Clinical Considerations and Technique for Providing Direct Veneers to the Adolescent Patient
Direct resin restorations offer a conservative approach that is often ideal for teenagers and young adults.
Children and young adults who have damaged and/or rotated teeth are still growing, and their teeth are often continuing to erupt. While orthodontic therapy is often indicated for these patients, many cases can be effectively treated via direct resin for immediate esthetic enhancement with little investment of both time and finances.1 Whereas porcelain laminate veneers may represent the optimal treatment option for adults with malpositioned, rotated, or unesthetic dentition, the more conservative approach afforded through direct resin restorations is frequently the best treatment modality for adolescents, in part due to their higher potential for trauma and for the favorable failure mode of resins compared to ceramics.1
Prosthetic treatments have been historically discouraged in young patients due to the difficulty of achieving the desired outcome and the limited longevity anticipated as a result of the maturation and volumetric changes associated with adolescents’ hard and sowft tissues.2 Approaching a case via direct resin therapy can also more effectively inform future orthodontic caregivers about the desired results as well as restore the confidence of teenagers and young adults through cosmetic treatment.
Principles of minimal intervention further influence the choices clinicians make daily in the care of their patients, affecting treatment planning and the treatment procedures themselves.3,4 Esthetic treatment of chipped anterior dentition, as well as diastemata or discolored or carious teeth can be effectively managed through a conservative approach to tooth preparation and subsequent resin placement.2-4
The physical and optical characteristics of today’s resin materials (eg, Esthet-X® HD, DENTSPLY Caulk,www.caulk.com; Point 4™, Kerr Corporation, www.kerrdental.com; Filtek™ Supreme, 3M ESPE, www.3MESPE.com), with their ability to be polished to a natural luster and to address the full range of shades displayed in the natural dentition, enable them to be used with minimally invasive techniques in support of direct restorations for posterior and anterior dentition.5-8 Their opalescence and translucency allow the clinician to mimic the natural teeth when used as either single-shade or multiple-shade restorations. Furthermore, the handling properties of microhybrid resins enable the clinician to deliver a highly esthetic and predictable restoration that begins to approximate the longevity of prosthetic alternatives. The versatility of these composite materials help enable the clinician to more precisely and predictably place them for the accurate reproduction of natural tooth structures.
The following case demonstrates a conservative treatment sequence where direct resin veneers were used to treat fractured anterior dentition and canting on a 16-year-old patient.
A 16-year-old male patient presented with a chief complaint regarding the esthetics of his maxillary anterior teeth. Teeth Nos. 7, 8, and 9 exhibited significant incisal edge fractures and minor canting that affected the smile line and the appearance of the midline (Figure 1). The patient desired a conservative treatment that would not cause the removal of sound tooth structure. After a thorough clinical examination that included digital photographs (Figure 2), radiographs, and examination for dental disease, occlusal factors, and esthetic disharmonies,9 a conservative treatment plan was developed. Although orthodontia was a consideration, the patient’s esthetic objectives required an expedient treatment alterative, ie, direct resin veneers. This modality was presented to the patient and, once informed consent was obtained, treatment commenced.
Tooth Preparation and Surface Conditioning
Minimal tooth reduction was initiated using a finishing diamond to roughen the facial surfaces of the anterior teeth. Tooth reduction was used to correct the proper arch form and, as possible, confined to enamel. This would ensure a uniform, even facial plane and a surface conducive to predictable resin bonding (Figure 3 and Figure 4). Care was taken in the preparation of tooth No. 8 to ensure that subsequent resin placement and contouring would enable correction of the midline discrepancy observed preoperatively. The clinician also ensured that the preparation design would allow for a seamless transition from the final translucent enamel shade of microhybrid resin to the natural tooth structure.
Each tooth was isolated with “dead soft” aluminum foil, etched with 34% phosphoric acid (TC Gel, DENTSPLY Caulk) for 15 seconds, and dried according to the “total-etch” technique. A fifth-generation bonding agent (Prime & Bond® NT™, DENTSPLY Caulk) was then generously applied over the preparation and allowed to sit for 20 seconds before it was air-thinned and cured with a halogen light (Figure 5). This approach was repeated on each tooth individually in order to prevent collapse of the collagen fibrils that may have been exposed at the hybrid layer and other undesired sequellae (eg, overdrying, overetching) that could have minimized the desired bond strength of the restoration to the etched tooth structures.
Resin Stratification for Natural Color
Using a freehand bonding approach, a body shade (A1) of composite resin (Esthet-X® HD) was applied to the facial surface of the tooth (Figure 6). The resin was delivered via compule, as the material was more pliable when dispensed accordingly for application and shaping. The body material was sculpted to full contour at the cervical third and tapered incisally to provide space for the application of enamel-shaded composite resin. Dentin mammelons were formed to provide esthetic incisal edge effects and to retain the patient’s youthful appearance. When the dentin body material was contoured (Figure 7), the material did not need to be smoothed facially; the mammelons were sculpted freehand to achieve a natural appearance in the direct resin veneers postoperatively. The dentin body layer was then light-cured for 10 seconds.
Translucent enamel resin (shade YE, Esthet-X® HD) was applied and formed over the incisal two thirds of the restoration (Figure 8). The enamel layer was thinned as it approached the cervical third, providing desaturation of the more opaque body shade from the cervical third and through the length of the tooth. An incisal halo was also created through the minimal application of body shade XL (Esthet-X® HD) to the incisal edge of the tooth (Figure 9). Following a 10-second light-cure (Figure 10), gross contouring was accomplished with a series of medium and fine diamonds, taking care to preserve surface texture during their systematic application.10
Tooth No. 9 was restored in a similar manner and readied for light-curing prior to the application of enamel-shaded composite. The adjacent central and lateral incisors were restored with the same shades and using identical techniques, with care and attention paid to the achievement of symmetry and natural-looking characterizations (Figure 11).
Finishing and Polishing Sequence
An aluminum-oxide impregnated resin finishing cup (Enhance® Finishing & Polishing System, DENTSPLY Caulk) was inserted in a contra-angle handpiece and applied with intermittent pressure to the tooth surface in a light, buffing motion (Figure 12). Care was taken to prevent excess heat buildup by frequently raising the finishing cup from the restoration surface. The definitive direct resin veneers were then polished using diamond-impregnated resin polishing cups and points (PoGo® Micropolishers, DENTSPLY Caulk) (Figure 13) that were also used in “staccato” fashion along the surfaces of the restorations. Clearly evident in the postoperative result were the restored smile line, corrected canting, and dramatic edge effects that reinforced the patient’s youth (Figure 14). The shaded buildup and inherent shade selection resulted in a natural, vital look suitable for an adolescent male (Figure 15).
Direct resin veneers were indicated for this patient, as correction of merely the incisal chipping could have made the restorations prone to fracture. Additionally, the direct resin veneers could be completed with minimal preparation and, due to the increased surface area available for adhesive bonding, would provide greater longevity than would simple incisal edge repair. Direct composite resins are both cost effective and easily repaired while the child continues to grow and his or her hard and soft tissues mature. As a result of this minimally invasive treatment, the patient will be well positioned for future orthodontia and/or porcelain restorations that provide long-term esthetics in adulthood.
Minimally invasive dentistry, and the associated direct composite resin restorations, is ideally suited for the treatment of children and adolescent dental patients. This immediate chairside approach provides an instantaneous cosmetic result during an awkward and unpredictable period of physical and social development. The repairability of direct veneers and the clinician’s ability to adjust the restorations as the patient continues to mature ensures the cosmetic result can be maintained until a final treatment plan for the adult patient is indicated.
In this case presentation, the patient’s esthetic expectations were realized through a conservative treatment approach that addressed the fracture of his anterior maxillary dentition. The additional benefit of long-term restoration in this manner is that the patient will develop a better and more specific idea of the kind of esthetics that will be desired as an adult.
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About the Author
Jeff T. Blank, DMD, PA, Private Practice, Fort Mill, South Carolina