Post-orthodontic treatment with direct composite veneers

This 19 years old lady was sent to my attention by her orthodontist, in order to plan the closure of multiple diastemas. Patient expectations for an aesthetic outcome were really high, and she asked for information about ceramic veneers.
Indirect ceramic partial restorations are probably the best tool in the hands of a restorative dentist to achieve the highest possible aesthetic, but they are expensive, and most of the times they require some (even minimum) tooth preparation. Especially in such a young patient, direct composite veneers should be considered as the first option.

style italiano styleitaliano intraoral picture showing multiple diastemata

Fig.1
In the pre-operative picture we can appreciate the presence of multiple diastemas from canine to canine, and two old restorations covering the peg laterals.

style italiano styleitaliano smile with multiple diastemata in the upper arch

Fig.2
The patient was not satisfied at all about her smile. A digital scan was made, and instructions for a wax-up were given to the lab technician, in order to be able to pre-visualize the final outcome through a mockup.

style italiano styleitaliano mock-up for direct veneering

Fig.3
The mockup showed well proportioned new shapes from canine to canine, and a higher thickness of the buccal surface on premolars, in order to fill the labial corridor.

style italiano styleitaliano isolation and retraction of rubber dam

Fig.4
Rubber dam isolation is always mandatory when performing adhesive procedures. Isolating for complete veneers might seem to be hard, but actually we just need to pay attention to details. B4 clamps were used to enhance the isolation on the central incisors.

style italiano styleitaliano sandblasting enamel surface

Fig.5
The surfaces were sandblasted with 53 µm aluminum oxide (Aquacare Twin, Velopex). Then total etch adhesion was performed with a universal adhesive (Universal Bond, Tokuyama).

style italiano styleitaliano retracting the rubber dam to create emergence profile

Fig.6
One of the B4 clamps was removed, and replaced by a retractor instrument (Gengiva, LM) used as a matrix for the new cemento-enamel junction. A body mass composite was used (Asteria A1B, Tokuyama).

style italiano styleitaliano rubber dam retraction creating the emergence profile during direct veneering

Fig.7
Same procedure on the other central incisor.

style italiano styleitaliano silicone key from wax up to build palatal shells

Fig.8
A silicone key was useful to easily establish the new incisal margin (Estelite Sigma Quick CE, Tokuyama).

style italiano styleitaliano second silicone key for buccal thickness control

Fig.9
The wax-up was removed from every tooth, except for the two central incisors. A new silicone key was made, to have a guide for the distal walls (Asteria A1B, Tokuyama).

style italiano styleitaliano layering proximal walls

Fig.10
The situation after the use of the second silicone key.

style italiano styleitaliano line angles layered in high-value composite

Fig.11
A high value mass (Asteria BL, Tokuyama) was used just to create the new transition lines, in order to give brightness to the restorations, without risking to create a fake looking color.

style italiano styleitaliano incisal characterization of inner masses

Fig.12
Body mass (Asteria A1B, Tokuyama) and supercolors (Estelite Color Blue and White, Tokuyama) were used in the incisal third to contribute to a natural outcome.

style italiano styleitaliano raw direct composite veneers

Fig.13
A final layer of high value enamel (Asteria WE, Tokuyama) was used to cover the buccal surfaces. Usually, with this kind of mimetic composites, it can be risky to use enamel masses, because they can lead to an increase in translucency, and so to a grayish appearance of the restoration. In a case like this, the natural tooth will take care of creating an opaque barrier for the light.

style italiano styleitaliano preparing for veneering of lateral incisors

Fig.14
B4 clamps were moved to lateral incisors, and the old composite was removed.

style italiano styleitaliano rubber dam retraction during cervical build up

Fig.15
After performing adhesion, the new CEJs were created.

style italiano styleitaliano palatal shells in direct composite veneering

Fig.16
The first silicone key was used to create the palatal shells (Asteria A1B, Tokuyama).

style italiano styleitaliano defining line angles with composite

Fig.17
The transition lines were highlighted with a high value mass (Asteria BL, Tokuyama).

style italiano styleitaliano raw direct veneers on incisors

Fig.18
The new shape was completed with a body shade (Asteria A1B, Tokuyama), and a small amount of enamel (Asteria WE, Tokuyama).

style italiano styleitaliano direct veneering of canines

Fig.19
All the other teeth were restored with a mono-shade approach (Asteria A1B, Tokuyama).

style italiano styleitaliano b4 clamps retracting rubber dam on premolars

Fig.20
B4 clamps were used on the premolars as well.

style italiano styleitaliano pencil marked line angles before contouring of restorations

Fig.21
The new shape of the teeth was highlighted using a pencil, in order to facilitate contouring procedures.

style italiano styleitaliano direct composite veneers after rubber dam removal

Fig.22
After contouring, finishing and polishing, gums were bleeding, because it was mandatory to perfectly smoothen the material in contact with soft tissues.

style italiano styleitaliano direct composite veneers and healed gums

Fig.23
After two weeks, gums had perfectly healed. Aesthetic integration was very good, and the patient was more than happy with the outcome.

style italiano styleitaliano smile after direct composite veneering

Fig.24
The new smile line.

style italiano styleitaliano smile with direct composite veneers

Fig.25
Lateral view of the smile.

style italiano styleitaliano smile with direct composite veneers

Fig.26
Comparison before/after.

Conclusions

Direct composite veneers are nowadays a great instrument to achieve highly aesthetic results, with a low financial effort, and without the need for tooth preparation.
Of course rules must be followed and respected: isolation, good adhesion, simple and effective layering, respect of the anatomy, thorough finishing procedures, are just some of the mandatory steps that are needed to obtain a good result.
The great mimicry of new composite resins really helps clinicians to achieve a natural outcome.

Bibliography

  1. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 5. Quintessence Books, 2012.
  2. 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):102-24.4.
  3. Vichi A, Fraioli A, Davidson CL, Ferrari M. Influence of thickness on color in multi- layering technique. Dent Mater 2007;23:1584-1589.
  4. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: A new concept in composite layering – Part II. Odontostomatol Trop 2014; 37(47): 5-13.
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