PMC5477167_01
Initial smile showing the inverted smile arc.
ccide-9-027Fig1.jpg
PMC5477167_01_ccide-9-027Fig1.jpg
f1-ccide-9-027
Initial case showing extensive restoration in the anterior teeth and inappropriate axial inclination of the incisors, which is considered as essential for smile esthetics.
ccide-9-027Fig2.jpg
PMC5477167_01_ccide-9-027Fig2.jpg
f2-ccide-9-027
On radiographic examination and pulp vitality test, the teeth showed vitality, with no signs of periodontal injuries (Figure 2).
(A) Diagnostic wax-up; and (B) cosmetic mock-up.
ccide-9-027Fig3.jpg
PMC5477167_01_ccide-9-027Fig3.jpg
f3-ccide-9-027
Then, the dental esthetic planning was performed and used as a reference for the realization of wax-up diagnostic by the progressive technique with wax type II (Asfer, Sao Paulo, Brazil; Figure 3A). TM 4, 3M ESPE). This mock-up is adapted in the mouth of patient (Figure 3B).
Clinical sequence of procedures.. Notes: (A) Removal of unsatisfactory restorations using a diamond bur; (B) dental substrate after removal of resin composite; (C) installation of nonimpregnated gingival retraction cord; (D) acid etching of the enamel for 30 seconds and dentin for 15 seconds (35% phosphoric acid); (E) rinsing for 30 seconds; (F) drying with slightly damp cotton aiming at humidity control of dental substrate; (G) Adper Single Bond 2 (3M ESPE) layer was applied according to manufacturer's instructions; (H) adhesive system light-cured for 20 seconds; (I) The adaptation of silicone guide was checked to perform the restoration of the palatal face; (J, K) composite resin increment first inserted in palatal face; (L) resin composite increments simulating the dentin; (M) surface resin composite increments simulating the enamel; (N) anatomical characterization of restoration with fine diamond bur; (O) all-ceramic crowns in units 14 and 23; (P) final restorations after finishing and polishing of resin composites.
ccide-9-027Fig4.jpg
PMC5477167_01_ccide-9-027Fig4.jpg
f4-ccide-9-027
The case was accomplished with direct restorative treatment (units: 13, 12, 11, 21, and 22) after obtaining clinical and patient approval (Figure 4). Units (14-24) were isolated, and the existing restorations were removed with a spherical diamond bur #1014 (KG Sorensen, Barueri, Brazil; Figure 4A and B). After teeth preparation, a retraction cord (Ultradent, Indaiatuba, Brazil) was used to ensure dryness of the gingival sulcus and to promote gingival retraction to view the margin of restoration (Figure 4C). The enamel and dentin surfaces were treated with 35% phosphoric acid gel (Ultradent) for 30 and 15 seconds, respectively (Figure 4D). The phosphoric acid was rinsed for 30 seconds and the excess water was removed with cotton pellets (Figure 4E and F). A two-step etch-and-rinse adhesive Adper Single Bond 2 (3M ESPE) was applied according to the manufacturer's recommendations (Figure 4G and H). The silicone barrier was positioned to reproduce the palatal portion of the teeth (Figure 4I) with a thin layer of a nanocomposite (WE-Filtek Z350 XT , 3M ESPE; Figure 4J and K). The body resin shade A2B (Filtek Z350 XT, 3M ESPE) was used to reproduce the dentin tissue (Figure 4L). Finally, WE-Filtek Z350 XT resin was reapplied, filling all the restored surfaces (Figure 4M). Then, polishing was performed using a felt polishing cloth associated with diamond pastes (Enemalize; Cosmedent, Chicago, IL, USA; Figure 4N). After finalization of the direct restorative procedures, a resin luting cement (Rely-X Arc, 3M ESPE) was used for cementing all-ceramic crowns (Figure 4O). Figures 4 and 5 demonstrate the final aspect of the restorative treatment.
Final case.. Note: Appropriate axial inclination of the incisors which is considered as essential for smile esthetics.
ccide-9-027Fig5.jpg
PMC5477167_01_ccide-9-027Fig5.jpg
f5-ccide-9-027
Figures 4 and 5 demonstrate the final aspect of the restorative treatment.
Final smile.. Note: Predominance of central incisors and the correction at inverted smile arc.
ccide-9-027Fig6.jpg
PMC5477167_01_ccide-9-027Fig6.jpg
f6-ccide-9-027