Minimally invasive cosmetic dentistry: smile ...

Anterior Composite Restorations

Minimally invasive cosmetic dentistry: smile reconstruction using direct resin bonding Lucia Trazzi Prieto, DDS, MS n Cintia Tereza Pimenta Araujo, DDS, MS n Dayane Carvalho Ramos Salles de Oliveira, DDS, MS Sergio Lins de Azevedo Vaz, DDS, MS n Maria Beatriz Freitas D’Arce, DDS, MS n Luis Alexandre Maffei Sartini Paulillo, DDS, MS, PhD Discrepancies in tooth size and shape can interfere with smile harmony. Composite resin can be used to improve the esthetics of the smile at a low cost while offering good clinical performance. This article presents an approach for restoring and correcting functional, anatomic, and esthetic discrepancies with minimal intervention, using composites and a direct adhesive technique. This conservative restorative procedure

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ransposed anterior teeth following aplasia, existing or remaining diastemas, abnormalities and discolorations, abrasion, erosion, and dysplasia are common clinical findings in all age groups that can interfere with the esthetics of a smile.1 A smile can be transformed by direct or indirect restorations. Full crowns or porcelain veneers are treatment options that offer esthetic and functional excellence.2 However, these options are considered to be invasive and expensive.3 The bonding capabilities of adhesive systems to both enamel and dentin make it possible to address unesthetic smiles by performing minimally invasive treatment involving adhesives and resin composites.4-7 The popularity of these procedures are due to the materials’ esthetic and functional qualities, allowing dentists to correct or improve esthetic problems with practicability, efficiency, and predictability.1 This article presents an approach for correcting a functional, anatomic, and esthetic discrepancy with minimal intervention using composites and a direct adhesive technique.

provided the patient with maximum personal esthetic satisfaction. Received: March 21, 2013 Accepted: June 13, 2013 Key words: composite restoration, direct adhesive technique, conservative restorative dental aesthetics

smaller compared to the lateral incisors, and the right central incisor showed a clear fracture line in the incisal edge. Comprehensive clinical and radiographic examinations indicated that the patient—himself a dentist—had previously undergone tooth whitening, but he was dissatisfied with that procedure because the canines appeared darker than the lateral and central incisors. Home bleaching was performed, using 10% hydrogen peroxide. The patient was aware that only after a waiting period of 7 days—the recommended waiting time post-bleaching before creating an adequate bond—could a restorative design be initiated.8 The patient was aware of the available treatment options and selected a direct resin bonding procedure due to its esthetic potential and its minimally invasive nature. Models of the patient’s dentition were mounted in a semi-adjustable articulator, where the 4 incisors and canines were

waxed up to ideal length, occlusion, and contour (Fig. 2). The diagnostic wax-up was used as a guide for the direct intraoral trial restoration, which simulates the restorative procedure and allows the practitioner to check color selection, in addition to the patient’s incisal position, length, and occlusion. No adhesive procedures were performed (Fig. 3). Conditioning of the tooth surfaces The procedure was performed under rubber dam isolation to ensure moisture control throughout the buildup of direct resin. After prophylaxis was performed with pumice, water, and a Robinson-type brush (KG Sorensen), the design of the teeth to be reconstructed involved applying 32% phosphoric acid to the interproximal areas and incisal third (Fig. 4). During etching and application of the adhesive system, the adjacent teeth were protected with thread seal tape before the restoration

Case report

A 28-year-old male patient was dissatisfied with his smile, particularly with the small size of his maxillary central incisors, which he thought gave him a youthful appearance that did not match his age (Fig. 1). A preoperative view of the patient’s teeth confirmed that the improper alignment and space distribution, form and size abnormalities, and incisal embrasures were similar to a child’s smile. The examination also revealed that the central incisors were

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Fig. 1. The patient’s smile after dental bleaching.

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Fig. 2. A diagnostic wax-up

Fig. 4. Phosphoric acid is applied to the interproximal areas and incisal third.

Fig. 3. The direct intraoral mock-up.

Fig. 5. The adhesive system is applied.

Fig. 6. The adhesive system is photocured for 20 seconds.

Fig. 7. The first increment is placed with the aid of the silicon index.

Fig. 8. The composite resin is placed in the central incisor.

was placed. After the enamel was etched for 30 seconds, 2 layers of a single bottle adhesive system (Single Bond 2, 3M ESPE) were applied (Fig. 5) and photocured for 20 seconds (Fig. 6).

resin shade was selected to reproduce the palatal portion of the teeth. The first increment was inserted using the silicon index (Fig. 7) and photocured for 20 seconds. Because an average thickness of 0.3 mm was required, it was necessary to monitor the thickness of the first layer. A thinner increment could result in a weak layer and result in fracture during subsequent layer placement, while a thicker layer may be too opaque and prevent proper light transmission.9

Composite stratification A nanohybrid resin composite (Amelogen Plus, Ultradent Products, Inc.) was selected. A silicon index was obtained from the working model after the anterior teeth were waxed-up. A translucent

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The second increment of composite was formed by using a white opaque shade resin (Amelogen Plus, Ultradent Products, Inc.) to mask the dark background and simulate dentin mamelons. A thread seal tape was inserted between each tooth to permit formation of interproximal walls and allow for the correct incisal embrasure. The incisal edge was formed using a whiteenamel shade, and the final increment to simulate enamel was placed using a shade A1 resin composite (Amelogen Plus, Ultradent Products, Inc.) (Fig. 8). Sable brushes were used to smooth the surface of the buildup; the side of the brush was used to create developmental grooves and the material was extended to produce the desired facial embrasures. The final increment of enamel resin was photocured for 40 seconds. To ensure customization of each tooth, the buildups did not touch each other during the layering process. The remaining maxillary incisors and canines were completed in a similar manner.

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Anterior Composite Restorations Minimally invasive cosmetic dentistry: smile reconstruction using direct resin bonding

Fig. 9. Excess material is removed using extra fine diamond burs.

Fig. 10. Initial polishing is performed.

Contouring and polishing The incisal length was evaluated and adjusted with a polishing disk. The facial embrasures and facial crest of the contour were evaluated from an incisal view, and the proximal contact was evaluated and modified as necessary. Finishing was performed with extra fine diamond burs (Fig. 9). Initial polishing was accomplished with a coarse-grit sandpaper disk (Sof-Lex Pop-On, 3M ESPE) (Fig. 10) and the final luster was obtained with a silicon carbide brush (Astrobrush, Ivoclar Vivadent, Inc.) (Fig. 11). The polishing was completed and the occlusion was verified in centric occlusion, followed by protrusive and lateral movements. The patient returned 2 weeks later and again 12 months posttreatment (Fig. 12). No problems were discovered and the patient confirmed his satisfaction with his enhanced smile.

a silicon index) is extremely effective in guiding the reproduction of the ideal proportions, shapes, and anatomy created with a diagnostic wax-up, which saves invaluable chairside time.9

Discussion

Conclusion

Thanks to the durability, load resistance, esthetics, and predictability of composite resins, they can be used to improve smile esthetics at a low cost, offering greater conservation of tooth structure compared to indirect restorative materials with relatively high clinical performance.5,10 The range of composites allows dentists to use different combinations of shade, translucency, and opacity which make it possible to re-create specific details and aspects of the patient’s natural dentition. In addition, color is distributed evenly within the restoration.11 Several direct techniques are available for esthetic enhancement. When several large multilayered restorations are desired, the matrix technique (using

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Fig. 11. A silicon carbide brush is used for the final luster.

Fig. 12. Anterior view of the patient’s smile 12 months post-treatment.

The direct restorative treatment is simple, effective, and minimally invasive, resulting in a shorter period of treatment while offering the possibility of reversibility. Composite restorations with the aid of a silicon index are easy to place and inexpensive while providing patients with satisfaction in their personal appearance.

Author information

Drs. Prieto, de Oliveira, and D’Arce are PhD students, Department of Restorative Dentistry, Piracicaba Dental School, State University of Campinas, Sao Paulo, Brazil, where Dr. Paulillo is a professor, and Dr. Vaz is a PhD student, Department of Radiology. Dr. Araujo is an assistant

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Professor, Department of Dentistry, Faculty of Sciences of Health, Federal University of Jequitinhonha and Mucuri Valley, Diamantina, Brazil.

References

1. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent. 2008;3(1):274-289. 2. Nakamura T, Nakamura T, Ohyama T, Wakabayashi K. Ceramic restorations of anterior teeth without proximal reduction: a case report. Quintessence Int. 2003; 34(10):752-755. 3. Blank JT. Case selection criteria and a simplified technique for placing and finishing direct composite veneers. Compend Contin Educ Dent. 2002;13(9 Suppl 1): 10-17. 4. Pini NP, Aguiar FH, Lima DA, Lovadino JR, Terada RS, Pascotto RC. Advances in dental veneers: materials, applications, and techniques. Clin Cosmet Investig Dent. 2012;4:9-16. 5. Ardu S, Braut V, Gutemberg D, Krejci I, Dietschi D, Feilzer AJ. A long-term laboratory test on staining susceptibility of esthetic composite resin materials. Quintessence Int. 2010;41(8):695-702. 6. Simoes MP, Albino LGB, Reis AF, Rodrigues JA. Restauracoes esteticas conservadoras em dentes anteriores. Rev Dental Press Estet. 2009;6(1):90-101.

Published with permission by the Academy of General Dentistry. © Copyright 2014 by the Academy of General Dentistry. All rights reserved. For printed and electronic reprints of this article for distribution, please contact [email protected].

7. Vellasco K, Campos I, Zouain-Ferreira TD, Basting RT. Dentistica minimamente invasiva: plastica dental. Arq Odontol. 2006;42(2):104-112. 8. Bittencourt ME, Trentin MS, Linden MS, et al. Influence of in situ postbleaching times on shear bond strength of resin-based composite restorations. J Am Dent Assoc. 2010;141(3):300-306. 9. Vargas M. Conservative esthetic enhancement of the anterior dentition using a predictable direct resin protocol. Pract Proced Aesthet Dent. 2006;18(8):501507. 10. Pontons-Melo JC, Furuse AY, Mondelli J. A direct composite resin stratification technique for restoration of the smile. Quintessence Int. 2011;42(3):205-211. 11. Feitosa DM, Fialho FP, Alves CM. Direct restoration of a fractured anterior tooth using dentin posts: a case report. Int J Brazil Dent. 2010;(6):176-182.

Manufacturers

Ivoclar Vivadent, Inc., Amherst, NY 800.533.6825, www.ivoclarvivadent.us KG Sorensen, Cotia, Brazil 55.11.4777.1061, www.kgsorensen.com.br Ultradent Products, Inc., South Jordan, UT 888.230.1420, www.ultradent.com 3M ESPE, St. Paul, MN 888.364.3577, solutions.3m.com

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