Often, patients and referring orthodontists have a preconceived idea that a cosmetic solution to a problem, such as congenitally missing lateral incisors, will be a very complex and clinically involved challenge. Furthermore, it is often thought of as being a very expensive ordeal to solve. In many cases, when clinically indicated and if the appropriate materials and techniques are employed, nothing could be further from the truth! The following article will focus on a real-world clinical example that demonstrates how a conservative and predictable direct restorative technique can be used to successfully treat a case involving congenitally missing lateral incisors.
CASE REPORT
Diagnosis and Treatment Planning
Rachel, a 32-year-old mother of 4 and a third-year law student, had been struggling with congenitally missing lateral incisors since the removal of her braces at age 18 years. Her oral health was excellent. She has no other dentistry in her mouth. Her gingival and bone health were both very good.
In reviewing her intraoral photos (Figures 1 and 2) together at her initial consultation, Rachel had many concerns regarding her smile. She felt that her smile looked “run down,” and she complained of food getting stuck under the lateral incisor restorations. Furthermore, she stated that she disliked replacing the lateral incisor restorations every year because they would fall out at the worst times, and the only thing she could count on is that they would look different every time the dentist replaced them. To add to her distress, Rachel had never been happy with the different restorative/aesthetic outcomes. Rachel’s other concern during our initial discovery was that tooth No. 9 looked disproportional to No. 8 due to the poorly executed composite on No. 9. Also, gaps in the lower anterior teeth and the nonharmonious gray, white, and yellow appearance of her teeth were also issues she that she desired to have addressed.
It was determined that Rachel was not a candidate for an implant to replace tooth No. 7 due to space constraints between the central incisor (tooth No. 8) and canine (tooth No. 6) roots. An implant in the area of No. 10 was possible and would be considered in the future; however, Rachel was constrained by time and money at this point in her life.
Given Rachel’s time and financial constraints, and considering her desire to do something more permanent in hopes that her financial situation would change in 3 to 5 years, a conservative mid-range plan was presented to Rachel addressing all of her concerns. An intercoronal fiber-reinforced direct lateral incisor bridge was presented as a dependable solution that, in the author’s experience, could likely last approximately 3 to 5 years, giving Rachel the appearance of a natural-looking and normal-functioning tooth. Teeth whitening and direct composite fillings were also presented to Rachel for consideration in order to address the upper left central (tooth No. 9) and 2 lower incisors (teeth Nos. 24 and 25). Rachel was informed that this work could be accomplished in only 2 appointments, within her budget. One appointment would be used for the one-hour in-office whitening procedure, and the other appointment (estimated to take about 2.5 hours) for the new restorations to be completed. Rachel was surprised that she could get everything done so quickly and within her budget. Mostly, she was excited to begin confidently smiling again.
Clinical Protocol
Prior to the chairside fabrication of Rachel’s new smile, a review of the informed consent, clinical timeline, procedure outline, and any final questions from Rachel were addressed. A preliminary vinyl polysiloxane (VPS) alginate substitute (Algin-X [Dentsply Sirona]) impression was taken of the upper and lower arches along with a bite registration (Blu-Mousse [Parkell]). These would be used to create a wax-up of the new lateral incisors, and also for the fabrication of an incisal/lingual putty (Sil-Tech [Ivoclar Vivadent]) matrix to be used chairside during the restorative process.
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| Figure 1. Pre-op anterior photo showing a discolored and poorly proportioned smile. | Figure 2. Pre-op retracted anterior photo gives appreciation for the poorly shaped laterals and the gaps between the lower anterior incisors. |
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| Figure 3. Creating the pontic space with diode laser (Picasso Lite [AMD LASERS]). Buccal border of pontic space to mimic ideal scalloping of gingiva. | Figure 4. A schematic diagram of the construction of the everStick C&B (GC America) fiber made up of an interpenetrating polymer network of polymethyl methacrylate and bisphenol A-glycidyl methacrylate. |
Two weeks prior to the restorative work to be done, a one-hour, in-office whitening (Zoom [Phillips Oral Healthcare]) procedure was accomplished; in addition, take-home whitening trays were fabricated. The patient was given a 16% carbamide peroxide whitening gel (Pola Night [SDI North America]) so that a baseline whitening shade could be established.
Once satisfied with the whitening results, the restorative procedure was initiated by removing the existing lateral restorations. Pontic areas were created using a soft-tissue diode laser (Picasso Lite [AMD LASERS]) (Figure 3) in order to create a proper gingival contour and to help make the pontic appear as though it were growing out of the gingiva. Intercoronal fiber (everStick C&B [GC America]) (Figure 4) would be used for the reinforcement of the bridge. The everStick C&B fiber differs from others in its construction. Instead of fiberglass fibers, everStick C&B is made up of thin glass fibers surrounded by a proprietary interpenetrating polymer network. This network gives everStick C&B its unique characteristics. The fiber can be used intercoronally or extracoronally, and it is also repairable if debonded or fractured. In addition, when the fiber is reduced or contoured by a bur, no threads or roughness remain, leaving the fiber material completely smooth and strong.
A gingival pontic button was created prior to restoration initiation in order to ensure a smooth interface between the pontic and gingiva. This was accomplished by placing a small mound of flowable composite resin (G-ænial Universal Flo [GC America]) on a Palodent Plus Sectional Matrix (Dentsply Sirona) and light-cured for 20 seconds. Next, this cured mound of flowable composite was removed from the sectional matrix and set aside (Figure 5).
Preparations were then made on the lingual surface of the abutment teeth with a round-ended tapered diamond bur (1847KR-016C [DENTSPLY Midwest]). Occlusion on the abutment teeth should be noted when creating these preparations in order to avoid opposing occlusion interfering with the margin of the prepared teeth (Figure 6). The depth of the preparation should also be deep enough to accommodate the fiber when cured in the preparation, usually 1.5 to 2 mm deep, and should extend into the interproximal area so that the fiber will be invisible from the buccal view when the restoration is complete. Then, after preparation of the adjacent abutment teeth, the fiber should be measured, cut, and prepared for placement.
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| Figure 5. Creation of the gingival pontic button with a flowable composite resin (G-ænial Universal Flo [GC America]) on a Palodent Plus Sectional Matrix (Dentsply Sirona) to ensure a smooth interface between the tissue and pontic. The button was placed on the gingiva during layering of material to create the pontic. | Figure 6. Intercoronal preparation: red lines indicate where lingual receptor sites for fiber were to be created. The opposing occlusion was checked for function and any interferences. |
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| Figure 7. To remove everStick C&B from silicone packaging, the adhesive paper layer on side where fiber is closest to the surface is removed. Grasp fiber with tweezers and pull out. | Figure 8. Fiber in place and bowed to the buccal. |
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| Figure 9. Reduced lingual excess material on abutments after placement of fiber. | Figure 10. Placing flowable composite resin onto the lingual surface of the putty matrix (Sil-Tech [Ivoclar Vivadent]). |
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| Figure 11. This photo shows the matrix almost in place. Once in place, light-cure it from the buccal. | Figure 12. Lingual border immediately after the matrix is removed. |
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| Figure 13. Pontic button placed and held in place with cured composite. The button is placed approximately one mm from each abutment tooth. | Figure 14. Build-up pontic 1: The photo shows the G-ænial Sculpt shade AO1 (GC America) placed to mimic opaque dentin, then translucent shades were built up around the fiber. |
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| Figure 15. Build-up pontic 2: Pontic was layered with G-ænial Sculpt composite in less translucent enamel body shades. | Figure 16. The restoration was then shaped and polished. |
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| Figure 17. The final outcome. |
The everStick C&B fiber is encased in a silicone package. Prior to removing the fiber, cut the package to the length needed by measuring the approximate length of the fiber with dental floss. To remove the fiber from the silicone, simply remove the paper covering on the silicone closest to the fiber, hold the fiber with a cotton forceps, then pull out (Figure 7). When ready to place the fiber, fill the preparations with flowable composite. Position the fiber into the preparations and press and hold with an instrument. Do not worry if the fiber is longer than needed, as the ends can be trimmed with a bur (Figure 8). Once satisfied with the positioning of the fiber, light-cure for 20 seconds. While positioning the fiber, make sure the fiber is bowed in toward the buccal in the pontic area; this positioning gives the clinician the ability to properly contour both buccal and lingual aspects of the restoration. Once the everStick C&B fiber is cured, cut back the lingual portion of the preps to the lingual contour of the adjacent tooth (Figure 9).
Next, the incisal/lingual putty matrix is tried in to ensure a proper seat.
In order to establish the lingual border, place flowable composite into the lingual of the putty matrix and position the matrix, then light-cure it from the buccal for 20 seconds (Figures 10 to 12). Position the pontic button on the gingiva leaving approximately 1.0 mm of space between the 2 adjacent abutment teeth (Figure 13). Remove the putty matrix and begin building the buccal portion of the restoration starting from the pontic button to the everStick C&B fiber so that everything is held in place. Using a compactable universal high-density composite (G-ænial Sculpt [GC America]) with a layering technique, start with an opaque dentin shade AO1 against the lingual border to mimic natural dentin (Figure 14). On top of these opaque layers, you can put staining or different enamel (translucent) shades to mimic the natural color of the surrounding teeth. In Rachel’s case, A2 was used on the outer enamel surface. A translucent shade was placed in the incisal portion concurrently with the placement of the enamel shade in this buildup to enhance the slight incisal translucency of the natural teeth.
After buildup of the desired shades of composite, shaping of the restoration was accomplished with a pointed carbide finishing bur (379-109 [DENTSPLY Midwest]), a pointed egg-shaped carbide finishing bur (389514 [DENTSPLY Midwest]), and a pointed cone-diamond bur (1859012C [DENTSPLY Midwest]) and finishing discs (Enhance [Dentsply Sirona]). Because of the unique size and consistency of the microfillers in G-ænial Sculpt composite, the finish and polishability of this material is very easy, and it will maintain its luster with daily brushing. In addition to this, excellent handling and wearability also makes G-ænial Sculpt a perfect composite choice for this particular application.
Once completed, Rachel could not get over how the teeth appeared to be a natural part of her smile (Figures 15 to 17). She said, “No more short teeth that catch food underneath! No more hiding my smile and trying not to laugh. Best of all, I feel great about my smile, and more confident!”
CLOSING COMMENTS
The clinician should realize that direct anterior tooth replacement is far from a perfect solution. Often, aesthetics can be compromised due to the amount of space and also depending upon the patient’s occlusion. However, if executed properly with the materials and techniques, these restorations are a reliable, affordable, conservative, aesthetic mid-range solution for patients who are in a holding pattern due to orthodontic care, other dental treatment related reasons, or budget limitations.
Dr. Simos received his DDS at Chicago’s Loyola University. He is the founder and president of Allstar Smiles and the Allstar Smiles Learning Center. He teaches postgraduate courses to practicing dentists on cosmetic dentistry, occlusion, and comprehensive restorative dentistry through Allstar Smiles’ state-of-the-art learning center and client facility in Bolingbrook, Ill, and throughout the country. He is nationally recognized as a leader in cosmetic and restorative dentistry, promoting awareness, communication, and education within the dental profession, and is an internationally published author on the use of innovative techniques and materials in dentistry. He can be reached at (866) 614-8455 or via email at sam.s@allstarsmiles.com.
Disclosure: Dr. Simos reports no disclosures.
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