In today’s society, esthetic enhancements are generally accepted as integral to creating a healthy self-esteem. Whether the individual chooses cosmetic surgery, laser eye correction, or cosmetic dentistry, the choices are all driven by the ultimate goal of obtaining a more pleasing appearance and, in turn, raising confidence and self-esteem. In an article “The Best Beauty Decision I Ever Made” in the January 2001 issue of The Oprah Magazine readers were asked, “What’s made the biggest difference to your sense of well being?” the first area mentioned was cosmetic dentistry.
Advances in materials science over the past two decades have made composite resin bonding a very predictable treatment for our patients from an esthetic as well as a longevity point of view. Because the entire case is under the complete control of the individual dentist, the smile design, individual tooth contours, surface morphology, hue, value, chroma, and translucency as well as the bonding technique are all reflective of the sum of the creator’s artistic and technical skills. This article will present a case restored with a systematic approach to bonding.
The patient was a 23-year-old female who was unhappy with her smile and especially some unaesthetic bonding on teeth #s 13 & 12. The treatment plan called for two phases, with phase one being orthodontics to create better tooth alignment allowing the final veneer preparations to be more conservative. The second phase of the case involved a minor gingivectomy on the 22 & 12 to create a more balanced gingival architecture, followed by tooth whitening and six direct composite veneers to create a more aesthetic smile and establish proper anterior guidance (Figs. 1-17).
The patient was asked to pick out samples of smiles she liked in magazines (Fig. 1).
These magazine photos helped guide the smile design to the patient’s desired aesthetic outcome. With the aid of the magazine photos and mounted study models the pre treatment mock-up was completed in composite resin (Fig. 2). This mock up was then used to create a putty matrix and a biostar stent (Fig. 3).
Prior to tooth preparation, local anesthesia was delivered painlessly using the Wand with the first infiltration being Citanest Plain to anesthetize the tissue, followed by Ultracaine Forte to provide profound pulpal anesthesia. The preparations were guided by a stent created on the Biostar unit (Fig. 4).
This stent was perforated with a small round diamond in 3 locations on the facial-gingival, body and incisal as well as on the incisal edge. With the use of a periodontal probe you can measure your reductions through the perforations and assess your preps compared to the proposed final restoration contours.
The author uses these preparation stents on all esthetic cases as a guideline to assess preparation depths to achieve adequate, even reduction for the creation of the final restoration. These preparation stents are also very useful for veneer and crown preparations with indirect restorations. The old composite resin was removed and a small amount of decay was discovered beneath the resin on #12, which was disclosed with caries detector and completely removed.
The mesio-incisal area of the cuspids were prepared approximately half-way down the mesio-palatal aspect of these teeth so the cuspid rise can be properly developed in these areas–this location for the cuspid rise was worked out on the study models with the composite mock-up prior to treatment.
With the preparations complete, the teeth were cleaned with a pumice/ chlorhexidine mixture and the gingiva packed with #000 Ultrapack cords that were pre-soaked in water.
Prior to bonding the adhesive resin, a dry field is required. This is accomplished with an expandex lip and cheek retractor, microcopy dry tips and cotton rolls. The first tooth to be bonded was the left central incisor, which was isolated for adhesive application with dead soft metal strips. After etching with Ultraetch, the tooth was rinsed and dried without desiccating and the Optibond Fl system was used for adhesion.
After curing the Optibond Fl adhesive, the metal strips were removed and the first layer of resin was prepared. A putty matrix created on the composite mock-up model guides the buildup creating the desired incisal edge position of the composite veneers (Fig. 5).
The first layer of resin was A1 Renamel hybrid, which was placed using an 8A Cosmedent Composite instrument and contoured with a gold Almore composite instrument, then finessed with a flat-ended sable brush. This dentin replacement layer was used to create dentin lobes in the incisal one-third. The putty matrix was used to guide the placement of this hybrid composite layer.
The patient’s desired translucency was then developed using Herculite XRV light incisal hybrid composite as an enamel replacement to create the incisal edge. The Herculite XRV Incisal is very translucent and, when polished gives the incisal edge a pleasing halo effect, which mimics enamel very well. The degree of translucent effect created by the Herculite XRV Incisal varies depending on the thickness of the material that you use (Fig. 18). This incisal layer was overbuilt beyond the putty matrix, which was removed to allow for room to finish the restoration.
To create more character in the restoration, Cosmedent’s Creative Color Violet tint was placed in the incisal one-third between the dentin lobes. This tint was placed in very small quantities to avoid overwhelming the natural translucency already created by the application of the XRV Light Incisal resin.
The body veneering material, A1 Renamel microfill was then rolled into a ball on the surface of the resin keeper and placed onto the body one-third region of the tooth using an IPC instrument and sculpted into place on the body one-third and towards the incisal one-third using the IPC, gold Almore instrument and the flat-ended sable brushes.
The incisal one-third was then completed by using a mixture of one-thirds incisal light Renamel Microfill and two-thirds A1 Renamel Microfill resins mixed together in the resin keeper palette. This mixture was then rolled into a ball- shaped convenience form, placed on the incisal one-third, and sculpted into place using the same instrument as the body microfill. The gingival one-third was created using a convenience form of A2 Renamel Microfill, which was placed and sculpted in a similar technique as the body and incisal increments.
The resulting build-up created a polychromatic, layered restoration with the desired internal characterization. The build-up was covered in glycerine and given a final cure of 60 seconds with a Demetron light and accompanying Turbo tip. This build-up technique was used for the 5 remaining veneers with the putty matrix as a guide to help develop the dentin incisal layers. The other central incisor was built-up using the same resin shades in the same protocol.
The laterals were then built-up together using the same protocol as the centrals except the incisal one-third layer used an A1/dark labial microfill resin blend to create slightly less value than the central incisors. The cupids were also built-up together using the same protocol as the incisors, except A2 shade was used for the body dentin and microfill shades and A3 was used in the gingival third to create more chroma in these teeth as compared to the incisors.
As the build-up of each veneer was completed, it was shaped, contoured, and polished prior to the build-up of the adjacent veneers to prevent the restorations from bonding together. The first step in finishing is the gross contouring to primary anatomical form using a 7901 carbide bur and a coarse soflex ET disc.
The incisal putty matrix and composite study model mock up were used as a guideline to create the overall desired shape. The 7901 carbide was used to create convexities and concavities on the surface of the restorations to provide a natural morphology.
Once the desired primary anatomical form was achieved, the veneers were further polished with the next ET disc and the secondary anatomy was created using a coarse flame-shaped diamond to create horizontal surface texture similar to the natural dentition.
The interproximals were polished with flexistrips and the entire veneer was further polished using blue and pink flexipoints and flexicups followed by the last two fine polishers of the ET system. The entire veneer was then polished using Enamelize and a flexibuff to create a surface polish similar to the remaining natural dentition.
The occlusion was then given a final evaluation using Accufilm II articulating paper and found to have the desired cuspid rise on lateral excursions with protrusive guidance on the central incisors. The retraction cords were then removed and the patient dismissed to be re-evaluated in 2 weeks.
The case presented in this article describes an overall system to create natural, aesthetic and long lasting restorations with direct composite resin. The overall pre-treatment system of the diagnostic mockup created on mounted study models with the diagnostic stents and putty matrix can be modified to indirect cases as well.
The author will often make a second Biostar stent for a crown or veneer case and use this to create precise provisional restorations. The three cases presented in this article illustrate how beautiful final results can be achieved using systems with accompanying materials and by varying the handling and layering of these materials.
Dr. Stephen Phelan is an accredited member of the American Academy of Cosmetic Dentistry. He has maintained a private practice in Oakville, ON since 1992. His practice emphasis is comprehensive aesthetic and restorative dentistry.
Oral Health welcomes this original article.
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