Teeth can, at times, heavily impact one’s self-confidence and social interaction development. Creating a beautiful smile can really give a whole new perspective on one’s self-esteem.
Hence, general practitioners and orthodontists are often asked to treat patients with one or several esthetic problems such as missing teeth. The solutions to treat these cases involve a multidisciplinary approach with ortho, perio and restorative dentistry, from the planning with a functional and aesthetic prototype build from a wax up/set up to the definitive restorations made in the most conservative way and sometimes by compromising to make the whole treatment easy to the patient.
In the following case, a 16 years old female patient is sent to our office by her orthodontist who asked us to find a solution to treat the multiple agenesis and to correct the shape of the teeth involved in her smile. The patient has a high demand in esthetics, indeed she is a teenager, but she cannot smile because of the persistence of baby teeth. The treatment goals are not only to restore shapes, texture, size but as well to give to this young lady a new self-confidence. According to the age of the patient, we cannot propose traditional implant treatment to replace the deciduous teeth and prosthetic therapy. We decided to treat only with flowable composite resin using an injection technique.
Fig.1
Initial smile shows the absence of teeth 12-13-22-23-24. It is easily understood why it can be difficult to smile when you are a 16 year old teenager.
Fig.2
The X-ray shows all the agenesis. One of our goals is to maintain this situation stable as long as possible before the patient reaches an age suitable for a conventional implant treatment.
Fig.3
This picture shows another problem, the cross bite won’t allow to modify the shape of the upper teeth. We asked the orthodontist (Dr Cécile Nigoghossian, Marseille) to correct the bite and to create space for the future restorations.
Fig.4
3D casts of the mouth help to plan the bite correction.
Fig.5
After a few weeks, we have a sufficient and evenly distributed amount of space to start designing the future smile.
Fig.6
The smile design is sent to the lab (Gilles Phillip laboratory). Shape, dimensions and proportions of the upper teeth are modified. The gum level won’t be touched. The lab closed the spaces between the teeth and transformed the deciduous teeth in permanent ones.
Fig.7
Before any intervention, the patient has to validate the project. To precisely transfer the esthetic project in the mouth of the patient we used silicone materials (Honigum Putty and Light). With a #15 blade, we removed unwanted parts of the silicone stent to obtain a very clean and precise mock up. At this point the patient can appreciate the final outcome and validates the treatment plan. We have as well to test and validate the occlusion relations.
Fig.8
After check up and adjustments for both esthetics and function, the DT built a transparent tray with a 3D printer (Formlabs) that we fill with transparent silicone material. Holes were made with a bur to allow the flowable composite syringe to be put in to inject the material.
Fig.9
Fig.10
Back to the clinic, we choose color with flowable composite check buttons.
Fig.11
Teeth should be restored one by one, and adjacent teeth protected with teflon tape.
Fig.12
Each tooth is etched, rinsed, and dried; then a bonding agent is applied and cured.
Fig.13
The transparent index is inserted and maintained firmly. The flowable composite resin (Enamel Plus Hri flowable, UD1, Micerium – Bisico FR) is injected through the hole made in the laboratory and then cured through the tray.
Fig.14
After the tray removal and another photo curing with glycerine gel, excess material is removed with a #12 blade and pop-on discs (Soflex, 3M).
Fig.15
Outcome after excesses removal, before finishing and polishing procedures.
Fig.16
Each tooth involved in the smile is treated in the same way. Finishing and polishing procedures can now be carried out.
Fig.17
Fig.18
Fig.19
TIP: by moving the flash of the camera above the mouth, macro and micro texture become obvious.
Fig.20
Finishing and polishing procedures (Style Italiano Finishing Style, Komet; Diamonds twist polishing paste, Smile Line) improve the texture of the teeth.
Fig.21
Final outcome after finishing and polishing procedure.
Fig.22
Final smile one month after treatment. The patient tells us that now she smiles a lot more.
Conclusions
Restoring a smile is not just about shapes, dimensions, proportions, color. We have to include social and psychological aspects. Smiling signals encourages positive interactions and quality social relationships.
In this clinical case, we used composites to restore a proper smile but as well we did our best to make the patient feel better about herself.
Bibliography
1. Douglas A. Terry. Restoring with flowables. QP 2017
2. Manauta J, Salat A. Layers : an atlas of composite resin stratification. QP 2012
3. Faucher AJ, Ortet S, Camaleonte G, Weisrock G, Etienne O, Paris HC. Réussir les composites antérieurs au quotidien. QP 2017
4. Camaleonte G.Direct and indirect composites in anterior
5. The power of a smile.Socialpsychonline, 2017.
6. Diaz Guzman Enrique.Watch video.
7. Coachman C, Calamita M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. QDT 2012
