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Operative Dentistry, 2017, 42-1, E10-E15

A Conservative Technique for

Repairing Class IV
Composite Restorations
VC Ruschel  SC Stolf  S Shibata  LN Baratieri

Clinical Relevance
The repair of the facial surface of a class IV composite restoration with poor coloration is a
minimally invasive treatment that allows satisfactory restoration of esthetics and function.

SUMMARY INTRODUCTION
Composite resin may make a restoration no- Restorative treatment with composite resin in a
ticeable as time passes, on account of its color fractured anterior tooth is generally considered
instability. The repair technique is a minimal- successful when there is optical integration between
ly invasive treatment for class IV composite the tooth structure and the restoration. In this
context, the concept of natural stratification propos-
resin restorations that show unsatisfactory
es the combination of optical properties from differ-
coloration. Thus, the objective of the present ent resin layers, with the objective of mimicking the
article was to report a clinical case involving a natural color and translucency of dental tissues
conservative technique used for repairing a without needing a bevel.1-4 Nevertheless, there are
class IV composite resin restoration in the left still difficulties in mimicking remaining tooth resto-
maxillary central incisor and the replacement rations in fractured anterior teeth using composite
of a class IV restoration in the right maxillary resin stratification. This difficulty occurs because of
central incisor. the variety of currently available shades, chroma,
and translucency levels of composite resin. Hence, it
*Vanessa Carla Ruschel, DDS, MSD, PHD, Federal Univer- is necessary to have a professional, detailed percep-
sity of Santa Catarina, Operative Dentistry, Florianopolis, tion of natural optical tooth characteristics and
Brazil
knowledge of the optical behavior of the composite
Sheila Cristina Stolf, DDS, MS, PhD, Federal University of resin used to reproduce the restorations.
Santa Catarina, Operative Dentistry, Florianopolis, Brazil
In addition, the color instability of composite
Shizuma Shibata, DDS, MSD, PhD, Federal University of
Santa Catarina, Operative Dentistry, Florianópolis, Brazil
resin5-7 can make the restoration noticeable over
time. Therefore, when an anterior composite resin
Luiz Narciso Baratieri, DDS, MSD, PhD, Federal University
restoration is considered clinically unacceptable, a
of Santa Catarina, Operative Dentistry, Florianopolis, Brazil
decision should be made whether the best option is to
*Corresponding author: Disciplina de Dentı́stica, CCS
repair or replace the entire restoration. Generally,
Campus Universitario Trindade, Florianopolis, SC 88040-
900, Brazil; e-mail: [email protected] replacement is the treatment of choice, mainly in
situations of color incompatibility between the tooth
DOI: 10.2341/15-316-T
and the restoration. The repeated replacement of the
Ruschel & Others: Repair Technique for Class IV Restorations E11

teeth showed a clinical survival of 10 years after the

repair procedure.16 Opdam and others10 reported
that the repair of composite resin restorations in
posterior teeth had a failure rate of only 5.7% four
years after clinical evaluation.
This technique can be an alternative to treating
aged class IV composite resin restorations with
unsatisfactory color, in which the original color and
composition of the materials are unknown. A
prerequisite for performing this technique is having
optimal marginal fit on the palatal surface. Further-
more, the repair may be performed in cases of a
fractured anterior tooth, where the restoration is
initially performed with a composite resin corre-
sponding to the basic color of the remaining tooth
structure and without stratification. In the following
session, the preparation of the facial surface is
performed, and the repair with composite resin is
stratified to reproduce the opalescent effect and
enamel.
With this in mind, this article reports on a clinical
case in which a conservative technique was used for
repairing a class IV composite resin restoration in
the left maxillary central incisor and a replacement
was made of a Class IV restoration in the right
maxillary central incisor.

CASE REPORT
A 22-year-old patient came to the Federal University
of Santa Catarina dissatisfied with the color of 2
class IV composite resin restorations, one in the
right maxillary central incisor (No. 8) and the other
in the left maxillary central incisor (No. 9; Figures 1
Figure 1. Initial aspects of the patient’s smile. Note the unsatisfac- and 2). The radiographic examination showed that
tory color of the class IV restorations in the two maxillary central the patient’s teeth had normal periapical and
incisors. periodontal tissues. During the clinical examination,
Figure 2. Intraoral view of maxillary anterior teeth.
Figure 3. Palatal view of maxillary anterior teeth. Observe that the teeth Nos. 8 and 9 showed pulp vitality. The palatal
palatal surface of the restoration in tooth No. 9 has adequate marginal surface of the restoration in tooth No. 8 was
adaptation, unlike the restoration in tooth No. 8. discontinuous, featuring marginal leakage. The
restoration on the palatal surface of tooth No. 9
same restoration causes wear of sound tooth struc- was complete and had adequate marginal adaptation
ture, leading to the need for more extensive (Figure 3). The replacement of class IV restoration in
restoration, injuries to the dentin-pulp complex, or tooth No. 8 and the restoration repair in tooth No. 9
fractured tooth remnants. were proposed to the patient.
Repair of a restoration is a conservative treat- Prophylaxis was initiated in the restoration region
ment, entailing the addition of restorative material with a nylon brush and prophylactic paste, followed
after the preparation of the aged restoration.8 Such a by color selection. The restoration in tooth No. 8 was
procedure favors restoration longevity and preserves removed, and an elastomeric impression of the upper
healthy tooth structure.9,10 There is growing scien- and lower jaw of the patient was taken (Express XT,
tific support in the literature for the repair of direct 3M ESPE, St Paul, MN, USA) to make diagnostic
composite resin restorations.8-16 A clinical study wax-ups of tooth No. 8. A tapered diamond bur (2135
found that composite resin restorations in posterior F, KG Sorensen, São Paulo, SP, Brazil) was used to
E12 Operative Dentistry

Figure 8. Intraoral view of the palatal enamel on tooth No. 8 and the
preparation of tooth No. 9 after adhesive procedures.

remove the restoration in tooth No. 8 and to prepare

the facial surface of the restoration in tooth No. 9
(Figure 4). The preparation was conducted to provide
space for the composite resin stratification, across
the entire facial surface of the restoration, respecting
the inclination of the mesial and incisal thirds. In
addition, the mesial surface was prepared to create
space for insertion of proximal artificial enamel
(Figures 5 and 6). A design of the mamelons was
made in the incisal region, using a sharp-ended
diamond bur (2137F, KG Sorensen), to obtain space
for the reproduction of an opaque and opalescent
halo (Figure 7). Afterward, a mock-up was conducted
to verify the correct composite resin color selection
and was left for 1 week as a temporary restoration.
During the next session, the operative field was
isolated with a rubber dam, the surface of the old
resin was sandblasted with aluminum oxide (50 lm,
MicroJet Gold Line, Essence Dental VH, Arara-
quara, São Paulo, Brazil), and the enamel and resin
were etched with phosphoric acid at 37% for 30
seconds (PowerEtching, BM4, Palhoça, SC, Brazil,
Table 1). Afterward, silane was applied (Monobond
Plus, Ivoclar Vivadent, Schaan, Liechtenstein) using
a disposable brush (Microbrush, Coltène/Whaledent,
Altstatten, Switzerland). The silane was gently air
dried for 60 seconds. Adhesive was applied (Scotch-
bond Universal, 3M ESPE) with a disposable brush
(Microbrush, Coltène/Whaledent). Care was taken to
ensure adequate solvent evaporation prior to light
curing (20 seconds), which was conducted using a
Figure 4. Restoration in tooth No. 8 removed and preparation of the
facial surface of the restoration in tooth No. 9 with a tapered diamond light-emitting diode-based light-curing unit (Trans-
bur. lux, Hereaus Kulzer, Hanau, Germany, intensity of
Figure 5. Aspect of the prepared facial surface of the restoration. 800 mW/cm2).
Figure 6. Lateral view of the silicone guide in position. Note that the
space for insertion of the composite resin is 0.7 mm. The stratification of the composite resin on tooth
Figure 7. Design of the dentin mamelons with a sharp-ended
diamond bur.
No. 8 included high translucent resin EB1 (IPS
Empress Direct, Ivoclar Vivadent) to reproduce the
palatal enamel, using a silicone guide obtained from
Ruschel & Others: Repair Technique for Class IV Restorations E13

Table 1: Materials Used For the Patient Treatment

PowerBleaching 16% BM4, Florianópolis, SC, Brazil
PowerEtching 37% BM4, Florianópolis, SC, Brazil
Monobond Plus Ivoclar Vivadent, Schaan,
Liechtenstein
Scotchbond Universal 3M ESPE, St. Paul, MN, USA
IPS Empress Direct Ivoclar Vivadent, Schaan,
(composite resins) Liechtenstein
Finishing strips 3M ESPE, St. Paul, MN, USA
Sof-Lex (polishing discs) 3M ESPE, St. Paul, MN, USA
Diamond Excel (polishing
paste) FGM, Joinville, SC, Brazil
Diamond Flex (felt disc) FGM, Joinville, SC, Brazil

low translucent resin DB1 (IPS Empress Direct,

Ivoclar Vivadent), in order to reproduce the dentin
body, and a translucent resin (Trans 30, IPS
Empress Direct, Ivoclar Vivadent), to reproduce an
opalescent halo. The facial enamel was reproduced
with a thin layer of high translucent resin EB1 (IPS
Empress Direct, Ivoclar Vivadent). Coarse removal
of excess material from both restorations was done
with a No. 12 sharp curved blade (Feather, Osaka,
Japan).
In the next session, the finishing and polishing
procedure was initiated with abrasive strips (3M
ESPE) on the proximal surfaces. The facial surfaces
were finished with sequential polishing discs of
decreasing grit size (Sof-Lex Pop On, 3M ESPE). A
carbide bur (FG 7664F, KG Sorensen) was used to
remove excess resin from the preparation margin
and to reproduce vertical texture. A felt disc
(Diamond Felt Disc, FGM, Joinville, SC, Brazil)
Figure 9. Aspect of the upper arch after the restoration is finished with diamond polishing paste (Diamond Excel, FGM;
and polished. Figures 9-11) was used to perform the final polish-
Figure 10. Palatal view of the finalized restorations. ing.
Figure 11. Patient’s smile after restorative treatment.

Potential Problems
the waxing (Figure 8). The incisal halo was repro- When assessing the three color dimensions, value is
duced with low translucent resin DB1 (IPS Empress what most influences natural tooth appearance,
Direct, Ivoclar Vivadent). Low translucent resin DA1 followed by chroma and shade.17-19 Greater translu-
(IPS Empress Direct, Ivoclar Vivadent) was used to cency of artificial dentin can decrease the restoration
reproduce mesial thirds dentin, and low translucent value and make the restoration more noticeable than
resin DB1 (IPS Empress Direct, Ivoclar Vivadent) an error in shade selection.4 In the case presented,
was used to reproduce incisal third dentin and the facial preparation depth of 0.7 mm on tooth No. 9
dentin mamelons. A translucent resin was used provided adequate space for insertion of dentin
(Trans 30, IPS Empress Direct, Ivoclar Vivadent) to resins, opalescent effect, and facial enamel. This
reproduce the opalescent halo, which was lightly depth was necessary since the color of the aged
applied to the dentin mamelons. The facial enamel composite resin was incompatible with the remain-
was finished with a thin layer of high translucent ing tooth structure. Thus, the thickness of the
resin EB1 (IPS Empress Direct, Ivoclar Vivadent). artificial dentin provided adequate opacity without
The restoration in tooth No. 9 was performed with interfering with the restoration value.
E14 Operative Dentistry

In the clinical cases in which the professional  Does not require anesthesia
restores a fractured tooth in its basic color and  Less clinical procedure time
carries out the repair in another session, the  Lower treatment cost for the patient
reduction of the facial surface can be slight without  Good acceptability by the patient
requiring a chamfer at the adhesive interface. It is
important to highlight that the thickness of the high Limitations
translucent resin, corresponding to the enamel, must
 Color difference between the restoration and the
be smaller compared with the natural enamel in
order to prevent a decrease in restoration value.20 tooth, because of the difficulty in color selection
The repair technique for the class IV composite resin and layering of the composite resin
restoration may also be a conservative alternative in
cases of permanent restorations that remain notice- CONCLUSIONS
able after treatment, due to errors in color selection.  The esthetic result of the new technique for
Once the facial surface has been repaired, the color repairing the facial surface of a class IV composite
can then be corrected, resulting in reduced clinical resin restoration is similar to that obtained by
time and preservation of sound dental structure in replacing the restoration.
comparison with replacement.  The repair of a class IV composite resin restoration
It is important to note that a restorative mock-up with unsatisfactory color is a viable alternative
should be performed whenever possible to ensure treatment that preserves sound tooth structure,
greater outcome predictability, since the composite restoring function and esthetics satisfactorily.
resin color changes during polymerization, as well as
24 and 48 hours after polymerization.5 Conflict of Interest
With regard to the surface treatment of the aged The authors have no proprietary, financial, or other personal
resin, studies report that the most favorable results interest of any nature or kind in any product, service, and/or
company that is presented in this article.
were obtained with the roughening and application
of a silane agent. The roughening procedure can be (Accepted 9 May 2016)
performed using diamond burs, sandblasting with
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