INTRODUCTION
As patients’ desire for a more attractive smile is growing, so too are the options to achieve it. One of the options that have proven its value and predictability in significantly enhancing a patient’s smile is porcelain veneers. These procedures are particularly successful when performed meticulously and with great attention to the basic occlusal and biological principles relating to each patient.
However, it is important to consider that all restorative dentistry is—for the most part—transitional, and that porcelain veneers almost always require the removal of natural, healthy tooth structure. In contrast, direct composite restorations seldom require any removal of natural, healthy tooth structure. Because patients are expected to live longer than ever before in our history, dentists must become more aware of, and comfortable with, more biologically conservative treatments that allow the preservation, and in some cases even protection, of the natural dentition. This is especially true now that patients seeking aesthetic care are younger than ever.
Advances in dental materials, as well as progress in the ability to predictably adhere these materials to the natural dentition and to reposition teeth with orthodontic aligners, have revolutionized dentistry’s ability to enhance a patient’s smile with minimal discomfort and good long-term success.
The purpose of the following case report is twofold:
- To demonstrate a more conservative option to the traditional porcelain veneer approach to enhancing a patient’s smile.
- To highlight how a new composite, Ecosite Elements from DMG America, can simplify direct resin dentistry and make it a viable option to ceramic restorations.
CASE REPORT
History
A 52-year-old female patient was unhappy with the shape, shade, “thinning” and “chipping” of her maxillary anterior teeth. She presented to her long-term dentist of record and asked him to correct these problems with porcelain veneers. Her dentist informed her that such a procedure would entail the removal a fair amount of her healthy enamel. The fact that her maxillary anterior teeth were minimally restored gave him particular concern. He was also aware of a history of bruxism in this patient during the time she had been under his care, and he wanted to avoid the future excessive wear of her lower anterior teeth that could result from the more abrasive nature of a ceramic restorations. For these reasons, he suggested that the patient consider direct restorative options using a contemporary composite material that had recently been used to restore his own teeth. The patient accepted his recommendation, but since doing large direct composite restorations in the aesthetic zone is not something he enjoys, he referred the patient to our office.
Initial Visit
Following her dentist’s advice, the patient presented to our office for an aesthetic evaluation and consultation. She was interested to learn more about the advantages and disadvantages of direct composite versus ceramic restorations. She was also curious to see “before and after” examples of smile enhancements using composite, including long-term followup images.
After a short discussion to understand the patient’s goals, initial photographs were taken for discussion purposes (Figures 1 to 3). While the images were being uploaded to view on a large screen in the operatory, examples of similar cases and their long-term followups were reviewed with the patient. She was impressed with the possibilities and decided to pursue treatment.
Figure 1.
Figure 2.
Figure 3—Figures 1 to 3. Preoperative photos.
A brief clinical evaluation confirmed that her existing restorations no longer matched their environment and would benefit from replacement (Figures 4 and 5).
Figure 4.
Figure 5—Figures 4 and 5. Restorations no longer match natural dentition and are in need of replacement.
It was further discovered that her lower anterior teeth were slightly misaligned, which had consequently caused uneven wear of the maxillary central incisors that resulted in the “chipping” and “thinning” of the incisal edges that had been her chief complaint. It was also determined that her maxillary anteriors had become vulnerable to further fractures (Figures 6 and 7).
Figure 6.
Figure 7—Figures 6 and 7. Maxillary anteriors indicate vulnerability to further fractures.
It was explained that in order to achieve her aesthetic and functional goals as conservatively as possible, a multidisciplinary phased approach would be necessary. The following treatment plan and sequence were proposed and accepted:
- Pre-restorative orthodontic alignment of the lower anterior teeth
- At-home tooth whitening
- A digital diagnostic wax-up to replicate the future form of the teeth to be restored (Nos. 6 to 11)
- A review of the design and verification of the silicone matrices for the procedure
- Replacement of the previous restorations and adhesive bonding with direct composite resin
- Re-evaluation of the bonded restorations and adjustments as needed
- New photographs and an optical scan to fabricate a maxillary night guard
- Annual evaluation
After her referring dentist was informed of her agreement to the above treatment plan, he referred her to his orthodontist and advised her to return to our practice upon completion.
Post-orthodontic Appointment
A few months after the completion of orthodontic treatment the patient returned ready to proceed with the restorative portion of her treatment New intraoral images were taken (Figure 8). The initial shade (Figure 9) was documented in preparation for the at-home whitening process (Figure 9), followed by an initial optical scan (Figure 10) with an intraoral scanner (Trios [3Shape]) to begin the design process and fabricate the whitening trays. The scan was digitally sent to Yagi Design Inc, a local laboratory that was instructed to idealize the shape and form of the teeth to be restored using an “additive process” (Figure 11). Once the design was approved virtually, the scan was printed in high-resolution and sent to our office for fabrication of silicone matrices (Panesil silicone putty [Kettenbach USA]) for design verification and preparation of a visual mock-up.
Figure 8 Post-ortho image.
Figure 9. Shade prior to bleaching.
Figure 10. Post-ortho digital model.
Figure 11. Digital wax-up using “additive process.”
The patient was instructed to return in two weeks to receive her customized whitening trays that were fabricated in our office from the digitally printed models, and to review the proposed aesthetic design.
Whitening Appointment and Followup
The patient returned for the delivery of the customized maxillary and mandibular trays and was given instructions by the staff about the process. She also was given an opportunity to review the virtual design, which she approved.
Design Verification (Mockup) And Whitening Evaluation
At this appointment, a quick design assessment was performed by applying a provisional crown and bridge material (Luxatemp Ultra [DMG America]) to a prefabricated silicone matrix – in a manner similar to what is typically done in the fabrication of veneer temporaries—to assess the design and fit of the matrices for accuracy. Figures 12 and 13 show how the visual mockup compares to the silicon matrix. It should be noted that this process is ONLY possible if the mock-up is done in an additive way without reducing any part of the existing model. Although fairly crude, this step serves a great purpose in both motivating the patient and reassuring the operator that the silicone matrices will work properly during the bonding procedure.
Figure 12. Visual mock-up.
Figure 13. Silicone matrix confirms accurate fit and desired aesthetics.
After 2 weeks of daily application of the bleaching material (Opalescence 15% [Ultradent]), it was confirmed that the whitening was progressing uneventfully with minimal sensitivity and no gingival irritation. The patient was pleased with her new shade and she was ready to proceed to the next step.
The patient was advised to stop whitening and to return for the bonding procedure two-to-three weeks later. It is important to note that all whitening procedures should stop at least two weeks prior to any adhesive procedure because the free oxygen released by bleaching agents negatively affects bond strengths. Another reason for a two-week interval is that achieving predictable shade matching requires adequate time for rehydration of the teeth that are to be restored.
Material Selection
For this case, the material of choice was a new compact composite system (Ecosite Elements [DMG America). The author had already used this material for multiple anterior and posterior cases and felt confident using it for a large case like this.
The advantages of this composite resin include long-lasting polish and great strength owing to a patented, state-of-the-art technology described as a “non-clustering” filler system.
Other advantages include outstanding handling and adaptation properties, allowing a unique “push-and-flow effect.” In addition, the mechanical and optical properties of Ecosite Elements make it ideal for both anterior and posterior restorations. Last, but not least, this composite has the very unique ability to mimic enamel shades using a simple and logical naming process (Figure 14).
Figure 14. Ecosite Elements enamel shades.
Figure 14a.
The Bonding Appointment
The bonding appointment is the main appointment for the procedure and the one that takes the most time. It is highly recommended that operators plan their schedule accordingly and not allow many interruptions in their workflow for this appointment.
The suggested sequence:
- Shade selection
- Shade rehearsal
- Isolation
- Tooth preparation and bonding protocols
- Material application and layering
- Polishing and texturing
- Occlusal evaluation & adjustments
- One-to-2-week followup and modifications as necessary
- New records and protective appliances when indicated
Shade Selection and Shade Rehearsal
At the bonding appointment, the Ecosite Elements shade guide was used to make the initial selection of the most appropriate enamel and dentin shades. It is important to note that teeth can dehydrate very quickly, which gives the operator very little time for an accurate assessment. For that reason, a photograph of the shade be taken for reference (Figure 15). Once the desired shades, A2 and Enamel Light in this case, were selected, the existing restorations in teeth Nos. 8 and 9 were completely removed and the cavity preparation was completed using plenty of water to avoid dehydration. It is the author’s strong opinion and experience that the ONLY way to predictably match the restoration’s optical properties to the surrounding tooth structure is by carefully layering, polymerizing and polishing the restoration with the appropriate thickness of materials. These steps are done without any isolation or bonding protocols for ease of removal before the actual procedure is performed.
Figure 15. Photograph of shade match.
Figure 16. Seated matrix prior to rehearsal.
Figure 17. Thin application of Enamel Light.
Figure 18. Evaluation of light transmission.
Figure 19. Application of opaque composite.
Figure 20. Final layer of Enamel Light applied layer (dentin replacement).
Figure 21. Shade rehearsal completed for evaluation.
After seating the matrix (Figure 16), the Enamel Light shade was applied in a thin amount approximating the natural tooth’s enamel thickness (Figure 17). The transmission of light and thickness was then evaluated (Figure 18), after which an opaque layer (G-aenial Achord shade AO2 [GC America]) was applied to avoid grayness (Figure 19). (This opaque tint was used due to our office’s familiarity with it, but Ecosite Elements opaque tints are also available from DMG.) A final layer of the Ecosite Enamel Light shade was applied to the full contour (Figure 20), and the unbounded restoration was then polished and evaluated for optical accuracy (Figure 21).
Isolation
Prior to the bonding process, the teeth were isolated from all external factors such as saliva, blood and other contaminants with a rubber dam (heavy non-latex; Hedy). Proper isolation prevents the tongue and lips from accidentally contacting the operating field. It also allows better access by both the dentist and dental assistant and prevents the seepage of crevicular fluids. Lastly, and perhaps most importantly, a properly placed and invaginated rubber dam retracts the gingival tissues in the interproximal areas to allow proper contouring and finishing of the restoration without damaging the tissues (Figures 22 and 23).
Figure 22.
Figure 23—Figures 22 and 23. Rubber dam isolation.
Tooth Preparation and Bonding Protocol
Once the tooth was isolated, care was taken to remove all of the restorative material that was used in the shade rehearsal, and to clean the fresh dentin that was exposed with copious water. Although there are many different effective approaches to bonding teeth today, it is the author’s preference to use is a 3-step bonding system (OptiBond [Kerr]). Once the tooth was sealed and the bonding resin was polymerized, it was time to apply the restorative material.
Material Application
Using a properly trimmed silicone matrix (Figure 24), the Ecosite Enamel Light shade was applied to replace the missing incisal and palatal tooth structure for tooth No. 9 (Figures 25 and 26). The enamel shade was applied in a thickness similar to the rehearsal which was meant to replicate the original enamel thickness prior to any damage. Two contoured convex thin metallic matrices were placed to help contour the proximal marginal ridge walls using the same enamel shade (Figure 27). The marginal ridges were built up to the proper contour and thickness (Figure 28). A reflective opaque layer of composite was placed to replace the missing dentin part the tooth (Figure 29). The facial final layer of Enamel Light was applied and was ready to be polished.
Figure 24. Matrix trimmed for composite applications.
Figure 25. Shade applied to incisal area of No. 9.
Figure 26. Shade applied to palatal area of No. 9.
Figure 27. Proximal matrix placement and composite application.
Figure 28. Marginal ridges built to proper contour and thickness.
Figure 29. Reflective opaque layer placed.
Polishing and Texturing
Upon completion composite application, the outer most layer of the restored tooth No. 9 was polished using an electric handpiece (BienAir USA) that allowed the appropriate speeds and torques to achieve the desired surface characteristics. This final surface characteristics and texture were accomplished using small polishing discs (Sof-Lex [3M]) to polish the convex surfaces of the tooth, and twist-shaped discs (Venus Supra [Kulzer]) to polish the flat and concave surfaces. Once the final shade and characteristic were accomplished, the final shine was accentuated using goat hair brushes (Jiffy [Ultradent]) and .5 micrometer diamond polishing paste at a high speed with light pressure and copious amounts of water. Tooth No. 9 was now completed (Figure 30). The same process was repeated for the remaining teeth that were to be restored (Figures 31 to 35).
Figure 30. Completed restoration of No. 9.
Figure 31.
Figure 32.
Figure 33.
Figure 34.
Figure 35. Figure 31 to 35. Nos. 6, 7, 8, 10 and 11 restored using same procedure as was use for No. 9.
Occlusal Evaluation and Adjustments
Upon completion the rubber dam was removed and the occlusion was adjusted. The patient was given post-op instructions and was requested to return in two weeks for any further adjustments that might be desired or needed.
Care was taken to ensure that the restorative material was functioning in harmony with the patient’s natural envelope of function. Composite material behaves well when it is under compression, but because it can fracture under tension, it is important that during the design phase the patient’s occlusion is studied and inspected for long term success. This can be easily evaluated using occlusal marking paper.
One-to-Two-Week Followup
By the time the procedure is completed, the shade can no longer be evaluated. If done properly, the restorative material is often darker in shade as compared to the natural surrounding tooth structure. The tooth will rehydrate in time, and a better shade match is often observed following complete rehydration. For this reason, it is important to inform the patient of this phenomenon and to bring the patient back for a short evaluation and assessments. If no adjustments are needed or requested during this appointment, it is a great idea to take some followup images and an optical scan (or a traditional impression) to have as a reference or use for any future repairs that might be indicated.
In this case, the patient returned 2 weeks later (Figures 36 to 42), when the shade, the contours, the gingival health and aesthetics were evaluated. The patient was very satisfied and no alterations were requested or suggested.
Figure 36.
Figure 37.
Figure 38.
Figure 39.
Figure 40.
Figure 41.
Figure 42—Figures 36 to 42. Patient at 2-week follow up appointment.
To complete the case, and to protect the restorations, a maxillary hard acrylic Night guard was ordered from Burbank Dental Laboratories (Burbank California) and delivered to the patient a week later. In the pre- and post-treatment scans (Figures 43 and 44), the contour changes and the surface improvements could be observed.
Figure 43. Scan prior to treatment.
Figures 44. Scan following treatment.
CONCLUSION
The biologic cost of composite restorations is very low when compared to any other restorative material. With the past decade’s advancements in optical, physical and material properties as well as in filler technologies, composite restorations have become more durable, predictable, polishable, and pleasurable in performance to the point that they can now rival ceramic restorations.
As treatment options are discussed with patients, the biological, clinical and maintenance costs for the entire life of the patient should be disclosed. For example, patients who are considering veneers or other indirect restorations that involve removing tooth structure should be informed of the many advantages of direct composite restorations. These advantages include:
- More biologically conservative treatment to the teeth being restored
- Less abrasiveness to the opposing dentition
- Fewer appointments
- Lower cost
- Minimal or no laboratory assistance and no provisional restorations
- Easy repairs
- More pleasant patient experience
- More enjoyable practice experience
- Great practice builder
Conversely, even though ceramic restorations typically last longer and age better, they are much more invasive to perform and much more difficult and costly to replace at a later time. They by nature are also more abrasive to the antagonist teeth, and they are typically less repairable than composite.
This case report demonstrated how a multi-disciplinary approach to a patient’s needs, using a newly developed composite material (Ecosite Elements) and a small amount of tooth movement, led to an ultra-conservative treatment that reached and exceeded the patient’s expectations.
The idea that the patient could improve her smile without any further biological sacrifice of healthy enamel or dentin to achieve her goals was much more appealing to her than having to deal with the concern that she may need more repairs or refurbishment as the years pass.
So despite the unquestioned success of bonded ceramic restorations that have enabled our profession to help so many patients regain their confidence by improving their smiles, it is strongly recommended that the reader take a close look at direct resin “artistry” as a viable alternative to its ceramic counterpart.
I personally have truly enjoyed this shift in my practice, as have my patients. Offering this alternative has been a significant practice builder for me, both in creating the original restorations and in occasionally refurbishing and renewing those restorations with minimal discomfort, cost or difficulty.
ABOUT THE AUTHOR
Dr. Sameni is a former adjunct clinical associate professor of dentistry and a 1991 graduate of the Herman Ostrow School of Dentistry at the University of Southern California (USC). He is the former chairman and developer of the USC International Restorative Dentistry Symposium for the Ostrow School. In 2019, he founded the Los Angeles Dental Symposium. Dr. Sameni lectures nationally and internationally on topics related to interdisciplinary dentistry, digital photography and its applications for dentistry, and various aspects of biomimetic and aesthetic dentistry. He can be reached at abdisameni@mac.com.
Disclosure: Dr. Sameni received an honorarium from DMG America for writing this article. He frequently lectures for DMG America, Bien-Air Dental, and Kulzer.
