CLASS FOUR FROM CAVITY TO SMILE

Success in restoration is a result in success in knowing the cause and the treatment

Composite resins allow clinicians to create restorations with improved biocompatibility, function, and aesthetics. By ensuring that the patients condition is clearly and thoroughly evaluated preoperatively, the clinician can develop natural, harmonious integration of the restorative material with the patients natural tooth structures. The critical information captured during the initial visit can also be used to ensure development of natural contours, light refraction, and characterization. This research describes the fundamentals of cavity preparation of class four and its restoration.

Class four etiology and treatment modalities.

Class four from cavity to smile.

Success in restoration is a result in success in knowing the causes and treatment.

Done by : Abdulla Hassanien Amira yehia Heba lotfy

Content:
1. Definition and classification. 2. Etiology. 3. Shade selection. 4. Peroperative consideration as a modern technique for better esthetic. 5. Traditional cavity preparation and restoration. 6. Modified class IV preparation restoration. 7. Specific finishing materials. 8. Uses of pins. 9. Case presentation. 10. Restoration of class IV fracture using nanocomposite. 11. References.

Black Class IV:

An extension of a Class III lesion involving the incisal corner or incisal edge of an anterior tooth. An alternative cause would be traumatic fracture of the incisal corner now classified Site 2, Size 4 Up to the recent time Profession has used a classification of cavities proposed by G. V. Black over one hundred years ago. The classification was designed before the widespread use of radiographs so lesions were not diagnosed until they were visible to the naked eye and were therefore, by modern standards, relatively large.A further problem was that ,it was a classification of cavity designs for amalgam as this was the principal restorative material available. The result was that regardless of the size of the lesion, a specific cavity design was required to deal with it. Today current knowledge offers many alternatives ranging from earlier diagnosis of caries activity, along with effective methods of control, to the application of adhesive and bioactive restorative materials. If our patients are to reap the full benefit of these advances it is necessary to review both the classification and the approach to the surgical treatment of lesions when they progress beyond remineralization alone classification However, as caries can be a progressive disease, it is desirable to be able to define the size and extent of the lesion at the time of identification and, therefore, the potential complexity of the restorative procedures required for treatment. It is possible then to define five separate sizes as the lesion progresses:

Size 0
The earliest lesion that can be identified as the initial stages of demineralization. This needs to be recorded but will be treated by eliminating the cause and should therefore not require further treatment.

Size 1
Minimal surface cavitation with involvement of dentine just beyond treatment by remineralization alone. Some form of restoration is required to restore the smooth surface and prevent further plaque accumulation.

Size 2
Moderate involvement of dentine. Following cavity preparation remaining enamel is sound, well supported by dentine and not likely to fail under normal occlusal load. The remaining tooth structure is strong enough to support the restoration.

Size 3
The lesion is enlarged beyond moderate. Remaining tooth structure is weakened to the extent that cusps or incisal edges are split, or are likely to fail if left exposed to occlusal load. The cavity needs to be further enlarged so the restoration can be designed to support the remain tooth structure.

Size 4
Extensive caries or bulk loss of tooth structure e.g. loss of a complete cusp or incisal edge, has already occurred.

Etiology :
A caries induced class 4 restoration is the result of a large class 3 caries lesion that has undermined the incisal edge.The need for class 4 restoration due to traumatic fracture occurs most often among children or young adults. The frequency of fractures of permanent incisors in children is reported to range from 5%to 20%.Traumatic fracture are likely to be more horizontal than vertical.

Shade selection: Composite shade is selected by working with a clean, moist tooth prior to placement of a rubber dam. Once teeth are isolated by a rubber dam they dry out and get lighter in color, making accurate shade selection difficult. Since the shade guides provided by many manufacturers are not made of composite, they may not accurately represent a composite shade. Studies show custom guides made of composite are considerably more accurate than a manufacturers mockcomposite shade guide. Even better accuracy is achieved if the custom shade tabs are stored in water, but problems with controlling bacterial growth make this mpractical. Storing in water hydrates the tabs, maintaining conditions similar to those of the mouth. Hydrated composite shade tabs are darker than dry ones. Once a shade is chosen for a discolored tooth, verify the masking ability of the composite by placing material on the tooth in the same thickness as will be used in the restoration and then curing. Placing a color modifier on the tooth under the composite can improve its color or masking ability. With auto cured systems, if the shade of the tooth does not match one of the shade guides, different shades can be mixed to obtain a more accurate match. With lightcured systems, composites can be layered, placing darker materials underneath and lighter materials over the surface to provide intermediate shades. Using a master shade guide system: All restoratives and chair side shade guides should be matched to a master shade guide. All materials should be tested to match this master, and restoratives should be relabeled when discrepancies occur. Before using a new restorative product, polymerize the material and place the sample in water for 24 hours. After the sample has rested for 24 hours, match its color to the office master shade guide. Materials are often a shade or more off of the master guide. For example, shade A3 of a particular product may match the A2 master shade guide, so it should be relabeled A2. Standardizing all office restorative materials to a single shade stabilizes restoration esthetics, such that once a patients shade is determined, all calibrated restoratives will match. A number of shade guide systems are commercially available. By far the most common is the Vita Lumin system (Vita Zhnfabrik, Bad Sackingen, Germany), which breaks shades first into hues and then shows hues with increased chroma and decreased value. Vitas newer Vitapan system breaks shades into value (darkness), hue, and chroma (color). Value is the most important characteristic of a shade since it is not light dependent. Hence, the new Vita system differentiates shades according to their most important characteristics. The most common shade used in indirect restorations is A2. It is so popular a shade that using it for full-mouth reconstruction pleases most patients. With older patients, this shade may appear light but is still preferred by most patients.

Preoperative Considerations as a modern technique for better esthetics:

The aesthetic restoration of a single anterior tooth is extremely difficult to perform using porcelain or composite resin. Shade selection should be accomplished prior to rubber dam isolation to prevent improper color matching that may result from dehydration and elevated values. When teeth dehydrate, the air replaces the water between the enamel rods, changing the refractive index that makes the enamel appear opaque and white. By using a previsualized mockup and knowledge of composite materials, the surrounding environment, the modifiers selected, and their shade and orientation, the definitive restoration can be visualized prior to completion. The transformation of this vision into an aesthetic creation that replicates natural variations constitutes the clinicians final challenge. Consideration of the surrounding environment is crucial for optimal color matching of composite restorations. Composite resin, enamel, and dentin cause considerable light scattering, which produces internal diffusion of incident light and allows the composite restoration to blend with the tooth appearance. This blending effect (or chameleon effect) occurs as diffused light enters from the surrounding tooth. When this light is emitted from the restoration it will absorb color from the tooth and alter it. This color alteration depends on the scattering and absorption coefficients, which can produce an undetectable color match by blending with tooth color. Once the shade analysis has been completed, the appropriate composite material can then be selected. An ideal composite resin should provide color stability, polishability, and sculptability; it should also endure functional stress and produce optimal aesthetics.

Traditional cavity preparation:

The standard setup and supplies required are listed later on. Specific additional materials needed for Class IV restorations include: A light-cured submicron or small-particle composite in a tube, or a material that can be shaped without slumping. In some clinical situations, a heavily filled composite is used as a core. Some operators prefer to use a microfilled composite as the final surface material for these restorations. A bullet-shaped chamfer diamond Preparations: Decide on the tooth shade prior to rubber dam placement. Anesthesia is often unnecessary for small fractures where the preparation is limited to enamel. Larger fractures with exposed dentin may be sensitive to air, cold water, and bur vibration and often require anesthesia. Determine the tooth shade, then place a rubber dam and clean the tooth with pumice and water.

Outline: . These preparations are appropriate for fractures that run one-third to two-thirds of the incisal edge, which often expose dentin. Most anterior teeth have horizontal and vertical grooves that can be used to hide the margins and increase the color-match and esthetic outcome . Chamfer design: Prepare a chamfer 1-mm long (or half the length of the fracture) to half the depth of the enamel on the labial and lingual surface. This type of preparation results in the most durable restorative margins . It is important that the chamfer is cut only halfway through the enamel surface. Horizontal and vertical lines are easily hidden in anatomy, whereas oblique lines conflict with natural anatomy and surface texture and are, therefore, more visible. Stair-stepping the labial enamel with a good chamfer cavosurface margin into the tooth anatomy helps achieve a good esthetic result . Beveled margins: An alternative to a stair-step chamfer design is to prepare a 2- to 3-mm bevel in place of a chamfer . This bevel creates a gradual change of color from the tooth to the restoration. Although the beveled margin is not as durable as a chamfer, beveled preparations usually provide more consistent esthetic results. Scalloping the labial enamel with a beveled cavosurface margin is less important in achieving an esthetic result. It is best to finish these bevels in a curve, going from horizontal to facial . The major problem encountered at recall with beveled margins is chipping.

Enamel conditioning: Clean the preparation of all debris. Make sure the enamel cavosurfaces are clean of any dentin lining materials. After protecting the adjacent teeth with a Mylar strip, etch with acid using an enamelresin bonding technique. This technique usually involves a 20-second etch of the enamel and a 10-second (or less) etch of the dentin, rinsing for a minimum of 5 seconds, then drying according to the manufacturers recommendation for the specific bonding agent.

Composite placement Prepare, etch, and dry the tooth; add bonding agent, and cure. Place a Mylar strip. Place and form the composite in a minimum of three increments, each 1- to 2-mm thick . For the first layer, the composite core, use a heavily filled material. Form it to the proper contour with Mylar, an interproximal carver, and an explorer. Remove the excess material from the gingival and proximal areas with an explorer. Polymerize for a minimum of 40 seconds on each side. For darker shades, polymerize for 60 seconds on each side (for materials with an EOP of 16 joules.)

Step 1. Place the composite core, using a heavily fill material. Wedge the composite between the Mylar strip and tooth fracture. Step 2. Shape the composite core by slowly pulling the Mylar through to wrap the composite to the lingual, which draws the composite around the tooth. Step 3. Polymerize the composite core. Step 4. Place the contouring layer, using a submicron material. Step 5. Slowly pull the Mylar strip through to wrap composite to the lingual. Step 6. Separate the composite from the Mylar strip, and contour. Remove the strip quickly. Step 7. Polymerize for a minimum of 40 seconds on each side (60 seconds for darker shades). Step 8. Replace the Mylar strip. Add a final layer of composite, and contour. Slowly pull the Mylar strip through to wrap composite to the lingual. Pull the Mylar strip through rapidly to separate the strip from the composite. Remove the strip. Step 9. Remove excess composite and carefully contour. Step 10. Polymerize for a minimum of 40 seconds on each side (60 seconds for darker shades). Step 11. When set, check for voids and excess material. Repair any voids . Step 12. Wait 10 minutes after the last addition of composite before contouring the restoration. Most composites do not cure thoroughly if built to a thickness greater than 2 mm. If the thickness of the fracture is in excess of 4 mm across the center of the restoration (from labial to lingual), the central area will be more than 2 mm from the surface. In this situation, multiple placement in place, add and cure a central core of composite within 2 mm of the final surface of the restoration. After this addition, a crown form can be used for composite final placement. If a crown form is not being used, add the composite in layers with a plastic instrument. Make sure each layer is less than 2 mm thick, and cure after each addition. The final layer should be contoured and shaped until it closely resembles the desired shape of the tooth, and then polymerized. Finishing Step 1. Remove flash with a sharp hand instrument or a No. 15 Bard Parker blade. Step 2. Use fine diamonds for gross reduction. Also use a lubricant to reduce heat and friction. Step 3. When approaching the margins, use only micron diamonds or flexible discs. A finishing strip is a good alternative at the proximal margins. Step 4. When using a microfill or submicron particle composite, rubber composite finishing cups and aluminum oxide pastes may be used to place the final finish. Occlusion plays an important role in the longevity of a restoration. The restoration should be in light occlusion (especially protrusive), since composites expand slightly over time.

Modified Class IV Tooth Preparation: The modified Class IV preparation for composite is indicated for smallor moderate Class IV lesions or traumatic defects. The objective of the tooth preparation is to remove as little tooth structure as possible, while removing the fault and providing for appropriate retention and resistance forms. Remove any existing lesion or defective restoration with a suitable size round bur or diamond instrument and prepare the outline form to include weakened, friable enamel. Usually little or no initial tooth preparation is indicated for fractured incisal corners, other than roughening the fractured tooth structure. The cavosurface margins are prepared with a beveled or flared configuration similar to that previously described. The axial depth is dependent on the extent of the lesion, previous restoration, or fracture, but initially no deeper than 0.2 mm inside the DEJ. Usually no groove or cove retention form is indicated. Instead, the retention is obtained primarily from the bonding strength of the composite to the enamel and dentin. The treatment of teeth with minor traumatic fractures requires less preparation than the beveled conventional example. If the fracture is confined to enamel, adequate retention usually can be attained by simply beveling sharp cavosurface margins in the fractured area with a flame-shaped diamond instrument followed bybonding.

SPECIFIC FINISHING MATERIALS: Burs Six-fluted burs cut rapidly, are difficult to control, dislodge particles, and cause fissuring . They should not be used to finish composites. Twelve-fluted burs may tear the resin matrix and actually weaken the composite near the margins. Use these burs for cutting preparations on indirect restorations. A 12-fluted bur generally provides a smoother surface than a 15- m diamond. Thirty-fluted burs effectively finish submicron composites.9 Forty-fluted burs can be used to trim excess composite resin from under gingival tissues because the burs do not cut tissue and they leave a smooth burnished surface. The main disadvantage is the slow cutting, which, without copious amounts of water, can cause the fine flutes to clog. Diamonds Coarse, medium, and fine diamonds are shown in . Coarse diamonds (>125 m) are particularly useful in resin-to-resin bonding becausethe roughness creates a mechanical interlock between the old and newly added composites. Fine diamonds are ideal for gross contouring. Micron diamonds are designed for use at slow speeds and with copious amounts of water; however, most practitioners use them at near stall-out high speed. The finish is slightly less smooth than the finish achieved with flexible discs. Micron diamonds are suited for the lingual surfaces of incisors and the occlusal surfaces of posterior composites. Studies show that these diamonds do not damage the resin matrices and margins as much as do some finishing burs . Stones White and green stones, if used dry, can loosen fillers from the resin matrix and cause interfacial fractures in a composite, which can weaken a restoration. Since they produce large amounts of heat, they should be used with large amounts of water as a
coolant

Use of pins: Retentive pins are not needed in resin composite restorations. The adhesive technique provides sufficient retention, and the use of metallic pins in resin composite restorations can greatly reduce the esthetic appearance.

water.

Case presentation:
A 55-year-old female patient presented with fractured maxillary right and left central incisors . Upon selfassessment, the patient requested the most conservative and aesthetic restorative procedure available. An enamel defect was evident in the maxillary left central around the middle one third of the tooth. Shade determination was accomplished using a customfabricated shade comparison, instrumental shade, and previsualized color mapping. To facilitate access to the cervical region of the tooth, the field was first isolated with a rubber dam using a modified technique. This process involved the creation of an elongated hole that allowed placement of the rubber dam over the retainers to achieve adequate field control. Once the extent of the preparation was determined, a cervical chamfer 0.3 mm in depth was placed 2 mm long around the entire margin to increase the enamel-adhesive surface and to provide sufficient bulk of material at the margins.

A scalloped bevel on the chamfer was placed to break up the straight chamfer line with a long tapered diamond. Since the margin was on enamel,a 0.5-mm bevel was placed on the gingival margin to reduce microleakage with a needle-shaped fine diamond. The lingual aspect of the chamfer was extended 2 mm onto the lingual surface, but not onto the occlusal contact area. The margin should not end on the occlusal contact area unless relocating it to a contact-free area would require excessive reduction of healthy tooth structure. The preparation was completed with a finishing disk and polished with rubber cups that contained a premixed slurry of pumice and 2% chlorhexidine. The preparation was rinsed and lightly air dried, and a soft metal strip was placed interproximally to isolate the prepared tooth from the adjacent dentition. A two-component self-etch was applied to the preparation and light cured . The Proximal Adaptation Technique in the Interproximal Zone Since composite does not have hydroxyapatite crystals, enamel rods, and dentinal tubules, the final composite restoration requires the clinician to create the illusion of the way light is reflected, refracted, transmitted, and absorbed by these microstructures of the dentin and enamel. Therefore, in recreating the proximal surface, a similar orientation of enamel and dentin is required. Since a silhouette of the cavity form is highlighted by the darkness of the oral cavity, it is necessary to use an opacious dentin replacement with higher color saturation. This ensures that when light strikes the optically denser dentin with more color saturation, more light is reflected back to the eyes. To reproduce the optical effects of the enamel, a translucent composite encapsulates the inner dentin core and alters the quantity and quality of the light as it is reflected back to the eyes. An infinitesimal amount of glycerin was applied to the mesial surface of the maxillary left central with unwaxed floss. The proximal adaptation technique was utilized because it allows optimal adaptation of the initial composite layer to the adjacent tooth without using a mylar plastic strip. Although studies indicate that a smooth surface can be attained with the mylar strip, improper proximal adaptation can result in inadequate contact, improper anatomical form and shape, and surface defects. Opacious dentin replacement was selected for strength and color, and the most suitable restorative material for the core of these restorations was the hybrids and the microhybrids. Because these small-particle hybrids have similar refractive properties to that of dentin and a variety of color selections, they imitate the natural tooth structure well and have enough resistance for most occlusal stress-bearing regions in the anterior segment. The Artificial Dentin Core The initial layer the artificial dentin body of opacious A03-shaded composite resin was applied and contoured with a long-bladed composite instrument and smoothed out with an artists sable brush. This step was crucial and each increment was polymerized for 10 seconds, which allowed placement of subsequent increments without deforming the underlying composite layer.

An elliptical increment of opacious A03-shaded hybrid composite was placed from the incisolingual aspect. Since surface irregularities could have interfered with placement of the tints for internal characterization, this step was crucial. To prevent overbuilding of the artificial dentin layer, it is imperative to monitor the composite from the incisal aspect to provide adequate space for the final artificial enamel layer. Internal Characterization: A thin layer of translucent composite was applied and cured to create a light-diffusion layer and provide an illusion of depth. The translucent layer caused an internal diffusion of light and control luminosity within the internal aspect of the restoration. A diluted white tint was applied to specific regions of the restoration using light brush strokes to create a cloud effect corresponding to the contralateral central incisor and shade diagram prior to polymerization . To alter the chroma and disguise the fracture line, a yellow tint was diluted with untinted resin and placed along the fracture line and on specific regions in the incisal third. These techniques utilize color variation to emphasize the tooth form and instill the restoration with a threedimensional effect. The Artificial Enamel Layer To recreate the natural translucency of the enamel, the artificial enamel layer of white translucent (WT) shaded composite was applied and contoured with a long-bladed composite & smoothed with a #4 artists sable brush. This layer was light cured from the facial and the lingual for 40-second intervals, respectively. Anticipating the final result and developing the restoration in increments while considering the occlusal morphology and occlusal stops allowed the clinician to minimize finishing procedures and results in a restoration with improved physical and mechanical characteristics with less microfracture. Once the final layer of composite was placed, and prior to final cure, an oxygen inhibitor was applied in a thin layer with a brush to the surface of the re storation and light cured for a 60-second postcure from the facial and lingual aspects. The restoration of the defect in the middle one third of the maxillary left central utilized the previous described self-etch adhesive protocol and an A-3 artificial enamel layer was applied and contoured with a long-bladed composite instrument and smoothed out with a #4 artists sable brush. The same preparation design, adhesive protocol, and restorative recipe as the previously restored maxillary right central was used on the facial and incisal edge of the maxillary left central incisor. The Final Restorative Phase Finishing and contouring was performed to ensure maintenance of a smooth surface texture. In this case, particular attention was given not only to the relationship between the expanse and direction of the marginal ridge, lingual fossa, and the anatomic variations of the teeth that will be adjacent to the restoration, but also to the light refraction and surface reflection resulting from microstructure of the tooth surface. To reproduce the shape, color, and gloss of the natural dentition while enhancing the aesthetics and longevity of the restoration, the following protocol was implemented. A long, needle-shaped finishing bur was used on the labial aspect to ensure development of proper anatomical contours . The lingual surface was contoured and smoothed with #16 and #30 fluted egg-shaped finishing burs used dry with light pressure to prevent heat buildup. This dry finishing allowed the clinician to visualize the margins and contours with the adjacent tooth and the shape of this bur conforms to the appropriate curvature of the morphological lingual contours of the tooth and restoration.

The interproximal region was finished and refined with silicon carbide finishing strips while contouring and finishing on the proximal, facial, and incisal angles was performed with aluminum oxide disks. These were used sequentially according to grit and ranged from coarse to extrafine. The extrafine finishing disks were used to impart a high luster while maintaining the existing texture and surface anatomy. The final polish was initiated with prepolish and high-shine silicone rubber points composed of aluminum oxide particles and silicone that permit surface defects to be effectively eliminated. The definitive polish and high luster was ccomplished with a soft white goat hair brush with composite paste and a cloth wheel using staccato motion. The contact was tested with unwaxed floss to ensure the absence of sealant in the contact zone and to verify adequate contact and the absence of a gingival overhang and the margins inspected. The rubber dam was removed and the patient was asked to perform closure without force and then centric, protrusive, and lateral excursions. Any necessary occlusal equilibration was accomplished with #12 and #30 egg-shaped finishing burs and the final polish was repeated. The surface quality of the composite is not only influenced by the polishing instruments and polishing pastes but also by the composition and the filler characteristics of the composite. The newer formulations of composites with smaller particle size, shape, and orientation provide a level of polishability that compares to porcelain and enamel. Although clinical evidence of polishability with these new small-particle hybrids appears promising, the long-term durability of the polish will need to be evaluated in future clinical trials. The postoperative results reflect the harmonious integration of composite resin with natural tooth structure.

Restoration of Class IV Fractures using nano composite:

A comprehensive clinical and radiographic examination is first performed , and all goals for the treatment are determined. Once the patients expectations have been discussed and a diagnosis has been reached, a definitive treatment plan is identified. When direct resins are to be used for the restorations, composite shades are selected prior to rubber dam placement to prevent improper shade matching via tooth dehydration. Once anesthesia is administered to the patient, the teeth are isolated to ensure adequate field control and protection against contamination. For a Class IV fracture, a chamfer preparation (approximately 0.3 mm in depth) is placed around the entire margin to increase the enamel-adhesive surface and provide a sufficient bulk of material at the margins. Using a long, tapered diamond bur, a scalloped bevel should be placed on the chamfer to break up the straight chamfer line. If the margin is confined to the enamel surface, a bevel of 0.5 mm should be placed on the gingival margin to reduce microleakage. The lingual aspect of the chamfer is extended 2 mm to the lingual surface. The margin should not end on the occlusal contact area unless the operator is relocating it to a contact-free area that would require excessive reduction of healthy tooth structure. The preparation is completed with a finishing disk and polished with rubber cups that contain a premixed slurry of pumice and 2% chlorhexidine. The preparation is rinsed and lightly air dried, and a soft metal strip is placed interproximally to isolate the prepared tooth from the adjacent dentition. The total-etch technique is utilized for such fractures due to its ability to minimize the potential of microleakage and enhance bond strength to dentin and enamel. The preparation is etched for 15 seconds with 37.5% phosphoric acid semi-gel (eg, GEL-Etchant, Kerr/Sybron, Orange, CA), rinsed for 5 seconds, and gently air-dried for 5 seconds. A hydrophilic adhesive agent (ie, Optibond Solo Plus, Kerr/Sybron, Orange, CA) is then applied for 20 seconds with a disposable applicator using continuous motion, and excess resin is removed prior to polymerization. A small amount of glycerin is applied to the mesial surface of the adjacent tooth with unwaxed floss. This proximal adaptation technique allows the author to optimally adapt composite resin to the adjacent tooth without using a mylar plastic strip interproximally. Although the literature has indicated that a smooth surface can be attained with a mylar strip, improper proximal adaptation can result in inadequate contact, improper anatomical form and shape, or surface defects.

The first layerthe artificial dentin bodyof nanoparticle hybrid resin (eg, Premise, Kerr/Sybron, Orange CA; Filtek Supreme, 3M Espe, St. Paul, MN) is applied, adapted and contoured to the proximal surface of the adjacent incisor with a long-bladed composite instrument and smoothed with a sable brush. Each increment is polymerized for 40 seconds, which allows placement of subsequent increments without fear of deforming the underlying composite layer. An elliptical-shaped increment of a nanoparticle hybrid composite is then placed from the incisolingual aspect and contoured to form an incisal matrix prior to polymerization from the facial and lingual aspect . Since surface irregularities can interfere with the placement of tints required for internal characterization, this step is crucial. In order to prevent overbuilding of the artificial dentin layer, it is imperative to monitor the composite from the incisal aspect to provide adequate space for the final artificial enamel layer. A thin layer of resin can be applied and cured to create a light-diffusion layer and provide an illusion of depth for restorations of limited thickness. This translucent layer will cause an internal diffusion of light and control luminosity within the internal aspect of the restoration. As directed by the color map of the contralateral tooth, tints are placed along the fracture line and on specific regions in the vertical invaginations and light cured for 40 seconds. This internal characterization technique utilizes color variation to emphasize the tooth form and to instill the restoration with a threedimensional effect. To re-create the natural translucency of the enamel, the final enamel layer of composite resin is applied and contoured . A precut mylar strip is placed and adapted over the facial surface and light cured from the facial and the lingual aspects for 40-second intervals, respectively . The initial contouring is performed with a series of finishing burs in order to replicate natural form and texture. The facial contouring is initiated with 30-fluted, needle-shaped. The lingual surfaces are contoured with 30-fluted football-shaped burs. Finishing the proximal, facial, and incisal angles is performed with aluminum oxide disks and finishing strips. These are used sequentially according to grit and range from coarse to extra fine. Finishing burs, diamonds, rubber wheels, and points are used to create indentations, lobes, and ridges . A soft goat-hair brush is used with composite polishing paste to impart a high luster for the restoration while maintaining its existing texture and surface anatomy. The final surface gloss is achieved with a dry cotton buff using an intermittent staccato motion applied at conventional speed.

References:
1.Art and science of operative dentistry. 2.Fundemental of operative dentistry. 3.Art and science of porcelain. 4.Tooth colored restoratives. 5.Ethetics in dentistry.