Fig.1
After orthodontic braces removal. With the smile picture we planned a non-invasive smile rehabilitation with direct composites free-hand and in a single visit. We planned a shape modification, giving the correct convexity for the proximal walls closing in that way the diastemas.

Fig.2
Some days after the composite smile rehabilitation. The single appointment approach with composite is the fastest of the existing protocols in dentistry. When spaces are small, when the practitioner is experienced in the field of composite handling and when there is a good knowledge of the anatomy, composites can be done free-hand without the help of the wax-up and silicon matrix. Silicon matrix can be even inconvenient in a case with small diastemas like in this particular case.

Fig.3
Patient after braces removal. After removing the braces the gingival tissues was irritated and inflamed due to the same procedure of braces removal and because the non optimal oral hygiene during orthodontic treatment. The approach consisted in providing the patient a provisional retention to avoid teeth movements and 1 week treatment with chlorhexidine 0,12% before the composite appointment. The single visit with composites consisted on 3 hours appointment.

Fig.4
The patient was extremely happy with her new smile which was very encouraging for the dental team.

Fig.5
As we saw in all the videos patient even change the smile line after the aesthetic rehabilitation. You can see in the “before picture” that labial commissures were facing downwards because the patient tried to hide teeth whilst smiling. She used the muscles to pull the lip in that position. Meanwhile after the treatment, the smile changed completely as she feels relaxed and the smile now looks natural with the right positive smile curvature.

Fig.6
A happy and satisfied patient is the ultimate goal of every restorative dentist, this is why simple but well executed techniques are a must.

Fig.7
Intra-oral view of the situation just before the composites.

Fig.8
Isolating from the midline to distal first, one side and after fixing the dental dam with the clamp we proceed with the other side.

Fig.9
Isolated field from first premolar to first premolar with 2 premolar clamps (W2A) and dental dam (medium opacity Nic Tone). Dental dam correctly invaginated with a thin spatula and air flow from the syringe.

Fig.10
Cleaning teeth from tartar, debris or adhesive residues before adhesive steps with a sharp instrument Eccesso (LM Arte Kit from LM instruments, Finland).

Fig.11
To provide a good substrate for adhesion we used the extra thin abrasive coarse disc dark orange (Sof-Lex from 3M)

Fig.12
Placing the matrices for bonding procedure.

Fig.13
Matrices in place to separate whilst doing the adhesive steps to avoid touching neighbor teeth. Matrices face “outwards” in order to have the best possible field of view.

Fig.14
The red gel is the etching gel (orthophosphoric acid 37%). Normally, phosphoric acid at a concentration between 30-40% provided retentive enamel surfaces (Silverstone, 1974). Originally, standard treatment time for enamel conditioning was 60 seconds. However, several studies have indicated that a 15-second etching time provides similar surface morphology and bond strength values (Barkmeier et al., 1986). The process involves discrete etching of the enamel in order to provide selective dissolution of prism cores or peripheries, with resultant microporosity into which resin can flow and can be polymerized to form a mechanical bond to the enamel. This procedure practically eliminated micro-leakage at the tooth/restoration interface (Retief et al., 1982). We etched for 15 seconds the enamel.

Fig.15
After rinsing and drying the etched surface can be detected as it is whitish and opaque.

Fig.16
Adhesive layer, we wait the adhesive to penetrate into the etched surface, we blow air gently.

Fig.17
60 seconds polymerization. Even if in the adhesive instructions it is recommended to polymerize for 20- 40 seconds depending on the adhesive used we prefer to polymerize longer in order to be sure that the adhesive layer is completely cured as it is the layer that will hold the entire restoration. Generally we do it of 60 seconds.

Fig.18
First increment.
THIN SPATULA ADVANTAGE no. 1
It allows the practitioner to be precise when modeling the proximal wall either in posteriors or in anteriors. Specially in small diastema like the one from the picture, the reduced thickness of the thin spatula allows the practitioner to enter in the interproximal space giving the precise shape to the interproximal wall. So it enables the modeling in narrow spaces and even penetrating them from side to side.

Fig.19
We can appreciate in the cervical area of tooth 11 the composite does not adapt very well in the cervical area. Natural hair brush helps us to adapt the composite in the vestibular area but in the cervical-interproximal area is convenient to enter with a very thin and small spatula.

Fig.20
THIN SPATULA ADVANTAGE no. 2
Adapting the composite in the cervical area is almost impossible to do if it is not with a thin and small spatula.

Fig.21
THIN SPATULA ADVANTAGE no. 3
Modeling the inter-incisal angle is also easier with the thin spatula. It is possible to insert the thin spatula in small spaces as you can see in the picture, the same concept that when modeling the inter-proximal wall.

Fig.22
THIN SPATULA ADVANTAGE no. 4
Modeling precisely the incisal edge. Even if there is plenty of space and the incisal edge could be performed with any conventional spatula, thanks that instrument Applica (LM Arte kit) is very elastic, it allows the practitioner to be subtle and feel the pressure applied when adapting composite to the tooth.

Fig.23
Readapting the composite to the tooth with the natural hair brush before polymerizing.

Fig.24
We light-cure for 20 seconds each increment as the increments are small.

Fig.25
Mesial inter-proximal wall and incisal angle already done and polymerized.

Fig.26
We proceed with the distal interproximal wall. Here we should mention that as the LM-arte Applica is very flexible, when taking the composite directly from the syringe is preferable to use a less elastic instrument to avoid loosing the material. For example the LM-arte Modella. Then is suggested to change to the thin spatula to model the composite.

Fig.27
THIN SPATULA ADVANTAGE no. 5
It can be used to gently smoothen the composite with more precision as the touch sensation increases.

Fig.28
We recreated the distal angle with the same thin spatula.

Fig.29
Brush facilitates the adaptation of the composite to tooth surface.

Fig.30
20 seconds polymerization for each layer as the composite is layered gradually. 40 seconds for the final polymerization.

Fig.31
Metal strip for trimming and finishing interproximal walls.

Fig.32
Diamond low speed bur for finishing (Finishing style kit, StyleItaliano by Komet). We should see the white powder in all the surface in order to confirm that the surface is evened.

Fig.33
Initial polishing of the composite with yellow disc (Sof-Lex from 3M).

Fig.34
Finishing strips (Sof-Lex from 3M) to finish the interproximal polishing steps.

Fig.35
In multiple restorations the golden rule is to finish one tooth before proceeding with the neighbor tooth. This kind of approach facilitates the full process.

Fig.36
We repeat all the clinical steps already explained for the tooth 11 in teeth 21, 22, 12.

Fig.37
After layering we proceed with the final details. We marked the transitional angles and we reproduced it with discs.

Fig.37
After layering we proceed with the final details. We marked the transitional angles and we reproduced it with discs.

Fig.39
Achieving ultimate anterior esthetics with a medium opacity body composite is possible. Some days after the layering stratification the situation was like you see in the control picture.

Conclusions

The single visit appointment with composites when changing a smile is convenient and economic compared to ceramic approach. As it is a reversible procedure we can always modify, repair or reshape easily directly in the mouth of the patient and if in a future the patient wants ceramic veneers the composites are not an inconvenient. The single mass approach allows us to perform multiple case restorations with moderate time letting us focus on the modeling and shaping. Modeling composite with the right instruments is important. The thin spatula like the Applica from the LM-Arte kit (from LM, Finland) is mandatory to adapt the composite in narrow spaces like in this case. Once you get used to use a thin and delicate instrument you would probably use it in each situation. Special attention from all the dental team is required for the maintenance of this spatula as it is thin and delicate. A delicate instrument should be treated delicately and we should explain it to our nurses and the staff in charge of cleaning the equipment.

Although more elaborate composite layering techniques exist and may be used in some esthetic scenarios, a simplified approach with a right color and opacity single shade and implementing basic dental anatomy concepts often will deliver highly acceptable esthetic results. You can also find single shade anterior restorations with esthetic results in this article published by Jordi Manauta.

Bibliography

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Retief DH, Woods E, Jamison HC: Effect of cavosurface treatment on marginal leakage in class V composite resin restorations. J Prosthet Dent 47: 296-501, 1982.
Fahl N, Jr. (2012) Single-shaded direct anterior composite restorations: a simplified technique for enhanced results Compendium of Continuing Education in Dentistry 33(2) 150-154.
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