Fig.1
This is the starting point, patient seeks aesthetic transformation but without any orthodontic intervention. The rotated right lateral is her most pressing concern in the smile apart from the mesial diastema on the left lateral incisor.

Fig.2
Frontal close-up also shows the thinning and mesial wear of the centrals and the notched defect on left central which is planned to be addressed too in the restorative plan.

Fig.3
A quick chair side mock-up with composite resin on stone model to create the envisioned final result.

Fig.4
The Vita Classic shade tabs are a starting point in the shade selection process.

Fig.5
Composite Shade Buttons of corresponding body shade composites to confirm shade match.

Fig.6
Proper seating of Silicone index done with rubber dam in place, pencil marking for areas of tooth to be prepped before bonding.

Fig.7
The final prep with most of all the enamel yet present as can be seen from the surface gloss.

Fig.8
Use of 32% Phosphoric acid with BAC on the labial and palatal surfaces of the right lateral incisor prior to application of a universal bonding agent.

Fig.9
Enamel shade composite loaded on the silicone key in the previously marked area of the planned restoration.

Fig.10
A palatal wall created after curing the enamel shade composite.

Fig.11
The palato-proximal line angles built-up against a pre-contoured metal matrix to create a hollow shell structure prior to multi-layering with different opacities.

Fig.12
A higher chroma dentin shade placed palatally on mesial half and labially on distal half of the lateral incisor to provide warmth and block-out effect due to the opacity.

Fig.13
A lower chroma body shade composite placed over the dentin shade to blend in the shade of the restoration with the natural tooth.

Fig.14
A matrix pull-through technique used to mould and create the mesial proximal enamel wall with an enamel shade composite.

Fig.15
A similar composite moulding technique followed on distal proximal wall to complete the build-up.

Fig.16
Selectively etching the periphery of the left lateral incisor to initiate the planned diastema closure and incisal augmentation.

Fig.17
The frosty appearance of the enamel following adequate etching, rinsing and drying protocol.

Fig.18
The first layer of the enamel composite created using the silicone key.

Fig.19
The diastema closure completed with a similar technique as used on right lateral incisor but using only one additional body shade composite.

Fig.20
Selective etching of both central incisors to carry out the planned additive restorations on incisal and mesial surfaces.

Fig.21
Incisal composite extensions with enamel shade composite moulded against the silicone key.

Fig.22
Dentin shade composite used to create incisal dentin lobe tips and a high value dentin shade used on the edge to create an halo.

Fig.23
Restoration of incisal and mesial surfaces completed with a body shade composite.

Fig.24
Gross composite excess removal and surface refinement with multi-fluted finishing carbide burs.

Fig.25
Pencil markings for creating and retaining the proximal transitional line angles. Graded Sof-lex discs used for shape refinement and pre-polishing.

Fig.26
Use of diamond-impregnated Sof-lex spiral at 20000 RPM to achieve final highly lustrous surface. A high surface gloss achieved after the final polishing step.

Fig.27
Intra-oral close-up at 1 week follow-up appointment.

Fig.28
The transformed smile after proper composite handling, finishing and polishing protocols, minimalistic yet effective.

Conclusions

Contemporary composites are highly versatile in nature from small additive restorations to extensive build-ups due to superior physical and optical properties.
They are very conservative of the innate tooth structure due to low or no-prep approach.
A rotated tooth can be selectively restored on palatal and labial surfaces with a direct approach to create a visually pleasing, well aligned tooth and with minimal removal of enamel. Its prudent for all restorative dentists to hone their skills in direct composite placement techniques so as to provide responsible esthetics to their patients.

Bibliography

1. Diagnosis and Treatment evaluation in cosmetic dentistry: A Guide to Accreditation Criteria, American Academy of Cosmetic Dentistry.
2. Dietschi D. Layering concepts in anterior composite restoration. J Adhesive Dent 3(1):71-80,2001
3. Scott W Finlay: Accreditation Clinical Case Report -Case Type 5:Six or more Direct Resin Veneers. Journal of Cosmetic Dentistry Vol.24,No.3, Pg.54, Fall 2008
4. LeSage B, Milnar F, Wohlberg J. : Achieving the epitome of Composite art:creating Natural Tooth esthetics, texture and anatomy using appropriate preparation and layering techniques. JCD 2008;132-41(special issue)
5. Howard S. Glazer, DDS: Simplifying Finishing and Polishing Techniques for Direct Composite Restorations. Dentistry Today, November 15, 2009