With the advent of technologically advanced dental adhesive materials and the mainstream media’s coverage of their long-term cosmetic potential, it is not uncommon for clinicians to increasingly encounter patients who desire smile enhancement in the most minimally invasive manner possible. In order to provide such sought-after elective treatment, it is incumbent upon astute practitioners to thoroughly examine both the hard and soft tissues that, combined, impact the aesthetics of a patient’s smile.1
Once the clinical and aesthetic parameters have been identified, the clinician can then determine the techniques, materials, and tools that should be incorporated into the treatment plan in order to effect the anticipated results in the most conservative manner possible.2 Such a systematic, evaluative review will allow the case to be completed to the satisfaction of the patient’s aesthetic needs, as well as minimize the amount of otherwise healthy hard tooth structure that would be sacrificed during the aesthetic enhancement process.3
This article presents a case report to demonstrate the manner in which an analysis of the patient’s gingival architecture was combined with a critique of the aesthetics of her anterior maxillary dentition (ie, including optical properties and characterizations, tooth position, width-to-length ratio) in order to formulate a convenient, conservative, and reversible smile enhancement plan using a small-particle hybrid composite. The considerations for evaluating each component of her smile enhancement are explained, and the clinical protocol associated with the ultimate diastema closure and class IV treatment is briefly described.
CASE PRESENTATION
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| Figure 1. Preoperative view of the patient’s natural smile. Note gingival disharmony and diastema between teeth Nos. 8 and 9, as well as the discrepancy between their incisal edge lengths. |
A 29-year-old female presented with concerns about the diastema and uneven gingival heights between her maxillary central incisors, the shortness of the incisal edge of tooth No. 9 compared to tooth No. 8, and the lingual inclination of tooth No. 8 compared to tooth No. 9 (Figure 1). She was not interested in bleaching, and stated that she liked the characterized white speckles in her front teeth and did not want them removed. She was not interested in orthodontics and, although potentially interested in porcelain veneer technology for the future, sought composite restorations at this time based on their conservative and reversible nature.
Examination, Diagnostic Wax-Up, and Treatment Planning
A complete examination was performed. This included radiographs, photographs, and a review of the patient’s periodontal condition. No pathologies were found that would impede aesthetic enhancement. Additionally, no contributory occlusal factors were noted that would require functional rehabilitation.
An impression was taken for the purpose of developing a diagnostic model and, ultimately, an aesthetically enhanced wax-up4 for patient review. During a co-diagnostic consultation, the patient accepted the proposed smile enhancement based on the enhanced wax-up and the proposed treatment plan. This would include the following:
- Gingival recontouring at the No. 8 site, followed by 6 weeks of healing, to lengthen the clinical crown and create a more symmetrical gingival architecture.
- Composite placement on the incisal edges of teeth Nos. 8 and 9 to create a more aesthetically acceptable incisal edge position in relation to her lip line.
- Closure of the diastema between teeth Nos. 8 and 9 with composite placement.
Addressing the Gingival Disharmony
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| Figure 2. Gingival recontouring was performed at the No. 8 site to lengthen the clinical crown and recreate a more aesthetic architecture. Image at 6 weeks postoperative. |
Gingival aesthetics has been regarded as among the factors significant to the overall aesthetics of a patient’s smile.2 In particular, its role in the aesthetic appearance of a smile involves its relationship in the ratio of teeth to the gingiva, in addition to its relationship to general facial characteristics.2,5 In this patient, the obvious lack of symmetry between the gingival heights of contour of teeth Nos. 8 and 9 was corrected through gingival recontouring and subtle crown lengthening, after which the patient was allowed to heal for 6 weeks prior to further restorative treatment (Figure 2). Careful consideration was given to the biologic requirements of exposing sound tooth structure as well as to the aesthetic expectations and restorative parameters to be achieved.6
Coloration and Aesthetics
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| Figure 3. View of the X-Rite ShadeVision spectrophotometer analysis of tooth No. 9. |
The patient’s maxillary central incisors inherently displayed areas of hypocalcification and variation in their hue, chroma, and value that would be challenging to replicate if not diligently analyzed.7 Therefore, the primary characteristics of these teeth were recorded using a Visual Thinking Strategy (VTS, Dr. Frank Milnar, St. Paul, Minn). Through this analysis, the preoperative condition of the dentin and enamel, as well as tooth shape, color, characterizations, and texture, were noted.
Additionally, the nuances of color-including hue, chroma, and value-were determined for teeth Nos. 8 and 9 using spectrophotometry (ShadeVision [X-Rite], Figure 3). To ensure the aesthetic success of the proposed direct composite placement treatment, an understanding of the optical characteristics of the patient’s natural teethÛand subsequently the optical properties of the selected restorative materialÛwas imperative.8
To best achieve the polychromatic effects observed in this patient’s dentition, but still ensure adequate strength and durability of the newly lengthened incisal edges, a small-particle hybrid was selected (Vit-l-escence [Ultradent Products]). The literature suggests that this category of materials demonstrates improved mechanical and physical properties (eg, strength, wear, and handling) as well as more natural optical properties compared to the respective classifications of composites that have been previously available.9,10 This Bis-GMA-based fluorescent and opalescent composite system chosen for this case incorporates fillers with a particle size of 0.07 µm, according to the manufacturer. Further, because this case would require the replication of both dentin and enamel layers (ie, diastema closure), this system would provide the requisite low-translucency fluorescent dentin composites and high-translucency, opalescent/transparent enamel composites that, when combined, would produce a lifelike restoration.
Diastema Closure and Incisal Edge Symmetry
Median diastemas may result from developmental, pathological, or iatrogenic factors.11 Determining the best manner for closing an unwanted diastema must be predicated upon a diagnostic evaluation of the diastema’s size, the length and proportion of the clinical crowns of the teeth involved, wear factors, occlusion, and anterior guidance.12,13 When orthodontics is not warranted, the patient declines indirect restorations, and/or no occlusal/functional rehabilitations require extensive reconstruction with indirect restorations, then today’s direct composites facilitate a conservative and practical approach to closing interdental spacing.14,15 Direct composite techniques have been noted as economical and successful for this purpose.15
Also relevant to this case, it has been advocated that the incisal edge position of a patient’s teeth be evaluated for the width-to-height proportion in order to best analyze aesthetics.16 Furthermore, evaluation of the patient’s smile line will enable the clinician to determine if the patient’s maxillary teeth are properly positioned in relation to the lower lip or if alteration or enhancement is necessary.16 Proximoincisal defects (class IV) have been successfully treated with direct resin-based composites.17 However, such treatment and/or aesthetic enhancement with direct composites requires the development of proper and functional lingual contour as well as an understanding of natural tooth anatomy, tooth color, and the role tooth structure plays in both.17
For this case, an aesthetically enhanced wax-up, which the patient accepted and approved, was used as the basis for a high-viscosity putty stent that would serve as a spatial reference for tooth reduction and composite placement.l8 This tool would be particularly useful in establishing the appropriate incisal edge positions of teeth Nos. 8 and 9, as well as the size and shape of the interproximal addition to tooth No. 8 to close the diastema.
Composite Placement Protocol
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| Figure 4. The putty stent created from the aesthetically enhanced diagnostic wax-up was tried into the patient’s mouth preoperatively. | Figure 5. Completed preparations on teeth Nos. 8 and 9, which included a 0.5-mm modified shoulder preparation and 0.5 mm to 1.0 mm of incisal edge reduction. |
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Figure 6. The teeth were acid-etched with 37% phosphoric acid for 20 seconds each. |
Figure 7. A single-component bonding agent was applied to the preparations for 15 seconds each. |
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| Figure 8. The incisal edge of tooth No. 9 was lengthened with the placement of Pearl Frost enamel composite. | Figure 9. The final enamel layer of the new incisal edge of tooth No. 9 was created with the application of a Translucent Ice composite. |
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Figure 10. The completed composite placement on tooth No. 9. |
Figure 11. The Pearl Frost enamel composite was used again to lengthen the incisal edge of tooth No. 8. |
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| Figure 12. The Opaque Snow composite was placed in the middle to incisal area of tooth No. 8 in order to replicate the diffuse white clouds seen in tooth No. 9. | Figure 13. A flowable, light-cured Bis-GMA-based composite resin was placed prior to the final enamel layers in order to prevent metamerism. |
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| Figure 14. The final enamel layer in Translucent Ice was placed over the entirety of the restoration on tooth No. 8. |
Figure 15. A green stone was used to create the surface anatomy of both restorations. |
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| Figure 16. A series of high-shine polishing cups, brushes, and rubber points and discs were used for final polishing. | Figure 17. The symmetry between restorations on tooth Nos. 8 and 9 was verified using a caliper. |
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| Figure 18. The dimensional accuracy of the completed restorations was verified with the putty stent. |
Prior to initiating tooth preparation, the patient was anesthetized, adequate control of intraoral fluids was ensured, and the putty stent was tried into the patient’s mouth and removed (Figure 4). The labial aspects of teeth Nos. 8 and 9 were prepared with a 0.5-mm modified shoulder preparation and 0.5 mm to 1.0 mm of incisal edge reduction (Figure 5).
The preparations were then etched with 37% phosphoric acid (Ultra-Etch, Ultradent Products) for 20 seconds (Figure 6), rinsed for 15 seconds with an air/water spray, and lightly air-dried. A single-component adhesive bonding agent (PQ1, Ultradent Products) was applied to the preparations for 15 seconds (Figure 7), lightly air-dried for 5 seconds, and then cured with an LED curing light for 20 seconds per tooth (Ultra-Lume LED 5 [Ultradent Products]).
The incisal edge of tooth No. 9 was lengthened first with the placement of Pearl Frost enamel composite (Ultradent Products; Figure 8), which was carefully shaped, verified against the putty stent, and cured for 10 seconds. Prior to placement of the final enamel layer, a flowable, Bis-GMA-based composite resin (DE Connector, Ultradent Products) was applied with a flock-tip brush and cured for 20 seconds to prevent metamerism. Then, the final enamel layer for the lengthened incisal edge was placed using a Translucent Ice composite (Ultradent Products; Figure 9). This composite build-up was then light-cured for 60 seconds from multiple directions (Figure 10).
Next, aesthetic enhancement proceeded by lengthening the incisal edge of tooth No. 8 using the same Pearl Frost enamel composite (Figure 11). Next, a 0.0015 dead-soft matrix band (Omni Band [Ultradent Products]) was placed. The artificial dentin layer in Shade A1 was applied to the interproximal aspect of tooth No. 8 to close the midline diastema. This composite increment was light-cured for 10 seconds. To simulate translucency, a Trans Mist enamel composite (Ultradent Products) was applied to the mesial aspect of tooth No. 8 and light-cured for 10 seconds. Then, to replicate the diffuse “white clouds” inherent in the patient’s natural dentition and to match tooth No. 9, a layer of Opaque Snow composite (Ultradent Products) was placed in the middle-to-incisal area (Figure 12), defined, and moved into proper position. This opacious layer was sliced and differentiated using an Almore Gold Microfill Spatula (Almore International) and light-cured for 10 seconds.
The matrix band was then removed, and as with tooth No. 9, the flowable resin was applied to prevent metamerism (Figure 13) and cured prior to placement of the final enamel layer. The Translucent Ice enamel composite was then applied to tooth No. 8 and light-cured from multiple directions for 60 seconds (Figure 14).
Finishing of the restoration on tooth No. 8 was initiated using an ultrafine finishing and contouring disc (Sof-Lex [3M ESPE]). Surface anatomy and texture were created using a green stone (Brasseler USA, Figure 15). Finishing and polishing of both restorations were then completed with a series of medium grade discs, a goat-hair brush with 0.5-µm diamond polishing paste, and high-shine points, cups, and wheels (Jiffy [Ultradent Products], Figure 16).
The dimensional symmetry of the final restoration on tooth No. 8 compared to tooth No. 9 was measured using a caliper (Figure 17). The overall shape and contours of both restorations were verified using the putty stent (Figure 18).
CONCLUSION
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| Figure 19. Postoperative, natural smile view of the patient’s complete aesthetic enhancement of her maxillary central incisors. | Figure 20. Retracted close-up postoperative view of teeth Nos. 8 and 9. Note the symmetrical gingival architecture and width-to-length ratio between both teeth. |
Paramount to achieving successful aesthetic smile enhancements is listening to patients and understanding their philosophical parameters in relation to how those may limit the treatment alternatives they are willing to accept.19 From there, the clinician can carefully study and analyze the case in order to develop a treatment plan that will ultimately satisfy all of the patient’s expectations.19 As demonstrated in the case presented here, conscientious evaluation of the patient’s gingival architecture and anterior maxillary dentition-including an analysis of tooth size, shape, color, characterizations, and texture-contributed to achieving the aesthetic results the patient anticipated (Figures 19 and 20). Because this systematic review was combined with the selection of appropriate techniques and small-particle hybrid composite, delivery of the minimally invasive, conservative treatment option the patient desired was realized.20
References
1. Rifkin R. Facial analysis: a comprehensive approach to treatment planning in aesthetic dentistry. Pract Periodontics Aesthet Dent. 2000;12:865-871.
2. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.
3. Staehle HJ. Minimally invasive restorative treatment. J Adhes Dent. 1999;1:267-284.
4. Garcia LT, Bohnenkamp DM. The use of diagnostic wax-ups in treatment planning. Compend Contin Educ Dent. 2003;24:210-214.
5. Braswell LD. Soft tissue contouring as periodontal plastic surgery. Curr Opin Cosmet Dent. 1997;4:22-28.
6. Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004;16:769-778.
7. Fahl N Jr. Achieving ultimate anterior esthetics with a new microhybrid composite. Compend Contin Educ Dent Suppl. 2000;(26):4-13.
8. Terry DA, Leinfelder KF. An integration of composite resin with natural tooth structure: the Class IV restoration. Pract Proced Aesthet Dent. 2004;16:235-242.
9. Mopper KW. Maximizing the potential of composite artistry: three decades of direct resin bonding. Picture Perfect Aesthetics: The AACD Monograph. Vol II. Mahwah, NJ: Montage Media Corp; 2005:95-99.
10. Terry DA. Natural Esthetics With Composite Resin. Mahwah, NJ: Montage Media Corp; 2004.
11. Chu FC, Siu AS, Newsome PR, et al. Management of median diastema. Gen Dent. 2001;49:282-287.
12. Lowe E. Simplifying diastema closure in the anterior region. Dent Today. Dec 2003;22:50-55.
13. Cordiero NPD, Martins LRM, de Goes MF, Chan DCN. Conservative technique for closing diastemata and recontouring peg-shaped teeth. Contemp Esthet Restor Pract. 2001;5:16-22.
14. Heymann HO, Hershey HG. Use of composite resin for restorative and orthodontic correction of anterior interdental spacing. J Prosthet Dent. 1985;53:766-771.
15. Lacy AM. Application of composite resin for single-appointment anterior and posterior diastema closure. Pract Periodontics Aesthet Dent. 1998;10:279-286.
16. Bruce WE. The missing link: on the edge of aesthetics and function. Picture Perfect Aesthetics: The AACD Monograph. Vol II. Mahwah, NJ: Montage Media Corporation; 2005:57-60.
17. Felippe LA, Monteiro S Jr, De Andrada CA, et al. Clinical strategies for success in proximoincisal composite restorations. Part II: composite application technique. J Esthet Restor Dent. 2005;17:11-21.
18. Behle C. Placement of direct composite veneers utilizing a silicone buildup guide and intraoral mock-up. Pract Periodontics Aesthet Dent. 2000;12:259-266.
19. Simon J. Using the golden proportion in aesthetic treatment: a case report. Dent Today. Sept 2004;23:82,84.
20. Terry DA. Developing natural aesthetics with direct composite restorations. Pract Proced Aesthet Dent. 2004;16:45-52.
Dr. Milnar is a graduate of the University of Minnesota School of Dentistry. An accredited member of the American Academy of Cosmetic Dentistry (AACD) and a Board Examiner for accreditation, he is also a developer/evaluator of new materials for several dental product manufacturers as well as medical device and biomedical companies. Dr. Milnar is the past editor for the AACD Academy Connection Newsletter and maintains a full-time practice emphasizing appearance-related dentistry in St. Paul, Minn. He lectures internationally and is a co-founder of the Minnesota Academy of Cosmetic Dentistry. He can be reached at (651) 645-6111 or frank@milnardds.com.
Disclosure: Dr. Milnar has received financial and materials/product support from Ultradent Products.
