Author: Dr. Mohamed Saad El Hachemi

It was 5pm, and the weekend was here, the office’s bell rang, the assistant told me “it’s an emergency ». In fact, it was a 15-year-old boy who has just fallen on his facewhile leaving his school. The helpless parents wanted an emergency treatment for their sad son. Both of his upper central incisors were fractured, the fragments were missing. As we were at the end of the week, I did not have the time to make the wax-up, so I decided to do a direct restoration composite without it. The implementation of a composite system according to a concept of color and optimal stratification makes it possible to reproduce the natural aspect of the teeth and to obtain a perfect integration of the restoration in their dental environment. « Under Microscope »

Why with microscope?

The gestures of dentists require such skill and precision
that the idea of working under magnification has become
an ideal solution. The microscope is no longer reserved for
endodontics, nor is it an instrument for finding root canal
orifices. Its use is permanent in general practice.
According to Mallet and Roussel, the microscope does not
save time, but the result is predictable and of higher quality

Aesthetic analysis; clinical picture for planning shape and color of the future restoration

In the initial situation, the fracture extended in the dentin but without pulp exposure.

Air inversion of the rubber dam by blowing air around the cervical area and, at the same time, delicately
pushing the rubber into the sulcus with a thin spatula.


One of the crucial steps in adhesive dentistry is the field isolation using a rubber dam to avoid any contamination and to have full vision of the teeth we are working on.

Neighbouring teeth were protected with teflon tape

Etching the enamel is still the gold standard in adhesion even if we want to use autoeching systems (Universal Adhesive) to bond

We start with a selective etching with phosphoric acid for 30sec in the enamel and 15sec in the dentin.

Autoetching system (Universal Adhesive) is used to bond the resin, three coats to obtain a uniform layer

After polymerization, a composite -enamel A2- is applied at the level of the palatal wall under an orange filter,
which is indicated because it prevents the polymerization of materials.

The palatal wall is realized using a conventional matrix strip plastic.

Adjustment of the incisal edge and removal of resin excess with abrasive discs, scalpel blade and
diamond bur at low speed, in order to achieve a well defined and clean perimeter

The correct configuration of the incisal edge conditions the final aesthetic result.

Now that we have the palatal shell, we can continue with the rest of the layers.

Using curved metallic matrices in a vertical way helps to create proximal walls easily, it gives a round contour to the proximal wall. This contour
shapes the tooth in a youthful way because it immediately gives the restoration a nice, open embrasure.

Application of the first proximal increment with enamel A2.

Adaptation of the matrix using a thin spatula before polymerization.





The Cut-Back allows us to facilitate the stratification. It was realized with the help of an explorer or a sharp
instrument. We start shaping the mamelons, maintaining a small space for the incisal effects with the
transparent masses.
At this stage, you can evaluate the space left for the enamel


The emergency aesthetic treatment is finished, the boy has finally found his smile.
I am exhausted, a second appointment is necessary.
This result is obtained immediately after the eviction of the rubber dam, we notice a dehydration of the teeth that denatures the shade.
In general, dehydration leads to decrease of chromaticity and increase of luminescence, the teeth need to be rehydrated.


Macro geography

To create a surface texture we should
always begin with vertical depressions.
We draw all the depressions with
a crayon and then etch them out
with a round-tripped flame-shaped
diamond burr.

Micro geography

After having made vertical depressions,
it will be necessary to reproduce
horizontal depressions (striae of
Retzius or Perikymata). We draw a
few guidelines with our crayon to
reproduce the wider and deeper
depressions with fine diamond burrs

Final shining is done with goat brushes and Diamond Polishing Paste. (Microscopic View)

Concentrating on precision, one arrives at technique, but by concentrating on technique, one does not arrive at precision.

If you do enough small things right, big things can happen.
Bruno Walte

In case of traumatic injuries and fractures of anterior teeth, the best solution is always the reattachment of the fragment. In case the fragment is missing, we should apply the less invasive solution by using composite resin restorations. For a good esthetic integration, reproduction of the correct anatomic shape is essential. Whenever possible, one should do a wax-up and silicone index, and use this at its full potential. Unfortunately, in our case, it was impossible to wait for the wax-up because of the reasons mentioned before. During one of my discussions with the parents, I learned that the young boy was wearing an ocular prosthesis in his right eye, which he had lost in an accident. Then Iunderstood their panic on the first day they came in. The patient’s smile is the best gift our work could give us

The appropriate incisal configuration becomes evident at this stage.

If you do enough small things right, big things can happen.
John Wooden