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Introduction
Enhancing or rehabilitating a smile
using directly sculptured and polished composite resin
veneers can be one of the most rewarding challenges in
cosmetic dentistry. Direct composite veneers require an
exceptionally high level of skills in blending science and
art of dentistry. Composite bonding has been used for years
to correct smaller defects. Now the materials and techniques
have changed, allowing complete tooth restoration with
composite. Composite resin often may be the most
conservative approach due to minimal preparation required.
The range of colors, translucencies, and opacities available
enables clinician to mimic nature. Also, the combination of
the ease of handling and strength of microhybrids with the
high polishability of the microfills in the final layers
result in restorations that is not only strong but extremely
esthetic as well.
History
The patient was a 32-year-old female
with no significant medical history except for smoking. She
took no medication, was in good health and had seen a
dentist regularly since childhood. The patient had received
orthodontic treatment as a teenager but did not wear a
retainer any more. Patient wanted her teeth to look
healthier and more attractive; however she wanted an
economic solution, as finances were a concern. Patient was
unhappy with her smile due to excessive staining of her
previous bonding on her anteriors. Her midline was canted.
There was wear on the incisal edges of the incisors and
teeth # 7 & # 10 were flaring out with some rotation of
tooth # 10. Patient was also complaining of the
decalcification areas after the orthodontic treatment.
Additionally, the buccal corridor was slightly deficient.
Clinical
Data
Clinically, all soft and hard tissues
were within normal parameters. Radiographs indicated sound
bone support and visual inspection detected no recessions.
Clinical examination of the patient revealed failing bonding
on the upper anterior six teeth. The patient’s midline was
canted to her left. Esthetically the smile would benefit
from cosmetic enhancement.
Periodontally, the patient had some
gingivitis with no significant pocketing and minimal
bleeding upon probing. Her tempromandibular joint was
asymptomatic with no internal derangement and no crepitis or
clicking of the joint. She had a class I occlusion with a
mild overbite and overjet relationship. The entire dentition
was carries free and there was no tooth mobility.
Radiographs revealed no periapical pathology. Patient had a
breaking down old composite on tooth # 4 that was temporized
for a Gradia onlay by her own general dentist.
After analyzing her study models,
careful consideration was given to the midline and the smile
design to achieve a symmetrical result. Overall improving
patient’s smile will enhance her image and her personal
satisfaction.
Diagnosis
The
patient’s original smile was not esthetically pleasing and
violated a number of principles of ideal smile design.
Previously placed bonding breaking down and staining. It was
determined that direct composite veneers would accomplish
the patient’s goals of a more uniform and symmetrical smile.
Longer incisors would result in fuller, more pleasing smile
that would correct the reverse smile line. Central dominance
would be achieved by increasing their length. Upon
completion of building the resins, guidance and envelop of
function will be addressed. Patient was motivated to improve
her appearance with conservative treatment modalities.
Treatment
Plan
A complete set of records was taken
which included full radiographs, study models and a set of
35mm digital photographs showing all twelve views as
recommended by the AACD.
A lengthy discussion of treatment
modalities aided in the formations of the treatment plan.
Different options were presented to the patient including
indirect porcelain veneers restoring teeth # 4 through # 13;
or 10 direct resin veneers restoring teeth # 4 through # 13,
with bleaching of her lower teeth. An occlusal guard would
also be made for her.
After equilibrating her dentition a
maxillary impression was taken to construct a study model
for a diagnostic wax-up. An impression of the wax up was
made in polyvinyl siloxane putty material. This impression
was cut along the incisal edges and used as a matrix in the
application of the resin. The wax up model was duplicated in
stone in order to create a vacuum formed stint that was used
as prep guide to help preserve as much tooth structure as
possible.
Gradia onlay on # 4 was to be
delivered by patient’s general dentist prior to restoring
her 10 anteriors with direct resin veneers.
Armamentarium
- #1 & #2 brushes (Cosmedent; Chicago,
IL)
- 20D EOS Digital Camera (Cannon;
Tokyo, Japan)
- Accufilm indicator liquid and
articulating paper (Parkell; Farmingdale, NY)
- Bard-Parker Scalpel # 12
(Bard-Parker; Franklin Lakes, NJ)
- Blue and pink cups and points (Cosmedent;
Chicago, IL )
- Clear Mylar Strips (3M ESPE; St.
Paul, MN)
- Clear Polyvinyl Siloxane impression
material (RSVP, Cosmedent; Chicago, IL)
- De-Ox (Ultradent; South Jordan, UT)
- EOS Digital Rebel Camera (Cannon;
Tokyo, Japan)
- Flexibuff discs and Enamelize
polishing paste (Cosmedent; Chicago, IL)
- Gingival Retraction Cord (Ultradent;
South Jordan, UT)
- Gluma desensitizer (Hereaus Kulzer;
Armonk, NY)
- IPC Carver (Cosmedent; Chicago, IL)
- Jeltrate Plus Alginate (Dentsply /
Caulk; Milford, DE)
- Microetch air abrasion (Denville
Engineering)
- Midwest 330 bur, 7902 finishing bur,
and 7406 egg-shaped bur (Dentsply)
- Mint waxed floss (Johnson & Johnson)
- Mopper anterior composite
preparation and finishing system (Brassler USA; Savannah,
GA)
- Optibond Solo Plus (Kerr; Orange,
CA)
- Optilux 501 curing light
- Renamel Creative Color Composite
Stains (Cosmedent; Chicago, IL )
- Renamel microfill, hybrid, and
opaquers (Cosmedent; Chicago, IL)
- Septocaine with 1:100,000
epinephrine (Septodont; New Castle, DE)
- Sof-Lex finishing and polishing
strips (coarse, medium, fine, super-fine) (3M ESPE; St.
Paul, MN)
- The Wand (Milestone Scientific;
Livingston, NJ)
- Ultra-etch 35% phosphoric acid (Ultradent;
South Jordan, UT)
- Unwaxed Floss (John O. Butler Co.,
Chicago, IL)
- Vision Flex diamond strips (WS37ET)
Brassler USA; Savannah, GA
- Vita Lumin shade guide (Vident;
Brea, CA)
- Yellow Hydrox Stone (Kerr; Orange,CA)
- Zoom2 Whitening System (Discuss
Dental; Culver City, CA)
Preparation
Patient’s teeth were bleached with
Zoom2 Whitening System (Discuss Dental). Post-op
instructions were given. Patient came few days later and
shade selection was made prior to preparation. Shade A1
(progressive shade) was selected. Before the appointment, a
full contour wax up had been done, creating ideal morphology
and arrangement of the teeth. The midline was corrected
without canting. A polyvinyl siloxane putty impression was
made off this wax up and the impression was trimmed along
the incisal edges to form a matrix. Essentially, this matrix
guided the lingual and incisal formation of the teeth and
created a backdrop onto which the composite resins could be
layered.
After anesthetizing the patient
preparation was initiated with a 770.10. Preparation of
tooth # 8 was done followed by tooth # 9 to ensure adequate
removal of tooth structure and uniform layering using the
pin hole prep guide. There was no evident decay under the
old composite. We continued to prepare the rest of the
anterior segment using a conservative veneer preparation.
Bonding was initiated with the
placement of 37% phosphoric acid on the preparations for 15
seconds. Acid was rinsed off, and then teeth were damped
with cotton pellets, leaving the surface moist. Next, a
dentin sealer was placed (Gluma). A dentin primer and resin
adhesive (Optibond Solo Plus; Kerr) was placed on the
surface of the teeth and cured with a 501 Opilux light for
10 seconds. The polyvinyl siloxane matrix was then
positioned on the lingual aspect of the maxillary anterior
teeth. The initial layer of composite shade A1 was placed on
tooth # 8. Since it is important to establish an accurate
midline and length, this initial layer created a lingual
shell to act as a support for the rest of the restorations.
A thin layer of pink opaquer was placed to block out any
shine through or transition from tooth to composite. After
20 second cure, a second layer of microfill A1 was sculpted
to mimic the mamelons then cured for 20 second. A very small
amount of diluted blue tint was painted onto the incisors of
each mamelon and then light cured. A small amount of white
opaque tint was placed along the internal aspect of the
incisal aspect of the incisal bevel to create an internal
halo effect. Some maverick colors including ochre were also
added to mimic her natural dentition. In the incisal one
third, room was left to add light incisal microfill. This
was sculptured with IPC carver and #1 and #2 brushes to
create slight developmental depressions. Then it was cured
for 60 seconds with De-Ox. Long flame shaped, red-stripped
diamonds were used to create the shape of the central
incisors.
Adhesion was accomplished similarly
with tooth # 9. All 10 front teeth were completed in general
shape and then the incisors were cut back to mimic
developmental grooves and mamelons. Using a putty matrix
from the wax up as a guide. Teeth # 6 & # 11 were also built
with A2 cervically and A1 incisally to blend better with her
posterior teeth.
Finishing
The contours were refined with the
upper anterior composite finishing kit. The finish was
generated with blue and pink points and cups: coarse,
medium, fine and super fine finishing and polishing strips
and Flexibuff discs with enamelize paste. Occlusion was
adjusted in centric occlusion and eccentric excursions prior
to the final finishing and polishing. Even contacts on teeth
# 8 & # 9 in protrusive movement were established. Centrals
were made slightly longer to create more convex pleasing
smile line. At this point, we took a series of photographs
and made another appointment to complete the case.
After evaluation of the mid-treatment
photos, some minor changes in contour were made and
restorations were polished with points and cups: coarse,
medium, fine and super fine finishing and polishing strips
and flexibuffs discs with enamelize paste. Another
appointment was made for postoperative photos one week
later.
An occlusal guard was fabricated, and
patient was advised to wear it every night to maximize the
longevity of her new restoration.
Conclusion
In some situations, as with this young
patient, composite veneers should be considered the
treatment modality of choice. Remarkable esthetic and
functional results can be achieved with direct resin veneer
restorations. The key to success is beginning with the end
in mind following specific smile design principles. The
esthetic results were mutually satisfying to the dentist and
the patient. This process gave this young woman a new
pleasing smile. The patient was extremely gratified.
References
Jimmy Eubank, Jeff Morely, UCLA
Esthetic Continuum, Level I (July – September 2001)
Jimmy Eubank, Jeff Morely, Advanced
Anterior Esthetics, Hands-on Lectures (February - April
2005)
American Academy of Cosmetic Dentistry
(AACD). Diagnosis and Treatment Evaluations in Cosmetic
Dentistry: A guide to accreditation Criteria, Nashville,
2005
Frank Spears, DDS, MSD, Occlusion in
the Clinical Practice, Seattle, WA (January, 2004)
Frank Spears, DDS, MSD, Advanced
Esthetic & Restorative Management, Seattle, WA (May, 2004)
Frank Spears, DDS, MSD, State of the
Art Esthetics, Seattle, WA (October, 2004)
Peter E. Dawson, DDS, “Combining Smile
Design with Function”, AACD, Nashville, 2005.
Corky Whillhite, DDS, “Freehand
Cosmetic Bonding Techniques”, AACD, Nashville, 2005
Douglas A. Terry, DDS, “Imagination +
Form + Color = Natural Esthetics”, AACD, San Diego, 2006
John Weston, DDS, “Direct Freehand
Bonding: Creating Esthetic Success for Accreditation Cases”,
AACD, San Diego 2006
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