A 14 year old boy was referred to me by a local orthodontist. His chief complaint was that the appearance of his diminutive lateral incisors made him “look really young” and it was affecting his confidence at school.
Treatment planning
After a thorough dental examination, all the options were discussed with the patient and his parents. Doing nothing was dismissed by the patient because he was self-conscious about his teeth, which were more obvious when he smiled. This left the options of direct composite veneers or indirect laboratory-made ceramic veneers/crowns, with some tooth preparation.
Given the patient’s age, we had to consider that his periodontal tissues may not have been fully mature. The soft tissues often continue to migrate apically until the late teens to early 20s. Therefore carrying out preparation on teeth, however minimal, is not advisable as the restorative margins will become visible. The more conservative treatment of full direct composite veneers was chosen as the margins would be easier to manage than with ceramic restorations.
A two-stage putty and wash impression was taken using Heraeus Kulzer Provil novo putty and Flexitime light body. The Heraeus putty and wash provide consistently high levels of detail, which are essential to ensure accuracy. A full series of preoperative photographs were taken. The impressions and photographs were sent to the laboratory for the preparation of a diagnostic wax-up and putty matrices.
Restorative appointment
The wax-up and palatal putty matrix were reviewed and checked for accuracy. A quick intra-oral mock-up was used to help visualise the proposed change, and to confirm sign-off with the patient and parents. A pre-operative record was made of the occlusion before any treatment started. The teeth were isolated using an Optragate lip and cheek retractor, a McKesson mouth prop and a saliva ejector.
The composite shades were selected at the beginning of the appointment, to avoid the effects of desiccation on the
tooth colour.
A total etch technique was used with Heraeus Kulzer iBond Total Etch (5th generation). The enamel was etched for 20 seconds, then thoroughly washed for a further 20 seconds. Heraeus Kulzer iBond was then placed. After 10 seconds the excess was removed by gentle air-drying, before curing for 20 seconds.
The composite was built up incrementally. The palatal shelf was adapted against the putty matrix with Heraeus Kulzer Venus Pearl shade CL and fully light cured for 20 seconds. The next layer was OMC dentine, followed by shade A1/B1 and a final CL layer. Each stage was fully light cured. The ease of use of Venus Pearl allows it to be employed both as a multilayer composite for aesthetic cases and as a single shade as required. The material has given me to confidence to provide direct composite veneers that mimic nature and conserve natural dentition.
The ‘Mylar Pull’ technique was used to ensure tight contacts. This uses a Mylar strip to draw unset composite through the contact area, to contour the material and adapt it well to the adjacent teeth. The occlusion was assessed against the pre-operative record.
Gross re-contouring and polishing were carried out with yellow and white grit composite burs. Finishing was completed with soft flex discs, before a final buff with the Venus Supra polishing kit. This two-step system ensures an even polish and a glossy finish, to mimic the natural dentition. Finally, glycerine gel was placed over the completed restorations. These were then light cured for a further 30 seconds, to eliminate the oxygen inhibition layer.
Review appointment
The patient returned for a review two weeks later. The occlusion was rechecked, contacts assessed and final photographs obtained. The patient commented, “This is so cool…..I don’t look like a little kid anymore. I feel like a real teenager now.”
I was happy with the final shade, shapes and imperceptible margins. I am confident that this should be the treatment of choice for most adolescent and many adult patients. With the aesthetic qualities of Venus Pearl and its ease of use, this becomes a simple and reproducible technique for any general dentist. It is now the mainstay of my clinical practice.