Fig.1
During the clinical examination we could easily appreciate the misalignment. Tooth 13 was tipped towards the palatal, as well as the two central incisors. Tooth 12 was rotated mesially, and the dental midline is not parallel to the facial one. We immediately proposed completely additive direct restorations to build new shapes and give a nicer color to the smile of the patient. To do so, we need a composite with some opacity to cover the highly chromatic areas, then a translucent one for the incisal third.

Fig.2
In this image we can better appreciate shape and position of each tooth.

Fig.3
From this point of view it’s easy to see that we have enough space to ask for the technician to create an additive wax-up.

Fig.4
Of course rubber dam isolation is mandatory, speaking of adhesive procedures.

Fig.5
A total etching procedure was performed, acting on 3 teeth at a time, to properly control the etching time with 37% phosphoric gel (DMG Etching Gel).

Fig.6
A universal adhesive (DMG LuxaBond Universal) was applied all over the teeth and light-cured.

Fig.7
The silicone key is useful to place the first layers of enamel composite in the right position (DMG Ecosite Elements Layer EL).

Fig.8
It’s time to complete the frame to our picture. Using a matrix, we can build the interproximal walls with an opaque mass (DMG Ecosite Elements Pure B1).

Fig.9
With the same opaque mass, we can create the dentin features, leaving some space in the incisal third for translucent materials.

Fig.10
Making our outcome natural is our main goal, so a highly translucent mass is used in between the tmamelons to enhance their appearance (DMG Ecosite Elements Highlight INC).

Fig.11
And, for the same reason, a white stain is used (DMG Ecosite Elements Highlight W).

Fig.12
The opaque mass (DMG Ecosite Elements Pure B1) the final shape is almost reached, we just leave some space for the final enamel layer (about 0.5 mm, just a little bit more in the incisal area).

Fig.13
The layering of the two central incisors is completed with a light enamel mass (DMG Ecosite Elements Layer EL).

Fig.14
On laterals and canines the layering is even simpler. For the lateral incisors the shaping is done with an opaque mass (DMGEcosite Eelements Pure B1) leaving the space for just a small amount of enamel in the incisal edge (DMG Ecosite Eelements Layer EL). In the canine no enamel is needed, just some B1.

Fig.15
After finishing procedures, the final polishing is done with a polishing paste (Lucida Diashine).

Fig.16
At one month check-up we can appreciate a natural look of the composite restorations. The patient is very happy with her new teeth and she feels much more confident when smiling.

Fig.17
Lateral view of the new smile.

Fig.18
Before.

Fig.19
After.

Conclusions

Composites are nowadays highly aesthetic and easy to use, which makes these materials a great solution for a wide variety of clinical cases.
Thanks to their versatility they can be modified, repaired, re-shaped, and, most of the times, they can be used in an additive way. The layering is simple and fast, as, after all the preliminary steps, the actual time for composite layering was about 1.5 hours. Also the financial aspect is very important, as composites are much less expensive than to porcelain.
We just need to have a good project, and to follow simple, yet strict, protocols, and, in less than 2 hours, we can give our patient a brand new smile.

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.