Direct and indirect composites in anterior
For any aesthetic treatment, the practitioner should encourage the patient to express his motivations and desires. The dentist must devote time to listen, understand and guide the demand. After a thorough analysis of existing problems, with clinical examination, x-rays and photos, a treatment may be proposed to the patient, who then might accept it or not. In case of refusal, it is important to understand its reasons and, if possible, to make another proposal in accordance with the patient’s expectations as long as they are realistic; the patient will have to understand and accept the limits of the second proposal. When agreement is reached, study models are needed and through the realization of diagnostic wax-up, dentist and laboratory can show the expected outcome to the patient. In the following case, we will see how we managed the treatment plan after the patient refused our first proposal.
Img. 1 – A young female patient came to the office to improve her smile. She asks us for a fast treatment because she is going to get married 4 months later. Her desire is to have white and aligned front teeth.
Img. 3 – X-rays of the deciduous teeth shows important root resorption. At this point, we tell the patient that, in order to obtain a long lasting result, we should extract teeth 5.3 and 6.3, open spaces between canines and central incisors by orthodontic treatment and then place implants to replace 1.2 and 2.2 after a bleaching procedure. The patient refuses this proposal and reminds us that she wants a fast solution. At this point we have the choice to stop the treatment or to find an altenative solution. We decided to propose to rebuild the teeth with indirect composite crowns on teeth 5.3 and 6.3 and to make direct restorations to transform the canines in lateral incisors. We explain to the patient that this treatment can make the root resorption of the deciduous teeth accelerated. The patient accepts to take this risk.
Img. 4 – First thing to do is to make study models and we send to the laboratory (DT Gilles Philip laboratory) digital design to guide the realization of the wax-up.
Img. 5 – The lab closed the spaces between canines and central incisors and transformed the deciduous teeth in permanent canines. We can notice in this case that the gum level of the 1.3 and 2.3 is lower than the gum level of the teeth 2.1 and 1.1, this is an opportunity for the final integration of the new smile.
Img. 6 – Before any intervention, the patient has to validate the project made in the laboratory. To transfer precisely the sculpture in the mouth of the patient we used silicone materials (Honigum Putty and Light) . With a #15 blade, we remove 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.
Img. 7 – The first step of the treatment is bleaching with White Dental Beauty 6%HP for 14 days. This picture shows the initial color of the teeth and the strong saturation of the canines.
Img. 8 – One week treatment (on the left) and final color (on the right). After bleaching treatment we make silicone impression to ask the laboratory to build composite crowns on the deciduous teeth. We remind the patient that because of the occlusion (even if we will try to avoid occlusal contacts in static occlusion), the root resorption of the 53 and 63 will certainly be accelarated. The patient is still motivated and tells us she understands the risks.
Img. 9 – The composite crowns (Gilles Philip lab) have been cemented with individual rubber dam. After excesses removal, we put again rubber dam from teeth 1.4 to 2.4 to transform 1.3 and 2.3 in lateral incisors with direct composites.
Img. 10 – The usual procedure to close spaces is performed. After sandblasting, etching and adhesive technique, palatal wall is built with a silicone stent made from the validated wax-up. Proximal walls are made by using posterior matrixes used in a vertical way. One amount of dentin is placed in order to manage a 0,5 mm space free for the layer of buccal enamel.
Img. 11 – Final result after polishing procedure, before rubber dam removal.
Img. 12 – Direct post-op situation, right after rubber dam removal.
Img. 13 – The outcome 1 month later is satisfactory.
Img. 14 – 6 months later, the patient is happy and the deciduous teeth show no mobility.
Before starting any treatment we have to listen carefully at the patient’s expectations. If we have to make realistic compromises, the patient has to understand and accept the limits of the new treatment plan. In the case here presented, the patient knows the outcome won’t last for many years. Despite this, the patient is grateful and comes back to the clinic every 6 months to check her mouth.