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 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

Management of dental erosive using composite layering technic and biomimetic efficiency 

Rafalimino HN1,2, Rakotonirina FP1,3, Radadisolo MEF4,5,Randriamalala NC1,6, 
Andrianjafinoro TH1,2,Ramaroson J1. 

1Sub-section of Conservative Odontology Endodontic at the Tropical Odonto-Stomatological Institute 
of Madagascar (IOSTM), University of Mahajanga 

² University Hospital Profesora Zafisaona Gabriel Androva Mahajanga Madagascar, 
3Oral Health Center, Ministry of Industrialization, Trade and Consumption Antananarivo, 

Madagascar, 
4Sub-section Odontology Pediatric at the Tropical Odonto-Stomatological Institute of Madagascar 

(IOSTM), University of Mahajanga 
5Military Hospital Ampahibe,Antananarivo, Madagascar 

6 University Hospital Joseph Dieudonné Rakotovao, Befelatanana Antananarivo, 
 

Corresponding author: Rafalimino Holy Nasandratra 

Sub-section of Conservative Odontology Endodontic at the Tropical Odonto-Stomatological Institute 
of Madagascar (IOSTM), University of Mahajanga 

 

Abstract  

In the world, in 2006, the prevalence of dental wear was 46.9% among individuals aged 14 to 

88 years. According to Schlueter N and colleagues, by calculating an approximate average 

from available data, they estimated the average prevalence of dental erosion to be between 

30 and 50% for deciduous teeth and between 20 and 45% for permanent teeth worldwide. 

They found that patients with gastro esophageal reflux (GERD) and eating disorders 

associated with vomiting had a clear impact on the prevalence of erosion. Regardless of the 

type of dental substance loss in the anterior sector, composite crown restoration remains 

the most chosen restorative therapy by dentists. Located in the anterior region, these types 

of dental substance losses affect aesthetics and make the smile unattractive. The individual's 

personality is disturbed as well as their communicative life. The objective of this article was 

to present the case of a patient with dental erosions in the anterior sector, managed by the 

composite layering technique, and to demonstrate the biomimetic efficiency of the 

restoration. 

 

Keywords: Biomimetic, dental erosion, layering, direct technique 

 

1. Introduction 

Faced with dental substance loss due to decay or tooth wear, composite crown restoration 

remains the primary restorative therapeutic option chosen by the dentist. Dental erosion is a 

chemical process characterized by acid dissolution of dental hard tissue not involving acids 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

of bacterial origin. Erosive demineralization can result in progressive, irreversible loss of 

tooth mineral substance, and may be caused by intrinsic factors like acid reflux and excessive 

vomiting[1].Located in the anterior region, these types of dental substance loses diminish 

aesthetics and make the smile unattractive. The individual's personality is disturbed as well 

as their communicative life. The objective of this article was to present the case of a patient 

with dental erosions in the anterior sector, managed by the composite layering technique, 

and to identify the factors determining the biomimetic success of the restoration. 

2. Observation 

This concerns a 44-year-old female patient, working as a client manager, who came to 

consult us at the specialized Odontostomatology center in Mahajanga. Her reason for 

consultation was an aesthetic concern. Upon examination of her general condition, the 

patient appears to be in good health, except that she frequently experiences almost daily 

gastro esophageal reflux. In order to limit this gastric problem, the patient frequently drinks 

lemon juice outside of meals. On physical examination, the extra-oral examination showed 

the absence of palpable or painful adenopathy in the submandibular, jugular-carotid, and 

supraclavicular areas. The intra-oral examination of the patient's hard tissues showed the 

presence of blatant erosive dental substance loss on the upper right and left central incisors. 

The dental wear was of moderate erosive type, with a BEWE score of 2, an ACE class IV, with 

a yellowish background indicating dentin exposure. The extent of the involvement includes 

the vestibular surface, the central incisal angle, one-third of the proximal surfaces, and one-

third of the palatal surface of each tooth. The percentage of hard dental tissue involvement 

was less than 5%. Aggravated by the patient's dietary habits, this dental erosion was 

observed to be actively progressing and requires immediate management to prevent further 

wear to other sextants. After a refined analysis of the remaining dental tissues, we opted for 

management by composite layering. Our therapeutic choice was motivated by the 

importance of adhering to the therapeutic gradient developed by Tirlet and colleagues and 

the biomimetic dental restoration principle presented by Pascal M and colleagues. Referring 

to the literature data, we adapted our therapeutic protocol according to the available 

technical resources. The technical setup used included a visual aid, a conservative dentistry 

examination tray, a mouth opener, a full-arch impression tray, type A alginate, high-viscosity 

silicone, a wax-up plate, a PKT-type instrument, a Heidemann® spatula, a dental wedge, 

some micro-applicators, a turbine, a green-band contra-angle, diamond ball burs, composite 

finishing burs, an etching system, an MR3-type adhesive system, a Micerium® Enamel Plus 

HFO enamel composite, a Micerium® Enamel Plus HRi enamel composite, a Charm Fill Plus® 

dentin composite in shade A3.5, a Charm Fill Plus® composite in shade A3, a celluloid matrix, 

composite restoration spatulas, 40µm thick articulating paper, a silicone composite finishing 

kit, a 12-megapixel camera. The therapeutic protocol presented was consented to by the 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

patient. In addition to patient clinical observation, eight steps were developed, including 

pre-stratification analysis of the causative tooth, making a silicone guide key, preparing the 

tooth for restoration, etching, applying the adhesive system, composite placement, 

composite finishing, and composite polishing. Pre-stratification analysis of the teeth to be 

restored was performed based on the anatomical shape and color of adjacent teeth. A visual 

chromatic analysis was performed in the absence of a spectrophotometer. A personalized 

shade taking was made using the chosen composites for restoration, which helped us assess 

the difference in dental tissue saturation. In addition to photography, a chromatography 

card of the two teeth to be restored was useful in guiding us on the choice of composites to 

use for each tissue to be restored. Brightness, enamel and dentin color, and intensity 

presence were noted on our chromatographic card. For shades, the dentin body was 

restored with Charm Fill® composite shade A3.5 at the cervical 2/3, the incisal 1/3 part was 

restored by Charm Fill composite shade A3, the dentin nipple was restored by Charm Fill® 

composite shade A2, the enamel on the vestibular and palatal surfaces was restored by HFO 

type OBN® enamel composite, and characterization was restored by Enamel Plus HRi 

composite by Micerium®. After the patient's consent to the therapeutic proposal, an 

impression was taken with type A alginate followed by pouring the positive model in plaster. 

Modeling of the desired morphology of the teeth to be restored was performed with CERA 

Reus Dental® modeling wax, followed by an impression of the positive model with high-

viscosity putty silicone. To obtain the silicone guide key, the hardened silicone was cut in 

such a way that only the palatal part was preserved. Its adaptation was checked in the 

mouth. Prior to composite placement, a tooth preparation step was developed by forming a 

vestibular chamfer limit and a palatal "butt margin". We then opted for a two-step etching 

and bonding system by applying 37% phosphoric acid for 15 seconds at the enamel level 

followed by rinsing, and bonding with CharmBond® photopolymerizable mono-component. 

The curing time was 30 seconds. The actual stratification began with the palatal aspect, then 

the proximal surfaces, the dentin body, and was finalized by the vestibular enamel. Our goal 

was to build walls from the restorations to transform the lack of dental substance into a 

simple cavity. To do this, the previously prepared silicone key was placed on the palatal side 

after applying the non-photo-polymerized palatal enamel composite layer with the 

Heidemann spatula. Photo polymerization was activated after checking the key's positioning. 

Then the proximal walls were restored using a matrix system such as celluloid strip. Dentin 

masses in different shades were applied while respecting their respective positions recorded 

in the chromatography card. We ensured that the composite thickness did not exceed 2mm 

before each photopolymerization. Part of the characterization was reproduced at the dentin 

nipple edge using Enamel Plus HRi® composite. Before polymerization, while respecting the 

surrounding tissues, the vestibular enamel layer was finally placed by tapping without 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

compressing the composite. As we did not have Modeling resin®, smoothing was done with 

a micro-brush soaked in adhesive. The superficial enamel composite layer was checked to 

ensure it covers the vestibular chamfer to mask the tooth-restoration junction, and the 

thickness and optical effect were verified. Primary and secondary anatomies were recreated 

based on adjacent teeth using diamond flame burs and round-ended cylindrical burs. After 

checking for occlusal discrepancies, the polishing step was performed, with decreasing grit 

size Pop-on discs mounted on blue-band contra-angle used. The operative procedure lasted 

60 minutes for the restoration of each tooth. Biomimetic effectiveness was assessed after 24 

hours of composite restoration rehydration and then after twenty-nine months of 

restoration. Simultaneously, the patient was advised to discontinue acidic dietary habits. 

Dietary hygiene education was provided to the patient. For the management of gastro 

esophageal reflux, she was referred to a gastroenterologist. 

3. Results 

After twenty-four hours of restoration, the tooth was checked, and rehydration was 

achieved, comparing it with the adjacent natural tooth considered as reference (figure 11). 

After 29 months of tooth restoration, we found that the biomimetic efficiency obtained was 

maintained, and we concluded that the ultra-conservative approach and the composite 

layering principle were effective and sustainable for our clinical case (figure 12). 

 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

 

4. Discussion 

According to the literature, the aesthetic success of a composite layering restoration has 

depended on the following factors: the choice of composite shades, the type of composite 

used, and the composite layering system. 

 

4.1 Aesthetic effectiveness of layering depending on the choice of composite shade 

During the pre-stratification stage, the choice of shade and the recording of the five 

dimensions of tooth color for a composite restoration have been discussed depending on 

the type of shade guide used. According to Vanini, the use of the VITA® shade guide 

combined with the concept of chromatography has served as a means of communication for 

practitioners, refining and noting all parameters contributing to tooth color restoration[3-

5].For our clinical case, our shading concept was based on two principles: the use of a 

custom shade guide combined with the chromatography concept. This custom shade guide, 

made with the same types of composites used, helped us achieve precise shades for each 

composite layer to be restored and yielded an optimal and aesthetic result. This finding is 

consistent with the study by Magne B and colleagues in 2010 and the study by Manauti and 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

colleagues in 2014, which evaluated the effectiveness of the custom shade guide for 

choosing composite shades compared to ceramic shade guides. The use of the 

chromatography guide was a very effective reference tool to avoid errors in placing each 

type of composite [6-8]. Using these two principles simultaneously yielded an aesthetically 

pleasing and biomimetic result. 

 

4.2 Aesthetic effectiveness depending on the use of the silicone key 

In terms of composite layering, we opted for using a single silicone guide key, which has 

been affirmed by Kleeberger B and colleagues in 2008 and Callin D and colleagues in 2014 as 

a key factor for aesthetic success and longevity of the restoration[9-10].  

 

4.3 Aesthetic effectiveness depending on tooth form restoration 

Regarding the form of tooth-restoration boundary, the use of a chamfer margin on the 

vestibular aspect and a butt margin on the proximal and palatal aspects has been suggested 

by Vanini and colleagues to combine aesthetic appearance with mechanical performance of 

the restoration[4]. For our clinical case, using chamfer margin on the vestibular aspect and 

butt margin on the palatal aspect, combined with adequate polishing, resulted in optimal 

aesthetic effectiveness.The ability to delimit the thickness of composite layers has been cited 

as a determining factor for the success of a restoration. In their layering practice, 

Dionysopoulos and colleagues in 2020 and Alleman and colleagues in 2017 emphasized the 

importance of limiting the thickness of the composite layers to less than 2mm to avoid the 

grayish effect of the restoration. For our clinical case, to reduce stress during polymerization, 

the thickness of the increment was limited to less than 2mm during the application of the 

dentin body and superficial dentin layers. The longevity of our therapeutic success marked 

this observation[11-12]. 

 

4.5 Aesthetic effectiveness depending on composite mounting technique 

The layering technique chosen for our case was the modern three-layer histological layering 

technique. Our therapeutic choice was motivated by the principle of layering respecting the 

natural arrangement of dental tissues. According to clinical practice of this principle by 

several authors, its aesthetic effectiveness has been affirmed[13-14]. 

 

Conclusion 

According to the philosophy of the author Magné P, biomimetic restorative dentistry 

involves respecting the natural structure and using it as a guide for restoration. The objective 

of this article was to present the case of a patient with dental erosions in the anterior sector, 

managed by the composite layering technique, and to discuss the expected results. The main 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

factors that optimized the aesthetic success of our restoration were: the use of a custom 

shade guide combined with the concept of chromatography, chamfer margin on the 

vestibular aspect and butt margin on the palatal aspect, the use of a single silicone guide key 

for mounting the palatal and proximal walls, adherence to the thickness of each composite 

layer not exceeding 2mm, and the composite layering system in three layers respecting the 

natural structure of dental tissues. These principles helped us achieve biomimetic efficiency 

of the crown restoration and the longevity of the restoration. In order to consolidate the 

benefits obtained through biomimetic practice, an effective matrix system should be 

analyzed. 

 

Conflicts of interests 

We, the authors of this manuscript, declare no conflicts of interest regarding the publication 

of this article. 

 

Patient consent 
The patient has given full permission for the publication other use of his clinical case and 

photographs. 

 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Management of dental erosive using composite layering technic and biomimetic efficiency 

 
 

 

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