Teeth Recontouring and Shape Perfecting

Tooth shape has a great impact on smile esthetics, especially when working with direct composite. The alignment and relation between adjacent teeth, and symmetrical proportions make the overall appearance of a smile to be attractive and functional.
In this article we will show how we can use direct composite veneers to correct the alignment and also modify the shape of teeth to make a smile beautiful.
The base for tooth recontouring is the apposition of composite material and tooth reduction only when there is a need to change the tooth position or shape.

discolored teeth with old pigmented restorations style italiano styleitaliano

Fig.1
A young patient came to my clinic complaining of the bad esthetics of her smile, which prevented her from smiling with confidence. She wanted to have a beautiful smile while containing expenses, and staying minimally invasive, so we decided to go direct to respect the patient’s needs.

intraoral view of old composite restoration style italiano styleitaliano

Fig.2
Teeth were discolored and had old composite restorations an mild misalignment between laterals and centrals.

slight misalignment of incisors style italiano styleitaliano

Fig.3
Mesial overlapping of laterals towards the centrals is visible. Also, the centrals were slightly tipped palatally.
We decided to recontour the teeth, and to modify the shape of both centrals and laterals to correct the alignment by using direct composite veneers, and to also enhance the color of the teeth.

rubber dam isolation before direct veneering style italiano styleitaliano

Fig.4
Rubber dam isolation is mandatory to control the field. Enhanced vision and clean, contaminant-free environment are the first step to such procedures.

position of teeth with respect to ideal alignment style italiano styleitaliano

Fig.5
The occlusal view shows the position of laterals and centrals in relation to the ideal curve. We decided to go additive on the labial surface of the centrals to correct the misalignment and to follow the curve.

buccal addition space for direct veneering style italiano styleitaliano

Fig.6
Although we could add thickness to both centrals, we would have a problem with the overlapping laterals, so need recontouring and shape modification needed little preparation to easily place the matrices between the centrals and laterals to correct the shape and the position.

area of tooth preparation for good recontouring style italiano styleitaliano

Fig.7
In the picture, you can see how placing the matrix without preparation would crush it, and lead to deformation and resulting in improper contour, unhygienic. So the areas highlighted in red needed to be prepared to open the space to create a new mesial contour for both laterals.

mesial areas to prepare for direct veneering style italiano styleitaliano

Fig.8
The areas to be prepared highlighted in the buccal view.

prepared incisors for direct veneering style italiano styleitaliano

Fig.9
After preparation and removal of old composite restorations.

matrix adaptation after tooth preparation style italiano styleitaliano

Fig.10
After preparation the space is open and ready to fit the matrix for recontouring.

project for direct veneering style italiano styleitaliano

Fig.11
We can see how easy composite veneering becomes after correct management of spaces on the right side.

space design for dental direct veneering style italiano styleitaliano

Fig.12
The same on the left side.

enamel etching under rubber dam isolation style italiano styleitaliano

Fig.13
Enamel etching using phosphoric acid for 30 seconds.

etched enamel before bonding style italiano styleitaliano

Fig.14
Frosty white enamel after sufficient etching.

Eighteeth curing pen with large tip style italiano styleitaliano

Fig.15
Application of a universal adhesive is done by active rubbing on the surface and light curing for 20 seconds using the Curing Pen by Eighteeth.
Composite material selection, composite instruments, matrix system, techniques and finishing and polishing all are important, but don’t forget to complete the circle and to have a good light cure with a multi-wave LED curing light that has the power and intensity to deeply cure composite material.

curing pen light style italiano styleitaliano eighteeth
curing pen light style italiano styleitaliano eighteeth
second generation curing lamp emission curve style italiano styleitaliano

Fig.16
Why use a Third-Generation LED Light. Multi-wave, Multi-peak, and Polywave?
The camphorquinone (CQ) photoinitiator used in the majority of dental resins has a bright yellow color, and this yellow color is problematic when trying to produce very light or translucent shades of restorative resin. As a result, some manufacturers have incorporated co-initiators to boost the effectiveness of CQ so that they could reduce the overall concentration of CQ, while others started using more efficient “alternative” photoinitiators to reduce the concentration of CQ. These “alternative” initiators, such as Lucirin TPO®, impart less of a yellow color than those that contain CQ. However, these alternative photoinitiators are activated by shorter wavelengths of light closer to violet light (at or below 410 nm), and although they can be activated by the broader emission spectrum from QTH curing lights, they are only weakly activated by second-generation LED curing lights that emit little light below 420 nm as shown in the curve. To solve the problem caused by the narrow emission spectrum from the blue-only LED units, additional LED emitters were added to the blue LED array. Each additional LED pad produces a different narrow range of wavelengths, and by incorporating several different LED pads into the curing light, a broad
spectral range can now be delivered. These curing lights have been called “third-generation” LED curing lights, meaning that they emit light of more than one wavelength range, usually violet and blue.
Example of the light output from two different second-generation LED curing lights. Note the peak spectral emission (nm), the limited power output below 420 nm, and the narrow full width at half maximum (FWHM) output as shown in the photo.

emission spectrum of third generation curing led lights style italiano styleitaliano

Fig.17
Emission spectra from three broad-spectrum, LED curing lights 3rd generations. Note the emission spectra are all different among these lights and from the second generation lights in the previous photo.

large tip of eighteeth curing light for composite style italiano styleitaliano

Fig.18
The Eighteeth Curing Pen also has a large diameter which can cover an entire central tooth without the need for multiple exposures.

standard small curing tip style italiano styleitaliano

Fig.19
Whereas a smaller diameter light tip will require multiple exposures to cover an entire central composite veneer.

palatal composite shell on upper incisors style italiano styleitaliano

Fig.20
Building the palatal shell using a silicone index using White Dental Beauty CompoSite System.

style italiano styleitaliano white dental beauty composite system
style italiano styleitaliano white dental beauty composite system
layering of dentin composite style italiano styleitaliano

Fig.21
Layering the dentin layer and mamelons.

side view of internal layering of composite style italiano styleitaliano

Fig.22
Side view after layering the dentin shade.

unica matrices for teeth contouring style italiano styleitaliano

Fig.23
After internal features are complete, we are ready to build the outer frame using the Unica matrix regular for centrals. The matrix is secured using plastic wedges.

style italiano styleitaliano polydentia matrix
style italiano styleitaliano polydentia matrix
unica minideep matrix for small teeth style italiano styleitaliano

Fig.24
For the laterals we will use the new Unica Minideep Anterior Matrix, which was specially designed for smaller teeth with an alloy that is malleable and can adapt to the desired shape.

adaptation of unica minideep to lateral incisor style italiano styleitaliano

Fig.25
Unica Minideep in action. Note the adaptability to the desired shape.

complete composite contour of anterior teeth style italiano styleitaliano

Fig.26
After finishing outer frame and proximal walls we are ready to characterize the incisal edges by using MP flow between mamelons.

raw composite veneers style italiano styleitaliano

Fig.27
After layering the final enamel shade using E shade White Dental Beauty, we are ready for finishing and polishing.

interments and steps of simplified polishing style italiano styleitaliano

Fig.28
For simplified finishing and polishing we use
1. Only one disc to control the shape
2. One bur to create surface texture
3. One spiral wheel for pre-polishing
4. One final universal polishing step

line angle marks for veneer finishing style italiano styleitaliano

Fig.29
Drawing the transitional lines to create symmetrical proportions between teeth. A flexible disc is used to finish the shape.

perio bur by styleitaliano for secondary and tertiary anatomy style italiano styleitaliano

Fig.30
The perio bur from the StyleItaliano finishing kit is used to create secondary and tertiary anatomy.

lucida star felt and paste for composite polishing style italiano styleitaliano

Fig.31
After pre-polishing with a spiral wheel, we are ready for the final polishing using Lucida polishing system from Diashine which provides the immediate shine within seconds.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
polished direct veneers style italiano styleitaliano

Fig.32
The final situation after teeth contouring, perfecting the shape and improving color of the teeth.

before and after direct veneering style italiano styleitaliano

Fig.33
Before and after.

smile after direct composite veneering style italiano styleitaliano

Fig.34
The final smile. The patient is very satisfied with the her new single appointment smile.

Conclusions

By using the proper techniques, materials and instruments, we can make our daily direct work faster, more predictable and repeatable. Moreover, we’ll make our patients happy by respecting their needs and sound tissues, while creating beautiful smiles.

Bibliography

1. Heintze SD, Rousson V, Hickel R. Clinical effectiveness of direct anterior restorations-a meta-analysis. Dent Mater 2015;31(5):481-95.
2. 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
3. Gill S, Naini F, Tredwin C. Smile aesthetics. Dent Update 2007;34:152–8.
4. Price RB, Dérand T, Sedarous M, Andreou P, Loney RW. Effect of distance on the power density from two light guides. J Esthet Dent. 2000;12:320–7.
5. Nitta K. Effect of light guide tip diameter of LED-light curing unit on polymerization of light-cured composites.
Dent Mater. 2005;21:217–23.
6. Rueggeberg FA. State-of-the-art: dental photocuring – a review. Dent Mater. 2011;27:39–52.
7. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc 2001; 132: 39–45.
8. Hosaka K, Tichy A, Motoyama Y, Mizutani K, Lai WJ, Kanno Z, Tagami J, Nakajima M. Post-orthodontic recontouring of anterior teeth using composite injection technique with a digital workflow
9. Heintze SD, Rousson V, Hickel R. Clinical effectiveness of direct anterior restorations-a meta-analysis. Dent Mater 2015;31(5):481-95.

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