Throughout the years, I have been known to favor direct composite bonding as a primary method for smile rehabilitation and have documented many such cases in Dentistry Today. Factors that have influenced my activities in this area have always been patient affordability, reparability, and the opportunity to exercise my creative abilities. Having presented many such cases both in print and to audiences, the expected life span of a direct composite smile rehab is often questioned. While we are all aware that although patient-specific occlusions and parafunctional habits have a great deal to do with the day-to-day need for maintenance of direct bonded creations, there still appears to be (at least in this author’s estimation) a finite life span after which the direct composite smile rehab mandates replacement. The time frame that I typically quote to both doctors and patients is 8 to 10 years before my once-shining accomplishment takes on the battered look that initiates the conversation, “Where do we go from here?” In that vein, I’d like to share with you just such a case that was indeed previously published in Dentistry Today some 10 years ago. This article will serve to illustrate what may have changed and what remains the same.
CASE REPORT
The Clinical Case As Completed 10 Years Ago
Let’s say hello once again to Denise. Ten years ago she presented as shown in Figure 1. At that time, Denise exhibited an excessive wear pattern on teeth Nos. 8 to 10 as well as a midline cant and several large, stained, composite restorations. As has been customary for my smile rehab cases, a digital simulation of Denise’s anticipated restoration was presented for her approval, after which a Resin Replica (mockup) was created by Smile-Vision that emulated what was seen in the cosmetic simulation (Figures 2 and 3). The Resin Replica served as the master model that allowed the fabrication of a clear vacuum-formed template that was then used to guide composite placement. In this instance, the template’s focus was incisal edge shape and position (Figure 4). A translucent enamel shade was chosen to form the template-guided portion of the restoration while a dentin, A2 equivalent, was used to cover the rest of the tooth by hand and blended in layered fashion to the incisal portion (Figures 5 to 7). The same process was carried out for each of Denise’s 8 maxillary anterior teeth. The composite resin chosen at the time was Esthet-X (DENTSPLY Caulk [now Dentsply Sirona Restorative]), a popular microhybrid restorative, filled to 60% by volume (77% by weight) with barium alumino fluoroborosilicate glass and nanosized silicon dioxide particles. Ten years later, an improved and more polishable version (Esthet-X-HD [Dentsply Sirona Restorative]) is now available. An A2 shade was chosen at that time, as Denise was more concerned about matching the lower dentition than she was in achieving a new brighter shade. The resultant case is seen Figure 8a.
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| Figure 1. Pre-op smile photo in 2006. | Figure 2. Cosmetic simulation (Smile-Vision). |
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| Figure 3. Resin Replica (Smile-Vision) mockup of the new smile. | Figure 4. Lab-derived incisal template shown in place. |
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| Figure 5. Filling incisal portion of template with composite resin. | Figure 6. Cured composite resin addition on incisal of tooth No. 8. |
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| Figure 7. Addition of body composite resin to complete veneer. | Figure 8a. Completed case in 2006. |
The Same Case Ten Years Later
Let’s fast forward and take a look at 10 years of wear and tear on Denise’s smile. In the current preoperative photo, taken at 10 years postoperatively (Figure 8b), one will note a wear pattern that closely resembles where the case began, before bonding, as well as an assortment of stained microvoids and repaired incisal corners. You may also note the lack of surface shine. Bottom line? Denise’s smile was no longer a pretty picture. (It should be noted that Denise never accepted the recommendation to wear a nightguard.)
It was this appearance that initiated the “what now?” conversation alluded to above. Since Denise’s overall experience with her bonding case was good for most of its existence, she did not hesitate to ask for current fees on redoing the case in composite. Porcelain, although ideal in her case, was dismissed as an option owing to its cost (“twice as much”). Having arrived at a mutually satisfactory fee, we began a brief discussion as to what, if any, changes Denise wanted in her smile makeover. As might have been anticipated, Denise wanted a much brighter shade, similar to what she was seeing in magazines. Her concerns regarding matching of the lower teeth were no longer an issue.
We spent some time during the remaining minutes of her consultation experimenting with a variety of composite products to determine a shade that might satisfy her wishes. This was done by creating small wafers of the composite resin being considered, then holding them in close proximity to her dentition. In instances when there is no pre-existing resin on the tooth surface, it’s better to apply the trial resin directly to the enamel surface, minus a bonding agent. This approach provides the most accurate preview of how the resin interacts optically with the underlying tooth substrate. It is typical to try out 3 to 4 shades before deciding upon one.
In the end, Denise chose the Bright White (BW) shade of a newer composite resin (G-ænial Sculpt [GC America]) now being used in the office. G-ænial Sculpt is a light-cured universal nanohybrid that comes with a color palette of 17 shades. It was brought to market at the close of 2015 along with an 8th generation light-cured adhesive (G-Premio BOND [GC America]) that is compatible with any of the currently popular approaches to direct bonding (example: total-etch, self-etch, selective-etch). These 2 newer items complement GC America’s pre-existing G-ænial Universal Flo, a sculptable and flowable composite resin with near identical shades and strength characteristics. From a practical standpoint, the selection of these modern composite materials for Denise’s case meant easy sculpting, even easier polishing, and enough optical density to mask out unwanted underlying tooth surface discolorations.
Clinical Technique
Removing all of Denise’s aged bonding resin and starting from scratch was indeed a daunting task, particularly when left with open contacts to close. As mentioned above, tooth morphology in the original case was assisted by a lab-fabricated template, and a duo-shade technique was employed. This time, with a mono-shade approach, a different type of anatomical template was used to a similar end. Enter Uveneer. Invented by Dr. Sigal Jacobson and now marketed in the United States by Ultradent Products, the Uveneer is a clear plastic, nonstick template system consisting of 3 sizes of maxillary and mandibular anterior teeth. It was designed to provide an instant template for anterior tooth morphology in the direct bonding process. With respect to Denise’s restoration, I chose to use the Uveneer in 2 ways. On certain teeth, the Uveneer was used for the incisal edge shape only, and on other teeth it was used to lay down the entire tooth surface. The determining factor was how well the Uveneer conformed to the tooth being bonded.
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| Figure 8b. Appearance of original direct bonded case in 2016. | Figure 9. Try-in of Uveneer (Ultradent Products) on tooth No. 8. |
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| Figure 10. Completed veneer using G-ænial Sculpt Bright White (BW) (GC America) on tooth No. 8. | Figure 11. Uveneer with G-ænial Sculpt BW placed in incisal portion of template. |
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| Figure 12. Placement of loaded Uveneer on tooth No. 6. | Figure 13. Completion of application of G-ænial Sculpt on tooth No. 6 using the Almore Gold Microfil composite instrument. |
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| Figure 14. Application of G-ænial Universal Flo BW (GC America) to touch up void in contact using simple Mylar strip. | Figure 15. Ultimate F & P Kit (GC America). |
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| Figure 16. Polishing direct composite veneer with composite finishing disk (Brasseler USA). | Figure 17. One-week post-op evaluation photo. |
In Figure 9, note the sizing of a Uveneer (size large). As the size matches were optimal, it was decided to restore the entire tooth surface with the help of the Uveneer. Following a phosphoric acid-etch and rinse and application of G-Premio BOND, G-ænial Sculpt BW was fully applied to No. 8 via the Uveneer (Figure 10).
In Figures 11 to 13, the maxillary right canine is restored from the top down, employing the Uveneer template to locate the size and shape of the incisal region of No. 6. The rest of the composite veneer was added and shaped by hand with the Hu-Friedy TNCIGFT2 composite instrument and Almore’s Gold Microfil composite instrument (96041). Each of the remaining maxillary anterior 8 teeth were restored similarly, often employing Mylar strips in between contacts to help corral excess composite and also for applying intermittent applications of G-ænial Universal Flo BW to fill in small voids (Figure 14). Final shaping and polishing was accomplished with a series of carbide finishing burs (Ultimate F&P Kit [GC America]) (Figure 15), polishing cups (Enhance Finishing Cup [Dentsply Sirona Restorative]), and composite finishing discs (Esthetic Finishing Kit [Brasseler USA]) (Figure 16). The final restorative outcome can be seen in Figures 17 and 18.
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| Figure 18. After portrait of the patient’s new bright white smile. |
DISCUSSION
What Remains the Same?
Not surprisingly, our patient’s desire for an attractive smile remained constant. What also remained constant was Denise’s bruxism, such that her anterior wear patterns bore remarkable similarities from beginning to re-beginning, 10 years later. Certainly, if she had been agreeable to wearing a nightguard appliance, the restorative results achieved the first time around would have been better preserved. Material application principles and the need for careful planning regarding material selection remain as hallmarks of full-composite smile rehabs, which are, indeed, demanding.
What Has Changed?
The most obvious change would be the current availability of a well-designed anterior matrix system that offloads much of the need for sculpting proficiency. The Uveneer system allows for the efficient creation of on-the-fly anterior morphology with a high degree of accuracy. Keep in mind also that this approach was used in lieu of a costly mock-up/template system, so the dollar savings are considerable with this welcomed tool in my practice.
Let’s also consider what makes G-ænial Sculpt another welcomed change. GC America describes G-ænial Sculpt as “the universal composite that keeps polishing in the mouth.” It attributes this “self-polishing” trait to a proprietary surface treatment of nanosized inorganic filler particles that are densely packed and uniformly dispersed in such a way as to provide high wear resistance and self-polishing throughout time. To be sure, it is hard to know how Denise’s new smile will look as the years progress, but certainly the present day handling, polishing, and system integration (matching flowable resin and a tenacious 8th generation bonding agent in G-Premio BOND) would point to enhanced possibilities for lasting aesthetics.
CLOSING COMMENTS
Are you old enough to remember the 2-paste A and B composite systems that required hand mixing and were impossible to polish? We can all agree that materials advances and improvements in matrix systems have enhanced our day-to-day experience when restoring the dentition with composite. Denise’s smile rehab provides an interesting retrospective that sheds some light on what has been expected from composite rehabs in the past, and what might be anticipated in the future as our materials systems continue to improve.
Dr. Goldstein, a Fellow of the International Academy of Dento-Facial Esthetics as well as a Fellow of the AGD, practices general dentistry in Wolcott, Conn. Recognized as a Leader in Continuing Education by Dentistry Today since 2002 and for his expertise in the field of dental digital photography, he lectures and writes on topics concerning smile rehabilitation and the integration of digital photography into the general practice. He can be contacted via email at martyg924@cox.net.
Disclosure: Dr. Goldstein discloses that GC America has provided materials and awarded him an honoraria for having written this article.
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