As dentists, we certainly know what a simple smile can provide, but we often hear from patients who do not like to smile or have forgotten how to smile due to the poor condition of their teeth and gums. We see the harmful effect this has on the patient’s comfort in sharing their smile.
Poor oral health affects their psychology and ultimately who they are. Cosmetic dentists approach these patients with the goal of restoring their oral health and creating a seamless, beautiful smile. This allows the patient to smile not only on the outside, but on the inside as well.
Case Study
After completing Invisalign treatment, a patient was referred for closure of the diastemas and correction of Bolton tooth-size discrepancies. The patient, a high school student, underwent a comprehensive examination and a full-mouth series of radiographs. After discussion with the patient and his mother, resin veneers on teeth Nos. 6 through 11 were selected to address the diastemas and tooth-size discrepancies because of the patient’s age and the absence of previous cosmetic treatment.1-3 This conservative approach would optimize esthetics while preserving tooth structure. The patient declined whitening in conjunction with the resin veneers.
Radiographic examination and oral cancer screening findings were within normal limits. The temporomandibular joint was asymptomatic with no clicking, popping, or crepitus. Palpation of the surrounding musculature revealed no abnormalities. The patient received regular dental care and demonstrated good oral hygiene and home care.
The treatment plan consisted of the following phases:
- Phase I: Obtain initial photographs and create a diagnostic wax-up of teeth Nos. 6 through 11 and a lingual matrix (Figure 1 through Figure 4).
- Phase II: Create direct resin veneers on teeth Nos. 6 through 11 according to the planned shape.1
- Phase III: Create cutback windows in the incisal third of the resin veneers to achieve a natural translucent appearance.1
- Phase IV: Finish and polish the restorations.
The patient accepted the treatment plan and elected to proceed. Maxillary and mandibular polyvinyl siloxane impressions were obtained, and photographs were captured and sent to the dental laboratory for creation of the diagnostic wax-up1 (Figure 1 through Figure 3).
Once the wax-up was received from the laboratory, Integrity bis-acryl temporary material, shade A3 (Dentsply Sirona), was used for a smile try-in to evaluate the proposed shape. The patient and his mother approved the smile design. OptraGate (Ivoclar) was used for isolation of the lips. Select HV Etch w/BAC (BISCO), a 35% phosphoric acid etchant, was applied, and photographs were obtained after etching (Figure 4).
Teflon tape and a clear matrix were used to isolate every other tooth, and Adhese Universal (Ivoclar) was applied and light cured. Shade Dentin A3 (DA3) of Estelite Omega composite (Tokuyama Dental America) was selected using a polarized lens. A lingual putty matrix was then used to establish the new incisal length and create a lingual shelf with the composite (Figure 1, Figure 5, and Figure 6). Teeth Nos. 8 and 9 were selected to demonstrate placement of the final composite layer (Figure 7). Composite placement continued in a systematic sequence using Teflon strips, progressing from teeth Nos. 8 and 9 to teeth Nos. 7 and 10 and finally to teeth Nos. 6 and 11.
A white coarse disc (Cosmedent) was used to establish the facioincisal edge. A 8392.31.016 fine needle/mosquito diamond (Brasseler USA) was used to refine the embrasures, and a long flame finishing diamond (Brasseler USA) was used to create the line angles. A white coarse disc (Cosmedent) was used to eliminate voids and surface irregularities. The window technique was then performed by outlining the intended area on each tooth with a pencil and removing the composite within the outline using a KS1 bur (Brasseler USA). The composite was removed to the greatest depth near the incisal edge, with the depth gradually decreasing toward the middle third of the tooth.
A 45° bevel was created to outline the incisal and interproximal portions of the window.1 The adjacent teeth were re-isolated with Teflon tape, and the entire tooth was etched before completion of the bonding protocol. Estelite Color Pink Opaque (Tokuyama Dental America) was applied to replicate the hypocalcifications present on the patient’s posterior teeth and provide a smooth transition to the buccal corridor (Figure 8).
After the tint was light cured, achromatic IPS Empress Direct Trans 20 composite (Ivoclar) was applied within the windows to create a custom shade that blended with the natural dentition. Modeling Resin (Clinician’s Choice) was used with an OptraSculpt Pad (Ivoclar) to smooth and sculpt the final composite layer before light curing. The contouring protocol was repeated using a white disc (Cosmedent) to refine the facial contour and facioincisal edge. Photographs were obtained after final contouring and before polishing. Final polishing was performed using a blue disc (Cosmedent), green and gray FLDC5M and FLDC5 polishing wheels (Brasseler USA), and Enamelize Polishing Paste (Cosmedent) (Figure 9 and Figure 10).
Cases such as this demonstrate the impact that changing a smile can have on a patient. Following treatment, the patient expressed greater confidence and regularly took selfies to show his new smile.
References
1. Terry DE. Esthetic and Restorative Dentistry: Material Selection and Technique. Quintessence Publishing; 2009.
2. Chu SJ, Tan JHP, Stappert CFJ, Tarnow DP. Gingival zenith positions and levels of the maxillary anterior dentition. J Esthet Restor Dent. 2009;21(2):113-120. Wiley Online Library
3. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Quintessence Publishing; 2002.
Figures and Images
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Tiffani Dunn, DMD
