CLINICAL REPORT

Interdisciplinary approach using composite resin and ceramic

veneers to manage an esthetic challenge
Heitor Cosenza, DDS, Msc,a Saulo Pamato, DDS, MSc, PhD,b Alef Vermudt, DDS,c and Jefferson R. Pereira, PhDd

Different techniques have ABSTRACT

been described for the correc-
This clinical report describes the management of an esthetic challenge in an interdisciplinary
tion of diastemas.1-4 When manner addressing both the soft tissue and the anterior dentition. Different restorative materials
planned in an appropriate were used in an esthetic and conservative manner to provide a pleasing smile. A minimally
manner, orthodontic therapy invasive approach was adopted to manage the anterior esthetics problems, including a maxillary
may be successful. However, diastema and inadequate width-to-length tooth proportions. (J Prosthet Dent 2020;-:---)
with excessive space, ortho-
dontic treatment should be combined with restorative tissues were inflamed, but no deep probing depths were
procedures to achieve the optimal width-to-length tooth detected. After explaining possible treatments, including
proportions.5-8 orthodontic treatment, restoration with ceramic veneers,
Composite resins provide an outstanding option for restoration with composite resin veneers, surgical gingival
conservative treatments.9-11 However, ceramic materials recontouring, and a combination of these treatments, the
may be required, as when patients ingest drinks and food patient chose ceramic veneers and surgical gingival
with high staining potential.12 Ceramic veneers can be a recontouring of the maxillary lateral incisors. This treat-
6,13-17 ment was complemented by increasing the length of the
conservative and long-lasting option. Regardless of
the restorative material, optimal esthetics in balance with lateral incisors with composite resin restorations.21
adjacent teeth and gingiva are essential. 18-20 A diagnostic waxing was performed for diastema
This clinical report demonstrates an interdisciplinary closure after impression making (Express XT; 3M ESPE),
approach to manage the gingival tissues and a diastema. and a silicone index was made for trial restorations. After
Additionally, multiple restorative materials were used for the trial restorations, some esthetic adjustments were
conservative treatment with enhanced esthetics and necessary, and after that, the new smile profile was
longevity. defined. New silicone indices were made, and the new
esthetic parameters were determined intraorally as seen
CLINICAL REPORT in Figure 2.
Following gingivoplasty, passive tooth eruption was
A 34-year-old woman presented to a private dental office achieved, and part of the enamel to be exposed was
complaining about the appearance of her smile and exposed. The biological width was redefined after
gingival inflammation (Fig. 1). Her general health was correcting the gingival contour around the maxillary
good with no systemic or local disease. She had diastemas lateral incisors after probing. The width-to-length tooth
among the maxillary central incisors and among the proportions were optimized. The surgery was undertaken
maxillary central and lateral incisors that had been with a surgical chisel (Cinzel Ochsenbein no. 1; Quine-
restored with direct composite resin. Her periodontal lato) with a flapless technique (Fig. 3), avoiding root

a
Private practice, São José do Rio Preto, Brazil.
b
Professor, Department of Prosthodontics, Avantis Universitary Center (UniAvan), Balneário Camboriú, Brazil.
c
Undergraduate student, Department of Restorative Dentistry, University of Southern Santa Catarina (UNISUL), Tubarão, Brazil.
d
Professor, Department of Prosthodontics, Avantis Universitary Center (UniAvan), Balneário Camboriú, Brazil.

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Figure 1. Preoperative view with diastema and unesthetic width-to-
length tooth proportions of lateral incisors.
Figure 3. After crown lengthening of right lateral incisor.
exposure. New gingival contours were established, as
seen in Figure 4 after 90 days.
After the periodontal treatment, an at-home bleach-
ing (8 hours/day for 28 days) procedure was performed in
both arches (Opalescence PF 10% Regular; Ultradent
Products, Inc). The enamel surfaces of the maxillary
central incisors were abraded with a diamond rotary
instrument (Komet Gerb Brasseler GmbH & Co), also
removing the existing composite resin restorations.
After rubber dam isolation, the enamel was etched
with 35% phosphoric acid (Ultra Etch 35%; Ultradent
Products, Inc), and the adhesive system was applied
(Scotchbond Multipurpose; 3M ESPE). Then, the maxil-
lary central incisors were restored with nanoparticle
composite resin shade A1 body and shade B1 enamel
(Filtek Z350 XT; 3M ESPE). Three days later, the anatomy
was redefined adding secondary and tertiary anatomy,
and the restorations were finished with rotary
instruments, aluminum oxide disks (Diamond Pro; FGM
Dental Products), abrasive strips (Epitex; GC America
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Figure 2. Trial restorations.
Figure 4. Forty days after crown lengthening.
Inc), and polishing (Diacomp Plus; EVE America Inc)
(Fig. 5).
The maxillary lateral incisors were prepared for
ceramic veneers (IPS emax CAD; Ivoclar Vivadent AG)
with diamond rotary instruments (no. 8850.314.012,
801.314.012. 8855.314.025, 8855.314.012,
H375R.314.014; Komet Gerb Brasseler GmbH & Co).
The gingival margin extended 0.2-mm subgingivally
(Fig. 6), a polyvinyl siloxane impression (Express XT; 3M
ESPE) was made and poured in Type IV die stone (Fuji
Rock; GC America Inc), and the casts were mounted in a
semiadjustable articulator (A7 Plus; Bio-Art Equi-
pamentos Odontológicos Ltda) by using interocclusal
records.
The restorations were cemented under rubber dam
isolation. Phosphoric acid (Ultra Etch 35%; Ultradent
Products, Inc) was used to etch the enamel and dentin. A
thin layer of adhesive system was applied (Scotchbond
Multipurpose; 3M ESPE) without polymerization. The
ceramic surface was etched with 5% hydrofluoric acid
Cosenza et al
- 2020
Figure 5. Composite resin restorations.
Figure 7. Completed treatment. A, Facial view. B, Lingual view. C, Periapical radiographs.
(Porcelain Etch; Ultradent Products, Inc) for 20 seconds,
and a silane coupling agent (Monobond Plus; Ivoclar
Vivadent AG) was applied. The veneers were cemented
with a light-polymerizing resin cement (RelyX Veneer;
3M ESPE) and light polymerized (Valo; Ultradent Prod-
ucts, Inc.). The veneer margins were evaluated with a
dental explorer (11/12 ODU Explorer; Hu-Friedy
Manufacturing Co), residual cement was removed with
a scalpel blade (15c; Hu-Friedy Manufacturing Co), and
Cosenza et al
3
Figure 6. Lateral incisors prepared for ceramic veneers.
the occlusion was evaluated. The patient was reevaluated
after 3 and 7 days for occlusal contacts, proximal contact
relationships, marginal integrity, and gingival margin
health (Fig. 7).
DISCUSSION
Although different materials and techniques are available
to achieve esthetically satisfactory results in clinical
THE JOURNAL OF PROSTHETIC DENTISTRY
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practice, dilemmas arise in the challenging situation of
anterior reconstruction, with composite resin being
commonly used in a minimally invasive approach. As
well as conserving tooth structure, composite rein has
excellent adhesion to enamel,9 with a reported overall
survival rate of over 88% after 10 years 10 Chipping has
been reported to be the most common reason for failure,
and shade matching can be challenging.11
Ceramic veneers also provide an appropriate restor-
ative solution with exceptional biocompatibility,
providing longevity, function, esthetics, and periodontal
health.12 Batalocco et al16 reported similar performance
for composite resin and ceramic veneer. Direct and in-
direct adhesive restorations are safe, predictable, and
recommended for diastema closure.16 Although
gingivoplasty and closing diastemas may solve width
problems, a lack of width-to-length proportions and
deficient interdental papilla creating a black triangle
would influence the choice of procedure.16
An advantage of diastema closure by direct restorative
approaches is to preserve tooth structure, as tooth prepa-
ration may not be necessary, making the procedure widely
indicated.18,19 For ceramic veneer, treatment planning and
the materials used will determine the tooth preparation
design, which can be invasive or not invasive at all. In
practice, a minimum amount of tooth structure should be
removed, respecting the requirements of the selected
restorative material, to achieve the objectives outlined for
the treatment.13 The present restoration was considered
excellent by the patient, providing a natural smile.
SUMMARY
A restorative treatment with direct composite resin,
ceramic veneers, and surgical gingival recontouring of the
maxillary lateral incisors was presented. This treatment
was based on a multidisciplinary, minimally invasive
approach.
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Corresponding author:
Dr Jefferson R. Pereira
Rua Recife 200 apto 601 Bairro Recife
Tubarão-SC
CEP 88701420
BRAZIL
Email: jeffripe@rocketmail.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.01.013
Cosenza et al