Conservative Aesthetic Enhancement Teeth

CONSERVATIVE AESTHETIC ENHANCEMENT

OF THE ANTERIOR DENTITION USING A

PREDICTABLE DIRECT RESIN PROTOCOLMarcos Vargas, DDS, MS*

Pract Proced Aesthet Dent 2006;18(8):501-507 501

Aesthetic enhancement of the maxillary dentition can be accomplished using a vari-

ety of direct and indirect methods. Composite resin procedures enable the clinician

to follow a predictable, conservative, and reliable chairside protocol for improv-

ing patients’ smiles. Combined with advances in adhesive materials themselves,

these procedures can be used successfully in the daily practice of restorative aes-

thetic dentistry. This article will demonstrate the protocol used to enhance the appear-

ance of a patient who presented with concern regarding short crown length.

Learning Objectives:This article discusses a conservative approach to providing a predictable aes-thetic outcome to the anterior dentition using direct composite resin. Upon read-ing this article, the reader should:

• Understand how the bevel preparation allows the practitioner to create aseamless, natural-looking restoration.

• Become more familiar with the lingual shell approach toward predictablecomposite resin buildup.

Key Words: direct, composite resin, anterior, microhybrid, lingual shell, matrix

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*Associate professor, Department of Family Dentistry, University of Iowa, Iowa City, IA.

Marcos Vargas, DDS, MS, Department of Family Dentistry, University of Iowa, Iowa City, IA 52242Tel: 319-335-7208 • E-mail: [email protected]

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Figure 2. Preoperative anterior view of patient.

Figure 3. The length, occlusion, and contour ofthe central incisors were determined in a diag-nostic waxup.

Figure 1. Preoperative view of patient who hadundergone previous tooth whitening one yearprior for aesthetic enhancement.

Practical Procedures & AESTHETIC DENTISTRY

Since the introduction of composite restorative materi-als and adhesive bonding procedures in the 1960s,

various resins have been developed in the industry’sattempt to enhance their longevity, clinical performance,and color compatibility with the natural dentition.1,2 Theearliest of these materials, self-cured composite resins,faced well-recognized limitations that included their inad-equate polishability, color stability, and durability.3,4 Withthe advent of light-cured composites in the followingdecades, however, adhesive bonding evolved consider-ably, enabling predictable resin placement in anterior andposterior regions.4,5 These materials overcame many ofthe limitations of the first materials and gained favor indirect bonding techniques. Numerous reports confirmedthe improved mechanical and optical properties of hybridand microfill resins, respectively, in such procedures.6,7

While still applied in the initial “sandwich” tech-nique by many clinicians, the use of hybrid and micro-fill materials has yielded to microhybrid resins,nanocomposites (eg, Filtek Supreme Plus, 3M Espe, St. Paul, MN), and resin technologies that incorporatenanofillers into microhybrid composites (eg, Premise,Kerr/Sybron, Orange, CA). As a result of their compo-sition and small-particle fillers, these new materials pro-vide improved strength, wear resistance, handling, andpolishability in a single resin material.8,9 Additionally, theyhave handling properties that are extremely conduciveto direct resin stratification techniques. Further demon-strating their aesthetic potential, some clinicians havereported on the similarities that exist between stratifiedporcelain restorations and direct composite resins.7,10,11

Similar developments have occurred in adhesivetechnology, allowing clinicians to achieve success withenamel and dentin bonding. Not only does this reinforcethe tooth structure and improve stress distribution at the

margin between the composite resin and the tooth,12

but it also reduces the potential of microleakage, stain-ing, and subsequent caries.4,13 As the bond strengthbetween acid-etched tooth surfaces and bonding agentshas improved, the longevity and popularity of direct resinrestorations has grown in kind.

Before applying any restorative material, however,it is first imperative for the clinician to conduct a thoroughpatient evaluation, to arrive at a single diagnosis, and

Sequential Aesthetic Checklist

• Incisal position and length• Occlusion• Tooth width• Tooth proportions• Embrasures

• Incisal• Cervical• Facial and lingual

• Facial crest of contour• Developmental

depressions• Surface characterization• Surface gloss

Table


Figure 6. Diagram of the scalloped bevel designused to conceal the margin between the naturalteeth and the resin materials.

Figure 4. A polyvinylsiloxane impression wasmade of the waxup and used intraorally for amock up and patient communication.

Figure 7. The composite was spread using an inproximal carver (IPC) instrument.

Figure 5. After a matrix was created, preparationof the four central incisors was performed follow-ing shade matching and rubber dam isolation.

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to formulate a treatment plan (Table). Since there arenumerous restorative options available to treat a givencondition, it is important to uncover the etiologic and bio-logic factors before recommending the course of therapy.As composite resins represent a more conservative alter-native to achieving aesthetic enhancement,14 it is impor-tant that clinicians have a reliable technique for deliveringsuch restorations with success and predictability.Demonstrated here is an effective technique that allows

the clinician to preview the intended outcome prior totreatment, to establish a guideline for tooth contour andproportion, and to deliver the restoration accordingly.

Clinical TechniqueDiagnosis and Treatment PlanningA 29-year-old female presented for aesthetic enhance-ment of her smile (Figures 1 and 2). Comprehensive clin-ical and radiographic examinations were performed,revealing that the patient—herself a dentist—had previ-ously undergone tooth whitening, yet had short clinicalcrown lengths and excessive gingival display in the ante-rior maxilla. The patient was already aware of the avail-able treatment options and selected direct resin bondingto restore teeth #7(12) through #10(22) due to its aes-thetic potential and its minimally invasive nature.

Models of the patient’s existing dentition were sub-sequently mounted in a semi-adjustable articulator, wherethe four central incisors were waxed up to ideal length,occlusion, and contour (Figure 3). This waxup was cap-tured in an impression and used by the clinician to mockup the planned restorations intraorally. This step allowedthe practitioner to check the patient’s incisal position,length, and occlusion with the planned restorations. Italso facilitated patient feedback regarding the antici-pated result and the related aesthetic goals. In the author’sexperience, this technique proves invaluable to establishpatient expectations and enables a comparison to therestorative treatment plan. A polyvinylsiloxane impressionof the palatal surfaces of the anterior teeth, canine to

Lingualbevel

Facial bevel


Figure 11. The IPC instrument was again usedfor shaping of the incisal embrasures.

Figure 8. A thin-bladed composite instrumentwas used to contour the material over the lin-gual matrix.

Figure 9. An artist’s brush was used to smooththe lingual layer (ie, shade XL1) of resin.

Figure 10. A small increment of resin was placedagainst the metal matrix to permit buildup of theinterproximal aspects.

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canine, in the diagnostic waxup was made and wasused as a matrix by the clinician throughout the resinbuildup (Figures 4 and 5).

Shade SelectionThe desired shade for the composite resin buildup was then determined using a shade-matching system (ie, Vitapan Shade Guide, Vident, Brea, CA). Since ahalo effect was desired in the restoration, a high value,opaque shade was selected and would be used as alingual increment. A shade with dentin-like opacity wasselected to replace the natural dentin, and a translucentlayer was selected to create translucency in the incisalthird. Ochre and white stains would be utilized to instillmaverick colors and natural characterizations for the com-posite stratification; an enamel-like material was selectedto provide the final facial layer. All shade selection wasaccomplished after pumicing and prior to tooth isolation,which could have negatively influenced assessment asa result of tooth dehydration.

Preparation Design and Conditioning of the Tooth SurfacesThe procedure was performed under rubber dam isola-tion to ensure the control of moisture throughout the directresin buildup. The required preparation design was sim-ply facial and lingual beveling of the remaining toothstructure, which would help conceal the transition linebetween the natural tooth structures and the resin mate-rials upon placement and polymerization.14,15 The scal-loped facial bevel served as a “functional-aestheticbevel,” which began slightly inside the dentin-enameljunction (DEJ) at a 75° angle, and disappeared towardsthe cervical area. The lingual bevel was a “functionalbevel,” and was a 45° angle of the enamel thickness(Figure 6). The bevels were also extended through theinterproximal areas for harmonious blending of the resininto these regions.

Contouring disks were used to render the marginimperceptible. Once the enamel and dentin had beenacid-etched and rinsed, a primer and an adhesive (ie,OptiBond FL, Kerr/Sybron, Orange, CA) were appliedover the tooth surfaces and light cured for 20 seconds.

Composite StratificationA nanohybrid resin composite (ie, Premise, Kerr/Sybron,Orange, CA) was selected for the procedure because


Figure 15. Translucent resin (ie, shade SuperClear) was placed to create the desired incisaltranslucency.

Figure 12. All lingual shells and proximal wallswere finished accordingly for the anterior teeth.

Figure 13. An opaque resin material wasselected to replicate the dentin layer and contoured to place.

Figure 14. To replicate natural characterizationsin the buildups, white and ochre stains wereadded incisally.

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of its handling and its tooth-like appearance. A smallquantity of resin (shade XL1) was placed in the lingualbevel to form the lingual shell for the buildups. This par-ticular opaque, bright shade was selected to facilitatethe reproduction of the desired incisal halo. Once thisincrement had been adapted to each lingual bevel toensure a marginal seal, the matrix was then inserted. Thematerial was spread over the matrix using a thin-bladedinterproximal carver (IPC) instrument. It was important tomonitor the thickness of this layer, as an average thick-ness of 0.3 mm was required. A thinner increment couldhave resulted in a weak layer and fracture during sub-sequent layer placement; a thicker layer may have beentoo opaque and could have prevented proper light trans-mission (Figures 7 through 9). The incisal halo was cre-ated in this layer by extending the increment to the incisaledge, where thickness further increased the opacity andvalue of the incisal edge.

To ensure customization of each tooth, the buildupsdid not touch one another during the layering process.Each tooth was cured for 20 seconds, and the matrixwas removed. Since the occlusion was planned in thesemi-adjustable articulator and translated from there tothe mouth by the lingual matrix, future occlusal adjust-ments would be minimal once the restoration was com-pleted, thus saving considerable chairside time comparedto other freehand techniques.

A thin metal strip was inserted between tooth #9(21)and #10 to permit the formation of the interproximal walls.Once in position, an increment of resin was placedagainst the strip and shaped with the IPC to the correctincisal embrasure (Figures 10 and 11); sable brusheswere used to smooth the surface of the buildup prior tolight curing for an additional 20 seconds. The proce-dure was then repeated, inclusive of the polymerizationstep, for the mesial aspects as well. The remaining max-illary incisors were then completed in a similar manner(Figure 12). This technique ensured proper proximal con-tour and proximal contact; the use of wedges was avoidedto prevent any potential tissue recession in this patientwho had a thin gingival biotype.

Development of the lingual-proximal shells conse-quently reserved space within each lingual shell for theplacement of additional resin materials and stains.Inadequate space could have required excessive andundesired finishing along the facial aspect of the restora-tion or prevented subsequent layers to be placed in


proper thickness. This could have negatively affected thetranslucency and resulted in an overly opaque result. Adentin-like opacity shade (ie, B1 Opaque) was appliedfor dentin replacement and feathered over the bevel toimperceptibly blend it over the tooth structure (Figure 13).Once dentin lobes had been created and evaluated inthe buildup of tooth #9, the dentin for the adjacent restora-tions was built up similarly. Prior to polymerization, thedentin increment was evaluated for proper thickness; ade-quate amount should remain for the final "enamel" incre-ment. To instill the proper translucent effects in the incisalthird of the restorations, minute white and ochre stains(ie, Kolor+, Kerr/Sybron, Orange, CA) were also addedto the dentin layer (Figure 14). With these characteri-zations complete, a translucent layer of resin was addedto the buildups, ensuring that the invaginations betweenthe dentinal lobes were filled (Figure 15). Upon light cur-ing and final polishing, this layer would create the desiredincisal translucency for the restorations.

The final enamel increment of composite was addedto the facial surface in one increment of resin. This incre-

ment was contoured to a round, ball shape and pickedup with the composite resin instrument for simple appli-cation that would prevent the undesired entrapment of airor voids that could compromise the completed restora-tion (Figures 16 and 17). The side of the brush was usedto create developmental grooves, and the material wasextended to produce the desired facial embrasures. Thethin-bladed instrument prevented excess material from accu-mulating in the cervical and interproximal regions. A goldalmore instrument was subsequently used to produce devel-opmental grooves in the resin buildup; this final incre-ment of enamel resin was polymerized for 40 seconds.

Contouring and Polishing ProtocolWhile the value of the restoration has the greatest affecton success, ensuring proper shape and facial anatomy isalso important for a successful restoration. The incisal lengthwas evaluated and any adjustments were made with apolishing disk. Incisal embrasures were evaluated and con-sistently opened distally to match the mesial embrasure ofthe canine. The facial embrasures and facial crest of the

Figure 16. A roller was used to spread the enamel com-posite material without entrapping voids in the resin.

Figure 17. A flat stiff brush was used to smooth the finalincrement of enamel-shaded resin.

Figure 18. A flame-shaped finished bur was used for ini-tial contouring of the direct resin buildup.

Figure 19. Rubber cups were used to render the finalappearance of the resin restorations.

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contour were evaluated from an incisal view, and the cer-vical embrasures and proximal contact were evaluatedand modified as necessary. The proximal areas weresubsequently polished with thin plastic strips (ie, Epitex,GC America, Alsip, IL). A flame finishing bur was used tofurther define facial developmental depressions (Figure18). A tapered diamond bur was used to produce sur-face characterizations, polishing was completed, andthe rubber dam was removed. Occlusion was verified incentric occlusion followed by protrusive and lateral move-ments (Figures 19 and 20).

The patient returned two weeks postoperatively for a follow-up examination, at which time no problemswere discovered and the patient confirmed her satis-faction with the smile enhancement achieved with thedirect resin procedure.

DiscussionWhen contemporary resin materials are used for therestoration of the anterior maxilla, several direct tech-niques can provide significant opportunities for aestheticenhancement. Freehand techniques offer a great deal ofcreativity to the attending clinician and have been demon-strated throughout the dental literature. The lingual matrixtechnique can be extremely effective in guiding the clin-ician’s reproduction of the ideal proportions, shapes, andanatomy created in the diagnostic waxup and savinginvaluable chairside time.

Several resin restorative systems and techniques areavailable to the dental practitioner to build imperceptibleanterior aesthetic restorations. The practitioner shouldmatch the material and technique to the anticipated restora-tive result and the patient’s desires and expectations. Thematrix technique is an excellent choice when several large

multilayered restorations are desired. Inversely small, sin-gle--shade-opacity restorations can be readily accom-plished without the use of a matrix.

ConclusionThis multilayered lingual matrix technique represents ahighly predictable and repeatable method for buildingup the direct resin restoration. This restorative techniquecan be used successfully with the available multipleshades and opacities. As composite resins are used foraesthetic enhancement, the procedure represents a valu-able framework on which to develop a rich stratificationof natural tooth colors and shades, all built to a naturalfinal appearance that achieves the expectations of bothpatient and professional.

AcknowledgmentThe author declares no financial interest in any of theproducts cited herein.

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Figure 20. Postoperative view of the completed restorationsshowing enhancements made to the anterior maxilla.

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Conservative Aesthetic Enhancement Teeth