Direct Composite Resin Restoration of Anterior Maxillary Teeth and Esthetic Smile Design: A Case Report

Dental esthetic complex involves more than one caries with malformed shape and malposition. Dental trauma most commonly affects maxillary anterior teeth, and subsequently affects the esthetics, functions, and psychological well-being of the individual. Composite resins have become an integral part of contemporary restorative and minimally invasive dentistry. Objective: To summarize the successful use of direct composite resin restoration in the management of a 29-year old male patient. Case Report: A 29-year old male patient presenting with multiple secondary caries and crown fractures in the anterior maxillary teeth, resulting in an unaesthetic smile. Comprehensive esthetic dental treatment was carried out. The patient was highly satisfied with the results even after eleven months of follow-up. Conclusion: restorative success with composite resins, the dental treatment plan should be carefully executed with attention to factors such as dental convexities and contours, re‐establishment of function, and esthetics. Smile design should always be a multifactorial decision-making process that allows the clinician to treat patients with an individualized and interdisciplinary approach.


INTRODUCTION
An individual's psycho-social well-being is largely dependent on their dento-facial appearance, and dental restorations can positively impact their self-confidence and overall mental health by improving their smile and appearance. 1 Compared to other ceramic restorations, composite resins offer excellent esthetic potential; are minimally invasive, requiring little or no tooth preparation at all; have acceptable longevity; and are available at a much lower cost for the restoration of both anterior and posterior teeth. 2 Direct composite resin restorations represent a viable alternative to indirect restorations as they allow maximum preservation of sound tooth structure. 3 Dental trauma to the maxillary incisors is fairly common, and the treatment plan is often influenced by the level of the fracture line, occlusion, and prognosis. However, some cases may require a multidisciplinary approach in order to improve their functional and esthetic outcomes 4 , which are dependent on careful consideration of the shape of the face and head and the volume, size, ratio, shape, texture, pattern of placement, and color of the teeth. Other factors, such as health and appearance of the soft tissue and gums, gingival line, smile line and width, relationship between the lower lip and upper-incisor line, dark areas at the corners of the mouth, and zenith point may also play a vital role. 1

CASE REPORT
A 29-year-old male patient reported to the conservative dentistry clinic at Gadjah Mada University with a complaint of dental trauma caused by a bike accident approximately two years ago. The patient underwent a dental check-up and restorative treatment one week after the accident. However, the patient presented with pain in the same tooth after six months and was prescribed pain medication. Within one week, the gums around the restored teeth were seen to be swollen, and the patient re-visited the dentist at which point performed the opening of the palate of the tooth with a drill. The patient was then referred to RSGM for restoration of the upper front teeth for esthetic reasons.
The patient was no longer in pain, and reported no history of systemic diseases or allergies to any drugs or food.
Patient consent was collected prior to treatment and collection of patient records (including impression, radiographs, and photos) was carried out.
Clinical and radiographic examination revealed a non-complicated crown fracture in teeth 11 and 21. The patient had previously undergone provisional composite resin restoration on the mesial and distal aspects of some teeth (12, 11, 21, and 22). No pulp exposure was detected in 12, 21, and 22 and, although the vitality test was negative, percussion of 11 showed a positive response (Figure 1, 2). Summary of patients oral condition was shown in Table 1.
After taking the position and pattern of the fractures into consideration, a composite resin restoration was considered as the best treatment plan and a diagnostic wax-up was made. Table 2 showed the phases of patient treatment plan. Color selection for the dentin, enamel, and incisal edges of the teeth was carried out for direct restoration. Endodontic assessment revealed a necrotic pulp with normal periapical tissue in tooth 11, and root canal treatment (RCT) was recommended.
Scaling and delivery of oral hygiene instructions was carried out in phase 1 of the treatment plan to improve the patient's oral hygiene habits and gingival health  and to also prevent further dental issues. Diagnostic casts and pre-operative photos were used to analyze the patient's smile, and a wax-up of the palatal tooth 21 was created ( Figure 3). This was done to enable the patient to provide his opinion, and also to allow for any adjustment needed in the next phase. Analysis showed that the facial and dental median lines coincided, although the horizontal facial line was not parallel to the incisal edge of the anterior maxillary teeth. The patient also had a convex facial profi le ( Figure 3).
Dento-facial analysis showed that (1) the upper lip smile line (shown in red) was precisely at the gingival margin for teeth 11 and 21 and above the gingival margin for teeth 13, 12, 22 and 23; (2) the lower lip smile line (also shown in red) was unbalanced in relation to the incisal plane of the anterior maxillary teeth (yellow line); and (3) the lip lines were not symmetrical during active smiling ( Figure 4).
Analysis of the anterior teeth from the front showed convergence of the axis toward the incisal edge. Tooth 11 appeared to be longer than tooth 21, with the incisal edges being slightly asymmetrical although this was not visible during active smiling; Tooth 23 was seen to be inclined labially to a greater extent than tooth 13 ( Figure 5).   Journal of Dentistry Indonesia 2020, Vol. 27,No. 2,[103][104][105][106][107][108] In phase 2 of the treatment plan, RCT was performed on tooth 11 (25 mm in length, Figure 6), and the orifi ce was sealed using glass ionomer cement. Post-operative follow-up was carried out after 1 week, and a post (21 mm in length) was inserted into the tooth in phase 3 of the treatment plan ( Figure 6B).
In phase 4 of the treatment plan, the tooth color (shade A3) was determined using a shade guide. Cavity preparation was carried out in teeth 12, 11, 21, and 22 using rotary instruments, and the teeth were sealed using temporary restorative material (Figure 7).
Treatment for teeth 11 and 21 included subgingival retraction cords were placed on teeth 11 and 21. The teeth were then prepared using a veneer design and a chamfer fi nish line. The incisal surface was reduced and prepared, and the interproximal portion of the cervical area was cut. The palatal section was given a short bevel. In tooth 21, the short bevel was created on the palatal aspect as a class III cavity. The cavities were cleaned, the enamel surfaces were etched with phosphoric acid, and the teeth were washed and dried. Application of bonding material (single bond, 3M, USA) adhesive was carried out using a regular-sized micro brush, and then light-cured as per the manufacturer's instructions. A palatal guide was attached to the teeth to mark the edge of the restoration. With the help of the guide, the palatal walls of teeth 11 and 21 were built using light colored enamel composite resin.
The cervical and incisal parts of the proximal walls were built using composite resins shades A3 and A2, respectively. A greater curve matrix (on the cervical section) and celluloid strips were used to assist with this, and the composite resins were then polymerized using light-curing ( Figure 7). The dentin color composite resin was applied and light-cured. Composite resin shades A3 (cervical third and body) and A2 (incisal third) were used on the labial aspect of the teeth, and light-curing was carried out.
Treatment for teeth 12 and 22 included re-contouring of the composite resin overlays and class III cavity preparation and restoration was carried out on the mesial incisal third. well as class III cavity deposition and addition of 1/3 of the mesial incisal side. Treatment for tooth 13 and 23 included selective contouring of the incisal 2/3 of the labial aspect of 13 was carried out. Selective contouring was carried out on the labial aspect of 23 which was protruding in relation to 13 in order to achieve a balanced appearance and convex smile lines. The fi nal restorations and at 11 montth follow up visit are shown in Figure 8.
All restorations were fi nished and polished using an extra-fine finishing bur and rubber polishing bur. Finally, the restorations were checked for any traumatic occlusal adjustment.
The follow-up visit after 11 months showed that the edges and marginal adaptation of the restoration were still good ( Figure 8C).

DISCUSSION
Dental esthetics is a primary concern for all patients 5 , and dental trauma involving both enamel and dentin most frequently occurs in the maxillary central incisors. This case report presents a conservative, timesaving, inexpensive treatment option for this common esthetic problem. 6,7 In the current case, the non-aesthetic appearance of the existing restorations in teeth 21, 12, and 22 could be attributed to the fact that the contours of the restoration were not well-formed. Foaming and bubbly saliva indicates increased viscosity which, in turn, decreases  the self-cleansing ability of the oral cavity. The higher the viscosity of the saliva, the more plaque retention and debris deposits occur on the restoration. This, in turn causes pathogenic bacteria from the plaque to develop rapidly and cause demineralization of the tooth surface, leading to increased tooth porosity and caries. Clinical examination revealed caries under the old restorations in teeth 12 and 22. Moreover, dental trauma caused an intra-pulmonary arterial rupture in the apical region of tooth 11 which, in turn, led to a periapical inflammatory response and subsequent pulp necrosis.
The patient reported to the clinic with considerable dental esthetic problems, and the composite resin layering method was found to be the key to obtaining esthetically successful results. Direct composite resin restorations are the most common treatment option as they are conservative, predictable, repairable, and inexpensive in comparison to indirect restorations. 8 Moreover, with this method, esthetic restoration of most teeth can be completed in a single appointment in a cost-effective manner and with no requirement for luting. Additional benefits of direct restorations include increased bonding area and strong and durable physical properties, thus decreasing the need for frequent repair. 7 Final estimation of the width and length of the maxillary anterior is an essential step during diagnostic wax-up. 9 Enamel deficiency often results in sensitivity of the tooth to thermal and contact stimuli; however, this can be treated with the help of composite resin restorations as they protect the remaining structure. The patient had no further esthetic complaints following restoration of his teeth using direct composite resins. 10 Most composite resin systems have a standard shade guide manufactured from unfilled methacrylates and, therefore, do not accurately represent the exact shade, translucency or opacity of the final polymerized restorative material. 11 Dental proportion is closely related to facial morphology, and is an essential part of creating an esthetically pleasing smile. The width to length ratio of the center of the tooth should be approximately 4:5 (0.8-1.0), with the width being approximately 75-80% of the length. The shape and location of the facial median line also influences the appearance and placement of the laterals and canines. The Golden Proportion (GP) concept was first introduced by Lombardi in an attempt to achieve balance between the dentition and the facial profile. 12 The important point to be noted here is that it is not the actual size but, instead, the perceived size when viewed from the facial aspect that these proportions are based on As per this principle, the width of each anterior tooth should not be greater than 60% of the width of the adjacent tooth (the mathematical ratio being 1.6:1:0.6) 13 when viewed from the facial aspect.
In the current case, the proposed GP (1/1.618 = 0.618) resulted in the visible (perceived) width of the canine being 62% (0.618) of the lateral incisor, and the visible width of the lateral incisor being 62% (0.618) of the central incisor. 12 Aesthetic post and core restoration of the anterior teeth was also indicated for better results 14 , and a fiberglass post was selected due to its increasing popularity. 15 Factors that must be taken into consideration when designing a smile include tooth components [ such as dental midline; incisal length; tooth dimensions; zenith points; axial inclinations; interdental contact area and point (ICP); incisal embrasure; sex, personality, and age; symmetry components] and soft tissue components (gingival health; gingival level and harmony; interdental embrasure; and smile line). 12 Anatomic wax-up represents one of the most vital steps in the process of redesigning a patient's smile 16 as it provides an opportunity to correct temporary restorations and verify final restorations (including intra-oral occlusion, length of the restoration, and relationship with the neighboring teeth and gingiva, position of lips at rest or while smiling, phonation, and harmony with the patient's face). As all these parameters can be visualized and experienced by the patient immediately, it is highly recommended that the clinician takes the patient's opinion of the mockup into consideration. 17 The fundamental criteria for esthetic analysis should include facial, dentogingival, and dental esthetics. 18

CONCLUSION
In order to achieve restorative success with composite resins, the dental treatment plan should be carefully executed with attention to factors such as dental convexities and contours, re-establishment of function, and esthetics. Smile design should always be a multifactorial decision-making process that allows the clinician to treat patients with an individualized and interdisciplinary approach. In order to reach these goals, the clinician should pay attention to the patient's expectations with regard to phonetics, biomimetics, and esthetics.