Direct and indirect techniques for smile improvement

Selecting the right treatment option is based on several factors: minimal invasiveness, operator factor, durability, patient’s age, cost etc. These differences are even more noticeable when we have to choose between direct and indirect methods where the indications are often similar. In my report I would like to show a case which demonstrates a combination of direct and indirect restorations to improve the patient’s esthetics.

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Fig.1
Initial situation. The patient came to our clinic with her desire to improve her smile. The main complaints were the diastemata between the central incisors and the narrow, pointy canines.

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Fig.2
Because the closure of diastemata between the central incisors meant to be an additive process without sacrificing tooth structure, we chosen direct method. On the contrary, altering shape of the canines is a reductive one because we wanted to shorten their length. So our choice of treatment was pressed ceramic veneers (e.max, Ivoclar-Vivadent Liechtenstein).

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Fig.3
The first step of treatment after oral hygiene instruction and motivation was the synthesis of information gathered from the consultation with patient and analysis of photos. Instruction was given to the dental technician based on these information to create a wax-up.

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Fig.4
Preparation for veneers was done through the mock-up (Gürel technique).

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Fig.5
Impression was taken with 3 consistencies, 2 step (Dentsply Aquasil, USA; 3M Espe Imprint, USA).

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Fig.6
Tissue adaptation after wearing temporary restoration for two weeks.

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Fig.7
E.max veneers ready for cementation. (Dental technician: András Váradi)

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Fig.8
We planned to make the diastemata closure and veneer cementation at the same appointment. The first thing to do was to isolate the working field meticulously. Clean environment enhances our productivity.

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Fig.9
Choosing enamel and dentin color for our restoration (GC Essentia, Tokyo).

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Fig.10
The space available between the central incisors doesn’t allow using silicone key based on the wax-up. So building the mesial contour of the right central incisor, we used a sectional matrix dividing the diastemata into two equal parts. Choosing the right wedge is critical to hold the matrix firmly in its position. (After placing dentin mass, excess have been gently removed from the palatal side before curing).

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Fig.11
We continued with the layering of the mesial part of the left incisor using transparent matrix which provided more control in the already narrow space. (Allowed to press it from the back with a finger to prevent excess on the palatal side).

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Fig.12
Initial polishing finished under rubberdam with arkansas bur, Soflex discs (3M Espe, USA) and silicone polishing wheels (EVE, Germany).

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Fig.13
Cementation was carried out using Brinker B4 clamp retracting the rubberdam from the preparation margin.

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Fig.14
Situation immediately after cementation.

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Fig.15
Two weeks postoperatively shows adequate tissue maturation.

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Fig.16
Two weeks control.

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Fig.17
Patient was pleased with the achieved result.

Conclusions

Choosing the right treatment option is not easy when the indications are similar. But regardless of our choice, the main goal should be to sacrifice as little tooth tissue as the given technique demands.
I would like to thank Janos Grosz for his help writing this article.

Bibliography

1. Perakis N, Belser UC, Magne P. Final impressions: a review of material properties and description of a current technique. Int J Periodontics Restorative Dent. 2004 Apr;24(2):109-17.
2. Magne P, Belser UC. Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent. 2004;16(1):7-16.
3. Magne P, Hanna J, Magne M. The case for moderate “guided prep” indirect porcelain veneers in the anterior dentition. The pendulum of porcelain veneer preparations: from almost no-prep to over-prep to no-prep. Eur J Esthet Dent. 2013 Autumn;8(3):376-88.
4. Magne P, Magne M. Use of additive waxup and direct intraoral mock-up for enamel preservation with porcelain laminate veneers. Eur J Esthet Dent. 2006 Apr;1(1):10-9.
5. Devoto W, Saracinelli M, Manauta J.Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth.Eur J Esthet Dent. 2010 Spring;5(1):102-24.

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