This document summarizes the restoration of a Class IV fracture using composite buildup. It describes taking a study model and wax mockup to create a putty index for placement of the composite layers. A self-etch adhesive system and nanofilled hybrid composite were used to place thin layers of enamel and dentin shades, sculpting the desired anatomy. Finishing involved establishing anatomy and removing excesses. New nanohybrid composites simplify techniques while providing strength, optical properties, and adhesion for minimally invasive restorations resembling natural tooth structure.

1. CLASS IV COMPOSITE BUILD UP
Dr Anamika Sinha
2nd year post graduate
Dept of Conservative Dentistry and Endodontics

2. INTRODUCTION
• Recognizing the unique biological architecture
of the natural tooth, we today practice
conservative procedures and minimally
invasive techniques in order to preserve the
maximum amount of healthy structure when
restoring dentition to proper form and
function.

3. • Additionally, visual ergonomics is of optimal
importance when restoring the anterior
segment of patients presenting with Class IV
fractures.
• When we study the histological cross sections
of natural teeth, we can appreciate the
complexity of structure that we are trying to
replace.

4. • Enamel is very crystalline, with specific
although varying orientation. It has very little
chroma, but does have a significant impact on
how the light is reflected.
• Dentin , on the other hand, is a very dense
and amorphic layer that absorbs light and has
the largest influence on chroma.
Vanini L. Light and color in anterior composite restorations. Pract Periodontics Aesthet
Dent. 1996 Sep;8(7):673-82.

5. • In understanding the shades of teeth and
attempting to restore what is missing, we have
to use materials that are similar in their light-
refractive qualities to the missing tooth (i.e.,
replacing dentin with a dentin substitute and
enamel with an enamel substitute.)
LeSage BP. Aesthetic anterior composite restorations: a guide to direct placement.
Dent Clin North Am. 2007 Apr;51(2):359-78.

6. CASE REPORT
A patient aged 23 years reported to the OPD of
department of Conservative dentistry and
Endodontics.
Patient complained of fractured restoration in
upper front region since one month.

7. • Vitality test performed using Endofrost revealed vital
11.
• On Clinical examination, periodontal probing was
within normal limits.
• Percussion and palpation showed negative response.
• Radiographic investigation showed no pulpal
involvement.

8. It was diagnosed with Ellis Class II fracture wrt
11.

9. ELLIS CLASS II FRACTURE IN 11

10. TREATMENT PLAN
Composite restoration irt 11 using a putty index
.

11. • Initially study model was taken.
• Wax mock up was made on the study model.
• Putty index was made using the study model.
• This is helpful to determine the ideal
anatomical contours and symmetry.

12. Putty index made

13. • After the template was made, the patient was
recalled.
• Shade was selected before application of the
rubber dam. It is important to evaluate the
tooth while it is fully hydrated. It was A2
enamel shade and dentin shade is one shade
darker.

14. • The tooth was isolated with rubber dam.

15. • Long irregular bevel of 2-3 mm was given on
the facial surface. A lingual bevel of 1mm was
given.
• A Soflex disc was used to make an invisible
margin and to round all sharp angle for a
better composite blend.

16. In this case the adhesive technique performed
was using self etch system, Xeno V by
Dentsply.
A nanofilled hybrid composite , Filtek Z 350 XT
was used.

17. • The lingual matrix was placed on the teeth
and the enamel shade composite was adapted
to the matrix and the tooth structure in a thin
layer about 0.3mm to create a lingual shell.
• Dentin shade was then applied slightly over
the facial bevel to conceal the fracture line
and sculpted to the desired anatomy with
developmental lobes.

18. • The thickness of the dentin layer is crucial and
was evaluated from the incisal edge before its
polymerization to ensure that an enamel layer
thickness of 1mm on top.
• The final layer was then placed in one
increment and carefully adapted to replicate
proper line angles, anatomy and symmetry.

20. • First finishing step was to establish the length,
the bucco lingual position of the incisal edge
and the incisal embrassure with a coarse
finishing disc.
• Then the gingival embrassure and gingival
excesses were eliminated using a flame
diamond finishing bur and # 12 scalpel blade.

21. • Lingual excesses were removed using diamond
egg shaped bur.
• Interproximal surfaces were finished with
diamond strips.
• Final polishing was done using Super snap
discs by Shofu.

23. DISCUSSION
• In the past, recreating the unique characteristics
of natural dentition could be difficult and
confusing. Manufacturers released multiple
composite shades, opacities, and translucencies,
all of which were required to reconstruct
individualized teeth. Therefore, the direct
composite placement technique became
overwhelming and time consuming. Fortunately,
dental material manufacturers have helped to
improve and enhance dental treatments by
developing direct composites that simplify the
layering process.

24. • Today's biomimetic direct composite materials
reduce the amount of composite colors
required to recreate aesthetic restorations and
simplify and enhance predictability. These
new composites address demands for
minimally invasive treatments while providing
increased strength and optical characteristics,
universal application, improved adhesion, and
optimal handling and sculptability when
reconstructing the biological, aesthetic, and
physical architecture of natural teeth.

25. • Among the new alternatives available are
nanohybrid composite resins indicated for
Class I to Class V restorations. These newly
developed universal nanohybrid restoratives
display greater wear resistance, enhanced
color stability, long-lasting polish retention,
natural dentition-like flexural strength, and
low shrinkage. composite resins also enable
simplified techniques.

26. • Although simulating natural tooth structure,
shape, and shade while blending with
surrounding dentition still requires careful
composite selection and artful procedures
during placement protocol, these new
nanohybrid resins also enable simplified
techniques.
Terry DA, Geller W, Tric O, et al. Anatomical form defines color: function,
form, and aesthetics. Pract Proced Aesthet Dent. 2002;14:59-67.

27. • A class IV fracture requires an understanding of
the components of the optical properties of the
adjacent tooth structure to create an invisible
restoration .
• A series of two bevels is helpful in visually
blending the cavosurface into the surrounding
tooth structure.
• The primary bevel involves the first 2 mm of the
preparation.
• The secondary bevel continues from this point
and tapers into the tooth’s final facial contours.
RESTORATIVE PROCEDURE

28. • A lingual shell of semi translucent enamel shade
composite defines the outline of the restored
tooth.
• This is best developed utilizing a lingual putty
stent created preoperatively from a diagnostic
wax-up, or a composite mock-up intraorally.
• A dentin shade (which typically has the highest
opacity in most resin systems) is then sculpted to
reproduce the natural contours of the dentinal
lobes observed in the adjacent tooth structure or
adjacent teeth.

29. • A chromatic or a body shade is helpful in
eliminating any visual recognition of the cavo-
surface. This demarcation should disappear
before the final translucent layer is applied.
• Also, if any maverick colors, fracture lines,
orinternal characterizations are to be applied,
this must be accomplished during preparation
of this layer.

30. • A final layer of enamel resin that mimics the
translucency of the adjacent tooth structure is
applied .
• Once the general contours of the tooth have
been created, it is important to replicate the
same surface texture and polish in the
restorative material as exist in the natural
tooth surface.
Villarroel M, Fahl N, De Sousa AM, De Oliveria OB Jr. Direct resin restorations based
on translucency and opacity of compositeresins. J Esthet Restor Dent. 2011
Apr;23(2):73-87.

31. Conclusion
• The clinician’s desire to create natural-looking
restorations is limited by the products available for
restorative procedures. Knowledge must be integrated
with the proper technique for each clinical situation.
• Manufacturers and scientists are leading the way with
new advances in restorative materials and adhesive
technology. These techniques, concepts, and ideas
from clinicians, scientists, and technicians around the
world are the spark that ignites the reaction.
• However, it is the clinical experience and judgement
that is the true catalyst of the reaction that creates
form, function, aesthetics, and longevity.