Carlos E. Pena, DDS

Graduate Student, Department of Operative Dentistry, Guarulhos University,

R Dr Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil

Ronaldo G. Viotti, DDS

Graduate Student, Department of Operative Dentistry, Guarulhos University,

R. Dr. Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil

Walter R. Dias, DDS, MS

Research Dentist, Dentsply Caulk, 38 W Clarke Ave, Milford, DE, 19963, USA

Edward Santucci, DDS, MS

Director of Clinical Research, Dentsply Caulk, 38 W Clarke Ave,

Milford, DE, 19963, USA

Jose A. Rodrigues, DDS, MS, PhD

Assistant Professor, Department of Operative Dentistry, Guarulhos University,

R. Dr. Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil

Andre F. Reis, DDS, MS, PhD

Assistant Professor, Department of Operative Dentistry, Guarulhos University,

R. Dr. Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil

CLINICAL APPLICATION

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Esthetic rehabilitation of anterior

conoid teeth: comprehensive

approach for improved and

predictable results

Correspondence to: Dr. Andre F Reis

Department of Operative Dentistry, Guarulhos University, Rua Dr. Nilo Peçanha 81, Predio U, 6o. Andar,

Guarulhos, SP, Brazil, 07011-040, Phone: +55 11 6464-1769 Fax: +55 11 6464-1758, e-mail: areis@prof.ung.br

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composite resin used for the esthetic reha-

bilitation of a patient presenting conoid lat-

eral incisors, and an unsatisfactory class IV

restoration in the left central incisor are

presented. An accurate diagnostic and in-

terdisciplinary approach is necessary for

obtaining improved, conservative and pre-

dictable esthetic results in esthetically

compromised areas, such as the anterior

maxillary dentition.

(Eur J Esthet Dent 2009;4:XXX–XXX.)

Abstract

The esthetic success of a dental treatment

depends on the correct diagnosis, treat-

ment plan and clinical and laboratory pro-

cedures. This clinical report describes a

diagnostically based protocol for conser-

vative preparations on anterior teeth for ad-

hesively retained composite and porcelain

restorations. The diagnostic additive wax-

up, periodontal esthetic crown-lengthen-

ing, direct acrylic mock-up, conservative

preparations for ceramic laminate veneers,

luting procedures, direct restorations with

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Introduction

The increasing demands of patients and

clinicians regarding esthetic restorations,

together with the improvements in adhe-

sive materials, composite resins and den-

tal porcelains have brought the possibility

of conservative long-lasting esthetic treat-

ments.1

Due to their lifelike appearance,

porcelain laminate veneers are often se-

lected for the esthetic restoration of the an-

terior dentition. The use of laminate ve-

neers and composite resins has matured

to a predictable treatment method in terms

of longevity, periodontal status and patient

satisfaction.2,3

Porcelain laminate veneers and com-

posite restorations offer a predictable op-

tion for creating a successful restorative

treatment that also preserves maximum

tooth structure.3-5

For conservative veneer

preparations, two essential tools are re-

quired during diagnostic steps and tooth

preparation procedures: the additive diag-

nostic waxup and the acrylic mock-up.6

When there is no need for color masking,

a minimal reduction of tooth structure al-

lows the translucency of the veneer to ren-

der a natural appearance. Furthermore, an

ultraconservative preparation preserves

the available enamel for bonding, thus in-

creasing the prognosis for long-term bond-

ing success.7

Factors contributing to the composition

of a pleasant smile, such as amount of gin-

gival display, gingival architecture, clinical

crown dimensions and tooth position play

an important role in the esthetic value of a

cosmetic restoration.8,9

In such cases, an in-

terdisciplinary approach is necessary to

evaluate, diagnose, and resolve esthetic

problems using a combination of ortho-

dontic, periodontal and prosthodontic treat-

Figs 1 and 2 Preoperative views of patient’s face

and smile.

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ments. The aim of this clinical report is to

describe a diagnostically based protocol

for conservative anterior teeth preparations

for adhesively retained composite and

porcelain restorations. In addition, this pro-

tocol is associated with an esthetic gingival

plastic surgery for maximal esthetic effect.

Case report

A 22-year-old female patient was initially

seen at the Graduate Operative Dentistry

clinic of the Guarulhos University School of

Dentistry with the chief complaint of ‘poor

dental esthetics’ especially due to conoid

lateral incisors. Relevant dental history in-

cluded previous orthodontic treatment. Be-

sides presenting with conoid lateral inci-

sors, the gingival contour of both teeth was

approximately 3 mm coronal to the zeniths

of the canines and central incisors. Thus,

before embarking upon the prosthetic

treatment, the ideal harmony in this specif-

ic region should be restored.9Her left cen-

tral incisor presented an unsatisfactory

Class IV composite restoration, whereas

the right central incisor, although unre-

stored, presented an inverted incisal edge.

The right canine showed white spots, and

the left canine presented a small but discol-

ored composite restoration on the buccal

surface.

After the patient had expressed her

treatment expectations, clinical and radi-

ographic examinations were performed. In

addition, photographs (Figs 1 to 5) and

stone casts were obtained to complete the

initial documentation. Based on the exam-

inations and diagnostic tools, the existing

problems and major elements of the treat-

ment were explained to the patient. The se-

quence of treatment planning consisted of

Figs 3 to 5 Preliminary intra-oral view of maxillary

anterior teeth. The patient presented lateral conoids, un-

satisfactory composite restorations and the central in-

cisors showed inverted incisal edges.

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tissue was removed from the lateral inci-

sors and right canine.

After healing of the gingival tissue, casts

of the teeth with the new gingival contour

were performed. One set of casts were

used for fabricating a soft tray for the night-

guard vital bleaching technique with 10%

carbamide peroxide, and the other set of

casts were sent, together with the initial

photographs to the laboratory technician

who produced the diagnostic waxup (Figs

12 and 13), with which a silicon index (Fig

14) was used to fabricate a mock-up di-

rectly in the patient’s mouth. This was done

using an auto-mix self-cured methacrylate

resin (Integrity) (Fig 15). Before applying

the resin for the mock-up, the teeth were

isolated with petroleum jelly. The excess

resin was trimmed with a no. 12 surgical

plastic periodontal surgery to optimize the

gingival contour, bleaching with the night-

guard vital bleaching technique, diagnos-

tic waxup, acrylic mock-up, laminate ve-

neers for the lateral incisors and composite

restorations for the central incisors and ca-

nines. The list of materials and manufactur-

ers’ is presented in Table 1.

Figures 6 to 11 demonstrate the se-

quence of the esthetic crown lengthening

procedure. According to probing depth

(Figs 6 and 7) the gingival margin covered

approximately 4 mm of the crown of the lat-

eral incisors, thus no osseous tissue re-

moval was necessary to establish a pleas-

ant gingival contour and rearrange zenith

positions. The heights of the lateral incisors

are generally 1 mm shorter at the gingival

margin than are the central incisors.10,11

Soft

Table 1

Product Procedure Manufacturer

#12 surgical blade Gingivectomy BD Bard-Parker, Franklin Lakes, NJ USA

10% carbamide peroxide Bleaching FGM, Joinvile, SC, Brazil

High Viscosity C-Silicone, Zetaplus Silicon index Zhermack, Badia Polesine, RO, Italy

Self-cure methacrylate resin, Mock-up and Dentsply Caulk, Milford, DE, USA

Integrity provisionals

Diamond burs Preparation KG Sorensen, São Paulo, SP, Brazil

Ultrapak deflection cord Gingival deflection Ultradent Products Inc., South Jordan, UT, USA

Aquasil Ultra Heavy and XLV (Digit) Impression Dentsply Caulk, Milford, DE, USA

Calibra Resin Cement Luting Dentsply Caulk, Milford, DE, USA

IPS Empress Esthetic, Laminate venners Ivoclar-vivadent, Schaan, Liechtenstein

leucite glass ceramic

XP Bond, two-step etch&rinse adhesive Bonding Dentsply Caulk, Milford, DE, USA

Teflon tape Isolating Tigre S.A., Joinville, SC, Brazil

SmartLite IQ2 LED curing unit Light curing Dentsply Caulk, Milford, DE, USA

Esthet-X Micro Matrix Restorative Restorations Dentsply Caulk, Milford, DE, USA

Enhance/Pogo Finishing and Dentsply Caulk, Milford, DE, USA

polishing

Astropol rubber polisher polishing Ivoclar-Vivadent, Schaan, Liechtenstein

Enamelize diamond paste polishing Cosmedent, Chicago, IL, USA

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Figs 6 to 11 Sequence of the esthetic crown lengthening procedure.

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blade (Fig 16) and the final luster was ob-

tained with a light-cured resin material

(Lasting Touch, Dentsply Caulk). Minor de-

fects and irregularities of neighboring

teeth were also revealed by the mock-up.

Figures 17 to 19 shows the acrylic

mock-up, which was approved by the pa-

tient. The patient subsequently used this

mock-up for several days to evaluate if the

planned restorative procedures were com-

patible with her personality, face, smile, oral

functions and subjective expectations.6,10

For preparation of the lateral incisors, a sim-

Fig 14 Silicon index.

Fig 16 The excess resin was trimmed with a no. 12

blade.

Fig 15 The silicon index was used to fabricate a

mock-up using a self-cured methacrylate resin

Figs 12 and 13 Initial stone casts and diagnostic wax-up.

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Figs 17 to 19 The clinical situation of the mock-up

and its effect on the patient’s smile and face is shown

on Figs 17 to 19.

plified technique for porcelain laminates

driven by the diagnostic mock-up de-

scribed by Magne & Belser was used.12

The

advantages of this technique compared to

tooth-preparation techniques based on the

existing tooth surface are: time efficiency,

enamel preservation, subsequent improve-

ment of adhesion and mechanics, and re-

spect of the pulp. The recommended thick-

nesses for porcelain veneers are less than

0.5 mm in the cervical area, 0.7 mm in the

middle and incisal thirds, and greater than

1.5 mm incisal coverage.6,10,12

To accurately

achieve these dimensions, the tooth provi-

sionally restored by the acrylic mock-up

was prepared using round calibration dia-

mond burs guided by the template itself

(Fig 20). Two round diamond burs were

used in this step: no. 1014 (Ø 1.4mm) and

no. 1016 (Ø 1.8 mm), (KG Sorensen) to act

as differential depth cutters. The larger bur

is used between the middle and incisal

thirds to produce a groove of approximate-

ly 0.7 mm, and the small round bur is used

to create a groove of 0.5 mm between the

cervical and middle thirds. This technique is

very conservative and most of the enamel

should be preserved. The grooves were

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Fig 21 The grooves were then marked with a pencil.

Figs 23 and 24 Tapered round-ended diamond burs were used for removal of excess tooth structure.

Fig 22 The remnants of the mock-up were removed

with a scaler

Figs 20 to 26 For preparation of the lateral incisors,

a simplified technique for porcelain laminates driven by

the diagnostic mock-up was used. Two round diamond

burs were used in this step to act as differential depth

cutters.

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then marked with a pencil (Fig 21) and the

remnants of the mock-up were removed

with a scaler (Fig 22). Tapered round-ended

diamond burs were used for removal of ex-

cess tooth structure. Sufficient tooth reduc-

tion is obtained when the pencil marks dis-

appear (Figs 23 and 24). The need for

incisal reduction can be accurately checked

with the silicon palatal index (Fig 25). The fi-

nal tooth preparation can be observed in

Figure 26. The impression was made using

a polyvinyl siloxane material (Aquasil Ultra

Heavy and XLV Digit, Dentsply Caulk, Mil-

ford, DE, USA). The one-step/double-mix

impression in conjunction with a double

cord gingival displacement technique was

used (Fig 27).13,14

The impression was sent to

the lab technician together with the photo-

graphs obtained from the mock-up. Provi-

sional restorations were prepared using the

same silicon index that was used for fabri-

cating the mock-up.

Fig 25 The need for incisal reduction was checked

with the silicon palatal index.

Fig 27 The impression was made using a polyvinyl

siloxane material. The one-step/double-mix impression

in conjunction with a double cord gingival displace-

ment technique was used.

Fig 28 Intra-oral view of preparation of the lateral in-

cisors prior to luting procedures.

Fig 26 The final tooth preparation is shown.

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area, they were protected with a teflon

tape. The adhesive system was applied

(Fig 31) and a gentle air stream was used

to evaporate the solvent and air thin the

adhesive. A coat of adhesive resin was al-

so applied to the veneers. It was air thinned

but not light cured, in order to avoid prob-

lems with marginal fit. The resin cement

was dispensed directly onto the veneer

and the restoration was seated slowly. Ex-

cess was removed with a microbrush pri-

or to light curing for 60 seconds with an

LED (SmartLite IQ2, Dentsply) from the

buccal surface, followed by another 60

seconds from the palatal surface. Polymer-

ized excess resin cement was removed

with a No.12 surgical blade (Fig 32). Final

polishing of the margins was performed

with silicon dioxide rubber polishers (As-

tropol, Ivoclar-Vivadent).

In the following session, the central inci-

sors were restored with a microhybrid

resin composite (Esthet-X, Dentsply). A sil-

icon index was obtained from the working

model after the central incisors were

waxed-up and with the ceramic veneers in

place (a procedure that was performed

prior to the final cementation of the ve-

neers). This palatal index guided the

palatal and incisal shape of the restoration

(Fig 33). After etching enamel for 15 sec-

onds, the single bottle XP Bond adhesive

system was applied and light cured for 10

seconds. The first composite resin incre-

ment (shade Y-E) was inserted with the aid

of the silicon index and light cured for 20

seconds (Fig 34). The second composite

increment was formed using an opaque

resin (shade W-O) in an attempt to mask

the dark background and simulate dentin

mamelons (Fig 35). The incisal edge was

formed using shade W-E (Fig 36) and the

final increment to simulate enamel was

Figure 28 shows the preparation of the lat-

eral incisors prior to luting procedures. The

porcelain laminate veneers were made of

a leucite-reinforced ceramic (IPS Empress

Esthetic, Ivoclar-vivadent, Schaan, Liech-

tenstein) (Fig 29). Veneers were first

checked for seating and marginal fit on

their original stone die and then on the

tooth preparations. Laminate veneers were

luted with a light-cured resin cement sys-

tem (Calibra, Dentsply) in order to bond

the ceramic restoration to the tooth struc-

ture. The adequate shade for the resin ce-

ment was confirmed by using the try-in

paste and the light shade was selected. Af-

ter try-in procedures, the internal surfaces

of the veneer were thoroughly rinsed with

a water spray and air-dried. In order to ob-

tain an effective bonding to the leucite-

based ceramic a combination of microme-

chanical interlocking produced by etching

with 10% hydrofluoric acid for 60 seconds

and chemical coupling with a silane (Cali-

bra Silane Coupling Agent) was used.15 Af-

ter rinsing the etchant, and prior to applying

the silane, the veneers were placed in a

95% alcohol ultrasonic bath for 4 minutes.

After the internal surfaces of the ceram-

ic veneers were prepared, the teeth were

bonded for receiving the ceramic restora-

tions. Deflection chords (Ultrapak #000)

were used to isolate the preparations. A

two-step etch-and-rinse adhesive system

was used (XP Bond, Dentsply). The prepa-

ration was etched with 34% phosphoric

acid for 15 seconds (Fig 30), thoroughly

rinsed with water for 15 seconds and air-

dried. The dry bonding technique was

used because the conservative prepara-

tion was limited to enamel. In order to pro-

tect the adjacent teeth from being unnec-

essarily etched and prevent accumulation

of excess resin cement in the interproximal

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Fig 31 The adhesive system was applied and a gen-

tle air stream was used to evaporate the solvent and air

thin the adhesive.

Fig 33 A silicon index guided the palatal and incisal

shape of the restoration.

Fig 34 The first composite resin increment was in-

serted with the aid of the silicon index and light cured

for 20 seconds.

Fig 32 Polymerized excess resin cement was re-

moved with a No.12 surgical blade.

Fig 29 Porcelain laminate veneers were made of a

leucite reinforced ceramic.

Fig 30 The preparation was etched with 34% phos-

phoric acid for 15 seconds thoroughly rinsed with wa-

ter for 15 seconds and air-dried.

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Fig 37 The final increment to simulate enamel was

placed using shade A1 resin composite.

Fig 39 Finishing was performed with extra fine dia-

mond burs. Initial polishing was accomplished with

rubber cups, and the final luster was obtained with a di-

amond polishing paste.

Fig 40 The final composite restorations, together with

the ceramic laminate veneers can be observed.

Fig 38 The restoration prior to polishing is shown.

Fig 35 The second composite increment was

formed using an opaque resin in an attempt to mask

the dark background and simulate dentin mamelons.

Fig 36 The incisal edge was formed.

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placed using shade A1 resin composite

(Fig 37). The restoration prior to polishing

is shown on Figure 38. Finishing was per-

formed with extra fine diamond burs. Initial

polishing was accomplished with rubber

cups (Enhance Pogo, Dentsply), and the fi-

nal luster was obtained with a diamond

polishing paste (Enamelize, Cosmedent,

Chicago, IL, USA) (Fig 39). The white spot

on the right canine was also restored and

the composite restoration that existed on

the buccal surface of the left canine was

replaced.

Fig 40 The final composite restorations, together with

the ceramic laminate veneers can be observed.

Figs 41 to 43 The integration of the esthetic restora-

tive treatment with the patient’s lips is shown.

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References

1. Magne P, Magne M. Treatment of extended ante-

rior crown fractures using Type IIIA bonded

porcelain restorations. J Calif Dent Assoc

2005;33:387–396

2. Peumans M, De Munck J, Fieuws S, Lambrechts

P, Vanherle G, Van Meerbeek B. A prospective

ten-year clinical trial of porcelain veneers. J

Adhes Dent 2004;6:65–76

3. Magne P. Composite resins and bonded porce-

lain: the postamalgam era? J Calif Dent Assoc

2006;34:135–147.

4. Kois JC, McGowan S. Diagnostically generated

anterior tooth preparation for adhesively retained

porcelain restorations: rationale and technique. J

Calif Dent Assoc 2004;32:161–166.

5. Edelhoff D, Sorensen JA. Tooth structure removal

associated with various preparation designs for

posterior teeth. Int J Periodontics Restorative Dent

2002;22:241–249.

6. Magne P, Magne M. Use of additive waxup and

direct intraoral mock-up for enamel preservation

with porcelain laminate veneers. Eur J Esthet

Dent 2006;1:10–19.

7. Rouse J, McGowan S. Restoration of the anterior

maxilla with ultraconservative veneers: clinical

and laboratory considerations. Pract Periodontics

Aesthet Dent 1999;11:333–339.

8. Claman L, Alfaro MA, Mercado A. An interdiscipli-

nary approach for improved esthetic results in the

anterior maxilla. J Prosthet Dent 2003;89:1–5.

9. Fradeani M. Esthetic rehabilitation in fixed

prosthodontics. Volume 1: Esthetic analysis.

Chicago: Quintessence; 2004;352.

10. Magne P, Belser U. Bonded porcelain restorations

in the anterior dentition: a biomimetic approach.

Chicago: Quintessence; 2002.

11. Reddy MS. Achieving gingival esthetics. J Am

Dent Assoc 2003;134:295–304.

12. Magne P, Belser UC. Novel porcelain laminate

preparation approach driven by a diagnostic

mock-up. J Esthet Restor Dent 2004;16:7–16.

13. Perakis N, Belser UC, Magne P. Final impres-

sions: a review of material properties and

description of a current technique. Int J Periodon-

tics Restorative Dent 2004;24:109–117.

14. Cloyd S, Puri S. Using the double-cord packing

technique of tissue retraction for making crown

impressions. Dent Today 1999;18:54–59.

15. Soares CJ, Soares PV, Pereira JC, Fonseca RB.

Surface treatment protocols in the cementation

process of ceramic and laboratory-processed

composite restorations: a literature review. J

Esthet Restor Dent 2005;17:224–235.

The final composite restorations, together

with the ceramic laminate veneers can be

observed in Fig 40. The integration of the

esthetic restorative treatment with the pa-

tient’s lips is shown in Figures 41 to 43. The

pleasant smile, as seen in figure 44 shows

the success of this esthetic treatment.

Conclusion

The present report describes an interdisci-

plinary approach for obtaining an excellent

final esthetic and functional result. Predict-

ing the treatment outcome is essential

when planning a substantial esthetic reha-

bilitation. The diagnostic steps were ex-

tremely important tools for the ultraconser-

vative laminate preparations and for the

satisfaction of the patient.

Acknowledgements

The authors give special thanks to Mr. José Carlos Ro-

manini for the excellent work on the ceramic laminate

veneers.

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