Figures 1a, 1b: This patient had peg laterals and a congenitally missing maxillary left canine. Because her natural teeth were not discolored, malformed or misaligned, but only lacking in size and shape, I determined that the additive technique of direct composite bonding would be an appropriate, minimally invasive treatment.

Figure 2: To treatment plan this case, I poured a second set of casts and created a diagnostic wax-up of the esthetic areas. I reduced the length of tooth #10, which originally was about even with the centrals, to achieve a better esthetic result. I applied wax to the mesial and distal surfaces of teeth #7 & #10, and to prevent the laterals from appearing too wide I added wax to the mesial portions of teeth #6 & #12. The left bicuspid occupies the space of the congenitally missing canine on that side of the arch, so I’m attempting to mimic the left canine by extending the bicuspid, lengthening it a little bit and bringing the mesial surface over.

Figure 3: From the wax-up, I fabricate a putty matrix that enables me to transfer the planned changes from the wax-up model into the mouth. I position the putty matrix intraorally along the incisal edge to allow me to see the planned position of the incisal edges. Also, the scalloping of the matrix helps me determine exactly where to position the interproximal areas on each tooth. The only area where I will remove tooth structure will be on the incisal edge of tooth #10, with the rest of the areas built up with composite resin.

Figure 4: At the start of the case, I recommend the use of a prophy cup and pumice to clean the tooth surfaces.

Figure 5: Prior to isolation, I try in the putty matrix to verify that it seats completely with the rubber dam in place. I then place a rubber dam to avoid contamination, because I will be performing bonding procedures on multiple teeth. I use the second-to-smallest hole punch so it will be more constricting at the base of each tooth. For additional stability, I place individual floss ligatures.

Figure 6: I apply phosphoric acid in a 37% concentration to all of the surfaces to be bonded. Because I am entirely in enamel, I will allow the acid to etch the surfaces for at least 20 seconds. To ensure the desired area is etched, it’s a good idea to apply the acid at least 2 mm beyond the anticipated restorative area. I like Gel Etchant from Kerr Corporation (Brea, Calif.) because of the material’s ideal viscosity and how it rinses off very quickly. When applying the etchant to the mesial surfaces of the laterals, I protect the centrals with a clear matrix.

Figure 7: Once I confirm the enamel surfaces have a frosted appearance, I apply Scotchbond™ Universal bonding agent (3M Company; St. Paul, Minn.) to all of the bonding surfaces. Like the etchant, I extend the bond slightly beyond where I expect to apply the resin. Once the bond is applied, I air-thin the bond to ensure the solvents evaporate. After drying, I polymerize the material for 10 seconds.

Figure 8: I begin the resin application with a spatula-shaped instrument by applying the material cervically to establish a new, natural emergence profile. The putty matrix aids in determining the new incisal edge position, and the interproximal scalloping along the incisal embrasures indicates exactly where I should extend the resin application on the proximal surfaces. I use the spatula resin applicator for most of the resin placement and shaping. For some of the finer shaping, an explorer or probe can be used. I light-cure for 20 seconds to fully polymerize the material.

Figure 9: In the esthetic zone, I try to shape the resin close to the final contours as much as possible, but slightly over-bulked. Rather than spend too much time smoothing the restoration during the resin application, I find it faster to dial in the final contours during the polishing phase. Before moving ahead to polishing, I’ll use a #12 blade to remove any roughness along the transition between the natural tooth and the resin application. Any overhangs or roughness can lead to gingival inflammation.

Figure 10: I like to use Sof-Lex™ discs (3M Company). The darker colors of the Sof-Lex discs are used primarily for gross reduction, and the lighter ones are used for refining the contours and margins and also removing any large areas of surface roughness. The lightest colors allow the polishing of the restorations to a high shine. My goal is for the margins to be indiscernible. After checking the occlusion, I’ll use a slow-speed round bur to adjust any high spots. It typically will remove the composite material with a minimal effect on the enamel.

Figure 11: I finish the restoration with a coarse composite polisher and then a fine composite polisher, to remove any surface scratches. It is important to polish well and get the surface as smooth as possible. Ensuring there’s no porosity in the composite will minimize the composite’s susceptibility to staining in the future.

Figure 12: I finalize the polishing by using an Occlubrush^® by Kerr Corporation. It has special impregnated fibers that polish the composite material to a high shine without the need for an additional paste. After that, I can check the restorations with floss, and confirm smooth contacts and the absence of rough areas along the transition to the natural tooth.

Figures 13a–13c: The patient was very excited about the final esthetic improvement. The completed composite treatment served as a minimally invasive way to alter the shape of the teeth in an affordable, reversible manner.

Figures 13a–13c: The patient was very excited about the final esthetic improvement. The completed composite treatment served as a minimally invasive way to alter the shape of the teeth in an affordable, reversible manner.

Figures 13a–13c: The patient was very excited about the final esthetic improvement. The completed composite treatment served as a minimally invasive way to alter the shape of the teeth in an affordable, reversible manner.

Figures 2a, 2b: Clinical evaluation revealed spaces between all anterior teeth, excessive gingival display throughout the esthetic zone and smaller clinical crown dimensions. In discussing treatment options with her, I recommended minimal-prep Obsidian veneers for teeth #4–12 and a crown-lengthening procedure.

Figures 2a, 2b: Clinical evaluation revealed spaces between all anterior teeth, excessive gingival display throughout the esthetic zone and smaller clinical crown dimensions. In discussing treatment options with her, I recommended minimal-prep Obsidian veneers for teeth #4–12 and a crown-lengthening procedure.

Figure 3: Using a diagnostic wax-up, I can fabricate a putty matrix to create an acrylic mock-up. This is an optimal method for evaluating the treatment plan, including the esthetics, function and speech.

Figure 4: After the patient has accepted the treatment plan, it’s time to move ahead to the gingivectomy. I use the Waterlase iPlus (BIOLASE, Inc.; Irvine, Calif.) to outline the new contours. For this initial step, I select a laser bandage preset, which allows me to superficially score the gums.

Figure 5: Next, I advance to a higher-wattage gingivectomy setting to steadily cut the tissue. With its easy-to-navigate interface and many presets, the Waterlase iPlus system is intuitive and straightforward to use.

Figure 6: After completing the crown lengthening procedure, I use Luxatemp Ultra^® (DMG America; Ridgefield Park, N.J.) in shade A1 to temporize the patient. The temporaries guide the soft-tissue healing.

Figure 7: When the patient returns for the final appointment, I use NX3 Nexus™ Third Generation (Kerr Corporation) to cement the Obsidian veneers on teeth #4–12. As this case shows, Obsidian veneers are exceptionally natural-looking in shade and translucency.

Figure 8: Post-gingivectomy, the gingival margins are more harmonious. Improving the contours and height of the gingival veil was pivotal for the overall esthetic outcome.

Figure 9: The patient was delighted upon seeing her new smile. The Obsidian veneers, in conjunction with the gingivectomy, resulted in a more proportional, vibrant smile.