Open Access Case

Report DOI: 10.7759/cureus.58712

Composite Injection Technique With a Digital

Workflow: A Pragmatic Approach for a
Review began 02/29/2024
Protruding Central Incisor Restoration
Review ended 03/11/2024
Published 04/22/2024 Diana F. Muslimah 1, Yuichi Hasegawa 2, Tichy Antonin 3, Foxton Richard 4, Keiichi Hosaka 1, 5, 6

© Copyright 2024
Muslimah et al. This is an open access 1. Department of Regenerative Dental Medicine, Graduate School of Biomedical Sciences, Tokushima University,
article distributed under the terms of the Tokushima, JPN 2. Department of Dental Laboratory, Dental Hospital, Tokyo Medical and Dental University, Tokyo,
Creative Commons Attribution License CC- JPN 3. Department of Dentistry, Institute of Dental Medicine, First Faculty of Medicine of the Charles University and
BY 4.0., which permits unrestricted use, General University Hospital, Prague, CZE 4. Division of Conservative Dentistry, King’s College London Dental Institute
distribution, and reproduction in any
at Guy’s, King’s and St Thomas’ Hospitals, King’s College London, London, GBR 5. Division of Interdisciplinary
medium, provided the original author and
Research for Medicine and Photonics, Institute of Post-LED Photonics, Tokushima University, Tokushima, JPN 6.
source are credited.
Microsystems Technology Laboratories, Massachusetts Institute of Technology, Cambridge, GBR

Corresponding author: Keiichi Hosaka , [email protected]

Abstract
Esthetic concerns frequently drive individuals to seek dental treatment, leading to a rising demand for
minimally invasive and time-efficient procedures. The Minimal Intervention Dentistry (MID) concept, which
employs dental adhesive and resin composites, offers an effective approach for enhancing esthetics while
preserving natural tooth structure. This case report outlines the esthetic enhancement of a protruding
maxillary right central incisor through a direct composite restoration approach, utilizing a composite
injection technique with a digital workflow. A 42-year-old male patient presented with a discolored and
protruding maxillary right central incisor. After declining orthodontic treatment due to time and cost
constraints, the patient opted for an alternative approach. A digital wax-up was 3D printed to create a clear
silicone index, enabling precise resin composite injection to achieve the desired esthetic outcome. After
internal bleaching and minimal labial surface reduction, a flowable resin composite was applied freehand to
the mesial-proximal surface using a curved plastic matrix manufactured universally. The composite
injection technique was subsequently employed through the incisal opening of the clear silicone index to
shape the labial surface and incisal edge. In order to address insufficient tooth reduction, an additional
partial labial resin composite cutback was performed, ensuring minimal reduction while enhancing
esthetics. This direct composite veneer restoration, combining conventional proximal surface creation with
a composite injection technique utilizing a custom-made clear silicone index prepared via a digital workflow,
emerged as a pragmatic solution in a case where orthodontic treatment was not preferred. Moreover, in
situations of insufficient dentin preparation, additional cutback preparation and composite placement can
enhance color matching with minimal reduction. The direct composite restoration, facilitated by the
composite injection technique and digital workflow, effectively rectified the inclination of the protruding
maxillary central incisor, highlighting the potential of this approach in addressing esthetic dental concerns.
The research and clinical technique presented in this case report hold clinical importance by offering a
minimally invasive and practical alternative to orthodontic treatment and conventional restorations for
patients with esthetic concerns. The composite injection technique with a digital workflow preserves natural
tooth structure, reduces chair time, and enhances esthetic outcomes. This approach is particularly relevant
to esthetic dentistry as it addresses anterior dental malalignment and discolored teeth while prioritizing
patient satisfaction and individualized care, aligning with the principles of pragmatic esthetics and MID.
The potential for long-term durability and patient satisfaction makes it a valuable addition to esthetic
dental practice.

Categories: Dentistry
Keywords: pragmatic esthetics, cut-back technique, protruding maxillary central incisor, digital workflow, direct
composite injection technique

Introduction
Pragmatic esthetics prioritizes practical considerations and patient well-being over elusive ideals of
perfection in dental treatment [1]. The Minimal Intervention Dentistry (MID) concept has gained attention
for its effective approach to addressing esthetic concerns through dental adhesive and resin composites [2].
MID emphasizes the preservation of tooth structure while achieving favorable esthetic outcomes, applied in
various cases such as space closure [3], recontouring crown morphology [4], anterior tooth prostheses [5],
and correction of dental malalignment [3].

Conventionally, bonded porcelain restorations have served as an alternative to orthodontic treatment for
correcting anterior dental malalignment [6]. Despite their effectiveness, these indirect restorations are more
invasive, time-consuming, and costly compared to direct restorations. Moreover, indirect restorations that
involve tooth preparation can expose a significant amount of dentin, necessitating a careful selection of

How to cite this article

Muslimah D F, Hasegawa Y, Antonin T, et al. (April 22, 2024) Composite Injection Technique With a Digital Workflow: A Pragmatic Approach for a
Protruding Central Incisor Restoration. Cureus 16(4): e58712. DOI 10.7759/cureus.58712
 restoration techniques. The resin coating technique, developed in the early 1990s, involves applying a resin
layer to exposed dentin prior to placing an indirect restoration, thereby enhancing the bond strength [7].
However, Akehashi et al. found that direct bonding to dentin can achieve higher dentin bond strengths with
appropriate adhesive materials [8].

On the other hand, direct free-hand composite restorations can be technically challenging, often leading
practitioners to opt for more invasive indirect restorations, especially in anterior esthetic cases where
restoration morphology significantly impacts esthetics [3]. To address this challenge, an innovative approach
involving the injection of flowable resin composite into a prefabricated clear silicone index has emerged,
offering a promising way of simplifying and expediting direct restorations [4]. This composite injection
technique, utilizing a clear index as a mold, has demonstrated its potential in reducing chair time and
delivering predictable outcomes, although it requires prior laboratory preparation. Furthermore, with recent
advancements in digital technology, laboratory work can be elevated to a higher level of precision and
reliability, enabling a seamless transition from the digital wax-up to the final restorative form [3,9-15].

Nevertheless, the nature of the injection technique itself may result in some overflow beyond the margin or
pose challenges in creating an appropriate proximal contact. Therefore, there may arise a need for the
incorporation of conventional proximal surface creation techniques, such as the use of a plastic matrix [16],
in conjunction with the injection technique to effectively address these challenges. This approach not only
addresses potential overflow challenges but also enhances the precision and esthetics of the proximal
contact, thereby contributing to the overall success of the dental restoration process.

In light of these considerations, this case report presents the application of the aforementioned techniques
within a minimally invasive framework to enhance the esthetics of a protruding, discolored maxillary right
incisor. This patient, who declined orthodontic treatment due to time constraints and cost considerations,
benefited from the utilization of a digital wax-up and a clear silicone index, which enabled precise
composite injection molding. The incorporation of the cutback technique and conventional proximal surface
creation further optimized esthetic outcomes while preserving valuable tooth structure.

Case Presentation
A 42-year-old male patient sought treatment to address the esthetic concerns related to his maxillary right
central incisor. The tooth was protruded and discolored as a result of previous endodontic treatment (Figure
1). While initially considering orthodontic treatment, the patient ultimately opted for a more conservative
approach due to time, cost constraints, and an upcoming overseas relocation. After receiving comprehensive
information about the proposed treatment, the patient gave informed consent.

FIGURE 1: Preoperative view of a protruded maxillary right central

incisor.

Internal bleaching and preparation of a clear index for composite

injection technique with a digital workflow
During the initial appointment, internal bleaching was performed to improve the tooth's color and achieve a
uniform shade. Simultaneously, a digital impression was obtained using an intraoral scanner (Trios3,
3Shape A/S, Copenhagen, Denmark). A digital wax-up was created using a CAD application (3Shape Dental
Systems, 3Shape A/S) to simulate the desired final outcome, with the goal of correcting the tooth's
protrusion (Figure 2a, b). The digital wax-up was created with consideration of minimal preparation of the
teeth and to obtain the golden proportion as close as possible.

2024 Muslimah et al. Cureus 16(4): e58712. DOI 10.7759/cureus.58712 2 of 6

 FIGURE 2: Digital wax-up in lateral view (a) and frontal view (b).

3D printed models were generated to represent the initial dentition (Figure 3a) and the simulated desired
outcome (Figure 3b). These models were used to create silicone keys to determine the appropriate
preparation thickness. Additionally, the wax-up model (Figure 4a) served as the basis for creating a clear
silicone index for the injectable resin composite technique (Figure 4b). The index was fabricated using clear
polyvinyl siloxane material (EXACLEAR, GC Corp., Tokyo, Japan) and polymerized at +0.2 MPa pressure for
10 minutes to prevent air bubble formation. An incisal opening was prepared on the silicone index (Figure
4b).

FIGURE 3: 3D printed models of initial dentition (a) and digital wax-up

model (b) and prepared silicone guides for each model.

FIGURE 4: A 3D printed model generated from digital waxing (a). A clear

silicone index with the trimmed entrance of an opening to facilitate easy
composite injection (b).

Composite placement with/without the clear silicon index and cutback

technique
At the subsequent appointment, the tooth displayed a successful result after bleaching (Figure 5a). The
discolored restoration was removed, and precise tooth preparation was conducted using silicone keys based
on the initial and post-restoration models (Figure 5b). The tooth was isolated using a split rubber dam
technique and cleaned with pumice and a chemical cleaning agent (Katana Cleaner, Kuraray Noritake
Dental, Japan). A two-step self-etch adhesive system (Clearfil SE Bond 2, Kuraray Noritake Dental) was

2024 Muslimah et al. Cureus 16(4): e58712. DOI 10.7759/cureus.58712 3 of 6

 applied with selective enamel etching using phosphoric acid gel (K-Etchant Syringe, Kuraray Noritake
Dental) following the manufacturer’s instructions (Figure 5c). To achieve an ideal interproximal contact, a
sectional curved plastic matrix (Sectional matrix, Kerr) was positioned (Figure 5d), and a flowable resin
composite (Clearfil ES Flow Universal, U shade, Kuraray Noritake Dental Inc.) was placed on the proximal
surface (Figure 5e). The clear silicone index was then seated, and the same flowable resin composite was
inversely injected through the incisal opening of the clear silicone index (Figure 5f) and polymerized using
an LED light curing unit (PenCure 2000, J. Morita, Tokyo, Japan) (Figure 5g). Upon removal of the index,
exposed dentin was observed on the labial surface, indicating insufficient reduction depth. To correct this,
the exposed dentin was reduced (ca. 1.5 mm), and an additional layer of flowable resin composite (Clearfil ES
Flow Universal, U shade, Kuraray Noritake Dental Inc.) was placed and polymerized following the two-step
self-etch adhesive system, ensuring “truly” minimal dentin reduction.

FIGURE 5: After removing the old restoration and approximately 1.5 mm

reduction, the dentin surfaces were exposed (a). A two-step self-etching
adhesive system was applied (b). The mesial surface was created
before the composite injection technique to make appropriate proximal
contact (c). Inverse injection of flowable resin composite through the
occlusal opening of a clear silicone index (d). Polymerization was
performed (e). The dentin was visible after the index was removed due
to insufficient reduction (f). The dentin was cut back, and an additional
flowable composite was placed (g). Lateral view of the final restoration
(h).

Finishing and polishing of the restoration

The excess composite was removed using a #12 scalpel, followed by polishing procedures employing a two-
step polishing system (FP9769M, FP9769F, Meisinger Polisher, Hager & Meisinger GmbH, Neuss, Germany)
and a polishing particle-embedded brush (OptiShine™, Kerr, Brea, CA, USA). The injection technique
allowed for minimal adjustments and significantly reduced chair-side finishing and polishing time (Figure
5h). After three years, the prognosis remained excellent. The patient provided informed consent for the
publication of this case.

Discussion
Esthetics stands as a primary concern motivating individuals to seek dental treatments, and this case report
demonstrates the effectiveness of the composite injection technique within a digital workflow in achieving
enhanced dental esthetics. Restoration using direct composite resin is a compelling alternative when
constraints related to time and cost deter orthodontic treatment. This strategy aligns seamlessly with the
principles of pragmatic esthetics, which prioritize practical considerations and patient satisfaction over
theoretical ideals of dental perfection [1].

While the composite injection technique necessitates multiple patient visits due to the laboratory
manufacturing process of the clear index, it simplifies and streamlines restoration placement compared to
freehand direct composite restorations, which can be challenging and time-consuming chairside [17]. The
approach is not only minimally invasive [4] and time-saving [17] but also offers superior bond durability to
dentin compared to indirect bonding methods [8,18]. When choosing between direct and indirect composite
resin restorations, the potential for dentin exposure underscores the importance of meticulous preparation
and bonding techniques, as direct bonding to dentin exhibits superior performance to indirect bonding
methods [8].

Concerns may arise regarding the longevity and mechanical properties of injectable resin composites when
compared to ceramics [6]. However, the presented case demonstrates that a satisfactory clinical outcome in
terms of esthetics can be achieved, aligning perfectly with the principles of pragmatic esthetics. The cutback

2024 Muslimah et al. Cureus 16(4): e58712. DOI 10.7759/cureus.58712 4 of 6

 technique minimizes tooth reduction and augments the overall esthetic result. This comprehensive
approach meticulously considers the natural anatomy of the tooth, faithfully recreating it while preserving
as much natural tooth structure as possible. Moreover, it effectively addresses issues like air voids that might
occur due to the nature of flowable resin composites after the removal of the index or when minor tooth
color enhancement using staining resin composites is necessary.

The amalgamation of the conventional creation of proximal surfaces with the injection technique overcomes
the challenge of achieving optimal interproximal contact, ensuring a successful reconstruction of the labial
surface and the inherent contour of the tooth. Although concerns about wear and fractures may arise with
flowable resin composites, the ability to store and reuse the same silicone index can simplify future
restoration repairs. Nevertheless, vigilant and regular monitoring of restorations remains vital to detect any
complications, such as marginal discoloration or chipping [19], and to promptly address them and extend the
longevity [20].

Incorporating digital workflows into this process enhances predictability, reduces technique sensitivity, and
achieves a high level of accuracy in translating the visual representation of the desired outcome from the
digital wax-up to the final form. As demonstrated by Gestakovski [4,14], this approach offers a multitude of
benefits, including reduced chair time, predictable outcomes, and simplified maintenance compared to
indirect restorations. However, further investigation is necessary to establish its long-term durability and
clinical efficacy. Future research efforts, such as randomized controlled trials with larger sample sizes, are
essential to validate these findings and assess long-term performance and patient satisfaction.

In summary, the restoration technique employed in this case has successfully addressed the patient’s
esthetic requirements while adhering to the principles of minimally invasive dentistry and pragmatic
esthetics. The selection of an appropriate restoration technique should take into account factors such as the
specific case requirements, patient preferences, the expertise of the dentist, and the availability of materials.
By considering these factors, dental professionals can offer individualized and effective solutions that
prioritize patient satisfaction and overall dental well-being.

Conclusions
In conclusion, the direct composite restoration approach, facilitated by the composite injection technique
within a digital workflow, exhibits great potential for achieving optimal esthetic outcomes while preserving
valuable tooth structure. Nonetheless, further research and comprehensive long-term clinical studies are
imperative to unlock the full potential and durability of this approach in everyday clinical practice.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Diana F. Muslimah, Yuichi Hasegawa, Foxton Richard, Keiichi Hosaka

Drafting of the manuscript: Diana F. Muslimah, Tichy Antonin, Keiichi Hosaka

Critical review of the manuscript for important intellectual content: Yuichi Hasegawa, Tichy Antonin,
Foxton Richard, Keiichi Hosaka

Acquisition, analysis, or interpretation of data: Tichy Antonin

Supervision: Keiichi Hosaka

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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