A Minimally Invasive Smile Restoration: A Case Report Describing a Multitechnique Approach Over Time

INTRODUCTION
The constant quest and demand for an aesthetic, healthy, and harmonious smile imposed by modern society; in addition to the concern by professionals to address differences in tooth shape, color, and proportions; gave rise to different cosmetic treatments, with a view to obtaining an aesthetic and functional result.1

Tooth enamel surfaces may be affected by stains that greatly detract from the aesthetics of the smile and, when they present a hard texture (irrespective of their intrinsic color and etiology), they may be submitted to the enamel microabrasion stain removal technique.2,3 Nevertheless, a satisfactory aesthetic result with the application of this technique depends on the depth and location of stains on the clinical tooth crown; those on the surfaces and middle third of the clinical tooth crown being most favorable to treatment. We want to emphasize that if it’s impossible to resolve the aesthetics of teeth affected by stains with a microabrasion technique, we are able to resolve the aesthetic condition of the smile by removing the stains and immediately restoring the region affected by them with resin composite.3

Restorative dentistry has access to treatment techniques that may be used either alone or associated with others to enable the recovery of dental aesthetics. In this context, one of the most requested and effective dental treatments is dental bleaching.3,4 This treatment with carbamide peroxide, which since its introduction5 has gained popularity and professional acceptance,6 along with 10% hydrogen peroxide,7 enables treatment to be performed in a shorter period of time.

It is important to mention that the versatility of technical possibilities to be used to achieve satisfactory aesthetics may be complemented by periodontal surgical techniques,8,9 such as gingivoplasty/gingivectomy for augmenting the clinical crown. The fundamental conditions for performing clinical crown augmentation are the presence of a large strip of keratinized cervical mucosa, absence of bone deformities, and motivating the patient to control bacterial plaque.10 Without doubt, this clinical and surgical approach goes a long way to obtaining improved aesthetics in the smile.
This article presents the treatment of a young patient who presented with vestibular white stains in the anterior teeth, presence of diastemas, dentinal chromatic alterations, and clinically short crowns. For this purpose, periodontal, bleaching, and resin composite restorative procedures were used.

CASE REPORT
The patient, a 14-year-old girl, after orthodontic treatment, presented with diastemas between the maxillary central incisors, hard-textured and opaque white stains in the middle and incisal thirds of the maxillary and mandibular anterior teeth, in addition to surface irregularities resulting from the removal of brackets (Figure 1). Initially, the option to perform dental bleaching with carbamide peroxide in both arches according to the data presented in Table 1 was considered. Applications of the bleaching product were made in the maxillary arch and mandibular arches, once a day for one month; the duration time of each application being 4 hours (Figure 2).

Figure 1. Preoperative condition of the teeth (1999). Figure 2. After dental bleaching (Opalescence 10% [Ultradent Products]) (1999).
Figure 3. After dental bleaching and restorations with composite resin (Amelogen Plus [Ultradent Products]) (1999). Figure 4. Four years after periodontal surgical technique for augmenting the anterior superior clinical crowns (2009).
Figure 5. Dental bleaching (Opalescence Trèswhite Supreme [Ultradent Products]) (2009). Figure 6. After dental bleaching (2009), old composite resin was removed.

Sundfeld et al, in 20073 and 2009,11 indicated that patients who undergo a carbamide peroxide bleaching technique should present the following criteria in order to have it performed: absence of caries lesions, fractured restorations, and periodontal diseases; it is indicated for nonpregnant women and breastfeeding mothers; nonsmokers and nonalcoholics; for those who have good systemic conditions and healthy oral soft tissues, as well as for those who have no history of adverse reactions to peroxides. The teeth to be bleached should present no exposed dentinal tissues in the cervical or incisal/occlusal regions while the bleaching treatment is being performed. When faced with this clinical possibility, dentinal protection must be performed before the application of bleaching material, by means of applying a conventional adhesive system, or a self-etching adhesive system. Undoubtedly, dentinal protection will help in the control and even the absence of dental sensitivity during and after performing the bleaching treatments presented above.

After 30 days, an attempt was made to remove the stains with a microabrasion technique, but it was observed that the stains were deep and unfavorably located for obtaining the desired aesthetic appearance. We therefore opted for the complete removal of the stains with the use of a 1,016 diamond tip (KG Sorensen) in a high-speed handpiece, under abundant water- and air-cooling. Immediately after this, and under absolute isolation of the operative field, the cavities were etched with 37% phosphoric acid (DENSTPLY Caulk) so that after washing and drying, they could receive the application of an adhesive (Adper Single Bond 2 [3M ESPE]) and resin composite Amelogen (Ultradent Products) (Figure 3). The resin materials were photo-activated with a halogen light source (Ultralux Dabi Atlante [Ribeirão Preto]) for 20 and 40 seconds, for the adhesive system and resin composite, respectively. The finishing and polishing procedures were performed with fine grained diamond tips 1,190 F (KG Sorensen), followed by the use in series of abrasive discs (Sof-Lex Pop-On [3M ESPE]).

Table 1. Sequence of Clinical Procedures to Be Performed for Dental Bleaching With a 10% Carbamide Peroxide Whitening Gel (10% Opalescence [Ultradent Products])

Stages in the Dental Office
1. Molding dental arches with alginate;
2. Obtaining plaster models;
3. Obtaining acetate molds, which after cutting, must be analyzed as regards the ease of inserting and removing them from the oral cavity; and
4. Protecting exposed dentinal tissue, if necessary, with a conventional or self-etching adhesive system, before the application of the carbamide peroxide based bleaching material.

Stages performed at the patient’s home—Under professional guidance
1. Brush teeth before inserting the tray that contains the bleaching product;
2. Wash hands well, then dispense one drop of the bleaching product inside the tray. Place tray on the dental arch to be bleached, ensuring that it is well adapted to the teeth;
3. Do not put more bleaching product into the tray than the amount recommended by the professional;
4. Immediately after inserting the tray in the dental arch, if necessary, use a toothbrush to remove excess bleaching product;
5. Use the tray with bleaching product for a period of 4 hours every day. During this time, do not ingest solid or liquid foods;
6. After 4 hours of use, remove the tray, and wash it under running water;
7. Immediately after removing the tray, rinse the mouth with running water. Brush teeth one hour after the tray is removed from the dental arch;
8. If necessary, repeat the operation on the following day, in accordance with the professional’s instructions, for the same time; that is, for a period of 4 hours;
9. When the tray and bleaching product are not being used, keep them in a cool place, away from heat;
10. While under treatment, avoid consuming candies and foods that contain any type of coloring agent (coffee, cola, grape juice) as well as acidic fruits (oranges, lemons, etc);
11. Should there be any discomfort, interrupt the treatment and inform the professional; and
12. After obtaining the desired shade, perform 7 applications of neutral 2% topical sodium fluoride gel, for the time of 4 minutes every day.


After 5 years had elapsed, the patient was submitted to gingivoplasty to augment the clinical crown in the anterior region (Figure 4). Four years later, dental bleaching maintenance was performed with the use of a 10% hydrogen peroxide bleaching product (Opalescence Trèswhite Supreme [Ultradent Products]), according to the data presented in Table 2 (Figure 5). Seven consecutive bleaching treatments were performed on the patient (once a day). This was followed by 7 topical applications of 2% neutral sodium fluoride gel for a period of 4 minutes each.

Seven days after conclusion of the bleaching treatment,12 repairs began on the old restorations using composite resin (shades A1 for dentin and EN for enamel) (Amelogen Plus), followed by shaping wearing the old restorations with a diamond tip 3,195FF (KG Sorensen) (Figure 6). Under absolute isolation, the teeth and restoration remainders were etched with 37% phosphoric acid (Figure 7) for 30 seconds, washed with a water/air spray, and then dried. A thin layer of the Adper Single Bond 2 adhesive was applied and photo-activated for 20 seconds (Figure 8). The composite resin was applied using an incremental technique, and each layer was light-cured for 20 seconds (Figures 9 and 10). Finishing and polishing were performed with a series of Sof-Lex Pop-On abrasive discs and finishing and polishing tips (Figures 11 and 12).

DISCUSSION
The enamel microabrasion technique has been shown to be an excellent method for removing irregularities and stains of any color and hard texture, when present in the most superficial layers of dental enamel. However, when faced with deep stains, their complete removal with diamond tips followed by restorative procedures with resinous materials offers a viable possibility for resolving this aesthetic inconvenience;1,3,13-15 a clinical condition that justified performing the technique in the present clinical case, complemented with the closure of the anterior diastema with which the patient had initially presented.

Figure 7. Enamel conditioning with 37% phosphoric acid. Figure 8. System adhesive application of adhesive (Adper Single Bond 2 [3M ESPE]).
Figure 9. Application of composite resin (Shade A1) (Amelogen Plus). Figure 10. Application of composite resin (Shade EN) (Amelogen Plus).
Figure 11. Completed composite resin restorations. Figure 12. Final smile.


In this case, after 10 years, the patient was submitted to clinical crown augmentation, by means of recontouring the bone and keratinized gingival mucosa, with the advantage of simplicity of the technique, good visual access, and a good aesthetic result; its indication being precise for cases in which there are 5 mm or more of keratinized mucosa. The fact has been related by the pertinent literature10,16 and considerably improved the aesthetic appearance of the smile.

It is worth pointing out that home bleaching with a 10% carbamide peroxide based agent was used when the patient was 14 years old.3 This technique has gained a great deal of popularity and is a safe and effective aesthetic course of action when indicated and if the treatment is overseen by a dental professional.17,18 It should be noted that when the patient returned after 10 years, dental bleaching maintenance was performed with a 10% hydrogen peroxide agent and its application showed the development of bleaching agents which, among other advantages and possibilities, present a shorter application time.11,19,20

 Table 2. Sequence of Clinical Dental Bleaching Procedures With Opalescence Trèswhite Supreme (10% Hydrogen Peroxide [Ultradent Products])

Stages of Bleaching Product Application in the Dental Office
1. After prophylaxis with pumice stone and water, if necessary, protect exposed dentinal tissue with a conventional or self-etching adhesive system, before application of the hydrogen peroxide-based bleaching material;
2. Apply the molded tray that contains the bleaching product to the dental arch to be bleached, adapting it well to the teeth; instructing the patient to apply suction to it, to fix it against the teeth to be bleached;
3. Remove the molded tray, and then use the fingers to press the plastic tray that holds the bleaching product to make it fit better against the teeth to be bleached;
4. Use the bleaching product for a period of 30 to 60 minutes;
5. After this time, remove the plastic tray that holds the bleaching product, then rinse the mouth with water;
6. If necessary, the operation will be repeated by the professional in the dental office on the following day, for the same period of time; that is, for a period of 30 to 60 minutes; and
7. While the patient is under treatment, he/she should avoid sweets and foods that contain any type of coloring agent (coffee, cola, or grape juice), as well as acidic fruits (orange, lemon, etc).


We have addressed that the advancements in procedures, techniques, and materials present in contemporary dentistry12,21,22 are of fundamental importance for attaining aesthetic anterior reconstructions that provide great naturalness and clinical longevity. This may be observed both in the first dental reconstruction of the anterior teeth and in the second performed after periodontal surgery, dental bleaching maintenance, and repairs to the resin composite restorations in the anterior teeth. Nevertheless, it is important to emphasize that in the clinical case presented, re-establishment of aesthetic appearance was obtained by the association of different clinical procedures, thereby demonstrating the importance of performing interdisciplinary work in the recovery our patient’s smile (Figure 12).

CONCLUSION
This article addressed the treatment stages and 10-year clinical follow-up of the aesthetic improvement of a smile for a young patient. The association of different aesthetic techniques over time enabled a satisfactory aesthetic appearance to be obtained, thereby evidencing the proven development of multirestorative solutions to aesthetic challenges.


References

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  3. Sundfeld RH, Croll TP, Briso AL, et al. Considerations about enamel microabrasion after 18 years. Am J Dent. 2007;20:67-72.
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Dr. Sundfeld is a full professor, Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. de Oliveira is a graduate student (MSc degree), Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Toseto is a graduate student (MSc degree), Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Arruda is a Graduate student (MSc degree), Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Machado is a Graduate student (MSc degree), Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Briso is an associate professor, Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Mestrener is an associate professor, Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosures: The authors report no disclosures.