Non-invasive smile rehabilitation using direct composite

My professional life has been greatly influenced by StyleItaliano since I was a last year dental student. The beautiful case presentations and up-to-date topics helped me through the years to address more and more challenging cases. Over the years styleItaliano has become the dental wikipedia. Here I give my modest contribution to it.

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Fig.1
Peg-shaped maxillary lateral incisors with diverging axes were found on the clinical examination The central incisors were with irregular incisal edges and small diastema between.The maxillary right canine tooth was rotated mesially and appeared large and bulky.

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Fig.2
Right lateral view. Note the irregular shape of the lateral and canine teeth.

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Fig.3
Left lateral view. A peg-shaped lateral incisor with distal inclination was evident. There was a large gap between the central and lateral incisors.

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Fig.4
Frontal smile view. We can observe how the right upper canine is deficient in length.

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Fig.5
Right lateral smile view.

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Fig.6
Left lateral smile view.

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Fig.7
Silicone impressions from both arches and bite registration in MI were taken. A Digital Smile Design of the case was fabricated and sent to the lab.

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Fig.8
The laboratory made a diagnostic wax up, changing the shape of teeth #13, 12, 11, 21, 22 as proposed in the DSD.

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Fig.9
Composite resin buttons were used for shade determination. Three dentin and three enamel masses were tested.

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Fig.10
Using simple picture editing tools we can better understand color. A black and white picture was used to evaluate the value of the enamel mass. A medium-value enamel mass was chosen for stratification.

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Fig.11
A high-contrast picture was used to chose the dentin mass and better understand natural tooth characterizations. Note the large opalescent area in the incisal edges and white spot characterizations.

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Fig.12
Operatory field isolation. The treated teeth were sandblasted, etched for 30 seconds and a 4th generation adhesive system was applied and cured for 60 seconds.

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Fig.13
A palatal silicone index was fabricated from the wax-up. Medium value enamel shade composite was applied on the silicon index to recreate the palatal wall of the restorations.

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Fig.14
The silicone index was applied in the mouth with gentle pressure and cured.

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Fig.15
The proximal walls of the restorations were recreated using vertically positioned distal garrison matrices. Medium value enamel mass was layered against the matrix to create the proximal curvature of the lateral incisors.

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Fig.16
Dentin masses were layered in the formed shell to restore the inner chroma of the tooth and define the mamelon structure.

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Fig.17
Opalescent masses were added between the mamelons to create natural appearance of the incisal edge and match the adjacent central incisors. Intensive white stains were applied in thin horizontal stripes to mimic the white spots on her natural teeth.

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Fig.18
The stratification was closed with a thin layer of medium value composite. A glycerin gel was applied and the restorations were light-cured for prolonged time.

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Fig.19
Restorations after initial finishing and polishing. Pictures were taken to analyze the shape. Patient was called a week after for final finishing and polishing.

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Fig.20
Final result after rehydration, shape corrections and final finishing and polishing.

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Fig.21
Right lateral view.

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Fig.22
Left lateral view. Note the soft tissue architecture created by the emergence profile of the restoration.

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Fig.23
Satisfactory color integration was obtained.

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Fig.24
A harmonious smile curve was achieved.

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Fig.25
Lateral smile view.

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Fig.26
Lateral smile view.

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Fig.27
The patient is happy with the result and now follows 6-month maintenance routine, including hygiene session and polishing the composite restorations.

Conclusions

Using a minimally invasive adhesive approach, we can improve the smile of the patient with just adding composite material to adhesively treated tooth surfaces without any need of preparation.

Bibliography

1. Manauta J, Salat A. Layers: An Atlas of Composite Resin Stratification. 2012 Quintessence publishing.

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