Perfecting Esthetics in Real Time

A 40-year-old male patient, who was a referral from the Kois Center, presented for a conservative solution to his discolored and fractured tooth No. 9 (Figure 1). His chief complaint was that his front tooth had a filling that was falling out. Per practice protocol, the patient was asked to come in for a consultation, photographs, and a provisional solution to his problem (if desired) with the understanding that an additional appointment would be necessary to accurately match his adjacent dentition using a more time-intensive technique.

The patient scheduled immediately, and at the appointment, a comprehensive head and neck exam was performed, digital radiographs were acquired, and preoperative diagnostic and shade photographs were taken. The radiographs revealed that tooth No. 9 had previously received endodontic therapy, and upon further questioning, the patient reported that this area experienced trauma during a bicycle accident that occurred when he was 15 years old. Tooth No. 9 had remained asymptomatic since the endodontic treatment was performed; however, in his mid-30s, the patient did notice discoloration and consequently underwent an internal bleaching procedure.^4,5 The result was an excessive value and a lighter shade when compared with the adjacent teeth (Figure 2), which was a byproduct not only of the whitening procedure's duration but also of the fact that the nonvital pulp chamber was filled with little more than a cotton pellet.⁴

Upon reviewing the macrodental casework images chairside with the patient, a subtle yet noticeably decreased value in tooth No. 8 was made clear (Figure 3). This was imperceptible to the naked eye but discovered through the use of macrophotography.² The patient was presented with both indirect and direct solutions, and he was informed of the probable need to restore tooth No. 8 in addition to tooth No. 9 given the iatrogenic mesial enamel scalloping, history of trauma to the esthetic zone, and noted lower value.⁶ Because of the additional cost, time constraints, and possibility of ceramic remakes associated with the indirect treatment option, the patient elected for a direct resin veneer for tooth No. 9 with a composite core buildup to replace the cotton pellet. Should it be deemed necessary for ultimate smile esthetics, he would also receive external bleaching for teeth Nos. 7 and 8 to increase their respective values to his preferred shade, which was epitomized by tooth No. 10 (Figure 4).⁷

First, a monochromatic shade provisional composite restoration (IPS Empress^® Direct [A3 Enamel], Ivoclar Vivadent) was created. After the peripheral enamel was etched for 30 seconds with 37% phosphoric acid (Ultra-Etch^®, Ultradent), rinsed, and then dried, the composite was placed without a bonding agent, shaped, and then light cured for 20 seconds (VALO^® LED Curing Light, Ultradent). Functional excursions were dialed into the occlusion using a football shaped, extra-fine finishing diamond (BrioPrep 379EF.31.023, Brasseler USA), and the linguoincisal anatomy was shaped using a blue disc for simplicity (FlexiDisc^®, Cosmedent).⁷ After the anatomy was refined, a palatal index was created using an impression material (Express^™ STD Putty, 3M) with a light body wash (Aquasil^® Ultra XLV, Dentsply Sirona) for extra accuracy (Figure 5). The patient was then rescheduled to subsequently receive the artistic composite restoration.

Prior to the next appointment, all of the case images were studied, and simple image editing software techniques were used to visualize nuances in the anatomic strata and value analysis of tooth No. 8 and mirror them onto tooth No. 9 (Figure 6). A strategic shade map of the anatomy and these characteristics was then rendered, which corresponded to the methods and materials of recreation (Figure 7).^8,9 Finally, the "Lumisynchroma technique" was used to ascertain an accurate resin palette for the final design.¹⁰

At the next appointment, the area was isolated (OptraGate^®, Ivoclar Vivadent), and the composite mock-up was easily removed because tooth No. 9 was nonvital and did not require anesthesia. Shade buttons (IPS Empress^® Direct Flow [A3.5], [A3], [A2], [Trans Opal], Ivoclar Vivadent) were placed on tooth No. 8 according to the strategic shade map to validate both the shade and the thickness needed for each material (Figure 8).^3,8,11 These were then removed, tooth No. 9 was prepared with a 2.0-mm sickle-bevel at the fracture line, and a 0.5-mm chamfer margin was placed gingivally with an interproximal elbow. It should be noted that the preparation style employed was less conservative than is typical of composite resin veneers because of the nature of the discoloration. After a 1.0-mm infinite bevel was prepared onto the lingual surface and all internal and external line angles were softened using a blue disc, the lingual endodontic access was reopened, the cotton pellet was removed, and the pulp chamber was irrigated with a 2% chlorhexidine antibacterial solution (Consepsis^®, Ultradent) to remove any debris and achieve disinfection. Next, a 1.0-mm circumferential bevel was placed around the access to increase bond strength, and a 37% phosphoric acid was placed on the peripheral enamel for 60 seconds, rinsed thoroughly, and dried. Two layers of bonding agent (Adhese^® Universal, Ivoclar Vivadent) were then applied, vacuum thinned, and light cured for 20 seconds. To restore the 6.0-mm access (Figure 9), a thin layer of flowable composite (Tetric Evoflow^® [A3.5], Ivoclar Vivadent) was placed, followed by two 3.0-mm increments of bulk-fill composite (Tetric Evoflow Bulk Fill [A3.5 Dentin], Ivoclar Vivadent), each of which was light cured for 20 seconds.^8,9

The palatal index was fitted and scored along the lingual aspect of the infinite bevel using a thin gold instrument (IPCT Composite Instrument, Cosmedent). Tooth No. 9 was then etched for 60 seconds, rinsed, and dried. The bonding agent was applied in two thin coats and vacuum thinned both times prior to a 20-second light cure. Next, an increment of translucent opal composite was placed inside the index, shaped, thinned, and pressed against the lingual aspect of tooth No. 9. Using instrumentation and a brush (Compo-Brush, Smile Line), the palatal shell was formed, and then it was light cured for 20 seconds. The index was removed, and the flowable composite was applied between the palatal shell and lingual aspect of tooth No. 9 to anchor the shell. The entire restoration was then light cured for 20 seconds. Care was taken to remove any excess composite prior to curing, but after curing, the remnant flash was removed from the palatal shell using a blue disc (Figure 10).^10,12

Next, tooth No. 9 was layered according to the strategic map. This is where a high degree of planning is combined with immediate feedback using a tethered digital camera to perfect the outcome and decision tree. First, a layer of composite (IPS Empress Direct Flow [Dentin A3.5], Ivoclar Vivadent) was placed at the gingival margin to prevent issues with crevicular fluids during the course of the appointment. Dentin shade A3 was applied next, extending 4.0 mm incisal to the zenith, over the fracture to 1.0 mm cervical and to the incisal edge in mamelon-like striations. This increment was thinned considerably near the incisal edge to create adequate depth for subsequent resin strata, characterizations, and effects.^3,10,12 Dentin shade A2 was placed in the incisal third as vertical lobal highlights to increase the overall value and opacity. At this point, a macrophotograph was taken while the DSLR camera was tethered to a laptop for immediate visualization of the progression and fine-tuning of the strategy. It was noted that more opacity was needed at the incisal edge as well as horizontal striations in the cervical area. To accomplish this, an additional increment of shade A3 was added to the incisal third for increased opacity, and the A3.5 shade of the flowable was laced in horizontal striations in the cervical third using a brush and an explorer tine. Again, a photograph was taken to reliably check the refinements and position of each resin addition. White and ochre characterization materials (IPS Empress Direct Colors, Ivoclar Vivadent) were then added to recreate the white and amber highlights while preserving the mesial line angle and minor incisal edge translucencies. Each was placed with precision using an enlarged high-definition tethered progress image as a reference (Figure 11). Finally, an increment of the translucent opal composite was applied to the entire facial and interproximal surfaces of the restoration, refined with a brush and instruments, and light cured. At this stage, the vertical craze line could have been applied using a No. 12 scalpel blade; however, the last macrophotograph led the clinician to believe that because tooth No. 9 more closely matched tooth No. 10, teeth Nos. 7 and 8 would require 3 to 4 nights of external whitening in order to achieve perfect harmony in the esthetic zone. The patient reviewed the photograph with the clinician in real time and decided that he preferred the shade of teeth Nos. 9 and 10 to that of teeth Nos. 7 and 8 and wanted to proceed with bleaching treatment. Therefore, the decision was made to forgo the addition of the craze line and a high-gloss polish until the next appointment, and instead, a simple polish was performed with white, blue, and yellow polishing discs (Figure 12). The patient was sent home with a 16% carbamide peroxide bleaching gel (Kör-Night^TM, KöR) and instructed to bleach every night then video call the clinician each morning. This call allowed the clinician to ascertain the progress on a daily basis and prevent the patient from whitening past the desired shade. Due to the effect that polishing has on microfills (ie, a subtle increase in value), the ideal shade for teeth Nos. 7 and 8 would be just slightly higher in value than tooth No. 9 was currently, if the patient could even achieve such a shade.¹³

After 3 nights of whitening, the patient and clinician were satisfied with the results and the increase in the overall value of the smile. Concomitantly, the clinician had studied the final images from the previous appointment (Figure 12) and noticed the need for a minor cutback to better adapt the gingival shade to the smile. Furthermore, because of the magnified highlights from whitening, some additional white chroma would be needed at the incisal edge of tooth No. 9. After a 0.2-mm cutback was made and the proper adhesive protocol was performed, the alterations and refinements were made and an image was taken to validate the placement and shade. Finally, a single layer of trans opal shade composite was overlaid, establishing the proper facial contours and prominence.

The midfacial, vertical craze line was added to tooth No. 9 by tracing a penciled replication with a No. 12 scalpel blade, and then a contouring and polishing protocol was followed (ie, white disc, blue disc, blue cup, yellow disc, pink disc, finishing with polishing paste [Enamelize^™ Polishing Paste, Cosmedent], pink cup, buffing point, buffing wheel). After contouring and polishing, a thorough rinse was performed, and a final postoperative image was taken to validate and critique the final result, ensuring esthetic success and patient satisfaction.

From the treatment planning to the techniques and time management, there is a high degree of difficulty associated with cases such as these as well as a perpetual question mark regarding the compounding effects that each composite resin layer will ultimately have on the facial esthetics. The performance of multiple techniques such as large endondontic access fills and tiny additions of an opaquer while battling dehydration and eye fatigue can be challenging. The self-assurance from genuine preparation only goes so far, and macrophotography and the virtual immediacy of a tethered rig can provide key advantages to the practitioner when making game-time decisions. Given the proper settings, composition, light modifiers, and technique, using photography to perfect an esthetic outcome in real time is robotic in its precision and can set the practitioner apart as a clinician who is particularly skilled.

The author would like to thank photographer Dillon J. Shook for the pre- and postoperative portraits as well as his expertise and support.

Galen Detrik, DDS
Private Practice
Albuquerque, New Mexico

Clinical and Online Instructor
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