Fig.1
This young lady come to the office complaining about her smile. She doesn’t want super white, perfectly regular, fake-looking teeth, she just wants to have a more harmonic smile.
She underwent too many years of orthodontic treatments in her childhood and teenage years, yet, she finished the therapy with a cross-bite on the first quadrant. Now she refused to come back to ortho, and she asked for a compromise. In our daily practice we often (not to say always) have to face with compromises. The secret is to understand which kind of compromise can be taken without exposing ourselves, or the patient, to unacceptable risks.

Fig.2
From this point of view we can better appreciate the rotation of the two central incisors, with the mesial edges rotated palatally. Using direct composite restorations we can easily give the illusion of reversing the rotation without removing tooth structure.

Fig.3
A close-up look of the central incisors.

Fig.4
A wider view of the upper arch. We decide to work free-hand from 13 to 23, perfectly knowing from the very beginning that on tooth 13 there is no buccal space because of the cross-bite (compromise!). For this reason, it was clear to the patient from the very beginning that no modification could be done on middle and incisal third of tooth 13, in order to avoid interferences.

Fig.5
Of course a proper rubber dam isolation is mandatory for every adhesive procedure.

Fig.6
After performing a total-etch adhesion with a universal adhesive (DMG LuxaBond Universal), a very useful instrument (LM Gengiva) is used to build all the new cementum-enamel junctions with a medium opacity composite (DMG Ecosite Elements PURE B1)

Fig.7
All the new CEJs are in place. At this stage, small excesses are overlooked. Note that the cervical area is not layered with multiple masses, but only one mass was used, so it will be possible to correct the final shape with a bur, without concerning about messing with the layering.

Fig.8
With the help of transparent matrices to keep all the teeth separated, we started building the new interproximal walls, using the same medium opacity mass (DMG Ecosite Elements PURE B1). It’s important to check every step, because the new walls will give the final dimension of the restorations.

Fig.9
A caliper can be of great help to check the width of each tooth, especially in a free-hand case like this one, without the help of a wax-up.

Fig.10
The patient asked for a very natural-looking result. We agreed not to make all incisal edges even, and to make some characterization of the margins, so some stains are used to aim for a natural appearance of the incisal third (DMG Ecosite Elements HIGHLIGHT INC and W).

Fig.11
A wide spatula (LM Arte Solo Anterior) is used to place the final enamel layer (DMG Ecosite Elements Layer EL) over the middle and incisal third.

Fig.12
The layering of the central incisors is complete, now we can move to laterals and canines using a simplified single-shade technique.

Fig.13
Just one mass is used to correct the shape of laterals and canines (DMG Ecosite Elements Pure B1). Doing so we have many advantages: we can speed-up the procedure, we can easily correct the final shape subtractively without concerning about different layers, and, in case of mistakes in color choice, it will be easy to correct the restoration.

Fig.14
Restorations are carefully finished and polished using coarse and fine grit diamond burs, silicone tips, and polishing stripes. No polishing paste is used in the first appointment, as we might need some corrections during the check-up appointment, so the final polishing is postponed.

Fig.15
Two-week check-up. The patient is very satisfied with the new appearance of her smile. Minor corrections are needed and the final polishing procedure is performed. The mimicry of the composites is very natural looking. Gums still need time to perfectly adapt to new dental shape.

Fig.16
Closer look from lateral points of view.

Fig.17
The new relationship with the lower lip.

Fig.18
Two-month check-up. Gums look healthier, and completely filled interdental spaces.

Fig.19
Smile comparison before, and after.

Fig.20
The patient’s satisfied smile.

Conclusions

As mentioned earlier, in our practice we must deal with compromises daily. Not having the chance to use orthodontics has been for sure an obstacle, but, with the help of adhesive dentistry and new generation composites, we were able to achieve a good result. The patient is deeply satisfied, and she’s very happy about the non-aggressive and quite cheap solution we found. Hopefully she will find, with this aesthetic improvement, a new stimulus to accept a new orthodontic treatment and finally fix the cross-bite.

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;23:15841589
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