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.

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.

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.

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.

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).

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).

Fig.7
Same procedure on the other central incisor.

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

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).

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

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

Fig.24
The new smile line.

Fig.25
Lateral view of the smile.

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.