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Case Study
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Comprehensive Restoration of Anterior Crown Length and Proportion

Using a Direct Resin Veneer Technique

Case Presentation

A 26-year-old male patient presented with decay, Type III periodontal disease inclusive of multiple 5 mm and 6 mm pockets, bleeding upon probing, and heavy calculus (Figures 1 and 2). Caries risk assessment was conducted and confirmed the patient was at considerable risk for caries; the patient was prescribed an at-home mouth rinse to reduce his decay risk.

Many of the posterior teeth were non-restorable and required extraction. Multiple teeth also required direct restorations. Once these clinical requisites were completed, it would be necessary to pursue the fabrication of diagnostic models and further posterior rehabilitation with the use of implants and fixed prosthetics. Aesthetically, the maxillary anterior teeth demonstrated interproximal decay, facial decalcification with decay, malpositioning, and poor crown width-to-length ratios.

Treatment Plan

The initial treatment plan consisted of root planing in all four quadrants, followed by thorough hygiene instruction and implementation of the caries prevention program. Non-restorable teeth would require extraction, and a direct resin veneer protocol was scheduled to restore teeth #5 through #13. Reparation of the buccal corridor deficiency, unesthetic tooth rotations, and malpositioned dentition--in addition to treatment of the areas of decalcification and decay--were also required. Endodontic therapy was necessary for tooth #15, followed by a post buildup and its restoration with a full-coverage crown. Gingival crown lengthening was necessary in the anterior segment to improve the existing width-to-length ratios and raise central tissue levels to be harmonious with the existing level of the maxillary right lateral incisor. The second phase of treatment would consist of fabrication of implant CT guides to identify the position of posterior implants, creation of a surgical guide, and implant placement to replace teeth #18 and #19 prior to their prosthetic restoration.

Clinical Procedure

Preliminary impressions were captured and models were fabricated. From these models, an ideal waxup was created based on smile design fundamentals. This was accomplished with an electric waxer and die wax. A silicone matrix was then created to guide the direct bonding technique.

The soft tissue was first recontoured using an Er:YAG laser following the administration of local anesthesia. Tissue levels were modified to be harmonious with tooth #7. All tissue modification was performed for the soft tissue only and never extended below the cementoenamel junction. The laser-treated tissues were allowed to heal for one week.

Smile design was based upon the position of the maxillary left central being ideal, and teeth #6 through #8 were treated at the first restorative visit (Figure 3). One week after laser tissue contouring, the direct veneer protocol was initiated (Figures 4-5-6-7). With putty incisal and facial matrices from the diagnostic waxup, areas that required enameloplasty were identified to eliminate potential show through. Areas with decalcification and decay were removed, and the teeth were air etched to maintain a minimally invasive preparation design.

Once each tooth was prepared, the silicone matrix was used to assist in the composite buildup procedure. The teeth were etched with a 35% acid material for 15 seconds, rinsed for 30 seconds, and air dried. A desensitizing agent was applied for 30 seconds and blotted dry with a microbrush. The bonding agent was then applied, air dried, and cured.

With the putty matrix in place, a bleach medium was used to recreate the lingual aspect and incisal edge of the tooth. An A3.5 dentin shade was then applied wherever dentin structures were missing. A thin ribbon of Incisal Clear was then placed around the dentin lobes and adjacent to the incisal edge to create some translucency in the central and lateral incisors. Next, an enamel shade was placed over the gingival third and feathered into the middle and incisal thirds. The tooth was then brought to full contour with a Medium Value shade. Each layer was contoured with sable brushes dipped in modeling resin and cured for 20 seconds. Following the application of a detoxifying solution, a final cure with was performed on each tooth for 40 seconds prior to finishing and polishing.

At the subsequent visit the maxillary left canine, lateral incisor, and central incisor had direct veneers placed using the aforementioned techniques. Both first premolars had buccal decalcification but were positioned well in the arch so facial resins were placed to conceal the decalcifications. The maxillary right second premolar also had a direct resin veneer placed to overcome its buccal corridor deficiency. The patient returned for additional visits to fine-tune line angles, complete final polishing, and obtain definitive photographs and radiographs (Figure 8). Throughout the procedure, the importance of proper oral hygiene was reinforced.

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