The latter approach was selected for a young female patient who presented to the clinic because she was dissatisfied with the resin composite veneers on her maxillary anterior teeth. Intra-oral examination revealed that the existing restorations had irregular, rough surfaces and discoloured margins, that the structural integrity of the material was compromised and that a fixed retainer had been placed (Figs. 1a–d). The agreed treatment plan was to remove the existing restorations on the maxillary anterior teeth and re-establish optimal aesthetic and functional integrity with new direct resin composite restorations on teeth #13–23.

Replacement of the resin composite veneers

To reproduce the translucency characteristics of the patient’s natural teeth and fulfil her aesthetic demands, a polychromatic resin composite layering approach was planned, based on dentine and enamel shades and supplemented with translucent and effect shades. This would allow for optimal interplay of opacity, translucency and opalescence in the anterior area.

For shade selection, a bilaminar shade assessment was performed to evaluate the combined shade effect of the selected dentine and enamel resin composite shades before the polychromatic layering procedure. The intended enamel shade was layered over the selected dentine shade directly on the tooth, without bonding agent, and the materials were polymerised. This cumulative shade effect, rather than the individual shades of the materials, was used to verify harmony with the natural tooth shade.

Photographs were taken with a camera equipped with a cross-polarised filter (Fig. 2). Subsequently, the fixed retainer and existing veneers were removed (Fig. 3). To save as much of the underlying healthy tooth structure as possible, the procedure was performed under magnification and blue-light illumination. The selected instruments were red- and yellow-band diamond burs as well as tungsten carbide burs.

Prior to the restorative procedure, the teeth were isolated using a dental dam secured with floss in the cervical area (Fig. 4). After etching of the enamel and application of CLEARFIL SE BOND 2 self-etching bonding agent (Kuraray Noritake Dental), layers of CLEARFIL MAJESTY ES-2 Premium resin composite were applied. The dentine core with its pronounced mamelons was modelled using Shade A1D. The incisal edges and mamelons were highlighted with spots of white tint. To create an opalescent effect, a thin layer of the translucent shade Blue was placed on top and the enamel parts were built up with Shade WE (Fig. 5). Since the retainer had been removed, an aligner was fabricated and provided to the patient at the end of the session for use until the subsequent appointment. After finishing and polishing with TWIST DIA for Composite (EVE Ernst Vetter), an appointment was made for re-evaluation and final adjustments (Fig. 6).

At the review appointment, the patient asked for the incisal translucencies and brightness in her maxillary incisors to be slightly reduced and for the shape of all restored teeth to be altered. She requested longer maxillary central incisors with softer, more rounded line angles and a smoother incisal contour.

A dental dam was placed again, and the labial surfaces of the restorations on the maxillary incisors were reduced slightly using red- and yellow-band diamond burs. To roughen the surface and enhance the topography for optimal micromechanical interlocking, the restoration surface was sandblasted with 50 μm alumina particles. Phosphoric acid etchant, silane and CLEARFIL SE BOND 2 were applied sequentially as part of the adhesive protocol. The restorations were then modified by lengthening, shade correction using CLEARFIL MAJESTY ES-2 Premium in Shades A1D and A1E, and refinement of the anatomical contours (Figs. 7 & 8).

During this final appointment, the patient expressed that she was very happy with her new smile. The restoration surfaces were repolished, a new retainer was bonded and final photographs were taken (Figs. 9a–e).

Conclusion

Talking to patients about every detail of the treatment and listening attentively to their ideas, expectations and requests does not always avoid the need for adjustments. This is because patients need to see and appraise the treatment result. Selecting appropriate materials and techniques enables dental practitioners to create restorations that can be modified without harming healthy tooth structure. This helps clinicians meet demanding and changing patient expectations.