Fig.1
The patient was very unhappy with her smile. That unhappiness resulted in unwanted tension in the lips with every smile, just to hide her teeth. Creating a beautiful relaxed smile of which the patient would be proud was our goal.

Fig.2
The right lateral view. The patient mentioned as her concerns both the dark general colour, and the localized brown and yellow discolourations of and around the old composite restorations. Note the round bulkiness of the central incisors.

Fig.3
The distal incisal edge of the lateral shows the very beautiful natural colour build-up of her teeth. Being absent in the central composite restorations. One of our objectives to achieve with the final restorations.

Fig.4
What defines an aesthetically pleasant smile? Is it the colour of the teeth? The condition of the gingiva?The lips? Definitely in the top three best answers, is the position of the incisal edge of the incisors together with the width/length ratio of the anterior teeth.

Fig.5
In this case the width to length ratio of the patients central incisors is off. They display a short clinical crown length. Resulting in the patients central incisors being square shaped. A rectangular shape is generally more esthetically pleasing because it just looks natural to the eye. On average W/L ratios of a central incisor tend to vary for many reasons also from wear because of age. If you hold in mind an ideal range roughly from 75-85% your final restoration will be pleasing to the eye and will not set off any alarm bells by the spectator that something is off and looks unnatural.

Fig.6
The length of cuspid, lateral and central incisor does not differ much. Embrasures are very closed. Making the smile look more worn and older. A treatment plan was made to give the patient a bright smile with pleasing W/L tooth ratio and beautiful harmony with the lips. Adding length to the incisal edge only to achieve the ideal W/L ratio would create a disharmony. A combination of surgical crown lengthening and incisal additive composite restorations was chosen in this case to achieve the ideal smile line. Improving oral hygiene and bleaching of the dentition was step one in the treatment.

Fig.7
Surgical crown lengthening was planned to expose the anatomical crown and create an ideal W/L ratio. A flap was raised and osseous resective and re-contouring surgery was performed.The blue line represents the new bone level. The black stripe is drawn where the newly revealed enamel borders the root cement (CEJ).

The bone level will determine the level of the gingiva and therefore the soft tissue design. A biological width of 2,5 mm between the alveolar bone crest and the CEJ which in this case represents the desired gingiva outline level, guarantees in most cases a healthy gingiva.

Fig.8
After surgery the gingiva shows good healing displaying a soft pink colour. To be in the ideal W/L zone extra length as anticipated has to be added to the incisal edge of the teeth.

Fig.9
Close up image shows the newly exposed enamel revealing the actual anatomical crown with the gingival outline on the CEJ. The wax-up and mock-up from the study models will guide us further towards the ideal W/L ratio of the incisors.

Fig.10
An all-over silicone impression was made of the wax-up. The impression was filled with bis-acryl provisional material and placed in the mouth to set. After removal of the silicone, a scalpel is used to trim the mock-up resin at the cervical. This offers a test drive for the initial plan.

Fig.11
The mock-up showed a beautiful, youthful display of anterior teeth with the lips at rest. Goal defined. Dental team and patient highly motivated. Time to shoot the ball!

Fig.12
Tucking the rubber dam in with the help of a thin spatula. Drying the rubber with air will make it stay firmly folded inwards, to ensure proper isolation.

Fig.13
After placing the rubber dam the old composite is removed using fine instruments and magnification to ensure no enamel or dentin is unnecessarily touched.

Fig.14
Etching and bonding is finished. Distributing the width of the two central incisors equally is of utmost
importance. We start by making the palatal ‘Box’ by first building the palatal and approximal walls. Central incisors that have equal width are soothing to the eye. The use of a small digital calliper in the process to check and possibly adjust the composite is recommended.

Fig.15
The palatal walls are made with the help of a silicone index. Remember that using a silicone palatal key might sometimes require you to remove the clamps temporarily. Sectional matrices and wedges are used to guide the construction of the approximal walls. In case of diastema closure, the first approximal wall build-up sometimes needs some support of the sectional matrix with the help of some liquid rubberdam.

Fig.16
Both boxes completed with cervical build-up with a body composite.

Fig.17
Mamelons sculpted in a dentin shade.

Fig.18
A body shade one shade lighter than the cervical was used on the mid third, as you can see on tooth #11. On tooth #21 the final enamel layer is applied.

Fig.19
Correcting the light reflecting angle lines on the surface according to the article: The power of Pencil.

Fig.20
Secondary and tertiary surface anatomy.

Fig.21
Multistep polishing procedure ensures a shiny enamel-like surface of the composite. From thermoplastic wheels to felt with aluminium oxide paste.

Fig.22
Final result after finishing and polishing procedures.

Fig.23
Before and after.

Fig.24
Final result. The glory of the patient’s dentition restored. Bringing back her beautiful smile.

Fig.25
The patient can laugh and smile confidently again.

Fig.26
The natural vibrancy of her teeth is restored. And the new length of the incisors is positioned perfectly in between the upper and lower lip. Patient feels now free to raise her upper lip. And smile. Carefree.

Conclusions

What defines a highly esthetical smile? Is it the colour of the teeth? The condition of the gingiva? The lips? So as we asked and mentioned before, the width/length ratio of the anterior upper teeth is for sure in the top three answers. This case has shown that, if you tick all these boxes, there is a big chance to satisfy all of the requirements for success. Yet, the number one definition of a beautiful smile is and must be confidence. To restore a patient’s confidence while smiling is the ultimate goal. A radiant smile equals a radiant person. How great is that to create!

Bibliography

1) Sterrett JD, Oliver T, Robinson F, Fortson W, Knaak B, Russell CM. Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J Clin Periodontol. 1999 Mar;26(3):153-7.

2) Gönülol N, Yilmaz F. The effects of finishing and polishing techniques on surface roughness and color stability of nanocomposites. J Dent. 2012 Dec;40 Suppl 2:e64-70.

3) Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 10 Surface and polishing Quintessence Books, 2012

4) Schmitt VL, Puppin-Rontani RM, Naufel FS, Nahsan FPS, Coelho Sinhoreti MA and Baseggio W. Effect of the Polishing Procedures on Color Stability and Surface Roughness of Composite Resins. ISRN Dent. 2011; 2011: 617672 published online 2011 Jul 11.

5) Chu SJ. Range and mean distribution frequency of individual tooth width of the maxillary anterior dentition. Pract Proced Aesthet Dent. 2007 May;19(4):209-15.

6) Gargiulo et al. (1961) Dimensions and relations of the dentogingival junction in humans

7) Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent. 2011 Apr;23(2):73-87.