In many routine dentistry cases, the mental state of the patient plays an important role. In the following clinical case the patient in question, a girl of only 12 years of age, no longer wanted to go to school because she was ashamed of her smile. This girl, whose teeth 11 and 21 had become intruded through a fall and who was thus undergoing orthodontic treatment to adjust her middle incisors, attended our clinic as a patient. Our task was to develop a strategy for reconstruction of her teeth that would restore to the patient, at least temporarily, a feeling of self-esteem without having any adverse effect on her ongoing orthodontic treatment.
Premises
The considerations and prerequisites for the treatment we were to undertake were as follows:
The work was to be entirely reversible and modifiable as the incisors had just undergone orthodontic extrusion.
The aesthetic build-ups were to be carried out without any contouring of the teeth. A highly aesthetic composite (Amaris, Voco) was to be used to ensure minimally invasive treatment.
The gingiva composite also planned here (Amaris Gingiva, Voco) was to extend no further than the natural gingival margin to prevent any harm to the marginal gingival tissue. It was also necessary to ensure good oral hygiene and provide for the reapplication of gingiva composite to the same degree as the progress of extrusion.
Under no circumstances was there to be any interference in the ongoing orthodontic treatment: the plan here was to create an interim solution aimed at restoring the patient’s feeling of self-esteem.
Findings and treatment
The patient’s smile was spoilt by the gingival margin of the middle incisors not being visible (fig 1). Both middle incisors underwent orthodontic extrusion, although a pronounced defect of the marginal gingiva was obvious at tooth 21. The incisors had already been treated with two build-ups which had likewise been used in an attempt to improve the aesthetic situation (figs 2 and 3).
Fig 1: The patient’s smile before minimally
invasive treatment.
Fig 2: Initial situation of tooth 11 and tooth 21.
Tooth 21 shows a pronounced defect of the
marginal gingiva.
Fig 3: Both middle incisors had already been
treated with build-ups to improve the aesthetic
situation.
A suggestion involving free-hand ‘remodelling’ of the middle incisors as well as repositioning of the gingiva for tooth 21 was put to the patient, a proposal which also found the approval of her mother. The plan was to make the proximal surfaces divergent in a cervico-incisal direction to give the incisors a more trapezoidal form and to additionally bring the gingival margin to the right position. The existing composite remained in place, and the build-up was roughened with a diamond bur (2200, KG Sorensen) and prepared for sandblasting with aluminium oxide (fig 4). This was followed by sandblasting of the entire vestibular surface using aluminium oxide with a grain size of 50µm (Microjato Plus, Oxido de Alumínio, Bio-Art) (fig 5). After sandblasting, the existing composite was silanised. For this purpose, we applied the bonding agent Ceramic Bond (Voco) with a brush made of marten hair (Line Artiste, Hot Spot Design) (fig 6). We then set to work on tooth 21.
Fig 4: The roughened build-up before
sandblasting with aluminium oxide.
Fig 5: The tooth surfaces sandblasted with
aluminium oxide.
Fig 6: The existing composite is silanised by
applying bonding agent with a brush made of
marten hair.
We started by applying a small wall of gingiva-coloured composite Amaris Gingiva to the tooth to delimit and mark the height of the future gingival zenith that was to be subsequently reconstructed (fig 7). The highly aesthetic composite Amaris in the base shade Opaque O3 was applied to the entire vestibular surface. The tooth of a young person should always have a characteristic form, with pronounced longitudinal ridges in the vestibular face and an irregular incisal edge. A flowable composite (Amaris Flow, Voco) in the individual shade HO (High Opaque) was applied at the incisal end of the longitudinal ridges to create the effect of hypocalcification. We opted for three-dimensional modelling of the dentine layer with three marked longitudinal ridges (fig 7), so leaving space among the remaining irregularities for application of the translucent enamel shades.
Fig 7: A small wall of gingiva-coloured composite
(Amaris Gingiva) marks the height of the
subsequent gingival zenith. The composite
Amaris in the base shade Opaque O3 is applied
to the entire vestibular surface.
The Amaris concept suggests working here with opaque base shades and translucent enamel shades. This makes it a very simple matter to produce aesthetic results. The balanced intensity of the opaque base shades fully compensates for the absence of core or layer shades. This intensity permits the irregular passage of a small amount of light through the effect of the glass particles in the material, thus producing scatter. It is also interesting to observe how the opaque base shades of the system behave in terms of brightness (‘value’) as even the darkest shades offer excellent brightness values, so leading to a natural aesthetic result. This is a system in which determining opacity and translucency is a simple matter by varying the selection and amount of the composite used for dentine design. Corrections can also be made while work is underway with the help of the enamel shades TD (Translucent Dark), TN (Translucent Neutral) or TL (Translucent Light).
In the present case, the enamel shade TL (Translucent Light) was used between the incisal mamelons to shape the tooth (fig 8). In the area acting as the cervical third we applied the enamel shade TN and from the middle third to the incisal area we used the enamel shade TL (figs 9 and 10).
Fig 8: Amarisin the enamel shade Translucent
Light is used between the incisal mamelons to
shape the tooth.
Fig 9: The enamel shade Translucent Neutral
is applied to the cervical third.
Fig 10: The enamel shade Translucent Light is
used from the middle third to the incisal area.
Reconstruction of the white aesthetics of tooth 21 was followed by the second step of the process, restoration of the red aesthetics (the gingival area). The gingiva-coloured restorative material Amaris Gingiva was used for this purpose. Here as well, the shade of the restoration can be individually adjusted step by step. Two application methods are possible here: either direct application to the tooth of an opaque shade (White, Light, Dark) to serve as a base, followed by the base shade Nature, or the mixing of opaquers and subsequent application of the base shade Nature (figs 11 and 12).
Fig 11: Reconstruction of the white aesthetics
is followed by restoration of the red aesthetics.
Fig 12: When used with the opaquers (White,
Light, Dark) and the base shade Nature, Amaris
Gingiva permits individual adjustment to the
colouring of the gingiva.
For conditioning purposes, a 37 per cent phosphoric acid solution (Ácido Gel, Maquira) was applied to the tooth (fig 13), followed by an enamel adhesive (Solobond Plus, Voco). The gingiva was then built up layer by layer using the opaquer shade Dark and the base shade Nature (fig 14), while being careful to ensure that no excess composite was introduced into the gingival sulcus. This was immediately followed by the build-up of tooth 11 using the same procedure as described for tooth 21 (figs 15 and 16).
Fig 13: A 37 per cent phosphoric acid solution
(Ácido Gel, Maquira) was applied to the tooth
for conditioning purposes.
Fig 14: After the application of an adhesive,
the gingiva is built up layer by layer with the
opaquer shade Dark and the base shade Nature.
Fig 15: Tooth 11 is built up using the same
procedure as for the restoration of tooth 21.
Once again, Amaris in the enamel shade
Translucent Light is applied between the
mamelons, and the enamel shade Translucent
Neutral is used on the cervical third.
Fig 16: The enamel shade Translucent Light
is used from the middle third to the incisal area.
The result of this treatment was in line with the patient’s expectations (fig 17). Her new smile also restored her feeling of self-esteem (fig 18).
Fig 17: Completed restorations at tooth 11
and tooth 21.
Fig 18: The restorations in the overall picture
of the patient’s new smile.