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Restoration of a Central Incisor with Tetric EvoCeram Dr. David Hacmoun

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A very close inspection of dental enamel reveals its intricate fabric. Having to reproduce these fine structures and shade nuances seems a daunting task. Due to the research and development efforts of dental composite manufacturers over the past few years, materials are now available to facilitate the placement of restorations. Nevertheless, the appearance of composite resin restorations is often marred by a grayish shimmer. The following clinical case shows a way to avoid this problem and realize the natural-looking results envisioned by the patient.

An 11-year-old male patient presented for surgery with a fractured central incisor (Fig. 1). The clinical examination revealed that the tooth was sensitive to temperature and percussion. A fracture close to the pulp was diagnosed (Fig. 2). Clinical evidence of a periodontal trauma was not found. I recommended the tooth be reconstructed by layering composite resin using a minimally invasive and conservative restorative technique.

Shade Selection
I determined the shade in daylight at the beginning of the treatment before the teeth were dried. I used the shade guide of the composite resin, which I subsequently used during the restorative procedure (Tetric EvoCeram). In order to check the selected tooth color, I applied a composite layer to a tooth and polymerized it. For the cervical area, I chose dentin shade A2 and for the incisal area enamel A1.

The Mock-Up
The treatment area was locally anaesthetized and the tooth was reconstructed free-handedly using a composite resin (deviating from the tooth color), without preparation or the application of an adhesive. I decided to use an easily recognizable shade; in this case A4 (Fig. 3). After polymerization, the shape and exact position of the margin and the occlusion were refined. Finally, a silicone matrix of the palatal surface and the margin was fabricated with a putty impression material. This matrix would facilitate the subsequent layering procedure. After the fabrication of the silicone matrix, the provisional restoration (mock-up) was removed. Later a composite resin in the desired tooth color would be placed.

The Cementation Protocol
When the adhesive was applied on the restoration, it was important to ensure that the tooth surface was not too wet. The placement of a rubber dam with ligatures is standard procedure. The rubber dam provides an unobstructed view of the treatment field and increases the safety and comfort of the practitioner and the patient.

The tooth substance was prepared with a featheredge in the labial enamel. This preparation design ensures tight sealing and forms the basis for an unobtrusive transition between the natural tooth structure and the composite resin (Fig. 4). The enamel and dentin were cleaned with a mixture of pumice and pure chlorhexidine (Paroex) at 0.2 percent. Next, Telio CS Desensitizer was applied.

Due to the wide enamel edge, the total-etch technique was used. That is, the tooth was etched with phosphoric acid before the adhesive was applied. Therefore, the enamel was etched for 30 seconds and the dentin for 15 seconds with total etch. This etching gel contains 37 percent phosphoric acid. The surfaces were rinsed for 20 seconds and then carefully dried according to the "wet-bonding" principle (adhesion on moist surfaces). As a result, the enamel was dry, while the dentin remained somewhat moist. This drying step requires utmost care when this type of adhesive is used. If the moisture content within the dentin tubules is too high or if the collagen fibers collapse due to excessive drying, the penetration of the adhesive, and therefore the bond strength, is reduced.

The single-component adhesive ExciTE was applied to the enamel and dentin and allowed to react for 10 seconds. An indirect stream of air was used to evaporate the solvent contained in the adhesive. In the process, the air spray was applied on a mirror in the mouth, which was held at an angle to the prepared tooth surface. As soon as the surface was lustrous, the adhesive was further polymerized for 10 seconds (low power mode of the bluephase G2 LED curing light).

Layering of the Composite Resin
First, the composite resin was applied to the palatal areas. The enamel material A1 was applied in the silicone matrix. In order to avoid the formation of bubbles, the composite resin was distributed very carefully. The matrix was placed in the patient's mouth and positioned on the palatal surface with light pressure. The composite resin was polymerized for 15 seconds using the soft start mode (Fig. 5). Small lobes of dentin material (A2) were subsequently applied. The position of these lobes was individually determined. The aesthetic results were based on the contralateral teeth, which served as a comparison. In this case, the mamelons were clearly separated. They ended below the incisal edge (Fig. 6). By observing the existing anatomical features, a natural-looking and aesthetic outcome was achieved.

The composite resin was applied in small amounts, which were periodically cured with a bluephase curing light in the soft start mode. The dentin material was applied and light-cured. Next, the incisal edge of the tooth, that is, the outermost part of the restoration, was reconstructed. Small portions of the translucent incisal material were placed between the dentin mamelons. A probe came in useful in these narrow areas. Finally, the entire labial surface was coated with Tetric EvoCeram Bleach 1, making sure both the dentin lobes and the incisal edge were completely covered. The bleach shade made the tooth appear lighter. The dentin material imparted the composite resin restoration with a tooth-like appearance. The shade was responsible for the tooth's natural-looking brightness.

Surface Finishing
The aesthetic outcome is largely based on the successful re-creation of the surface texture. The imitation of the shape and surface details is just as important as that of the fine color nuances. In the treatment of a child's tooth in particular, it is important to take the micro- and macro-anatomical structure into consideration. The surface was finished with finishing diamonds (first red, then yellow). Spray was not used. Work was done using a surgical microscope. The restoration was finally polished with the Astropol system (using water spray). In contrast to polishing discs, these rubber tips do not harm the surface structure.

Conclusion
The fabrication of natural-looking, highly aesthetic restorations is a rewarding task with Tetric EvoCeram materials and the increment technique. The bleach shade on the tooth surface brightens the restoration. This approach is extremely helpful in the restoration of children's teeth. With the help of this adhesive technique, teeth can be restored in a minimally invasive way (Figs. 7a, b).

Fig. 1: Pre-operative view: fractured central incisor

Fig. 2: Considerable loss of dental enamel; fracture line near the pulp

Fig. 3: Mock-up made of composite resin (A4) for the palatal silicone matrix

Fig. 4: Preparation of a featheredge under rubber dam isolation

Fig. 5: Build-up of the palatal surface with enamel material (A1). The precision of the morphology is already impressive at this stage.

Fig. 6: Lobes are created with dentin material (A2). The translucent material is placed between these mamelons.
Figs. 7a, b: A comparison: before and after: The shade on the surface of the restoration imparts the tooth with the necessary brightness.
Author’s Bio
Dr. David Hacmoun practices in France. He can be reached at doc.hacmoun@hotmail.fr.
Dentaltown Magazine
September 2025
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