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Case Study
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Anterior Aesthetic Restoration Using a Direct Resin Veneer Technique

A 32-year-old female patient presented for smile enhancement (Figure 1). A clinical examination with necessary radiographs and a professional cleaning indicated that no soft or hard tissue pathology was evident. Although the patient had previously undergone orthodontic treatment in addition to esthetic crown placement, fillings, and routine care, Class I occlusion and Class III tendencies remained evident (Figure 2). Minimal, if any, wear patterns existed in the enamel. Functionally, the patient guided well on right, left, and protrusive excursions. No balancing or working interferences were noted in the posterior region.1,2 No history or complaint of temporomandibular disorder, pain, popping or crepitis upon maximum opening, or lateral, or protrusive excursions were noted (Figure 3).

Facial symmetry was evident, with no midline shift. A mild cant was present on the left side, with low tissue evident in the gingival architecture. Short central and lateral incisors resulted in a reversed smile line and poor esthetic proportions (Figure 4). The buccal corridor appeared satisfactory (Figure 5). The patient did not feel comfortable with the white and brown spots visible on the anterior dentition, and desired greater incisal length, improved phonetics, and enhanced esthetics.

The patient’s periodontal health was excellent. Tooth #13 was restored with a provisional crown and required replacement with a definitive porcelain restoration. Adequate composite restorations were present on teeth #2 through #5, and #9, #12, #15, #18 through #23, and #26 through #31. Teeth #1, #16, #17, and #32 were missing. Minor gingival tissue correction would also be required to improve the cant.3

 

Treatment Plan

After multiple treatment options were discussed with the patient, direct veneers  were selected to restore teeth #5 through #12, to alter the smile line as well as the shade. Tooth #13 was also scheduled for crown replacement. The following steps would be followed in the treatment plan:

  1. Continued periodontal maintenance and good home care was expected, as it was already habit for this patient.
  2. Teeth #5 through 12 would be prepared for veneers or veneer onlays.
  3. A hybrid composite would be placed as a base for the dentin shade and strength in the final result.
  4. Because the dentin structures were more opaque and contain a more saturated chroma, the use of a layered restorative technique with calibrated translucencies was selected to allow development of exceptional esthetics and an accurate shade match.
  5. An enamel-shaded microfill would be placed over the dentin layer to be polished to a natural luster.
  6. Occlusal adjustments would ensure that the new composite veneers would last in the new length and shape.

Restorative Sequence

Discussion regarding tooth length and the removal of the brown spots were of primary importance because these were, essentially, the patient’s primary concerns. Each tooth was prepared and rebuilt individually so that tooth form and position would not be lost (Figure 6). Tooth depth cuts were placed at 0.5 mm in the facial tooth structure.4 The tooth preparation design was maintained in a simple manner, with margins maintained supragingivally, and the incisal third of each tooth prepared more aggressively to allow space for the development of incisal shade and translucency. Care was taken to extend the preparations into the interproximal area far enough to eliminate interproximal shadowing.5  

Following rubber dam isolation, a clear plastic strip was placed between each preparation to maintain optimal interproximal contacts. Using the total-etch technique, the dentition were etched with a 35% phosphoric acid material for 15 seconds and rinsed thoroughly. A micro brush was used to absorb the excess water on the bonding surface. An adhesive material was generously agitated on the preparations for 20 seconds and air dried to evaporate any alcohol carrier in the bonding agent.6 This layer was light cured for 20 seconds per tooth.

Shade B1 Dentin was placed on the cervical aspect and tapered towards the insisal to establish the body color and to provide strength to the addition in incisal length.7 This also helped eliminate a transition in color between the dentin body of the prepared tooth and the desired length. This layer became the functional surface on the lingual aspect. Developmental lobes were subsequently formed in this layer and then stained. Internal characterizations were then added to give warmth and help decrease the natural tendency of teeth to become too gray when increased in brightness. Translucency was instilled along the incisal edge to encourage recognition of the underlining characteristic colors. Beveling back the incisal edge at the proper angle to create a line of light being refracted created the incisal halo effect. Several layers of the final resin layer were removed and replaced in an attempt to create proper tooth contour (Figure 7). Canine guidance was then developed on the lingual aspect.8 The Bennet shift was induced with mild pressure on the balancing side of the mandible to ensure the new canine guidance cleared all balancing and working interferences.9 Protrusive occlusion was verified prior to definitive finishing and polishing.

Interproximal resin was removed with finishing strips and fine-fluted carbide burs under copious water irrigation. Although the facial surfaces were polished using disks with varying grits, care was taken not to remove all surface texture created during placement of the enamel layer of composite resin (Figure 8).10


References
 

      1.    Okeson JP. Management of Temporomandibular Disorders and Occlusion. Fourth Edition. St. Louis, MO: Mosby, 1998.

      2.    Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. Second Edition. St. Louis, MO: Mosby, 1989.

      3.    Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Carol Stream, IL: Quintessence Publishing, 1994.

      4.    Heymann HO. The artistry of conservative esthetic dentistry. J Am Dent Assoc 1987;Spec No:14E-23E.

      5.    Beagle JR. Surgical reconstruction of the interdental papilla: Case report. Int J Periodont Rest Dent 1992;12(2):145-151.

      6.    Heymann HO, Bayne SC. Current concepts in dentin bonding: Focusing on dentinal adhesion factors. J Am Dent Assoc 1993;124(5):26-36.

      7.    Albers HF. Tooth Colored Restoratives. 7th ed. Hamilton, Ontario; BC Decker, Inc, Alto Books Divison,1985.

      8.    Manns A, Chan C, Miralles R. Influence of group function and canine guidance on electromyographic activity of elevator muscles. J Prosthet Dent 1987;57(4):494-500.

      9.    Rufenacht CR. Fundamentals of Esthetics. Carol Stream, IL: Quintessence Publishing, 1990.

      10.  Miller MB, Castellanos IR. Reality. Houston, TX: Reality Publishing, 2001.

 

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