusal position (Static)
and lateral excursions (Dynamic) final polishing
should be started.
TECHNIQUES FOR POLISHING

THE COMPOSITE FILLING MATERIAL
1. Start with 12 bladed carbide bur under low speed and
very light pressure without water spray for better view,
burs 7103, 7714, 7406, 7214, 7642 (Dentsply) may be
used. Wet finishing obscures the view and sometimes
results in ditching the cementum at gingival margins.
2. EnhanceTM Sol-LexTM or polishing kit by 3M, KENDA,
etc. are very good polishing kits. The advantage of
Enhance TM is that only one grit is needed to smooth
the surface rather than changing of grits in other
systems.
3. For final polish Prisma GlossTM (aluminous oxide) is
good with a rubber cup or synthetic foam-polishing
cup supplied with the paste pack.
4. Never overheat composite use low speed and light
pressure.
5. A well polished surface lasts longer as it attracts less
plaque and shall have better wear resistance.
Summary of Filling Steps with Composite

1. Shade determination: In moist and in very start.
2. Prepare cavity: As per principle of cavity preparation
protocol.
3. Isolation: Cotton rolls with high suction or ideally
rubber-dam.
4. Base protection: In deep cavities with DycalTM (calcium
hydroxide paste).
5. Fix Matrix band: Use interdental wedges.
6. Conditioning: Total etch 37 per cent phosphoric acid
for 15 seconds.
7. Wash etchant: For 5 to 10 seconds with air-water spray.
8. Remove excess water: Leave some moisture.
9. Apply adhesive/primer: Freely by brush tip and leave
undisturbed for 20 seconds.
10. Remove excess solvent after 20 seconds: With air syringe
for 1 to 2 seconds without moisture or water (Air
thinning).
11. Light-cure for: 10 to 20 seconds. Inspect for Matt like
areas (unglossy surface). If present repeat this steps in
that area till glossy surface is achieved.
12. Use increment: Of 2 mm each and light-cure them
separately for 40 seconds.
13. If using flowable composite/compomer: First increment
film should be thin of about 0.5 mm or so and light-
cure for 50 to 60 seconds.
14. Contour last occlusal layers: To replace surface anatomy
of the tooth and light-cure for 50 to 60 seconds.
15. Remove high points: With the help of articulating paper
in centric occlusion position (Static) and in lateral
excursions (Dynamic).
16. Polish as per protocol:

The photographs from Figures 7.1 to 7.20 are of a
clinical case. A step by step presentation of
replacement of old defective amalgam filling in teeth
15-16, which were replaced by light-cure composite
filling using flowable material for the base, i.e. first
layer (Figs 7.14, 7.15 and 7.21) followed by filling of
the rest of the cavity by a micro-filled light-cure
composite material (Figs 7.16 to 7.18).
i. The polishing kit is shown in Fig. 7.22.
ii. Another composite filling case is also shown
in the following diagrams (Figs 7.23 to 7.25).
iii. Different restorations class III and class I by
BeautifilTM (Shofu Inc.) (Figs 7.26 to 7.31).
iv. A case of decayed 45 (Distal) restored by iBond
is shown in Figures 7.32 to 7.38.
v. Deep pit and fissure sealing by ultra seal X.T.
plusTM (Ultradent) is shown in Figures 7.39 to
7.44.
vi. A glass-ionomer coating for the early protection
of erupting molars (Figs 7.45 to 7.46).
Fig. 7.1: Initial situation: defective amalgam fillings in teeth 15 and 16

Fig. 7.2: Shade selection with the shade

guide of the restorative system
Fig. 7.3: Situation after removal of the amalgam

fillings and initial preparation
Fig. 7.4: After excavation both cavities were finished.

The cavities are completely surrounded by enamel
Fig. 7.5: Covering of areas close to the pulp on tooth 16 with calcium
hydroxide (DycalTM) in dot like fashion covering minimum area and leaving
maximum area for bonding
Fig. 7.6: Situation after restoration of the second premolar with light-
cure composite
Fig. 7.7: Application of 37 per cent phosphoric acid initially to the

enamel margins only. Sparing dentine surface
Fig. 7.8: After 15 seconds of enamel conditioning, filling the entire cavity
with etchant and conditioning the enamel and dentine for another 15
seconds (total etch)
Fig. 7.9: The typical chalky-white appearance

of successful enamel etching
Fig. 7.10: Application of the adhesive Prime and Bond NT TM with

micro-brush to enamel and dentine
Fig. 7.11: Careful evaporation of the excess solvent from

the adhesive system after 20 seconds(air thinning)
Fig. 7.12: Light-curing of the adhesive for 20 seconds
Fig. 7.13: The adhesive shows a glossy surface on the entire cavity.
No matt areas noticed
Fig. 7.14: Application of a layer of flowable material,

Tetric flow as stress-breaker
Fig. 7.15: A thin layer (0.5 mm) is important

light-cure for 40 seconds
Fig. 7.16: Re-contouring of the matrix and application of a first layer 2

mm of the light-cure composite restorative material. Light-cure for 40
seconds
Fig. 7.17: Situation after incremental build-up of the filling

Fig. 7.18: First check of the occlusion after

removing cotton rolls/rubber-dam
Fig. 7.19: Second check of static and dynamic occlusion after

finishing and pre-polishing of both fillings
Fig. 7.20: Finished restoration re-establishing the initial shape of the

teeth and adapting its shade well to the surrounding tooth substance
Fig. 7.21: Thin 0.5 mm layer of flowable material should be used. Red
area is the layer of flow able material, whereas blue area is the area of
regular composite material
Fig. 7.22: Polishing kit

i. Polish with white-coarse grit until correct form and a smooth surface
achieved
ii. Polish with green which gives smooth and silky surface
iii. Polish with pink fine grit, a high gloss and finest surface are instantly
achieved
Fig. 7.23: Etch

Fig. 7.24: Bond: Syringe deliver PQ1 (Ultradent) directly into

preparation with Inspiral Brush Tip, air thin and light-cure
Fig. 7.25: Restore. Finished restoration

Fig. 7.26: Before Fig. 7.27: After
Filled by Beautifil (Shofu Inc.)

Fig. 7.32: The decay is noted on

the distal surface of 45
Fig. 7.33: The decay is accessed

and removed with bur
Fig. 7.34: The conservative cavity preparation is complete. The tooth

is matrixed
Fig. 7.35: The preparation is bonded with iBond (Heracus Kulzer)

Fig. 7.36: The bonding agent is light-cured
Fig. 7.37: The cavity is restored with Venus (Kulzer)

Fig. 7.38: The occlusal surface is pre-shaped with duck-head

instrument and light-cured finished and polished
Fig. 7.39: Before Fig. 7.40: Etch

Fig. 7.41: Dry & Prime Fig. 7.42: Seal
Fig. 7.43: Cure Fig. 7.44: After
Figs 7.39 to 7.44: Ultra seal X.T. plusTM (Ultradent) is a fluoride

releasing quality, predictable, easy to use as pit and fissure sealent
Fig. 7.45: Before
Fig. 7.46: After
Figs 7.45 and 7.46: A case of glass ionomer coating (Pink) for the early
protection of erupting molar with GC fugi VII resin free glass ionomer self
set it just cures in 20 to 40 seconds bonds in moisture, can also be
applied quickly and easily to coat and occlude pits fissures and tooth
surfaces. It releases very high level of fluoride and can easily be
distinguished because of its Pink colour
CHAPTER 8
Restoration of a
Fractured Incisor
(Class IV Defect)
The decision should be made between selection of repair

of large class IV defect either by bonding or by full facial
veneer. The veneer, however, does not have more strength
than bonding, but in most of the cases necessary for
aesthetic reasons.
Bonding, though a conservative method of restoring
tooth, some preparations are necessary for optimum
results. Restoration should not only be pleasant looking,
but also functionally correct to resist the occlusal forces.
Hence the operator must be well acquainted with the
principles of occlusion. Bruxism being a major hazard and
is contraindication for a direct composite veneer, however,
if unavoidable then occlusal nightguard must be provided
to the patients.
Because mandibular incisors glide on the palatal surface
of the maxillary incisors during protrusion it is important
that any abnormal forces during protrusive phase may
fracture the restoration, if improperly contoured.
1. Preparation of the tooth: Old restoration and caries
should be removed. Make a chamber of about 0.25 or
0.3 mm deep of about 3 to 4 mm width along round
the whole periphery. Now place a long bevel up to
crest of the gingiva from mesial to distal direction.
2. Selection of shade: Both enamel and dentine shades
should be selected. The dentine replacement material
is placed as strong and opaque base to prevent shine
through.
Enamel replacement material is generally more
translucent. If properly selected, composite shades,
eliminates need for opaquers. Opaquers should be
avoided as far as possible because of their shine
through enamel shades produce unaesthetic looks.
3. Abutments: At this stage tooth should also be checked
for any proximal caries, because it is the best time to
Restoration of a Fractured Incisor (Class IV Defect) 59
restore them because of easy approach from proximal

side, over hanging or over contoured restorations if
any, may be contoured conveniently at this juncture.
4. Removal of the stains etc: Any debris or stains should
now be removed with a coarse stone or bur.
5. Protection of pulp: If properly sealed with bonding
material protection of the pulp is not required. If,
however, very thin covering of dentine is suspected
then it should be covered with quick setting calcium
hydroxide liner like DycalTM. It is mandatory to cover
this layer of DycalTM with flowable compomer for final
aesthetic reasons otherwise the shade of DycalTM will
be apparent under translucent composite enamel
replacement material.
6. Etching the preparation: Etching may be done with 37
per cent phosphoric acid gel. Abutments should be
protected by mylar strips whereas tooth should be
etched a little past the bevel.
7. Apply adhesive: Now apply the adhesive and light-cure
it after elapse of 20 seconds for 10 seconds. The
resultant shining area should be checked and
reapplication of adhesive and curing should be done
if matt (hazy) areas are left behind till total adhesive
area should become glossy (these matt areas where
bonding shall not be perfect will be the potential
sources of postoperative sensitivity of the tooth).
8. Matrix bands: Generally they are not required as the
composite if sculptable and does not slump, it is
possible to complete the entire restoration without a
matrix. Mylar strips, however, may be used if deemed
necessary to safeguard abutments.
9. First build the lingual shelf: The lingual shelf should be
built first with opacious shade of composite (already
preselected). Lingual shelf should cover the entire

lingual portion and should also be sculpted into
Chamfer area of the facial side. In most of the cases
this step will result in opaquing out the shine through
of the dark background.
10. Facial buildup: It should be done in two shades and
two layers, if necessary. The first layer is the body
shade which is contoured up towards the incisal area
in a scalloped fashion. This is then light-cured for 40
seconds. Then the translucent incisal shade is placed
on the incisal edge from mesial to distal side and
feathered into the body of the tooth and light-cured.
This step would result into slightly over contouring of
the restoration.
11. Contouring and polishing the restoration: First the incisal
edge should be reduced to proper length . Next contour
the lingual surface with finishing burs without water
to enable better visualization of the margins and the
developing anatomy. The occlusion can now be
checked and adjusted.
The facial finish is now started with 12 bladed
finishing bur (7714 dentsply) paying special attention
to the resin interface. Do not over finish lest it should
result into a white line. If white line do appears then
slowly smooth the transition from resin to the tooth
till the white line disappears. Finishing discs are of
particular help in achieving this and preventing
scaring of the tooth. The final gloss is achieved by
Prisma GlossTM and Prisma Gloss extrafine TM paste
and rubber cups or foam cups, etc.
Diagrammatic representation of :
i. How to change 13 into missing 12 is shown in Figures
8.14 to 8.17.
Fig. 8.1: The mandibular incisor path as it transverses during

protrusive phase along the palatal surface of upper incisor
Fig. 8.2: Diagrammatic representation of preparation

of a fractured incisor
Fig. 8.3: Lingual shelf is made of opaque composite being

spreaded partly overlapping labial chamfer
Fig. 8.4: Layering of body shade is done with pre-selected shade

composite and light-cured for 40 second for each layer
Fig. 8.5: Apply and blend incisal (transparent) shade into body shade
and light-cure for final results after polishing
Fig. 8.6: Fractured central incisors before direct bondings
Fig. 8.7: Fractured central incisors restored

Fig. 8.8: Diastema, small spaced incisors

which required aesthetic improvement
Fig. 8.9: After direct micro hybrid composite (TPH SpectrumTM,

Dentsply) bonding (See Chapter 9 for details)
Fig. 8.10: Smile before direct bondings
Fig. 8.11: Smile after direct bondings

Fig. 8.12: Discoloured, abraded old restorations which require

aesthetic direct bondings
Fig. 8.13: Old restorations completely removed and replaced with full
veneers on centrals and laterals. Prime and Bond NTTM and micro hybrid
TPH SpectrumTM were used for bonding the veneers
Fig. 8.14: Clinical findings: anterior teeth of upper jaw on right-hand

side of a 28 years-old patient with missing lateral incisor
Fig. 8.15: The area was isolated with rubber dam. After the enamel
surface was roughened slightly, etching of the adhesive surface was
carried out with ortho-phosphoric acid gel
Fig. 8.16: An opaque dentine core was

built up with the shade A3D on 13
Fig. 8.17: The final picture shows change of canine into lateral incisor
ii. Incisal 1/3rd of 21 restored with bonding with

composite in a vital tooth (Figs 8.18, 8.19, 8.22 and 8.23).
iii. Incisal 1/3rd of 21 restored with bonding with
composite in non-vital tooth (Figs 8.20 and 8.21).
(endotontically treated)
iv. Heavy fluorosis of vital 11 and 21 treated by bleaching
and composite bonding, 12 and 22 were left for
comparison (Figs 8.24 and 8.25).
v. A case of tetracycline stains cervical 1/3rd of 11 and
21 (21 Non-vital) treated by bleaching and bonding
with composite (Figs 8.26 and 8.27).
vi. A case of fluorosis treated by composite lamination
(Figs 8.28 and 8.31).
Fig. 8.18: Situation before Fig. 8.19: Situation after bonding

(Vital 21) 21 with composite
Fig. 8.20: Situation before (Non- Fig. 8.21: Situation after bonding
vital 21) 21with composite
Fig. 8.22: Incisal edge Fig. 8.23: Incisal edge

fracture in 11 repaired by composite
Fig. 8.24: Heavy brown discoloura- Fig. 8.25: Stains of fluorosis

tion (fluorosis) in the teeth 11, 12, cleaned by grinding and bleaching
21-22 from 11 and 12 laminated with
composite and polished. Note the
difference in look comparing with
12-22 (Initial situation)
Fig. 8.26: Brown stains tetra- Fig. 8.27: Tetracycline stains

cycline in cervical of 1/3rd of 11 completely covered by bleaching
and 21 (21 being non-vital) followed by composite lamination
(Slight dark hue of 21 is due to Non-
vital discolouration)
Fig. 8.28: A case of heavy Fig. 8.29: Treated by bleaching,

fluorosis micro-abrasions and composite
lamination
Fig. 8.30: Brown stains Fluorosis.

Note: Distinct lines showing age and the time of deposit of stain
Fig. 8.31: Typical Khat stains. (A rare case.). A habitual chewing of

khat leaves will leave yellowish-brown discoloration of fluorosis probably
due to deposition of tannin found in the leaves. (Khat leaves from Yaman
contains 360 ppm fluoride)
CHAPTER 9
Diastema
Closure
Closing of the diastema with composites can immediately

and dramatically change the beauty of the smile just in a
single appointment. It may also help to improve speech
and food particles being caught in the space between the
teeth.
The ratio between length and width of incisors teeth is
about 10:8, so first step would be to measure the
dimensions of the incisors where diastema is to be
eradicated.
If the space between incisors (diastema) is less than 3
mm it can be categorized as simple diastema. If,
however, the space is more than 3 mm then the problem
of shine through the two incisors would be too big to look
natural, hence the condition shall be tackled by complex
diastema closure technique.
Simple diastema closure: can easily be done by simply adding
composite on both effected sides of the incisors
(abutments).
Complex diastema closure: If the gap is more than 3 mm,
then the diastema is closed as in simple diastema closure
but to compensate the increased width of the tooth opposite
side; the tooth is also reduced to maintain the basic length-
width ratio of 10:8. Now the so created diastema on distal
side of the tooth can be closed by simple diastema closure
technique on the mesial side of the abutment of the
primarily effected tooth. For example, if there is diastema
of more than 3 mm between two central incisors the
reduction of increased width of central incisor is
compensated by reduction on its distal side till the ratio of
10:8 is maintained.
Now diastema so created between central and lateral
incisors can be filled by adding composite on the mesial
side of the lateral incisor. This complex diastema closure
Diastema Closure 73
technique may have to be combined with full facial veneer

sometimes.
STEPS IN CLOSURE OF DIASTEMA

1. Measure the space (diastema) and plan for choosing simple
or complex closure techniques.
2. Select the shades
3. Preparation of the tooth: For simple closure no
preparation is required. Check the tooth for stains and
remove them if present. Remove tooth material from
the distal side in complex cases to main 10:8 ratio of
length-width of the tooth. It should be done without
local anaesthesia and without exposure of the dentine,
lest it should become sensitive tooth later. Start with a
single tooth first and complete the procedure up to final
polishing, before starting the next tooth.
4. Etch the tooth: Etch the surface of the tooth for 15 seconds
on mesial, facial and lingual/palatal side with 37 per
cent phosphoric acid etchant gel, use mylar strips to
avoid etching of the abutments. The restoration should
cover up to one-third of facial and lingual or palatal
side of the tooth.
5. Wash the etchant gel: With air/water spray for 5 to 10
seconds and blot dry the tooth.
6. Adhesive application: Apply adhesive as per protocol for
20 seconds avoiding contamination of the adjacent
tooth. Light-cure for 10 seconds.
7. Filling the gap (diastema):
Simple Diastema: Inject a small amount of some microfil
like hybrid from the facial side, completing the whole facial
contour, check the midline before curing, light-cure for 40
seconds. Next inject second incremental layers from
palatal/lingual aspect, blending the material evenly into

labial/lingual sides with proper attention to restore the
tooth anatomy on diastema side. Complete contouring,
curing, finishing and polishing of this restoration before
starting the job on the next affected (abutment) tooth.
Repeat the steps on the next needy prepared tooth with
or without using a mylar strip as composite does not stick
to highly polished surface and so shall not bond to it.
For the above procedure sometimes we need immediate
separation of the teeth to restore the correct mesial slope
anatomy. Separation can be done with the help of a plastic
instrument or a carver (Lacrons) held in the gingival
embrasure between the incisors, give a twist torque force
till a popping sound is heard which indicates that the teeth
are seprated.
Complex Diastema: Complex diastema closure needs use of
hybrid opaque composite to prevent shine through
followed by use of a translucent microfil. If recent
compounds like Esthet- XTM is used there is no need of a
microfiller as this material comes in 31 shades selection
pack. Other options of materials are: Point - 4TM (Kerr)
RenewTM (Bisco) and vitalescene (Ultradent).
SUMMARY
To close a diastema decide wheather it is of simple or
complex variety by measuring length and breadth of the
tooth, ideal ratio is 10:8 length/breadth. More than 3 mm
wide diastema is categorized as complex variety.
In complex variety preparation, reduce opposite side
of the diastema side of the tooth maintaining its anatomy
and length breadth ratio, reducing only in enamel. Do not
expose dentine and use no local anaesthesia.
Diastema Closure 75
Steps
1. Measure length and breadth of the tooth.
2. Select shade.
3. Prepare the tooth remove stains, etc.
4. Etch the tooth on mesial/facial and lingual aspect
beyond area of bonding after separating abutments
with mylar strip.
5. Wash etchant gel from the tooth surface after 15 to 20
seconds with air-water spray for 1 to 2 seconds and
blot dry, leaving some moisture for hydrophilic
adhesive material to penetrate deep into hybrid area.
6. Apply adhesive material taking care not to contami-
nate abutment. Leave the adhesive undisturbed for 20
seconds.
7. Air blast (by air syringe) the excess solvent of adhesive
material for 5 seconds. (Air thinning).
8. Light-cure for 10/20 seconds.
9. Check for glossy surface, matt free surface should
be achieved. If matt surface is still present repeat
the adhesive application and cure again till they also
become glossy.
10. Apply microfilled composite material to build the
required shape of tooth paying special attention to the
midline, sculpt facial side first.
11. Light-cure each increment for 40 seconds.
12. Apply material on lingual/palatal side of the tooth and
sculpt the anatomy specially on the mesial side and
then light-cure for 40 seconds.
13. Add layers till perfect anatomy of the tooth is achieved.
14. Finish and polish as per protocol.
15. Repeat the same steps on the next tooth in complex
diastema closure using or not using mylar strips.
Note: In complex diastema closure use opaque layer
first followed by translucent layer of composite
material. But with recent microfilled materials it may
not be necessary.
Fig. 9.1: After preparing/cleaning total etch is done by applying 37 per

cent ortho-phosphoric acid up to a little past the required area for 15 to
20 sec. After 15 sec wash etchant with air-water spray
Fig. 9.2: After Primer application for 20 sec. air thin and light-curing for
10 sec. preselected shade of composite is placed on proximal surface
and sculpting it towards the facial surface light-cure for 40 sec
Diastema Closure 77
Fig. 9.3: Shows placement of composite on lingual aspect and

blending it into the cured labial portion
Fig. 9.4: Measure the completed restoration to make sure that the
correct width is achieved as pre-determined
Fig. 9.5: Compo-DiscTM in use for immediate

separation of bonded tooth
Fig. 9.6: Cross section view of incisor teeth

restored to eradicate diastema
Diastema Closure 79
Fig. 9.7: Diastema/spaced incisors which

required aesthetic improvement
Fig. 9.8: After direct micro hybrid composite

(TPH Spectrum TM, Dentsply) bonding
Fig. 9.9: Diastema before direct bonding
Fig. 9.10: Closure of Diastema after direct bonding

CHAPTER 10
Bleaching
of the Teeth
Hydrogen peroxide has been used as bleaching agent

material since almost 100 years. It was used by dentists in
their chair in high concentrations of 20 to 30 per cent by
volume.
Superoxol (perhydrol): is 30 per cent sol. of H2O2 by wt. and
100 per cent by vol. in distilled water (H2O2 up to 135 per
cent is also available through textile industry).
Pyrozone: is 25 per cent sol. of H2O2 in ether. Extreme care
in its handling should be used as it is extremely corrosive.
It was only around 1989 when Home bleaching with
10 to 22 per cent carbamide peroxide was introduced.
Both chairside and home bleaching systems are
effective and generally lighten the colour of the teeth by 2
to 5 shades.
IN-OFFICE BLEACHING
Light and heat is generally used along with high
concentrations of H2O2 (17% to 35%) researches have
proved that addition of light and heat does not increase
lightening of teeth shades and are not necessary for
bleaching the vital teeth. On the contrary light and heat
causes more pain and post-treatment sensitivity and create
unnecessary complications like caustic burns of the
gingiva. Some of the office bleaching products are:
i. HILITETM (Shofu Dental )
ii. Opalescentra XtraTM (Ultradent).
Recently Dentsply has come out with IllumineTM which
contains 15 per cent H2O2 in an elastic putty (gel) and is
held in vacuum forged tray (nightguards) which is held
in oral cavity for 30 minutes or more in dentists office.
This shows greater promises because of ease of use, as
compared to high concentration H2O2 requiring rubber-
Bleaching of the Teeth 83
dam for isolation of gingiva, which generally causes caustic

burns inspite of all the safety measures.
AT-HOME BLEACHING
It is popular because of good whitening effect of teeth (2
to 5 shades) is achieved by a fortnights use only and, of
course, the safety of its use under the supervision of a
dentist.
In view of increasing bleaching effect in short time
manufactures tried 10 to 22 per cent of carbamide
peroxide, but the fast obtained result are temporary, there
is little difference in whitening of the teeth after elapse of
6 weeks, no matter whether done with 10 per cent or higher
percentage of carbamide peroxide.
The thicker and stickier gel putties are considered
convenient and better. Following are the popular brands:
i. Nupro goldTM (Dentsply)
ii. OpalescenceTM (Ultradent)
iii. Nite-whiteTM (Descus Dental)
iv. PlatinumTM (Colgate Palmolive) not very viscous but
effective equally.
Conservative method of bleaching of the original teeth
is better than more aggressive methods like veneering,
crowning or bonding.
In non-vital tooth H2O2 percolates through the enamel
and dentine to reach the pulp in few minutes time.
Therefore bleaching is not only to remove superficial
staining but also to remove discolouration from deeper
pulpal parts.
Although the teeth shade initially may lighten, within
few days, but the best results are obtained after 2 to 6 weeks
which should be told to the patient in advance.
Before bleaching After bleaching

Fig. 10.1

Fig. 10.2

Fig. 10.3

Fig. 10.4
Bleaching of the Teeth 85

Fig. 10.5

Fig. 10.6

Fig. 10.7
Tetracycline stains take longer time to bleach, i.e. 2 to 6

months, but very dark gray or blue stains are difficult to
bleach specially when they are present in gingival 1/3rd
area. In such cases veneer may be required in addition to
bleaching.
Most of the cases (about 60% to 70%) experience

sensitivity of teeth after bleaching process. This sensitivity
can be treated with toothpaste containing potassium nitrate
and sodium fluoride. It should be used for topical
application for 30 minutes duration, each day for several
days till sensitivity is reduced.
TYPES OF STAINS THAT CAN BE BLEACHED:

i. Ageing discolouration, tea and coffee stains are easily
removed.
ii. Teenagers teeth are easy to bleach and it is easy to
remove stains from them.
iii. Nicotine stains are difficult to bleach.
iv. Dark gray and blue stains of tetracycline are most
difficult to bleach especially in gingival 1/3rd area and
may take more time.
Fifty per cent of the peroxide in bleaching agent is
released in first 1 to 2 hours and the rest of it is released in
next 4 to 6 hours. Hence over night bleaching is preferred
to day time 1 to 2 hours bleaching.
Proper diagnosis as to the pathogenic cause of
discolouration of teeth by dentist and bleaching under his
supervision shall be more fruitful, than using advertised
products straightaway.
ADA has approved 10 per cent carbamide peroxide as
safe, reliable and effective at home agent for whitening
of the teeth but, however, ADA has not yet allowed higher
percentage of carbamide peroxide for at home bleaching.
CHAPTER 11
Indirect Metal Free

Restorations (MFR)
Porcelain fused to metal (PFM) restorations shows a

unaesthetic gray line at the gingival margins. Hiding it
subgingivally may cause periodontal problems. Moreover,
the presence of metal in the PFM prevents light being
passing through and make these restorations look
unnatural, when using gold as base recession of gingiva is
unavoidable.
Recently, etching of internal surfaces of the full ceramic
restorations with hydrofluoric acid and bonding them to
enamel and dentine with dental adhesive and aesthetic
resin cement give them a long lasting seal of cavo-surface
margins with resultant better gingival health. It also
increases fracture resistance of the restoration and that has
been a long desire of a dentist.
PRESSABLE CERAMICS
There are many all ceramic restoration systems available
but the most popular today are the pressed ceramic because
of their excellent fit and marginal integrity.
i. Empress and
ii. Empress II (Ivoclar) had been in lead for last 10 to 12
years. Recently Dentsply Finesse all ceramicTM has
been introduced with an edge over others because of
its increased aesthetics, less wear of opposite teeth,
easy polishability and thermal stability even after
several consecutive firings. It has proved perfect for
anterior and posterior full coverage, crowns veneers,
inlays and onlays. This materiel is fired at low fusing
temperatures which enhances the utilization of
proprietary, as it is a naturally opalescent powder it
would be unstable at higher temperatures. The core
material as well as low fusing ceramic exhibit natural
look in all lighting conditions.
Indirect Metal Free Restorations (MFR) 89
SELECTION OF DENTAL ADHESIVE

AND RESIN CEMENTS
Pressable ceramics can be etched from ventral side with
hydrofluoric acid and then bonded to the prepared tooth
with dental adhesive and resin cements.
Many good aesthetic resin cements are available:
i. CalibraTM (Dentsply)
ii. Variolink IITM (Ivoclar)
Light-cure/dual Cure Dental Adhesives
Prime and Bond NT Dual cureTM (Dentsply)

It is important that cementation kit should also have water
soluble try in paste which has perfect shade match key
to the cement shades. These pastes greatly simplify colour
matching of the indirect restoration. It is also important
that the base cement can be used light-cured and for
veneers and then matched with a catalyst and can be dual
cured (light activated and chemically activated) for crowns,
inlays and onlays. Similarly it would be safe to use a dual-
cure adhesive like Prime and Bond NTTM with a self-cured
resin cement, as research by Reality group has shown
that a number of light-cure adhesives do not bond to the
self-cure cements.
Impression Taking for Indirect Restorations

Beside aesthetics, the marginal fit of a restoration
determines its clinical longevity in the oral cavity. Hence
taking a perfectly accurate impression is mandatory in a
well fitting restoration. Several factors influence the
registering of impression of a prepared tooth.
i. Gingival health: Should be perfect to facilitate recording
of an impression. In a pool of saliva/blood/exudates,
etc. it is almost impossible to record perfect impression.

Hence prior supra and sub gingival scaling, by scaling
and curettage technique should be done well in
advance to achieve perfect gingival health.
ii. The impression tray should be rigid and of perfect size
which locks the impression material (like RimlockTM
dentsply). It should not touch any part of the tooth.
iii. Accurate impression material should be used: AqusilTM
(Dentsply) a hydrophilic quadra functional modified
polyvinyl siloxane contains four reactive vinyl groups
which results in increased cross-linking of polymer
web, than that obtained with conventional A-silicones.
Its tear strength is very important in wet conditions
and also results in superior cast production. The
improved wetting ability of the material is of prime
importance specially in recording perfect surface
details in gingival sulcus areas.
iv. Working time: It is important that one should do fast
work because if once polymerization of the impression
material starts it should be discarded and a fresh
impression should be planed. Because if polymerizing
material rebounds after impression is made, unnoticed
by the operator, it will result into a tight fitting crown.
Both low viscosity (LV) syringe marital and putty
or medium viscosity (MV) tray materials should be
flowable at time of recording the impression.
TECHNIQUE FOR RECORDING IMPRESSION
Gingival Retraction
It is better to use double cord retraction technique. The
first cord is left in the sulcus and the second cord is packed
on top of the first. Just prior to syringing the material
around the tooth, the top cord is removed leaving the first
cord in sulcus. The advantage being no blood, serous

discharge at the time of impression taking because blood,
saliva, serous discharge, etc. can cause interference in the
flow of material from the syringe.
Squeezing of syringe impression material is started
from the bottom of the prepared crown and circulated
around the stump (tooth) with the material against the
tooth structure and only syringe tip being in the material,
voids shall occur if the placement is done at different areas
and then brought together. Care should be taken not to
pull the material away from the tooth during the whole
procedure.
It is important not to compress the material while taking
it out of the oral cavity, because compression can cause
permanent deformities of the impression. Break the seal
of the impression holding tray from back of it and loosen
it gradually to prevent tearing. Only after loosening of the
impression the handle of tray should be used to take it
out. AquasilTM because of its quadra functional resin has
excellent tear strength even in thin layers of the impression
material.
After withdrawal check the impression with a
magnifying glass for voids, wrinkles, bubbles and also
specially that the prepared tooth do not touch the tray
surface at any place. Small defects can be masked by
technician but if the defect is large, repeat the impression
procedure.
Bonding of the Metal Free Restoration

Etch the internal surface of the prepared restoration with
10 per cent hydrofluoric acid for 1 to 2 minutes.
Some recent studies recommend sand blasting of the
internal surface of the preparation before treating with 10
per cent hydrofluoric acid. Examine the internal surface
for roughness of the etch, then clean the internal surface

with regular 37 per cent etchant gel (phosphoric acid). This
step does not etch the ceramic, except to clear the surface.
Rinse thoroughly and dry the surface.
Apply silane to the sand blasted, etched and acidified
internal surface of restoration and leave undisturbed for 1
minute. Blow out the excess gently with an air syringe for
5 seconds.
When the thickness of the restoration is less than 2 mm,
only thin Prime and Bond NTTM is enough to bond the
restoration by light-cure. If the thickness is more than 2
mm, it is safe to use Prime and Bond NT Dual cureTM.
Apply it on the internal surface of the restoration and also
wet the tooth surface and then after 20 seconds, air dry
both separately and light-cure each for 10 seconds. The
film thickness of Prime and Bond NTTM is 6 to 7 microns
and hence shall not disturb sealing of the restoration even
if cured before cementation.
Now place the resin cement on the internal surface of
the preparation and gently guide it into place on the
prepared tooth till it sits completely. Remove the excess
cement with brushes and interdental silk floss.
Light-cure the surface for 60 seconds from all the sides
of the tooth, i.e. buccal, lingual/palatal, mesial and distal
surfaces, individually for 60 seconds each surface.
Care should be taken not to use resin reinforced glass
ionomer cement (RRGIS) for cementing ceramic
restoration, because it generally results in fracture of the
crown, because of the forces of the internal expansion of
the cementing material in the oral cavity. However, some
of the recent RRGIS like Protec CemTM (Ivoclar) and
compomer cement Dycal Cem PlusTM (Dentsply) claim
very little expansion and are recommended for cementing
of all ceramic restorations.
DIRECT PROVISIONAL CROWN

AND BRIDGE MATERIAL
Self curing components material for creating direct
temporary crown and bridge based on multifunctional
methacrylic esters and glass fillers. It is free from methyl
methacylate, therefore the finished temporaries have an
excellent bio-compatibility and safe for the pulp at a low
curing temperature of approximately 38oC. It attains
compressive strength of 220 MPa, flexural strength 80 MPa,
tensile strength of 36 MPa and knoop hardness of 17 HK.
It is available in market under brand name of Swift-
TempTM. (Shofu Inc.).
The technique of using this material for fabricating
temporary crowns etc. is self explanatory (Figs 11.1 to 11.4).
Diagrammatic representation of:
i. Pressed all ceramic crown making procedure shown
in Figures 11.5 to 11.10.
ii. Crome Cobalt (Metallic) full crown with acrylic buccal
facing (Figs 11.11 to 11.14).
iii. Dowel pin crown made on RCTed 12 (Figs 11.15 and
11.16).
Fig. 11.1: An impression is taken Fig. 11.2: After tooth preparation

prior to tooth preparation load the impression tray with Swift-
Temp (Shofu Inc.) and place over
the tooth preparation
Fig. 11.3: After 3 Fig. 11.4: Finish and polish the

minutes remove the temporary restoration
tray from the mouth
Fig. 11.5: Teeth after bleaching Fig. 11.6: Full veneer preparation
with Nupro Gold (Dentsply). The on the right central incisor
direct composite bonding on the (endodontically treated) and partial
upper central incisors could not be veneer preparation on left central
bleached and hence appears incisor
darker than natural teeth
Fig. 11.7: Provisionals prepared Fig. 11.8: Restorations outside

from TPH SpectrumTM (Dentsply) the mouth
and cemented with non-eugenol
cement
Fig. 11.9: Restoration seated on the Fig. 11.10: Pressed all ceramic
master model crown on right central incisor
and pressed laminate veneer
on left central incisor bonded
with Prime and Bond NT Dual
CureTM (Dentsply) and Calibra
CementTM (Dentsply)
Fig. 11.11: Initial situation, note Fig. 11.12: After proper reduction
the broken but vital 14 impression were taken and a full
chrome cobalt metallic crown with
acrylic facing was planed
Fig. 11.13: Internal view of the Fig. 11.14: Final finished metallic
prepared crown crown with acrylic facing cemented
on stump of 14
Fig. 11.15: Tooth prepared for dowel pin crown

after root canal treatment of 12
Fig. 11.16: Dowel pin crown cemented in place on 12

INDEX
A after correcting 34
base/pulp protection 30
Aclit flow TM (bisco) 24
Adhesive resin 7 cavity preparation 30
Aesthetic dentistry 2 conditioning/application of
bonding agent 31
conditioning 3
history of bonding materials 2 fix the matrix/inter-dental
scope 2 wedge 31
isolation 30
smear 3
remove the excess water 31
B shade determination 30
use incremental technique 32
Bis-GMA 14
wash off the etchant gel 31
Bleaching of the teeth 81
at-home bleaching 83 D
in-office bleaching 82
Dentinal tubules 5
C Dentine bonding material 4
Diastema closure 71
Compoglass flow TM (ivoclar) 25
categories 72
Compomers 17
complex diastema
brands 18
closure 72
Compoglass TM
simple diastema closure 72
(ivoclar) 18
steps 73
Dyract AP TM
Direct provisional crown and
(dentsply) 19
bridge material 93
Elan (Kerr) 19
Dyract flow TM (dentsply) 25
F-2000 (3M Corp) 19
Hiytac TM (Esp) 18
E
contraindications 19
indications 19 Enamel rods 5
Composite for posterior teeth EnhanceTM dentsply 14
(molars) 27
contraindications 28
F
indications 28 Flowable composites and
Compulsory steps in successful compomers 23
bonding 29 composition 24
contraindications 25 R
indications 25 Renamel flow TM (cosmodent) 24
Filling steps with composite 35 Restoration of a fractured
apply adhesive/primer 35 incisor 57
base protection 35 abutments 58
conditioning 35 apply adhesive 59
contour last occlusal layers 35 contouring and polishing the
fix matrix band 35 restoration 60
isolation 35 etching the preparation 59
light-cure for 35 facial buildup 60
polish as per protocol 36 first build the lingual shelf 59
prepare cavity 35 matrix bands 59
remove excess solvent after preparation of the tooth 58
20 seconds 35 protection of pulp 59
remove excess water 35 removal of the stains 59
remove high points 35 selection of shade 58
shade determination 35
use increment 35 S
wash etchant 35 Selection of dental adhesive and
resin cements 89
H impression taking for
indirect restorations 89
Hybrid composites 14
gingival health 89
Hybrid zone 4
working time 90
light-cure/dual cure dental
I
adhesives 89
Indirect metal free restorations Shofu Inc 15
(MFR) 87
T
M Technique for recording
impression 90
Matt surface 75
bonding the metal free
Microfill like hybrid composite 14
restoration 91
N gingival retraction 90
Techniques for polishing the
Non-rinse conditioners (NRC) composite filling
self-etching primers 21 material 34
Tetric flowR (ivoclar, vivadent) 24
P
Types of stains 86
Prereacted glass (PRG) ionomer
technique 15 U
Pressable ceramics 88 Ultra seal XT plus TM (ultradent) 54

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What are some of the techniques discussed for aesthetic and cosmetic dentistry?

What are some of the techniques discussed for aesthetic and cosmetic dentistry?

What materials are used for indirect metal free restorations?

What materials are used for indirect metal free restorations?

Aesthetic and Cosmetic

Dentistry Made Easy

Pramod Bansi Mathur

Sanjay Bansi Mathur

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Aesthetic and Cosmetic Dentistry Made Easy

My Naniji Smt. Phool from whom I learnt devotion and parity

Aesthetic and Cosmetic Dentistry Made Easy is written for

Pramod Bansi Mathur

Chapter 1 Introduction --------------------------------------- 1

Chapter 2 Recent Advances in the Improvement of

Chapter 3 Compomers -------------------------------------- 17

Chapter 4 Non-rinse Conditioners (NRC)/

Chapter 5 Flowable Composites and Compomers - 23

Chapter 6 Composite for Posterior Teeth (Molars) - 27

Chapter 7 Compulsory Steps in Successful

Chapter 8 Restoration of a Fractured Incisor

Chapter 9 Diastema Closure ------------------------------ 71

Chapter 10 Bleaching of the Teeth ----------------------- 81

Chapter 11 Indirect Metal Free Restorations (MFR) - 87

HISTORY OF BONDING MATERIALS

dentistry materials, became interested in this branch and

by the properties of the composite to which it is attached,

The pressure spray of water and air will remove the

Fig. 1.4: Ground dentine

Fig. 1.5: Dentine with FL-bond/Primer

Fig. 1.6: Fluoride release into dentine

Fig. 1.7: The above scanning electron microscope image shows an

We are now entering the post-amalgam age of operative

BONDING MATERIALS FILLED DENTAL PRIMERS

Table 2.1: Bonding generation chart

7th Recent Single component 18-25 MPa iBOND 1

Bonding When Characteristics Bonding Examples Compo-

MICROFILL LIKE HYBRID COMPOSITE

iii. RenewTM (Bisco)

PREREACTED GLASS (PRG) IONOMER TECHNIQUE

Fig. 2.1: A nano-composite is combination of Nano-particles (shown by

Compomer was first introduced in 1993 by Dentsply when

iii. F-2000 (3M Corp)

No doubt compomers can be used directly only after

In restorative dentistry it was realized that a less viscous

i. Dyract flowTM (Dentsply)

The advancement in the field of submicron hybrid

INDICATIONS FOR POSTERIOR TEETH (MOLARS)

1. Shade determination: Clean the tooth before determining

5. Fix the matrix/inter-dental wedge: Use a transparent

a. Take the Prime and Bond NT TM/Optibond

be of more than 0.5 mm or so and of course it should

TECHNIQUES FOR POLISHING

Summary of Filling Steps with Composite

16. Polish as per protocol:

Fig. 7.1: Initial situation: defective amalgam fillings in teeth 15 and 16

Fig. 7.2: Shade selection with the shade

Fig. 7.3: Situation after removal of the amalgam

Fig. 7.4: After excavation both cavities were finished.