Communication between patient, clinician, and dental technician is fundamental for success in the art of dentistry.1 Esthetic dentistry is currently in high demand by patients, and veneers have become the ideal treatment for many situations. Ceramic veneer restorations have proved to fulfill high esthetic demands and offer an acceptable longevity.2 Freehand composite veneer restorations are achievable for clinicians with artistic skills.3 Fortunately there is also a novel option for composite veneers based on the diagnostic wax-up in which flowable composite is transferred to the mouth using a clear matrix.4 The properties of flowable composite allow the transfer of every single detail from the wax-up to the mouth. Moreover, with recent improvements in properties such as shrinkage and microleakage, flowable composite now offers reliability similar to that of conventional composite.5 Due to the favorable handling and sculpting properties of flowable composite, injectable composite veneers have become a popular dental technique providing very predictable outcomes. The clinician can completely transfer details such as line angle, embrasure shape, and incisal edge position from the diagnostic wax-up. It is therefore recommended that the patient be involved during the sculpting of the diagnostic wax-up. Ideal tooth proportions have been clearly described in previous articles, and they provide an essential tool for patient evaluation and fabrication of the diagnostic wax-up.6 The flowable composite technique can be used for several applications, including diagnostic evaluation, repair of fractured teeth, long-term provisional restorations, and even final restorations.7,8 Furthermore, communication between patient, clinician, and dental technician can be improved using this technique, since the patient can request an intraoral modification and then a solid copy of the desired restoration can be provided to the technician for matching in the final restoration. In most situations, this technique can be performed using a conservative approach that does not require preparation of the natural teeth, eg, for patients with spaces between the teeth or with non-ideal tooth length.9 Patients presenting loss of enamel by erosion are especially well indicated for this procedure because of its conservative approach in pre-serving all the remaining tooth structure.10 Another advantage of this technique is that it can be executed without applying anesthesia, so patients with needle phobia can be treated. Last but not least, patients are aware that conservative treatment is the new approach in health care, so the removal of less enamel will be more appealing to them.
CASE PRESENTATION
A 30-year-old woman presented to the office wishing to improve her smile (Figs 1 and 2). The clinical findings of the detailed diagnostic evaluation revealed worn teeth, spaces between the teeth, non-ideal teeth proportions, and non-ideal gingival margin position (Fig 3). The patient’s dental needs were explained to her and she was offered the option of periodontal gingivectomy to improve the gingival margin position followed by flowable injected composite veneers and finalization with ceramic veneer restorations. Due to the patient’s significant esthetic concerns, the final ceramic restorations would not be provided until the composite veneers fulfilled her expectations. An added benefit of temporary flowable composite veneers is that they provide patients time to save to cover the cost of the final ceramic restoration.
Periodontal probing depth was evaluated to diagnose passive eruption, and gingivectomy was performed using the flap repositioning technique following specific measurements to achieve ideal gingival position (Figs 4 and 5). The gingival tissue was allowed to heal for 2 months and was evaluated before moving to the restorative procedure(Fig 6).
Diagnostic impressions were made with polyvinyl siloxane (Virtual, Ivoclar Vivadent) and poured with type IV stone (Fujirock, GC America), followed by a facebow record and diagnostic mounting on an articulator (Artex CR Amann,Girrbach). A diagnostic wax-up (Wax GEO Classic, Renfert) was made with close attention to the patient’s requests and desires (Figs 7 and 8). A putty matrix and light-body impression material (Elite P&P, Zhermack) were placed on the diagnostic wax-up to fabricate a guide for the diagnostic mock-up (Figs 9 and 10).
The patient was pleased with the diagnostic mock-up and approved the result. A new transparent polyvinyl siloxane guide (Exaclear, GC America) was fabricated based on the same diagnostic wax-up using room-temperature water in a pressure pot (Aquapres, Lang Dental) under 30 psi for 5 minutes. The clear acrylic matrix was removed from the pressure pot and cleaned (Fig 11), and access holes were made on the incisal edge of each tooth to inject flowable composite.
Tooth surfaces were treated one tooth at a time, with adjacent teeth isolated with Teflon tape (Thread Seal Tape, Loctite), in the following sequence: application of 37% phosphoric acid etching gel (Total Etch, Ivoclar Vivadent) for 15 seconds and gentle air drying for 5 seconds (Fig 12), followed by adhesive application (Tetric N-Bond Universal, Ivoclar Vivadent) for 20 seconds, removal of excess adhesive gently by air, and light curing for 20 seconds (Valo LED, Ultradent). After the single tooth was treated, the clear matrix was positioned and nanohybrid flowable composite shade A1 (Tetric N-Flow, Ivoclar Vivadent) was injected through the access hole of the incisal edge (Fig 13) and light cured (Valo LED, Ultradent) for 20 seconds on the facial, 20 seconds on mesial, 20 seconds on distal, and 20 seconds on incisal surface, all without removing the clear matrix. The clear matrix was then removed (Fig 14), followed by removal of interproximal excess of composite using a sterile stainless scalpel blade no. 12 (General Surgery blade, Myco), and then removal and reshaping of gingival excess with a high-speed handpiece (Alegra Turbine TE-97, W&H) and fine diamond burs (diamond bur FG 859 012, Jota). The same sequence was then followed for the remaining teeth.
After fabrication of all the composite veneers, the oxygen inhibition layer treatment was provided with a glycerine-based gel on the surfaces and light cured for 40 seconds (DeOx, Ultradent). Finally, the composite restorations were finished by removing excess composite with a no. 12 scalpel blade, then first polishing of the surface with green and gray composite polishers (Composite Diamond Polisher, Jota), application of polish paste (Diamond Polish Mint, Ultradent) using a polishing brush [Au: Fig 16 shows a polishing wheel, not brush] (Jiffy Composite Polishing Brush, Ultradent), and finally smoothing the interproximal contacts with an extra-fine polishing strip of 50-micron thickness (Epitex, Orange strip, GC America) (Figs 15 to 17).
The final results of the flowable injected composite veneers fulfilled the patient’s expectations, and they would serve as a prototype for the future final ceramic restorations (Figs 18a and 18b).
After the 8-month follow-up, the patient decided to continue with the final ceramic restorations (Fig 19). New diagnostic impressions, facebow record, and articulator mounting were completed. Conservative veneer preparation was provided with horizontal depth grooves using a diamond bur (801 FG, Jota) (Figs 20a and 20b), and the composite restoration was removed. Retraction cord #000 (Ultrapak, Ultradent) was placed and a fine diamond bur was used to refine the gingival margin (Diamond Bur FG 859 012, Jota); the final preparation was polished with polishing discs (Sof-Lex XT Disc, 3M) and polishing wheels (Polishing Composite, Kit 1921, Jota) (Figs 21a to 21d). Preparation reduction guides were used to verify the amount
of reduction (Figs 22 and 23). A final impression with polvinyl siloxane in heavy-body and light-body consistency (Virtual 380, Ivoclar Vivadent) was taken (Fig 24). The final master cast was made in type IV stone (Fujirock, GC America) and refractory feldspathic porcelain veneers were fab-
ricated (Noritake Super Porcelain EX-3, Kuraray Dental) (Figs 25 to 27). A dry try-in of the restorations was performed in order for the clinician and patient to evaluate the fit and contours on the teeth. Once approved, the treatment proceeded.
A rubber dam (Dental Dam, Nic Tone) was placed from second premolar to second premolar and retained with clamps (Clamp #00, Hu-Friedy) in order to achieve good isolation. A clamp was also placed along the gingival contours of every tooth to be treated (Clamp B4, Brinker, Hygenic), followed by sandblasting of the teeth with water and 29-micron aluminum oxide particles (AquaCare Aluminum Oxide Air Abrasion Powder, Velopex).
Surface treatment of the teeth was carried out prior to bonding of the final restorations—first total etch of the enamel with 37% phosphoric acid (Total Etch, Ivoclar Vivadent) for 15 seconds and gentle air drying, followed by primer application and gentle removal of the excess with air. A light shade of adhesive (Variolink Esthetic LC, Ivoclar Vivadent) was applied, the ceramic restorations were bonded, and the excess adhesive was removed. Finally, each of the definitive restorations was light cured on the facial surface for 20 seconds, floss was used to clean the inter-proximal surfaces, followed by another light cure time of 20 seconds on the palatal, 20 seconds on the mesial, and 20 seconds on the distal surfaces of each ceramic restoration (Figs 28 to 30).
The patient was pleased with the contours, shape, and shade of the final feldspathic veneer restorations (Figs 31to 34).
CONCLUSION
Injectable flowable composite restorations have numerous applications in dentistry. This article presented a step-by-step approach for veneer restorations that are used as long-term prototypes before final ceramic restorations. There are many advantages to having these provisional restorations: they can be used to evaluate and achieve a patient’s esthetic expectations before fabrication of the final restorations, they allow the patient to improve their financial situation before moving to the final restorations, and they provide more accurate information for the dental technician regarding the shape of the final restorations. This may appear to be a technique-sensitive restoration; however, by following the correct sequence, as outlined herein, a reliable result can be achieved that is more viable than that of freehand composite restorations. Finally, following this conservative approach with reduction guides, very minimal or no enamel removal is required, and bonding to the enamel structure has been shown to be highly successful.
