Case Study: Utilizing a Multi-Layer Technique for Conservative Direct Resin Veneers

Author : Dental Product Shopper
Published Date 12/10/2012
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Case presentation
A 42-year-old male presented in good medical and dental health. His chief complaint was regarding the size and shape of his lateral incisors (Fig. 1).
The patient stated that he was happy with everything else about his teeth, but had never liked the appearance of his incisors.

A conservative treatment plan utilizing direct veneers on Nos. 7 and 10 was discussed with the patient. The patient?s occlusion was examined for risk factors that would contraindicate direct bonding. He exhibited immediate canine disclusion and anterior coupling. The patient had an anatomically healthy posterior dentition with no occlusal wear, and no CR-CO slide. Based on these findings, it was determined that direct veneers would be an acceptable treatment, and the patient agreed to proceed.

Procedure

During the consultation appointment, alginate impressions of the patient?s upper arch were taken to create a quick wax-up for use as a guide for the direct veneers, due to the fact that a considerable amount of length was to be added. Virtual putty was used to impress the wax-up and cut back to the incisal edge to allow it to be carried to the mouth as a matrix for the lingual shelf of enamel composite. 
At the next visit, the direct veneer treatment was performed. The teeth were prepared by pumacing with Consepsis scrub. A total etch technique was followed with phosphoric acid and Excite F adhesive, during which Mylar matrices were used to protect the adjacent teeth. 

3M? ESPE? Filtek? Supreme Ultra Universal Restorative was selected to create the veneers in this case, due to the material?s esthetics and ability to maintain a strong polish over time. 1 This material has been shown to have wear resistance very similar to human enamel, which was an important consideration for this anterior case. 2 Additionally, the product?s shade wheel simplifies shade selection for the multi-layering process, which was planned for use in this case.

The pre-made matrix was seated fully, and Filtek Supreme Ultra restorative in clear enamel was placed to build the lingual shelf in a very thin layer (Fig. 2). The shelf was built just to the incisal edge, and the composite was cured with a 3M? ESPE? Elipar? S10 LED Curing Light for 20 seconds.

Next, the dentin replacement layer was created using an A3 shade. Natural lobing effects were created with an IPC TTN and multi-use instruments (Fig. 3). The layer was cured for 20 seconds.

Following this step, the amber translucent layer was placed for the opalescent layer between the dentin lobes. The translucency of this layer allows for the subtle lobing effect to show on the final restoration. To match the adjacent teeth, a white tint (renamed white opaque) was placed in the opalescent layer at strategic spots and cured for 20 seconds. 

A Mylar strip was then inserted between contact areas. If the Mylar did not pass freely between the teeth, an IPC instrument was placed interproximally in the gingival embrasures and turned gently to separate the teeth until a click was heard, indicating the separation of the composite from the adjacent tooth. The final layer of A1 enamel composite was placed with an IPC and condensed against the facial surface and into the interproximal areas. The Mylar strip was pulled toward the lingual with the IPC instrument, placing gentle pressure on the facial to create mesiofacial and distofacial line angles. Simultaneously, the composite was pulled into interproximal areas by this technique.. 

The Mylar strips were removed, and the enamel layer was contoured with an IPC TTN instrument around the gingival areas and into contact areas. The IPC was also used to create horizontal banding in the teeth. The teeth were designed to be proportionally long and narrow, so the horizontal banding helped create the illusion of a shorter tooth by breaking up the long vertical lines. When the basic shape of the tooth was satisfactorily achieved with the desired restorative material, the area was cured for 40 seconds. 

Line angles were then marked on the teeth with a mechanical pencil, and a bur was used to create the line angles in their ideal position while smoothing and polishing the restoration. Disks were then used to modify the incisal edges, and a small diamond disk was used to open the incisal embrasures to match the surrounding dentition. The occlusion was checked in centric, lateral and protrusive positions to make sure the new restorations were the proper size for mandibular movements.  Final finishing was completed with Enhance cups, and polishing was performed with Pogo cups. Enamelize polishing paste was then used with a soft sable brush to create the final polish (Fig. 5).

Conclusion
Conservative cosmetic dentistry is about pursuing minimally invasive cosmetic treatment modalities whenever possible in order to give patients confident smiles. 3 In this case, use of Filtek? Supreme Ultra restorative enabled easy placement of strong direct resin restorations that polish easily and will maintain their polish over time. The patient was informed that with proper care, this treatment will last for seven years or longer. Additionally, if repairs are needed in the future, they can be accomplished easily with composite. The conservative nature of this treatment makes this an outstanding and minimally-invasive long-term solution for the patient.


1 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003 Oct;134(10):1382-90.

2 Christensen GJ. Overcoming the challenges of Class II resin-based composites. J Am Dent Assoc. 2006 Jul;137(7):1021-3.

3 Christensen GJ. Are veneers conservative treatment? J Am Dent Assoc. 2006 Dec; 137(12): 1721-1723

 

Fig. 1: The patient was dissatisfied with the size and shape of his lateral incisors

Fig. 2: The clear enamel layer created the lingual shelf

Fig. 3: Lobing was created with the A3 dentin shade

Fig. 4: The Mylar pull technique was used to achieve the proper line angles

Fig. 5: Final result achieved with Filtek? Supreme Ultra Universal Restorative

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