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Inside Dentistry
October 2021
Volume 17, Issue 10
Peer-Reviewed

Esthetic Smile Enhancement With Direct Composite Overmolding

Achieving proper tooth proportions and diastemata closure in a case involving congenitally missing lateral incisors

Jihyon Kim, DDS

Maxillary lateral incisors are the third most common teeth to be congenitally missing among patients. Today, numerous options for replacement are available. In this case, a 36-year-old male patient with bilateral congenitally missing maxillary lateral incisors presented with maxillary cuspids that had been orthodontically repositioned into the lateral incisor spaces and bonded with composite to simulate the contours of lateral incisors. The patient's priorities for smile enhancement included conservation of tooth structure, closure of all diastemata, and attainment of a brighter color.

An indirect restorative approach would necessitate the removal of sound tooth structure due to the path of draw and insertion. Alternatively, a direct restorative method would be the most conservative, but it would be challenging to camouflage the large cuspids to simulate smaller lateral incisors without removing tooth structure. This case was treated using a monolithic direct composite overmolding approach to add volume to the teeth and change the proportions of the patient's smile. The method used an extension of the "snow plough" technique, in which warmed flowable composite was used to wet the tooth and constricted areas then further adapted with warmed regular composite. The effect of injecting two viscosities of composite around a tooth is similar to the effect of crown and bridge impression techniques involving two viscosities of vinyl polysiloxane impression materials. The result is a highly polished monolithic restoration with the potential for improved longevity regarding wear and esthetics.

About the Author

JIHYON KIM, DDS
Director
Injection Overmolding Institute
Seattle, Washington
Private Practice
Seattle, Washington

JIHYON KIM, DDS

Preoperative smile photograph.

Fig. 1

Preoperative radiograph.

Fig. 2

Palatal view revealing the dimensional prominence of the cuspids relative to the central incisors, highlighting the challenge to get them to mimic smaller lateral incisors.

Fig. 3

Close-up maxillary retracted view with a golden proportion contraster in place to plan space closure. The shifted grid position prompted the decision to close the diastemata with the addition of composite to the mesial aspect of tooth No. 8 and the distal aspect of tooth No. 9.

Fig. 4

After a heavy gauge rubber dam (Nic Tone Dental Dam, MDC Dental) was placed to achieve papilla retraction and an apical seal of the matrices, the existing composite was removed, and the teeth were air abraded with 27 μm aluminum oxide powder.

Fig. 5

Spot etching was performed and an adhesive (Adhese® Universal VivaPen®, Ivoclar Vivadent) was applied to secure flowable composite buttons that were used to approximate the contacts and aid in matrix stabilization.

Fig. 6

Mylar sectional posterior matrices (Transparent Restoration Matrices, Kormed) were trimmed to accommodate the interproximal bone and seated vertically, beginning with tooth No. 9. Insertion of the matrices between the teeth and the rubber dam provided the cervical seal.

Fig. 7

After the tooth was etched and the adhesive was applied and cured, the matrices were overmolded with flowable and regular viscosity composites (Filtek™ Supreme Ultra, 3M) that were then simultaneously light cured.

Fig. 8

Following shaping of tooth No. 8, the matrices were placed to restore tooth No. 9.

Fig. 9

Palatal view showing insertion of the matrices into the rubber dam to create a cervical seal. The occlusion was marked prior to isolation, and the marks were preserved to facilitate fast shaping back to the original position.

Fig. 10

Facial view of both central incisors shaped. After the rubber dam was removed, and the patient was seated to confirm the midline position, a medium gauge rubber dam (DermaDam™, Ultradent) was placed for the remainder of the treatment.

Fig. 11

Following the overmolding and shaping of teeth Nos. 5, 6, 11, and 12, teeth Nos. 5, 6, 8, 9, 11, and 12 were further refined with coarse abrasive discs (Sof-Lex™, 3M) and trimmers (Contours™ Coarse Anatomy Trimmers, Clinician’s Choice).

Fig. 12

Facial view of the final polish that was achieved (One-Step Polisher, Komet).

Fig. 13

A postoperative palatal view permits visualization of the additional tooth volume and new proportions.

Fig. 14

Immediate postoperative close-up retracted view of the final restorations.

Fig. 15

Immediate postoperative smile photograph.

Fig. 16

Postoperative radiograph.

Fig. 17

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