Aesthetic and Restorative Dentistry Techniques: Maxillary Central Incisor Restoration

My patient is female, 36 years old, married and have 2 children, work as social economy assistance, train in gym 2-3 days in a week, don’t smoke, no alcohol.

Oral hygiene: brush twice daily with fluoride toothpaste and electric toothbrush, use approximal cleaning, she thinks that its little difficult with flossing in molar regions, fluoride mouth wash daily.

Diet: 3 meals every day, snack in the evening once weekly, no sugar in tea and coffee.

Medical history:

Patient is healthy, nil medicine, nil allergy.

Dental history:

The patient didn’t visit dentist för 2 years, she thinks that her teeth is very healthy and don’t need to visit dentist for checkup.

Chief complaint:

The patients visited my clinic to treat the fracture in tooth 21, the old trauma to 21 with leads to tooth necrosis after many years, an endodontics treatment did to the tooth, but it has been yellow discolored after the endodontics treatment, tooth 21 has been fractured again while she played with her son. Fig 1. Patients seek emergency treatment of 21 to improve the shape of tooth after fracture then to discuss a permanent treatment of this discolored and fractured tooth.

Extra Oral Examination:

Face profile: Normal side view (normal profile), symmetrical face. Fig.2

TMJ Examination:  normal TMJ movement, no crepitus or grinding, more than 35mm measuring av inter incisal distance when patient is fully open sin mouth, normal lateral movement more than 12mm each side, no pain or tenderness of mastication´s muscles. My patient doesn’t have pathological teeth wear, no history of recurrent teeth fractures.

Lip seal: competent lips.

Lymph nodes: normal, no swelling or tenderness in lymph nodes.

Intra oral examination:

Lips, labial and buccal mucosa, palate, floor of the mouth, tongue are normal.

Hard and soft tissue examination:

Teeth assessment:

No signs or symptoms of teeth wear or non caries tooth lost.

Tooth 14d: enamel caries.

Tooth 21: endodontics treated, no evidence of apical changes. Yellowish discolored, fracture which involves m,b,p i sides, the suitable diagnosis of 21 is: enamel-dentin fracture.

Tooth 26o: resin composite restoration.

Tooth 27d: dentin caries.

Tooth 28m: dentin caries.

Tooth: 37o: resin composite restoration.

Tooth 46o: resin composite restoration. Fig 3.


Tooth 14d: Remineralization which is calcium and phosphate irons supplied by external source and deposit inside spaces in the crystalline of demineralized enamel to increase the crystalline lattice which is achieved by removing the biofilm from tooth surfaces by brushing and flossing, brushing with highly fluoride toothpaste is recommended.

Tooth 21: this tooth is the chef complaint of the patient because of discoloration and fracture, did an emergency treatment and build up with resin composite restoration to achieve better aesthetic appearance. Permanent treatment will be discussed in detail.

Tooth 27do & 28mo will restore with resin composite restoration or extraction option is available for 28.

Information to the patient to keep good oral hygiene. The most important reason of placing a restoration is to aid plaque control, the caries process is sent back to the tooth surface to start again, therefore it is important do preventions method to prevent caries progression.

Periodontal assessment:

Patient brush twice daily with fluoride toothpaste, use approximal cleanings methods like flossing.

Risk factors:

Acquired local factors: generally little plaque and calculus in lower anterior teeth.

Acquired systemic factors: no smoking, no alcohol, sometimes stress in work.

Anatomical: no anatomical problem, Fig.4

Periodontal screening with BPE score:

       1        1         1
       1        1         1

Treatment of periodontal disease:

# Oral hygiene instruction like brushing and flossing daily, Removal of plaque retentive factors like supra gingival calculus. Fig 4

#Rutin visits to dental hygienist and new assessment with BPE score every visit.

Treatment planning for aesthetic dentistry

It considers the same basic principles as another form of restorative dental care; it should be all active disease stabilized as a priority by helping to restore oral health and function with acceptable aesthetic outcome.

# Acute stage, treatment in this stage can range from the little pain because of hypersensitivity of dentin which needs applying varnish to seal dental tubules to placement of splint for treatment of incomplete fracture.

This patient received an acute treatment in the first visit which was: tooth 21 with big fracture and patient need to do a filling to improve aesthetics, don’t matter about the discoloration now.  

Acute treatment begin with checking the fractured tooth 21, amount the tooth loss and surfaces which involved in fracture which was m,b,p,I surfaces, no caries, no crack, no pathological pocket, previous restoration which was composite restoration in palatal surface due to previous endodontic treatment.

Took a photograph and x-ray to tooth 21, Fig 5.                                                                                                                  

 After the checking of x-ray and photograph, tooth 21 is endodontically treated with good root filling, no evidence of apical pathology and no bone destruction, 21 is yellow discolored.

Acute treatment is temporary build-up 21 with composite resin to restore shape of tooth using the same tooth shade, Fig 6, this provision treatment did in the first visit.                                                              

# Preventative phase, in this phase try to advise patients to prov dental health and hygiene, in my patient’s situation oral hygiene is good, it’s important to advise her to be more effective in toothbrushing and flossing specially in molar region that will minimize calculus accumulation, advise her to use fluoride mouth wash and sometimes chewing gum with fluor, Fluoride is the primary intervention for the prevention of dental caries, the fluoride ion act by driving remineralization duo to solubility product differences between hydroxyapatite and fluorapatite which will lead to minimize enamel solubility.

 It’s vital to assess the efficacy of the preventative phase, this involves evaluation of habit change, plaque and calculus, it was done after 3 and 6 months with very good results.

# Stabilisation: in this phase will take the effect of pathology and the management of carious lesions, active periodontal disease, soft and non-dental tissue lesions.

The patient needs first to treat the caries decay in teeth 27,28 with caries removal then composite resin restoration.

Tooth 27 was examined with vitality test, it was vital with both electric and cold test, no pathological disease in x-ray, no deep pockets, then tooth restored with composite resin restoration, it was deep caries near the pulp chamber.

Tooth 28 was extracted according to patients need. Fig.7                                                              

Treatment of periodontal disease that is calculus, there are no deep periodontal pockets, treatment is scaling of sub and supra calculus, instruction and information to improve her dental hygiene.

After several weeks interval re-evaluating patients’ compliance with preventive and stabilization stages, and after 6 months, new check-up and assessment of teeth and periodontal tissue, the result is good with good oral hygiene, no calculus, no evidence of new caries decay.

My patients’ aesthetic desire and expectations are normally realistic.

I will discuss with patient treatment options of tooth 21 which firstly is internal bleaching due to yellow discoloration then composite resin restoration the missing part of tooth if the shade of the tooth be satisfied after bleaching, it’s important to keep oral hygiene good during and after treatment.

Another treatment option is achieving a better smile which needs to treat the tooth 21 without bleaching and with little preparation on buccal side to try remove the discoloration to achieve acceptable shade, then build up the buccal and fractured area with direct composite veneer or make a preparation for the indirect porcelain veneer or crown.

Composite resin, porcelain veneers or crown will be the final restorations, patient know price of each option, properties of composite and veneers must patient know like treatment with composite resin has high risk of discoloration and low maintenance time compared with porcelain veneer or crown.

All treatments options should be presented in comprehensive written format and signed copy retained in dental records; these treatment planning options will include financial options of each treatments plan, and duration of treatment that will be take one or many visit. It should give the patient full information about the maintenance of both material porcelain is much better than composite resin.

I gave the patient many days to think about treatments options, the patient decided to improve his smile with treatment of tooth 21 with direct composite veneer, which is less price than the other porcelain restoration and can archived in one visit.

# Definitive phase which includes definitive direct restoration and replacement of aesthetically compromised restorations.

In this stage assess the need for all surgical, periodontal and orthodontics treatment.

# Definitive complex restorations, this may indicate the need of crowns, onlay or veneers restorations.

Any edentulous spaces may also need to be restored in this phase by removable denture, fixed bridgework or dental implants.                                                    

Restoration of the 21 with direct composite resin veneer

# The first step of treatment is checking the occlusion of the tooth 21, there is slight contact of incisal edge of lower anterior teeth with the apical third of palatal surface of tooth 21, Fig 7.a.  Impression with putty(silicon) taken to palatal surface of 21 while the tooth I ready build up with temporary composite filing, this silicon index will help to make an accurate palatal shell with composite. Fig. 7.b.

# Remove the temporary composite restoration and make all the edges bevel, Fig 8.a, check the silicon index in place fig 8.b.

# Preparation the buccal surface för composite veneer. Fig 9.

# Isolation the maxillary anterior teeth with rubber dam. Fig.10.

# Etching (total etching) the enamel and dentin with phosphoric acid 37% for 15 seconds then rinse the acid with air-water spray and dry it with airflow. Fig 11.a, then apply the adhesive bonding agent scotchbond universal, rub the bond for 20 seconds, Fig 11b, then gentle air dry for 5 seconds then light cure for 10 seconds Fig 11.c.

#Application the silicon index and make the palatal shell with composite resin (Estilite Asteria, Tokuyama dental*) Fig .12. a, then remove the silicon index and check the palatal shell Fig 12.b, put the sectional matrix band and wedge to ensure good contact area with the adjacent tooth, Fig 12.c.

# Select the proper shade of composite, the shade of composite selected with help of adjacent tooth 11 which is A1 (vitapan scale) Fig 13.

# Build the body and inner layer of composite shade A1B then the enamel layer with composite Estilite WE (white enamel), Fig 14, the shade of the result was dark compared with 11 while I used the most bleach shade of composite, this shade failure due to heavy discoloration of tooth.

Remove all the composite layers and re-etch and re-bond then use an opaque flow composite (beautifil opaquer) to mask discoloration, then composite body layer (A1B), then composite enamel layer (WE), which give the good shade and patient was satisfied.

With the incisal view can check the width of 21 Bucco-palatal and buccal surface which is must be with the same level of tooth 11, Check the contact area with 11 and check the palatal surface for any overhang then check the occlusion contact with lower teeth with occlusions paper. Fig 15.a

Polishing and correction of some points and angles was done. Fig 15.b

*Filler:82 WT% supra nano spherical filler (200 nm Sio2-ZrO2). Base resin: Bis-GMA, Bis-MPEPP, TEGDMA, UDMA.

Maintenance of direct composite resin veneers

# Brush with an ultra-soft toothbrush two times a day.

# Reduce exposure to materials which make tooth staining like tobacco, coffee, tea, curry, cola ets.

# Don’t rinse routinely with mouthwash that contains alcohol because alcohol can soften bonded composite resin.

# Sodium fluoride is the only home fluoride that should be used.

# Habits such as opening packages with your teeth, biting thread, nail biting, or pipe smoking should be avoided.

Current composite material lasts for long time, but it depends on habits and how much stress is placed on the front teeth, with presence of proper care.

Critically appraise of the functional and aesthetic outcome

In this case the tooth was very discolored, which needs to think about the type of material will use or need to think about internal bleaching before do treatment.

This patient did not want to make bleaching to avoid extra payment for bleaching which make the treatments option restricted such using lithium disilicate crown with do not have discoloration block property.

The sequence of direct composite resin veneers procedure is very important, which leads sometimes to unacceptable results of treatment if some step or steps are missing. I took the shade after cavity preparation and rubber dam places, the tooth was dehydrated and choosing of shade was wrong.

The result of composite veneers is good, and the patient was satisfied, the advantages of direct composite resin are direct placement, easy to modify or repair, low cost while disadvantages are discoloration, surface staining, plack accumulation and limited wear resistance the aesthetic appearance of composite declines over time.

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