Dr. Luken De Arbeloa
DDS, MS
• Education Strategy Director at Digital Smile Design (DSD) in Madrid, Spain.
• Specialist in Prosthodontics, Implant-Prosthodontics, and Aesthetic Dentistry, with an advanced postgraduate degree in these fields. • Expert in clinical photography, interdisciplinarity, and the integration of chairside 3D printing technologies for restorative excellence.
• Direct clinical lead for global educational programs, overseeing the development of advanced curricula focused on digital workflows and comprehensive rehabilitation.
• International speaker and expert in DSD Systems and Case Acceptance Mastery.
• Co-author of scientific publications in indexed journals, with a focus on injectable resin techniques and model-free digital workflows
Angelo Raphael, Alicia Quintana, Christian Coachman
Traditional silicone-key direct composite restorations suffer from variable thickness, internal voids, imprecise trimming and high labor cost. Pressed composite integrates facially-guided Digital Smile Design, dual-step 3D-printed IBT-Flex guides, and a volumetric “PRESS” dispenser filled with high-fill composite. In a two-visit restorative session following clear-aligner therapy and guided crown lengthening, this workflow achieved exact replication of the planned anatomy, texture, form, and function. The 18-month follow-up findings show stable margins, minimal wear and high patient satisfaction.
introduction
introduction
Since Belvedere’s 1980 silicone-key injection approach, Terry’s 2014 composite injection technique and Díaz et al. ’s 2018 DSD-guided analog adaptation, direct composite techniques have aimed for greater predictability. Manual silicone keys, however, introduce errors in guide thickness, bubble formation and manual trimming, extending chairtime and compromising outcomes. Pressed composite represents the next evolution, uniting the following:
- Facially guided 3D Digital Smile Design (DSD)
- Dual-step 3D-printed indexes (partial and complete)
- Volumetric composite dispenser calibrated by mesh volume and resin density plus 20 %
- High-fill composite for occlusal stability and pressed technique delivery
Limitations of Traditional Silicone Keys
Limitations of Traditional Silicone Keys
- Uncontrolled thickness: Manual pressure yields uneven guide walls
- Bubble entrapment: Frequent voids require 2–3 bar pressure-pot degassing
- Imprecise trimming: Manual cutting risks over-/under-cuts and repeats
- Orifice drilling tears: High-pressure burs can desiccate or rip inner guide walls
- High time & cost: ~40–50 USD per key, plus hours of hand-finishing
From Silicone to 3D-Printed Guides
From Silicone to 3D-Printed Guides
Angelo Raphael proposed CAD-designed guides printed in Formlabs IBT-Flex resin. After bracket-cement resin trials and collaboration with Formlabs, IBT-Flex was optimized to deliver the following:
- Bubble-free design: Fit-ensure windows integrated into the CAM model
- Uniform thickness: CAD-controlled ~5 mm cross-sections
- Automated fabrication: Printer runtime replaces hours of manual work
- Digital precision: Precise trimming in the cervical and papillae area
- Cost efficiency: ~4–6 USD per guide (only material)
Pressed Composite Design Protocol
Pressed Composite Design Protocol
- Facially driven digital wax-up using the DSD Natural Restorations concept (pioneered by Coachman in 2013–2014: this framework is built on a “copy-paste” approach to natural anatomical forms from scans to create lifelike, facially integrated monolithic restorations)
- Partial-arch model: Step 1 press for the restoration of alternating teeth
- Full-arch model: Step 2 press for the remaining teeth of the first direct restoration
- Volumetric calculation:
– Mass (mg) = Volume (mm³) × Density (g/cm³) × 1000
– Density: 1.94 g/cm³; +20% safety margin - Composite dispenser design: Half sphere per tooth, labeled by mass 6..3D print: IBT-Flex at 50-µm print layer resolution; IPA wash; manufacturer’s post-cure protocol
Pressed Composite Clinical Protocol Step-by-Step
Pressed Composite Clinical Protocol Step-by-Step
- Shade Check: Try-in color guide without etch/bond
- Isolation Step 1: Teflon wrapping over teeth that will not be restored in this step
- Bonding: 37% phosphoric etch, rinse/dry, adhesive cure
- Press Step 1: Load index 1A and 2A → warm the index with the composite → press the composite over the tooth → light-cure each tooth
- Intermediate Cleanup: Scalpel, burs, and curette remove cervical/interproximal excess
- Isolation Step 2: Protect Step 1 restorations with Teflon
- Press Step 2: Repeat etch/bond and press with index 1B and 2B
- Final Cleanup: Scalpel, burs, and curette remove all excess
- Final Polish: Diamond paste → low-abrasion rubber → felt for high gloss
- Occlusal Check & Guard: Verify occlusion; deliver night-guard
Case Illustration
Case Illustration
Patient: Male with missing teeth, esthetic disharmony, malposition, narrow maxilla and uneven smile curve.
Treatment Sequence:
- Visit 1 (Records): Full scan, photographs and videos, design and plan (DSD 1st & inter-appointment protocol) (Fig. 1–3)
- Visit 2 (Plan & Mock up): Present combined plan; Smile Test Drive (Fig. 4, 5)
- Visit 3 (Ortho Start): Deliver clear-aligner therapy
- Visits 4–N (Ortho Control): Periodic aligner adjustments
- Visit N+1 (Ortho QA): Post-aligner scan; confirm tooth positions (Fig. 6)
- Visit N+1 (Restorative planning). Updated esthetic analysis and next step alignment (Fig. 7, 8)
- Visit N+1 (Pre-Surgical Analysis): DSD Perio analysis (Periodontal-bone evaluation); define crown lengthening (Fig. 9)
“The DSD Natural Restorations concept is built on a “copy-paste” approach to natural anatomical forms from scans to create lifelike, facially integrated monolithic restorations.”
- Visit N+3 (Guided Crown Lengthening): CAD guide design; perform lengthening (Fig. 10, 11)
- Healing (4–6 weeks) (Fig. 12)
- Visit N+4 (Restorative Planning): Post-healing scan; Design adaptation, DSD Direct Pressed kit design & manufacture (Fig. 13–16)
- Visit N+5 (Delivery): Execute Pressed Composite (upper & lower) (Fig. 17–23)
“Pressed Composite embodies the pinnacle of digitally guided direct restorations.”
Immediate Outcome
Exact replication of planned anatomy, texture, shape and occlusion. (Fig. 24, 25)
Eighteen-Month Follow-Up:
Stable margins, healthy periodontium, negligible composite wear; high patient satisfaction.
Benefits of Pressed Composite
Benefits of Pressed Composite
- Reproducibility: Millimeter-exact anatomy and texture
- Efficiency: ≈2 h 30 min total chairtime full mouth
- Predictability: Void-free, uniform adaptation, precise volume control
- Flexibility: Custom guide count and sequence
- Cost-Effectiveness: Reduced labor and material waste
Conclusions
Conclusions
Pressed composite embodies the pinnacle of digitally guided direct restorations. Mastery of isolation, dual-step pressing, meticulous cleanup and precision polishing ensures consistently esthetic and functional results. Success depends on stable occlusal design, rigorous CAD–CAM guide fabrication, and careful case selection.
NOTES
1) Belvedere PC. An indirect/direct injection molding technique for the placement of micro-filled, type II composites. Northwest Dent. 1980 Nov-Dec;59(6):332–338.
2) Belvedere PC. Posterior composites: injecting composite resins and using Mylar matrix bands will eliminate gingival margin failures and increase tight contacts. Northwest Dent. 1994 Mar-Apr;73(2):19–22.
3) Terry DA, Powers JM. A predictable resin composite injection technique, Part I. Dent Today. 2014 Apr;33(4):96, 98–101.
4) Díaz Guzmán E, Conejo J, Blatz MB, Flores Reyes J. Flowable Injection Technique. In: Duarte S Jr (ed.). Quintessence of Dental Technology 2018. Quintessence Publishing; 2018.
5) Coachman C, de Arbeloa L, Mahn G, Sulaiman TA, Mahn E. An improved direct injection technique with flowable composites: a digital workflow case report. Oper Dent. 2020 May-Jun;45(3):235–242. doi:10.2341/18-151-T
6) Liaropoulou YM, Jiménez AK, Chierico F, Blatz MB. The multilayer flowable injection technique for highly esthetic restorations. J Esthet Restor Dent. 2025 Jun 27. doi:10.1111/jerd.13500.