Page 30 - GP Fall 2024

Simplified Protocol for Creating Symmetry and Anatomy

in Direct Composite Veneers

Authors: Arthur R. Volker, DDS, MSc, MSEd, Walter Devoto, DDS, Angelo Putignano, DDS, and Serhat Koken, DDS, PhD

Introduction neer was injection-molded. A large, coarse
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Direct composite veneers can be an excel- diamond and sandpaper disc were used to
1,2
lent material to enhance a patient’s smile. create an approximation of primary anato-
Composite resin is easy to adapt, is easily my (Figure 5). To better visualize the orien-
repaired and can be an economical alterna- tations and depth of the facial depressions,
3
tive to indirect ceramic veneers. The clini-
cian’s skill will impact the final outcome’s
esthetics. Shade, shape and polish are fac- Figure 1. Pre-operative smile.
tors that must be managed to produce a fa- unhappy with her smile (Figure 1). She felt
vorable result. This article aims to demon- that her teeth looked uneven. Tooth #8 had
strate a clinical protocol using a dedicated an existing porcelain fused to metal (PFM)
bur kit (Finale, Style Italiano) to predictably crown, which appeared longer incisally than
provide the appropriate form and anatomic #9 when viewed from the direct facial per-
features to a direct composite veneer. spective (Figure 2). There was asymmetry Figure 5. Primary anatomy created with

Anatomic Considerations of Maxillary of the gingival zeniths, and the patient had sandpaper discs.
a low lip line.
Incisors and Smile Design as well as line angles, articulating paper was
The primary anatomy of the incisor com- rubbed onto the facial surfaces of both cen-
prises the outermost extent of the tooth. It tral incisors (Figure 6).
includes the mesio-distal and inciso-gingi-
val dimensions of the tooth. From the facial
aspect, it also includes the mesiofacial and
distofacial line angles. 4

Between these line angles, there are typically Figure 2. Pre-operative retracted view.
two facial depressions, which result from the A mock-up with a single shade composite
coalescence of dental lobes during develop- (Filtek Supreme Ultra, 3M) was placed on Figure 6. Articulating paper rubbed
ment. The lobes can be more or less promi- the tooth without etch or bonding agent.
5
nent owing to several factors such as wear or (Figure 3). This allowed assessment of over both central incisors.
aging. This undulating appearance provides
depth to the facial surface and is referred to shade, shape and occlusion. Photos were The Style Italiano Finale (Polydentia) bur
as the secondary anatomy of the tooth. kit (Figure 7) was used to create secondary
anatomy and develop texture on the com-
Additionally, there may be small horizontal
lines in the tooth, resulting from develop-
mental enamel deposition, which provide
the tertiary anatomy or texture to the tooth.
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Like secondary anatomy its prominence can
depend on factors such as wear or aging. Figure 3. Intraoral mock-up.
There are several criteria needed to create a taken, as was a digital scan to serve as a
harmonious, esthetic smile. Proportionality, study model. Multiple treatment options
shape and color must all be considered. were presented including orthodontic thera- Figure 7. Style Finale bur kit.
6-8
Perhaps one of the most important elements py and indirect restorations. The patient opt-
involves the shape of the two maxillary cen- ed for a direct composite veneer on #9. The posite veneer. First, the F1 round diamond
tral incisors. It is imperative that they are patient was not interested in correcting the bur was used to place facial depressions
mirror images of each other. This bilateral gingival asymmetry, which would not be an (Figure 8). The advantage of using the
symmetry is even more critical the closer esthetic issue due to the existing low lip line. round bur is that subtle depressions can be
we get to the midline of the smile. If the cli- created and the potential risk of gouging the
nician is charged with the task of trying to On the day of treatment, topical anesthetic facial surface is minimized when compared
match a single central incisor, it is vital to was applied, and an intra-oral retractor was with a thinner bur. The F4 bur is a medium
successfully mimic the primary, secondary placed (Hoopla, Zyris) (Figure 4). Using
and tertiary anatomy of that contralateral heated nanohybrid composite (Filtek Su-
tooth. preme Ultra) and a flat Mylar matrix, the ve-
Clinical Case
The patient is a 62 year-old female in good
clinical health who presented to the office

www.nysagd.org l Fall 2024 l GP 30 Figure 4. Placement of soft tissue Figure 8. F1 bur used to create facial
retractor. depressions.