104 volume 1 • issue 1 January / March 2011 • pp 104-107

AbstractThe study presents the case of a patient, who, dissat-

isfied with the aesthetic aspect of her upper anterior teeth,especially of the two central incisors, required a fast butless invasive treatment solution.

Composite materials allow a slight invasive adhesiverestoration of the anterior teeth and, at the same time,meet the aesthetic needs of the patients. Resizing thespace of the anterior teeth and achieving aesthetic sym-metry by means of composite materials is a fast method,with immediate satisfaction for both dentist and patient.The direct technique here described can be easily used,however a complex case analysis, including X-ray exami-nations, work and study models, silicone guiding key, isrequired.

Keywords: composite materials, mesiodistal reduc-tion, direct veneering

INTRODUCTION

Composite materials allow adhesive restora-tions of the anterior teeth for meeting the aes-thetic demands of the patients. Consequently,angle restoration, restoration of the incisal edge,diastema closure, coronary remodeling, changesin color and – why not – resizing of mesiodistalwidth in the frontal area, are now possible. (1, 2)

Resizing of the frontal area could be made bydifferent orthodontic methods, by indirect resto-rations or composite restorations, using direct orindirect-direct techniques.

The advantages of a direct technique withcomposite materials are represented by the con-servative tooth preparation, by reduced treat-ment sessions, by simple repairs in the dentalsurgery and by lower prices, compared to theindirect techniques. The nano-hybrid compos-ites now in use have optical, mechanical andphysical properties superior to the previouscomposites. (3)

DIRECT AESTHETIC RECONSTRUCTION BY RESIZING THE UPPERCENTRAL INCISORS. A CASE STUDY

Mona Iona[1, Mariana Sab\u2, T. Iona[3

1 Assist.Prof., Dept. Dentistry, Faculty of Medicine, ‘Lucian Blaga’ University of Sibiu2 Assoc. Prof. PhD, Dept. Dentistry, Faculty of Medicine, ‘Lucian Blaga’ University of Sibiu3 DMD, Private practice, Sibiu, RomaniaCorresponding author: Mona Ionas,e-mail monaionas@yahoo.com

CASE REPORT

A 28 year-old female patient came to the den-tist dissatisfied with the aesthetics of her frontteeth, especially of the two central incisors: 1.1protrusion with deviated insertion axle, obliqueinter-incisor line. The rotated canine 1.3 was notconsidered a problem. As the patient was satis-fied with the natural color of her teeth B1, whit-ening was not necessary. (figure 1)

During the first examination, an orthodontictreatment was suggested for realignment of thefront teeth, as well as a surgical periodontaltreatment for gingival recontouring. The patientrefused both treatment options. Taking into ac-count the fact that the patient had a low smileline, gingival recontouring was not consideredas a major aesthetic objective.

A rigorous clinical examination followed,retroalveolar X rays, intra-and extra-oral photo-graphs were taken, occlusion and periodontalhealth were examined. Impressions were takenfor subsequent study model and wax workingmodel. The patient had a satisfactory oral health

Vertical line

Interincisive line

Figure 1. Initial aspect of the upper front group.Displacement of the inter-incisive line and

the mal-position of 1.1 is clearly emphasized.

Aesthetics

International Journal of Medical Dentistry 105

status, and no occlusion interferences that wouldprevent correction of the front area with com-posite materials were identified.

ESTABILSHING THE TREATMENT PLAN

The case under analysis required:• 1.1 significant reduction of the distal angle

and a discrete reduction of the remaininglabial surface;

• 2.1 gradual reduction of the mesial facet, ofabout 1 mm at incisor level and lost to thegingiva, coating of the labial surface with acomposite material, to create its alignmentto the neighboring teeth;

• such changes would allow framing of thetwo central incisors within the line of thearcades, while keeping and even improv-ing the proportion of the upper front group.

The teeth were prepared on a working modelaccording to the changes indicated by the ob-tained results. It was considered that polishingof 1.1, although quite extensive in the distal area,is framed within the parameters necessary tomaintain tooth vitality and its resistance to theocclusion forces. Dentine exposure during pol-ishing was regarded as inevitable, however thecurrently used adhesive systems provide effec-tive sealing of the dentinal wound, simultane-ously with tight adhesion. (4)

The mesial surface of 2.1 was prepared on themodel according to the measurements from themodel study. The radiological assessments ofenamel thickness estimated the value of reduc-tion, of about 1 mm at incisor level, as occurringwithin safe limits (maintaining a protective layerof enamel). (2) Correction of the inter-incisiveline became clearly visible after this stage ofmodel preparation. Considering that the pro-posed changes are feasible, the wax model of thefuture restoration was designed. (figure 2)

The patient agreed on the proposed aestheticsolution. A silicone key of the wax model wasdeveloped, serving as a guide to achieve restora-tion symmetry. Colorimetric determination wasperformed by the visual method, using the VitaPan Classic color key, and the color, texture andstructure characteristics were registered.

CLINICAL STEPS

The first clinical step involved reduction ofthe mesial surface of 2.1, to correct the inter-inci-sive line position, and to assess the availableclinical space for inclusion on the arch line of 1.1.Reduction was carried out with diamond discs,because they create a flat surface, which facili-tates evaluation of the vertical midline. An alter-native way is preparation with diamond burrs.Finishing of the mesial surface, adjustment ofthe angles between the facets of the teeth weremade with fine diamond burrs, polishing discs,polipant polisher and felt disks.

Special care should be taken not to affect theenamel on the mesial surface of 2.1 after prepa-ration, because no composite material will beapplied on this area. Altering the mesial surfaceof 1.1 is not so problematic, if considering itsrestoration during composite layering.

Reduction of the labial surface of 1.1 was per-formed as similarly as possible to that realizedon the working model. Mesial surface prepara-tion required just roughing up the surface, toobtain a more chemically active enamel surface.

Figure 2. Model study and wax-up from incisalperspective. One can notice here correction ofthe inter-incisive line position and framing of

the incisal edges into the arch line

DIRECT AESTHETIC RECONSTRUCTION BY RESIZING THE UPPER CENTRAL INCISORS. A CASE STUDY

106 volume 1 • issue 1 January / March 2011 • pp 104-107

Mona Iona[, Mariana Sab\u, T. Iona[

A rubber dam was then applied and used as atotal-etch adhesive system. 37% phosphoric acidwas applied for 15 sec, followed by washing for10 sec and drying with cotton bullets, for notdessicating the dentine. Adper Single Bond 2adhesive was applied in two layers, dried andpolymerized with a photopolymerization lampLED Elipar Freelight 2, 3M Espe, guide Ø 8 mm1000mW/cm2 for 10 sec.

Reconstruction of the mesial surface of 1.1 withcomposite material offered support for applyingthe material for the veneer and for assessing themesiodistal size of the two central incisors.

The next step was the application of the com-posite material for the veneer. A silicone matrixwas used as guidance to apply the compositematerial, thereby facilitating finishing and pol-ishing. The used composite was Filtek SupremeXT, 3M ESPE. First, the dental composite B2Bwas applied, followed by a B1E fine enamellayer, the transparent color YT being selected forits effects in the incisal area.Photopolymerization was performed for 20 secon each layer.

FINISHING AND POLISHING

The anatomy and symmetry of the two fron-tal teeth were checked. Ultrafine finishing andpolishing discs were used to smoothen the in-cised edge and the incised embrasure. A greenstone was used to give texture. Next came pol-ishing with polishing cups and gums, with pol-ishing paste and finally with polishing felts. Thefinal aspect is presented in figure 3.

Figure 3. Final aspect of the frontal group. The patientwas very much satisfied with the result and wanted

to return for further treatment

DISCUSSION

The incisal edges of the front teeth are sub-jected to very high mechanical forces. The cur-rent adhesive systems and composite materialsare strong enough for a lasting therapeutical re-sult. (1)

Choosing the right color for the frontal area isvery important. The most famous system usedin dental medicine is that proposed by Vita com-pany, with the VITAPAN Classical color key.Unfortunately, the correlation between thecolors of the Vita key and those of the real key ofmaterials is often reduced. Sometimes, not eventhe standard colors from different color keys ofthe same manufacturer do correspond. (5, 6, 7) Acolor key made of polymerized composite mate-rial available in the cabinet helps the doctor tochoose the right color. (1)

Choosing the color for dentine is made at cer-vical level as, in this area, dentine is covered byonly a thin layer of enamel, being thus responsi-ble for the base color of the tooth. Enamel colorand, especially, transparency, are determined inareas unsupported by dentine, usually in the in-cised areas of the dental crown. The enamel as-sures light dissemination. (8, 9)

Besides color and form, texture is anotherimportant factor for aesthetic reconstructions,influencing in a decisive manner the propertiesof reflection (glossy or rough surface) and lightrefraction (overlapping of transparent materials,translucent, opaque). (10)

The final step involves finishing of the resto-ration work. The first concern in the finishingprocess was to obtain a rough anatomical form.Contouring started with the inter-proximal area,to set the desired physiognomy proportions.Next came contouring of the gingival edges andof the gingival third, to shape the gingival em-brasure spaces. (11)

However, in aesthetic dentistry, an importantrole is played by the patient. Visual informationhas a major impact on people’s life. A satisfiedpatient means the achievement of a successfultreatment. The patient was satisfied with the re-sult, achieving the desired smile.

International Journal of Medical Dentistry 107

CONCLUSIONS

Resizing of the frontal space and obtainingaesthetic symmetry by means of composite ma-terials is a fast method, with immediate satisfac-tion for both physician and patient.

Doctor’s experience on stratification andprocessing composite reconstructions is veryimportant of the direct techniques with compos-ite materials. In the direct techniques, the doctoris the only one responsible for the chosen aes-thetic solution and for putting it into practice.

References

1. Noetzel J., Kielbassa A., Reconstruc]ia estetic\ adin]ilor frontali cu ajutorul materialelorcompozite, Cosmetic Dentistry, 2008, 1: 9-14.

2. Goldstein R.E., Esthetics in dentistry, B.C. DeckerInc., London, 1998

3. Milnar F.J.Closing Anterior Interdentar Spaces andEnhancing Tooth Form Using a Small-ParticleHybrid Composite. Compendium, 2006,27(2):121-125.

4. Iliescu A., Gafar M. – Cariologie [i odontoterapierestauratoare, Editura Medical\, 2002.

5. King K.A.,De Rijnk W.G. – Variations of L*a*b*values among Vitapan Classical Shade Guides,J.Prostodont, 2007, 16(5):352-356.

6. Yap A.U.- Color attributes and accuracy of Vita-based manufacturers’ shade guides. Oper. Dent.,1998, 23(5):266-271.

7. Browning W.D., Contreras-Bulnes R., Brachett W.W.– Color differences: polymerized composite andcorresponding Vitapan Classical shadetab.J.Dent., 2009, 37(1):34-39.

8. Ardu S., Krejci I.-Restaura]ii biomimetice dincompozit pe din]ii frontali, Quintesence Interna-tional România, 2006, 4: 351-358.

9. P\str\v O., Pop A., P\str\v M. – Principii modernede tratament al leziunilor coronare frontale,Clujul Medical, 2009, 2: 275-277.

10. Romînu M., Bratu D., „Materiale dentare no]iuniteoretice [i aplica]ii clinice”, Editura Brumar,Timi[oara, 2003.

11. Longello G.J.-Smile enhancement with direct com-posite veneers:a clinical case raport, Contempo-rary Esthetics and Restorative Practice, 2003,26-31.

DIRECT AESTHETIC RECONSTRUCTION BY RESIZING THE UPPER CENTRAL INCISORS. A CASE STUDY