Universal Hybrid Composite Facilitates Conservative Enhancements to Patients’ Smiles

In today's world of high-demand cosmetic dentistry, the use of composites enables clinicians to treat more patients with artistry and in a conservative manner. Composite materials have become increasingly sophisticated in a wide range of properties, such as chameleon-like effects to blend with surrounding tooth structure and adjacent teeth, improved handling and sculptability, high polishability, better wear resistance and strength for durability, and opacity both in appearance and radiographically. Additionally, more color choices are available, and costs have become more affordable. In the 21st century, patients often judge their dentist by how their restoration looks.

The following two case reports demonstrate the use of a composite material (BRILLIANT EverGlow^®, Coltene, coltene.com) where functional and beautifully esthetic results were achieved. The restorative material is described by the manufacturer as a universal submicron hybrid composite. Its prepolymerized 0.20-micron filler lowers volume shrinkage (shrinkage rate: 2.3% to 2.8%). When applied in a 2-mm increment technique, this composite has excellent polishability and strength. Based on the author's experience after having used this product for more than 3 years, the material's smooth consistency makes it easy to handle, and its "duo shade" feature aids in achieving superb esthetics and simplified shading for a chameleon effect with highly efficient placement.

A 58-year-old male patient presented with a smile that was compromised by crowding and tooth wear, and he desired a healthier, more youthful-looking smile. After a thorough examination that included digital photography and scanning, it was determined that parafunction as well as orthodontic relapse had led to an esthetic breakdown. Anterior and posterior wear and chipping were generalized because of occlusal dysfunction; the patient had a history of orthodontic therapy to correct crowding as a youth, was satisfied with his appearance after his care, and subsequently stopped wearing his retainers not long after. The patient was vulnerable to further health risks to biomechanics and periodontal stability (Figure 1 and Figure 2). Fortunately, the remaining enamel volume was still acceptable for conservative repair if the functional risks could be overcome.

A conservative approach was recommended to and accepted by the patient that involved alignment, bleaching, and bonding, as described by Qureshi.¹ The treatment started with clear aligner therapy with Invisalign^® (Align Technology, Inc, invisalign.com). Aligner treatment took place for 6 months to pronate the maxillary anterior teeth while retruding the mandibular anterior teeth using interproximal reduction and attachments. The patient was compliant with orthodontic care and a hygiene regimen (Figure 3).

Ample time was allowed for post-orthodontic care so that solid tooth positions and occlusion could be established. This involved 3 months of retention along with deprogramming, whitening, and occlusal equilibration at the end of the time period. A wax-up of teeth Nos. 7 through 10 and 23 through 26 was used in the planning of the new esthetics, which would be aided by improved function. Putty matrices of the diagnostic blueprint were key elements in establishing lingual, incisal, and facial contours.

A mock-up of composite shades prior to treatment helped the clinician collaborate with the patient, who wanted a natural-looking appearance. Repair of chipped and damaged teeth was done additively. Tooth preparation was minimal using an erbium dental laser to create internal retention and thin, external, low-depth diamond bevels that would help in blending the composite materials with tooth structure for essentially invisible, minimal-stain-producing margins.

After surface conditioning with 27-micron aluminum-oxide powder and etching with 37% phosphoric acid, thin layers of a one-component multipurpose bonding agent (ONE COAT 7 UNIVERSAL, Coltene) were placed for 20 seconds, gently dried for 5 seconds, and light-cured for 10 seconds per tooth. Using the putty matrices, incremental placement of BRILLIANT EverGlow, shade A1/B1, was done starting with the establishment of lingual incisal parameters, followed by facial layering using a non-sticky gold composite instrument (Almore International, almore.com), small gold ball burnisher, and interproximal carver, the latter two both being coated for easier placement and contouring.

Benefits of BRILLIANT EverGlow, according to the manufacturer and based on the author's experience, are that "double shading" (ie, combining two shades in a single shade) allows for multichromicity, the composite handles well without slumping, and it polishes easily to a very high gloss. Final adjustments of the bonding were done with 12-fluted ET composite burs, fine and extra-fine interproximal strips, discs of varying grits, two-step Alpen Composite Plus Polishers (Coltene), and a felt polishing disc with aluminum-oxide paste to create a natural, high-gloss finish for esthetics and longevity (Figure 4 and Figure 5).

After the restorative phase was completed, the patient was fitted for a mandibular clear retainer and flat biteguard to decrease nighttime friction and diminish the effects of any tooth movement.

In summary, the patient was ecstatic to have his smile enhanced in a conservative manner while also having the causes of the original breakdown corrected. Along with a predictable treatment plan, the exceptional hybrid composite enabled the relatively easy completion of a highly esthetic restoration that is anticipated to be long lasting, giving the patient and dental team peace of mind.

Not every situation allows the clinician sufficient time to perform a full diagnostic work-up as in the previous case. In this next case, the patient was experiencing the effects of poor bonding technique. As the lead assistant to a referring plastic surgeon, it was important to the patient that her situation be resolved quickly so she could return to work in a timely fashion without being embarrassed by her smile. To the patient, it was an esthetic emergency. At the same time, however, the clinician felt it was important to educate the patient on the risk factors involved for long-term success.

The 53-year-old patient presented with tooth No. 8 discolored and misshaped after bonding that was performed about 1 month prior (Figure 6). She stated that she originally had bonding done on the tooth at age 13 due to trauma when her sister hit her in the mouth with a telephone receiver. She said only the "fractured corner" was repaired at that time and it matched "nearly perfectly." She recently visited a new dentist who suggested that the bonding be updated with a newer material to improve the esthetics. The patient said she did not think esthetic improvement was needed but decided to accept the dentist's recommendation and have the bonding replaced. She was extremely disappointed in the result, as the shade was yellowed and the bonding was too short. According to the patient, the dentist explained that he needed to order a specific material for her teeth due to the level of brightness and translucency present. The patient returned to have the bonding redone, however no improvement in the result was achieved.

During a limited examination at this emergency visit, which included photographs and a radiograph, the clinician discussed with the patient the details of the situation in order to manage expectations. The patient felt it was important to return to work as quickly as possible and was embarrassed about her smile and was focused only on the tooth in question. The clinician's focus was on the evident mesial discoloration and short appearance of the existing bonding on the distal half of the tooth. The surrounding parameters were critical, and it was important for the clinician to let the patient know the limitations with which he was dealing, as the patient's time constraints allowed no opportunity to scan for models and create a wax-up putty matrix. In the author's experience, however, it is always better to diagnose than make excuses later.

Despite mandibular crowding and incisal discrepancy between teeth Nos. 25 and 26, the clinician verified that enough clearance was present to add length to the distoincisal aspect of tooth No. 8. In addition, it was determined that generalized recession throughout the mouth and the fact that tooth No. 8 naturally protruded labially might affect shade appearance slightly (Figure 7). The clinician also advised the patient that matching a single central incisor to the surrounding teeth can be extremely challenging. Nevertheless, based on his experience, the clinician was confident that the optical properties of BRILLIANT EverGlow would facilitate a major improvement in the situation.

To keep the patient comfortable, half of a carpule of 4% articaine with 1:100,000 epinephrine buffered with sodium bicarbonate was administered. The quick onset allowed treatment to be provided efficiently in a timely manner to accommodate the patient's needs.

Removal of the existing composite provided the clinician a clear view of the natural dentin and enamel and enabled a mock-up of shades to be done to create proper hue and value. Given the amount of missing tooth structure on the mesial aspect, opacity was needed to block out light and build value into the restoration. In addition, due to some translucent incisal characteristics, care had to be taken to anatomically control the shading to optimize blending in the anterior zone. The clinician's plan for shading was to first place BRILLIANT EverGlow OBL (Opaque Bleach), which would provide opacity to block out transparency and allow for the same hue range to blend in with the adjacent tooth structure. This would be usedto replace the missing mesial dentin, with the composite material stopping short of the incisal edge. Then, the clinician would layer BRILLIANT EverGlow BL translucent shade overall as an enamel replacement.

The creation of the mock-up helped the clinical team collaborate with the patient and verify the treatment with her while demonstrating to her how challenging this restoration was with regard to material selection and nuanced technique. The mock-up helped the patient appreciate the complexity of the case and the skill and artistry involved in the procedure.

After removal of the mock-up and isolation of the adjacent surfaces with a mylar strip (Figure 8), the surface of tooth No. 8 was minimally prepared with fine diamond burs and 27-micron aluminum oxide, which was in a paste form and applied with a felt-coated polish disc to help provide a high gloss to the composite. The tooth surface was etched with 37% phosphoric acid and bonded with placement of thin layers of ONE COAT 7 UNIVERSAL for 20 seconds, then gently air-dried for 5 seconds and light-cured for 10 seconds. Using the BRILLIANT EverGlow compule delivery system (Figure 9), the OBL shaded compule was placed and the composite was sculpted anatomically with the instruments previously mentioned in Case 1 to rebuild lost dentin.

Rebuilding the facial and incisal aspects of the tooth with the BRILLIANT EverGlow BL translucent shade (Figure 10) involved shaping and sculpting with a contouring instrument (OptraSculpt^® Pad, Ivoclar Vivadent, ivoclarvivadent.com) (Figure 11), as well as the paddle tip of the gold composite instrument cited in Case 1 (Almore International) (Figure 12). Additional blending and smoothing was done using a fine sable brush and sculpting gel (Figure 13). The restoration was adjusted and polished to correct contour and occlusion in the same manner as in Case 1.

Upon being shown the new restoration the patient noted vast improvement and took self-portrait photographs for her own verification. The clinician's digital dental camera photograph immediately postoperative is shown in Figure 14; a slight dehydration of adjacent teeth is noted. The patient was very pleased and quite relieved with the result after experiencing the embarrassment and frustration of living with a discolored central incisor. The clinician recommended and the patient agreed that plans would be made for the long-term health, function, and esthetics of the tooth. The clinician was also gratified that the plastic surgeon for whom the patient worked texted him a note of appreciation.

Based on the author's experience and as demonstrated in these two cases, the composite system highlighted in this report enables dentists to replicate natural esthetics and provide durable, enhanced cosmetic dentistry. Being able to perform restorations with predictability helps build confidence in a clinician's skills and makes excellence more achievable.

This article was commercially supported by Coltene.

Hugh Flax, DDS
Private Practice, Atlanta, Georgia; Accreditation, American Academy of CosmeticDentistry; Master, International Congress of Oral Implantologists; Diplomate, American Board of Aesthetic Dentistry; Educator, Catapult Education