Simplified Stratification Technique

A Predictable Guide
for Direct Composite
Masterpieces
Lukasz Lassmann, DDS

Ahmed Tarek Farouk, BDS, MSc

Abstract
Mimicking the color and optical properties of natural teeth using composite resins is not an easy task in daily dental practice.
Several application techniques and materials with various optical properties have been proposed. These techniques and materials
aim to facilitate shade matching and imitation of optical properties using a natural layering concept, but it requires a skillful
dentist to be able to mimic the color of the adjacent natural tooth. This article presents an approach, the Simplified Stratification
Technique, to perfectly matching both natural color and optical properties.

Key Words: opacity, translucency, relative thickness, value, simplified stratification

Last Modified:
2/19/21 @2:05pm

46 2021 • Volume 36 • Issue 4

 Farouk

“Creating perfect direct composite resin

restorations using traditional techniques
has become an elusive goal.”
Introduction
Dental esthetics and a minimally invasive philosophy have direct composite resin restoration, the clinician must control
become increasingly essential over the last decade when multiple factors, such as hue, chroma, value, opacity, and
considering diagnosis and treatment planning. Creating translucency.1 Translucency is one of the most crucial factors, as
perfect direct composite resin restorations using traditional it creates optical phenomena that give a lifelike appearance to
techniques has become an elusive goal. This is due largely the composite resin restoration and matches the restoration with
to the difficulty of obtaining a proper optical match between the adjacent natural tooth structure in a harmonious way (Fig
mono-opacity composite resins and natural tooth structure. 1).2 Although some clinicians have been able to master different
Currently, this issue can be solved by the application of a variety natural layering techniques, many still struggle with technique
of composite resin-layering techniques. These techniques use sensitivity, as these layering techniques are affected by a variety of
different composite resin opacities as a substitute for both factors, such as translucency, color combinations, and the relative
enamel and dentin tissues. To reproduce a highly esthetic thickness of enamel to dentin.

Journal of Cosmetic Dentistry 47

 A grayer color tone occurs when increasing enamel composite
Enamel Composite Resin Sensitivity thickness, but the scenario might be completely different with body
composites. Such an increase in material thickness might have a minimal
Manufacturers have developed many enamel and
effect on the value of the restoration, and this effect could be material-
dentin composite shades to fit different layering
dependent. For this reason, body composites could be used on top of
techniques; however, these techniques do not always
dentin to mask the effect of the oral cavity’s dark background, as long as
guarantee the same results or even an acceptable color
the dentin composite layer thickness is kept to a minimum of 1 to 1.5
match for every clinical situation. The problem is
mm. Reduced thickness of the dentin layer is necessary to minimize its
typically related to the effect of the relative thickness
impact on the overall chroma and value of the restoration, leaving the
of enamel to dentin. Many studies in the literature
task of controlling these factors to the body composite (Fig 4). It has
have proven a detrimental effect on the overall color
been proposed in the literature that a C4 background was masked by a
perception of increasing the final enamel shade
thickness,3,4 and some researchers have demonstrated
the drawbacks of increased enamel thickness on
the value of the restoration.5 The value is defined as
the relative lightness or brightness of the tooth or
Translucency is one of the most
restoration and is considered a measure of the relative
degree of whiteness or blackness of the color.6 The crucial factors, as it creates
restoration’s value is considered the most crucial
factor in shade matching.7,8 There is a consensus that,
with an increase in thickness of the final enamel shade
optical phenomena that give
layer, an increase in the grayness of the restoration
also tends to occur.1,9,10 Other studies in the literature a lifelike appearance to the
have shown contradictory results on the effect of the
final enamel layer thickness on the chroma of the final composite resin restoration…
restoration. Some authors have suggested that chroma
increases with increased thickness, while others have
concluded the opposite.9,11
All these factors contribute to a potentially stressful
experience for the clinician when undertaking
composite resin layering, as any sensitive mistake may
affect the final esthetic masterpiece. The question now
is, is there a simplified solution that can overcome
such sensitivity of the final enamel layer? Or, in other
words, can we substitute enamel opacity?
Figure 1: Lifelike Figure 2: Enamel and Figure 3: Comparison
restoration created body discs, all 0.5-mm of a body disc (left) and
The Simplified Stratification Technique employing the SST. thick, from different enamel disc (right),
manufacturers. displaying an almost
The idea behind the Simplified Stratification Tech- similar translucency (TPH
nique (SST) is to provide a streamlined protocol that Spectra ST, Dentsply
clinicians can follow for restoring dentition to a more Sirona; Charlotte, NC).
natural appearance. In this technique, the clinician
can control the amount of translucency and opacity
needed based on the analyzed clinical situation.
In both the middle and cervical regions, more Body Shade
opaque composite resins are necessary to mask the
effect of the oral cavity beneath the restoration, which dentine shade
can gray out the restoration color. Incisally, a higher light
transmission is required to mimic enamel translucency translucent shade
and achieve a lifelike restoration. Composite resins are
available in different translucencies, with body shades
typically having an intermediate translucency.12 But in
a thin section of 0.5 mm, enamel and body opacities
behave almost similarly in terms of light transmission Figure 4: Schematic diagram illustrating the SST, showing, from left to right,
and translucency (Figs 2 & 3). low-, medium-, and high-translucency scenarios.

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Figures 5a and 5b:

Maxillary right central incisor
representing a medium- a
translucency scenario, and left
central incisor representing a
high-translucency scenario.

dentin composite resin thickness of 0.5 to 1.0 mm, evaluating the color compatibility of various composite resin systems
while a black background required a thickness of 1.0 with VITA shade tabs reported poor results.15-19 The need for further color
to 2.0 mm.13 Therefore, the proposed reduced dentin standardization of esthetic dental materials, especially composite resins,
thickness, along with the effect of increased overlying rather than relying solely on VITA shade guide tabs, is recommended.
body thickness, will be able to diminish the effect Two approaches: In this technique, two simple approaches can be
of the black background through what can be called used to facilitate accurate shade matching, especially for the color of the
cumulative opacity. Enamel tissue could be substituted body composite, which has a major role in the final color perception. The
with body and translucent composite resins of varying first approach uses composite resin samples placed adjacent to the keyed
thicknesses according to the desired amount of tooth without etching and bonding.20,21 This is essential for evaluating
translucency to be restored (Fig 4). the degree of color match between the tooth and the resin material that
Translucency can be described as partial opacity or as will be used for restoration. The composite resin samples should match
a state between complete transparency and complete the corresponding zones of the tooth according to the degree of fracture
opacity, and, as such, depends on the relative amount involvement (incisal, middle, and cervical).
of light transmitted through the material.13,14 In the The second approach is customizing shade tabs from the composite
proposed technique, three levels of translucency are resin material to be used for restoration, which offers a precise method
possible: low, medium, and high (Fig 4). The degree for shade matching using the same material (Figs 6a & 6b).19,21 This could
of opacity employed to build the palatal shell, whether be achieved simply by taking an impression of a VITA shade tab using
translucent or body composites, as well as the relative putty material to act as a mold,19 packing the desired composite resin
thickness of body/translucent layers incisally, are material, placing a mylar strip or glass slab on top of it, and then curing
considered the determinant factors (Fig 4). In cases (Fig 7). Any suitable handle can be attached simply by using a micro
with highly translucent incisal edges, the final body brush along with a piece of composite material of the same shade or a
layer should be a minimum thickness of 0.5 mm, and clear glue for that purpose, then labeling. With this simplified approach,
translucent composites should be used to build both a custom-made shade guide using the composite materials to be used for
the palatal and proximal walls (Figs 5a & 5b). Such restoration can be achieved (Figs 6a & 6b). It should be noted that this
thicknesses could be analyzed simply by using silicone
guides that help the clinician to control the amount of
material needed in each layer. Following this protocol, In this technique, the clinician can
clinicians could overcome the problem of the relative
enamel-to-dentin thickness and at the same time
achieve artistic masterpieces.
control the amount of translucency
Simplifying Shade Selection
and opacity needed based on the
Proper shade selection plays an integral role in the
success of any esthetic restoration and there are various analyzed clinical situation.”
techniques to facilitate this process. Several studies

Journal of Cosmetic Dentistry 49

 shade guide will fit the used syringes only, since the
color of the composite material may vary from batch
to batch.19,21
Digital photography: Digital photography can play
a fundamental role in shade matching as a confirma-
tion tool,22 as more precise color evaluation can be
achieved on a computer screen.22 Value confirmation
a b
of the proposed shade could be easily achieved using
Figures 6a and 6b: Custom shade guide fabricated from the same material used black and white photography (Fig 8).21 Underexpos-
for composite layering to allow for more precise shade selection. ing the image and increasing its contrast using different
software could be useful in enabling better color visual-
ization (Fig 9).22 Using a cross-polarization filter might
have added value, since this filter eliminates unwanted
specular reflections, which obscure the fine details and
true color visualization of dental structures.6

Technique Description
This section provides a simple step-by-step description
of the proposed technique for a medium-translucency
Figure 7: Custom shade guide fabrication, Figure 8: Black and white scenario with two layered acrylic resin teeth having
step by step from the upper left to the photography used to confirm two horizontal fractures (Fig 10). VITA- and non-VITA-
bottom right. value match.
based composite resins were used to restore these two
defects employing three opacities: dentin, body, and
translucent. The maxillary right central incisor was
restored with two nanofilled composites, A3 body
and Clear translucent (Filtek Z350 XT, 3M; St. Paul,
MN), and one nanohybrid-based dentin (Amaris, O3,
VOCO; Briarcliff Manor, NY). The maxillary left central
incisor was restored with three nanofilled composites:
A3 dentin, A3 body, and Clear translucent. The selected
Figure 9: Underexposing a color Figure 10: A medium-translucency scenario of dentin composites had an almost similar chroma; this
image and increasing its contrast two fractured maxillary central incisors. was important since they might have a minor impact on
could be useful for better color the overlying body layer that is material- and thickness-
visualization. dependent. The goal here is to demonstrate that any
brand can be utilized with this technique without any
limitations, but it is mandatory to be familiar with the
material that is intended to be used.
Shade selection: Shade selection was accomplished
with the custom shade guide protocol employing the
same composite materials to be used in layering (Fig
11). The remaining part of the fractured teeth and the
adjacent teeth were utilized to achieve a satisfactory
Figure 11: Shade selection using Figure 12: Palatal silicone index used as an shade match. In this layering protocol, the body com-
a custom-made shade guide to accurate matrix against which the palatal posite should have a close chroma and value match
select the correct chroma and increment can be adapted. with the keyed teeth for a highly esthetic outcome. For
value of the body composite. more predictable results, the base color of the dentin
could be selected at the junction between the middle
and cervical third of the keyed teeth.
Silicone index: A palatal silicone index was used
for accurate and guided palatal shell buildup, above
which the successive layers were to be adapted. A
sufficient thickness is necessary to avoid any flexing
action during material adaptation (Fig 12). The palatal
matrix should copy the facial-incisal line angles for a
more predictable outcome. Another silicone index was
Figure 13: Different silicone matrices Figure 14: During the palatal shell buildup,
used for guided composite resin note that the color of the index could be employed as a guide to allow proper thickness control
buildup, including the matrices visible through the material, reflecting its by preparing a full index, then sectioning in the labio-
used for thickness control. minimal thickness. palatal direction at the desired tooth (Fig 13).

50 2021 • Volume 36 • Issue 4

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Palatal shell buildup: Both palatal shell buildups

were completed with A3 body composite. The material
was adapted first on the index to control its thickness,
which should be kept as thin as 0.5 mm to avoid any
detrimental effect on the overall incisal translucency.
This could be evident when the color of the index
is visible through the material. The matrix was
positioned and the material was dragged against the
tooth, followed by proper curing (Figs 14 & 15). Figure 15: The cured palatal shell Figure 16: Two sectional matrices
Proximal wall buildup: Precontoured sectional reproduced the correct form and level were fixed vertically to build the distal
matrices (Quickmat, Polydentia; Mezzovico-Vira, of the incisal edges. walls of both teeth.
Switzerland) were used to restore the proximal pro-
files of both teeth to mimic the proximal convexity
outline. The same body material was rolled and then
adapted to the matrices and the teeth and light-cured,
and the matrices were then removed (Figs 16-18).
Dentin layer: Both dentin composite resins were
placed, adapted, and shaped to obtain the internal
anatomy of the dentin core. It is important in this
step to drag the material against the tooth at the frac- Figure 17: Note the convex proximal Figure 18: Both the mesial and
ture line using a suitably sized flat brush wetted with profile obtained mimicking the natural distal walls were restored using
modeling resin. This will allow for a smooth transi- anatomy of the teeth. body composite. It is crucial to pay
tion from the restoration to the tooth at the interfacial attention to the location of the
area (Fig 19). The adapted dentin layer should not midline during this step.
exceed the previously discussed thickness, which can
be verified using the sectioned silicone index (Fig 20).
Translucent layer: The Clear translucent layer was
placed and adapted occupying the incisal one-third,
leaving a space of 0.5 mm for the final body layer in
that area according to the medium-translucency sce-
nario. The translucent material thickness should fade
out gradually toward the middle third for a more
natural-looking restoration with favorable light Figure 19: Dentin increments should Figure 20: Working with a silicone
behavior (Fig 21). be kept as minimal as 1 to 1.5 mm to guide could help to control the material
Final body layer: The final A3 body layer was diminish impact on the overall chroma thickness of each layer applied. Note
placed, packed, and contoured to the final desired and value. the reduced dentin thickness.

Figure 21: Translucent increments should Figure 22: Application of the final body layer Figure 23: The finished restorations, showing
fade gradually toward the middle third of the could be done in one or two increments. an acceptable esthetic outcome utilizing a
restoration and be kept away from the bevel. simplified approach.

Journal of Cosmetic Dentistry 51

form. This can be done in one or two increments to allow for
better material control (Fig 22). The material was thickest in
the middle third and decreased gradually toward the incisal

Beginner
edge. After final curing, both teeth were contoured to the desired
primary anatomy, surface textured, then polished employing a
two-step polishing protocol to obtain the final esthetic outcome
(Fig 23).
» Try to employ more simplified approaches as much
Clinical Cases as possible to avoid making unnecessary mistakes.

The following cases represent different clinical scenarios, with

different degrees of translucency, utilizing the SST.

Medium Translucency
The case shown in Figures 24a through 24i represents a
medium-translucency scenario. In this case, total replacement
of the existing composite resin veneer was accomplished. After
shade selection using the composite resin sampling technique,
Intermediate
the deteriorated restoration was removed. Part of the palatal
wall was completed with A2 body composite (Grandio, VOCO).
Both proximal walls were built with the same body composite
employing precontoured sectional matrices, restoring the tooth’s
proximal profile. Reduced thickness of the dentin increments was
achieved with O2 dentin (Amaris), and a Clear translucent layer » Remember the success of any restorative treatment
was placed incisally (high-translucent Amaris Flow). The final starts with proper analysis to be able to emulate what
body layer was contoured to the desired form using two shades: exists in the natural adjacent teeth.
A3 cervically, and A2 for the rest of the surface, providing an
acceptable esthetic result.
The same layering method was followed in the second medium-
translucency case (Figs 25a-25h) , but a different composite was
employed (Filtek Z350 XT).

Low and High Translucency

Figures 26a through 26g illustrate a low-translucency case, while
a high-translucency scenario is shown in Figures 27a through 27f.
These cases also demonstrate the extent to which acceptable esthetic
results can be achieved using a simplified layering technique.
Advanced

»To create a composite masterpiece, a perfect inte-

gration between tooth optical properties and tooth
shade should be achieved along with adjacent form
and texture.

52 2021 • Volume 36 • Issue 4

 Farouk

a b c

Figures 24a-24c: Clinical case representing a medium-translucency scenario. (a) Preoperative smile view showing a defective single direct
laminate veneer. (b) Left lateral view. (c) Shade selection.

Clinicians should be
d e familiar with the
properties of the
materials that are used
in their daily practice,
f g
especially their
opacities/translucencies,
for more predictable and
h i consistent highly esthetic

Figures 24d-24i: (d) Rubber dam placed for field isolation. (e) Soft tissue
masterpieces.
retraction using a B4 clamp and vertical placement of a precontoured sectional
matrix. (f) Mesial and distal proximal walls with body opacity. (g) Fully
contoured restoration. (h) Postoperative smile view reflecting a restoration
harmonious with the adjacent teeth. (i) Left lateral view showing a totally
integrated single composite veneer.

Journal of Cosmetic Dentistry 53

 Discussion
Composite resins occupy a paramount position among
restorative materials because they offer excellent esthet-
ic potential and acceptable longevity at a much lower
a b cost than equivalent ceramic restorations.23 Many layer-
ing concepts have evolved from a primitive approach
to imitating natural tooth tissues and optical properties
into reliable protocols, allowing for a perfect match of
tooth color, opacity, and translucency.24 The presented
technique is based on the trilaminar approach, which
uses three opacities to emulate the optical properties
of the tooth while providing a perfect color match.
The body layer in this technique will control the over-
c d all chroma and value of the final restoration, so shade
matching should be performed precisely. The SST of-
fers three possibilities for translucency, which can be
fully controlled by the clinician in a simple and reliable
way. Several manufacturers now offer expanded lines
of different shade categories, with differing levels of
opacity and translucency. Clinicians should be famil-
iar with the properties of the materials that are used
in their daily practice, especially their opacities/trans-
lucencies, for more predictable and consistent highly
e f
esthetic masterpieces.

Summary
Achieving highly esthetic, natural-looking direct
restorations in the smile zone can be an elusive goal for
many dental professionals. This article has addressed
some challenges that clinicians may face in their
g h daily practice, offering a simplified protocol for more
consistent esthetic results. The Simplified Stratification
Figures 25a-25h: Clinical case representing a medium-translucency scenario. (a) Technique could be a gateway to achieving a proper
Preoperative retracted frontal view. (b) Shade selection with a customized shade color match, as well as harmonizing the optical
tab. (c) Post-preparation rubber dam isolation. (d) Freehand palatal shell buildup, properties of the restoration with those of the adjacent
followed by proximal wall buildup using sectional matrices. (e) Dentin increment natural teeth.
placement. (f) Application of clear translucent layer. (g) Final body layer.
(h) Postoperative retracted frontal view showing a natural-looking restoration.

54 2021 • Volume 36 • Issue 4

 Farouk

a b c

d e f

Figures 26a-26g: Clinical case representing a low-translucency scenario. (a) Preoperative

close-up view. (b) Rubber dam isolation, palatal shell, and proximal wall buildup with body
composite. (c) Incremental dentin placement. (d) Clear translucent layer. (e) Final body layer.
(f) Immediate postoperative image after proper finishing and polishing. (g) Three-month
follow-up showing a completely integrated restoration.

a b c

(26a)

d e f
(26c)
Figures 27a-27f: Clinical case representing a high-translucency scenario. (a) Preoperative full-face view. (b) Postoperative full-face view
showing a more harmonious direct composite restoration. (c-f) Different views showing similar behavior of the restored tooth compared to
the adjacent teeth when subjected to light from different directions, proving the efficiency of this simplified technique.

Journal of Cosmetic Dentistry 55

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