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Optimizing Smile Composition and

Esthetics with Resin Composites
and Other Conservative Esthetic
Procedures
Didier Dietschi, DMD, PhD
Senior Lecturer, Department of Cariology and Endodontics
School of Dentistry, University of Geneva, Switzerland
Adjunct Professor, Department of Comprehensive Care
Case Western University, Cleveland, Ohio, USA
Private Practice and Edudation Center
The Geneva Smile Center, Switzerland

Correspondence to: Dr Didier Dietschi

Department of Cariology and Endodontics, School of Dentistry, 19 Rue Barthlmy Menn, 1205 Geneva, Switzerland;
phone: 41 22 38 29 165/150; fax: 41 22 39 29 990; e-mail: ddietschi@medecine.unige.ch.

The Geneva Smile Center & education @ the Geneva Smile Center. 2 Quai Gustave Ador, 1207 Geneva, Switzerland;
phone: 41 22 700 78 56; fax: 41 22 700 78 57; e-mail: ddietschi@genevasmilecenter.ch.

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Abstract
Numerous esthetic deficiencies may be

improved in practicability, efficiency, and

present in natural, restored, or orthodonti-

predictability. The search for a perfect smile

cally enhanced smiles. The most frequent

should not always lead to invasive solu-

defects are transposed anterior teeth follow-

tions such as veneers and crowns, since in-

ing

di-

vasive treatments may have a negative im-

astemas, form abnormalities and discol-

pact on the long-term tooth biomechanical

orations, abrasion, erosion, and dysplasia.

behavior and global treatment cost. This ar-

Conservative treatment modalities such as

ticle discusses the treatment rationale for

enamel recontouring, bleaching, micro-

the use of nonrestorative and additive pro-

abrasion, and resin composites have the

cedures and their respective indications

potential to correct or improve esthetic

in a comprehensive approach to dental

problems. These treatments deserve more

esthetics.

attention because they have tremendously

(Eur J Esthet Dent 2008;3:1429.)

aplasia,

existing

or

remaining

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bleaching, microabrasion, and resin com-

perfect physical appearance. Natural, re-

posites have the potential to correct or im-

stored, or orthodontically enhanced smiles

prove these esthetic problems and recently

may present esthetic deficiencies that re-

have shown tremendously improved prac-

quire treatment. However, the search for a

ticability, efficiency, and predictability.26

perfect smile should not drive clinicians to

Bonded ceramic restorations or full crowns

use invasive solutions such as veneers and

should be considered for more critical den-

crowns to treat all of these esthetic anom-

tal conditions.79

alies, since such treatments may have a

The aim of this paper is to review the

negative impact on the long-term tooth bio-

current conservative restorative modalities

mechanical behavior and global treatment

aimed to correct functional, anatomic, and

cost. Transposed anterior teeth following

esthetic anomalies found in patients with

aplasia, existing or remaining diastemas,

healthy or orthodontically corrected denti-

form abnormalities and discolorations,

tions. The implications of this new thera-

abrasion, erosion, and dysplasia are com-

peutic philosophy in a comprehensive ap-

mon clinical findings in all age groups.

proach to dental esthetics will also be

Conservative treatment modalities such as

discussed.

Table 1
Modern treatment strategies for effective and conservative correction of different esthetic deficiencies according to the dental conditions and the patients age
Dental condition

Deficiencies

Typical patient age

Discoloration
Virgin teeth

Form or functional abnormality

Preferred treatment options

Bleaching and microabrasion

Young/young adult
Free-hand bonding

Diastema
Erosion
Abrasion (incisal wear)
Abfraction
Slightly decayed

Young adult/adult

Free-hand bonding
Bonded ceramic restoration

Adult/elderly

Bonded ceramic restoration

Full crowns

Dysplasia, hypoplasia
Caries lesion
Failling restoration
Erosion
Abrasion (incisal wear)
Abfraction
Largely decayed
Dysplasia, hypoplasia
Caries lesion
Failling restoration

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In todays world, there is a strong focus on

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nician toward the best possible therapeutic

Many functional, anatomic, or esthetic defi-

consideration when treating young patients.

ciencies can be treated using either conser-

Maintenance and replacement of indirect

vative techniques, such as free-hand bond-

ceramic restorations will tremendously in-

ing, or more invasive techniques, such as

crease treatment costs in the long-term.

indirect ceramic restorations. The decision

Likewise, indirect restorations do not neces-

should be based not on technical or mate-

sarily offer superior esthetic results com-

rial considerations, but rather on each

pared to properly selected and meticulous-

choice (Table 1 and Fig 1). In addition to the

potential supplementary tissue loss, financial considerations must also be taken into

7,8,10,11

This

ly applied conservative techniques. The

means that age, severity of tissue loss, and

conditions suitable for conservative smile

size of the restoration should guide the cli-

enhancement will now be discussed.

Fig 1

biomechanical

status.

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A new approach
to comprehensive
esthetic dentistry

tooths

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(a to c) Preoperative view of a young adult

with worn and irregular incisal edges, diastemas, and

global aging of the smile. (d and e) Smile configuration was corrected using direct bonding according to
a functional and esthetic waxup. (f) Postoperative view
showing the enhanced smile obtained with only additive procedures.

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Missing anterior teeth and

postorthodontic conditions

bilitations and their potentially negative in-

The early loss of permanent teeth follow-

ways been considered the main factors fa-

ing trauma or congenital aplasia may be

voring an orthodontic solution. However,

corrected by orthodontic or prosthetic

different anatomic, functional, and esthetic

means,

The

anomalies may result from the orthodon-

proper diagnosis of dental and skeletal

tic approach. Patients increasing concern

conditions normally guides the choice be-

for esthetics obliges the dental team to

including

implants.

1214

tween treatment options.

fluence on periodontal health15,16 have al-

The need for

long-term maintenance of prosthetic reha-

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consider these potential deficiencies (Figs

2 and 3):

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Fig 2

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(a) Postorthodontic

status following closure of

spaces resulting from bilateral incisor aplasia. (b and c)
Premolars and canines were
recontoured and bonded to
create

more

harmonious

tooth forms. (d to f) Posttreatment view showing improved smile configuration.

Correction of the gingival
profile will be performed after
completion of tooth eruption.

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(a and b) Postorthodontic status following

alignment of the anterior teeth. Significant tissue loss

resulted from previous malocclusion and accidental
fractures. On the left side, the lateral incisor is missing.
(c) Direct bonding was used to reconstruct incisal
edges of the maxillary incisors and restore a proper
smile line. Adhesive, additive restorations are in line
with the conservative approach formerly applied with
the orthodontic treatment.

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Fig 3

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Unusual crown dimensions (larger or

torthodontic modalities involving a multi-

smaller)

disciplinary approach.

Unusual root diameter (larger or smaller)

Unusual shape of the crown

Congenital esthetic deficiencies

Difference in color (mainly for canines)

Since patients are increasingly aware of

Difference in gingival contour or level

these esthetic anomalies, conservative esthetic correction is more and more man-

Moreover, these anomalies may prevent

dated (Fig 4). Related conditions in the

the displaced tooth from achieving proper

smile frame include:

position, thus leading to functional disturbances. The unfavorable outcomes of or-

Discolorations

thodontic treatments and spontaneous

Hypoplasia

space closure should be anticipated by

Unsual tooth forms or dimensions

planning appropriate orthodontic and pos-

Diastemas

Fig 4

(a) Preoperative situation showing extensive

dysplasic and hypoplasic lesions. (b and c) Light

home bleaching preceded the removal of existing
restorative material and remaining white or brown discolorations. (d) Conservative preparations on the
central incisors and the larger circumferential cavity of
the right lateral incisor were filled with dentin- and
enamel-like materials, imitating normal tooth anatomy.
(e and f) Postoperative views showing the enhanced
appearance following a highly conservative treatment
approach.

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Acquired and other esthetic

deficiencies

Abrasion, abfraction, and erosion lesions

Tooth fractures

Many other esthetic deficiencies in intact

Caries

dentitions require the attention of the mod-

Functional deficiencies

ern dental team (Fig 5). Such conditions in

the smile frame include:

All aforementioned conditions are potential indications for conservative additive

Discolorations (ie, traumatized, nonvital

treatments, according to preexisting tissue

tooth)

loss and functional status.

Diastemas

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Fig

(a)

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Preoperative

view of a 50-year-old patient

with natural tooth arrangement following bilateral incisor aplasia. (b and c) Lateral

views

showing

the

numerous esthetic deficiencies, including poor space

distribution, improper tooth
forms,

and

abrasion.

(d

and e) Postoperative view

of the reconstructed smile
following bleaching and additive procedures. This case
illustrates the potential of
conservative adhesive dentistry in relatively complex
cases.

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Nonrestorative, additive,
and other treatment
options
Conservative, nonrestorative modalities

Free-hand bonding to correct localized

morphologic and functional deficiencies
Bonded ceramic restorations for extended

include:
Bleaching techniques and microabra-

morphologic and functional corrections

Nonconservative modalities include:

sion for color correction

Recontouring to achieve minor anatomic

Bonded ceramic restorations to correct

corrections

limited

retrieve normal soft tissue outline17

and

functional

problems

Gingival recontouring (gingivoplasty) to

morphologic

Crowns for full-tooth reconstruction and

extended functional corrections

Fig 6

(a) Preoperative view of a 60-year-old patient showing incisal abrasion and smile aging. (b) After length-

ening the incisal edges of the central incisors, followed by recountouring of the incisal edges of the lateral incisors, a younger and more attractive smile line is established. (c and d) The rounded angles of the lateral incisors help to conservatively rejuvenate abraded smiles.

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Additive modalities include:

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Enamel recontouring
(enameloplasty)

dimension, and shape differences may re-

After an orthodontic mesial drift of lateral

quired coronoplasty is made, color correc-

segments to close spaces resulting from

tion should be carried out for vital teeth,

lateral incisor aplasia, the new position of

preferably with home bleaching22 or even-

the canines may demand minor form cor-

tually with chairside bleaching23 when the

rections to be performed before additive

color difference is discrete.

sult in an esthetic problem. After the re-

reshaping of the teeth using resin compos-

Microabrasion aims to remove superfi-

ite (Fig 2).18,19 Similarly, incisal edge or cusp

cial stains usually related to discrete or

leveling may be needed prior to, simulta-

moderate fluorosis.2426 This condition is

neously with, or instead of other restorative

fairly

procedures (Fig 6). In many situations, mi-

restorative treatment; indeed, mimicking

nor form corrections can be performed, eg,

enamel opacities is difficult and creates a

to level incisal edges or canines cusps or

situation that is rarely esthetically pleasing

to round the edges of anterior teeth.

(Fig 7). The procedure is conservative,

common

and

complicates

any

though it requires the removal of some su-

Bleaching and microabrasion

perficial enamel.

Vital bleaching is used routinely as a single elective esthetic treatment or as a pre-

Free-hand bonding

restorative procedure. Home bleaching

Along with dramatic improvements in their

using 10% to 20% carbamide peroxide

physicochemical

proved safe and efficient over long-term

resin composites present superior esthetic

periods2,3; therefore, it is the preferred and

qualities and satisfactory color stability.28

most economical approach to conserva-

They allow excellent esthetic results to be

tively brighten a smile. Moreover, it proved

achieved with relatively simple application

more effective than chairside bleaching in

and layering methods. State of the art treat-

tissue depth, which favors its use for alter-

ment includes the use of dentin- and

ing dark natural tooth color.

20

properties,27

modern

Nonvital

enamel-like masses, which are completed

bleaching is another useful procedure for

with effect materials in well-selected indica-

traumatized anterior teeth in young pa-

tions (Figs 1 to 7). This simplified approach

tients, especially those with minimal tissue

potentially extends the esthetic benefit of

loss. However, the risk of discoloration re-

modern resin composites to a much larg-

lapse is significant, and a more stable,

er number of practitioners and patients.

though less conservative, esthetic solution

is often mandated for long-term patient
21

satisfaction.

Veeners and crowns

When complete reconstruction of the labi-

Following orthodontic transition of ante-

al surfaces is requested and major tooth

rior teeth, a color problem often appears

anatomy corrections are needed, partial or

with canines moved to a more mesial po-

full indirect ceramic restorations are suit-

sition (Figs 2 and 5). These teeth present

able.79,29 Due to improvements in the es-

higher color saturation (in most cases, a

thetics and surface quality of modern

similar hue but higher chroma) compared

porcelains, the veneer option is favored

with incisors. The combination of shade,

when the entire buccal surface must be re-

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j
Fig 7

(a) Postorthodontic smile presenting esthetic challenges such as improper alignment, space distribution,

gingival hyperplasia, fluorosis, and enamel damage following removal of ceramic brackets. (b and c) Extra- and
intraoral views following bleaching and gingivectomy around the right canine. (d and e) Microabrasion was performed with Opalustre (Ultradent) under rubber dam until most of the white flakes disappeared. (f to h) Embrasures between the central incisors and canines, along with the distal corner of the right central incisor, were reshaped with composite. Premolars were also elongated. (i and j) Posttreatment views showing the restorative
and esthetic compromise justified by the patients age (17 years). Microabrasion facilitated the restorative phase
and allowed a more esthetic and smooth transition with natural tooth structure. Further procedures may be necessary to deal with the excess space on the left side.

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placed, such as in severe tooth displasia,

Conclusion

tours and root diameter diverge too far

To satisfy new demands regarding tissue

from the accepted esthetic standards, or

conservation, function, and esthetics, treat-

when dealing with extremely decayed

ment parameters must be redefined for all

teeth, crowns may be indicated. The will-

kinds of smile deficiencies concerning

ingness and ability of the patient to accept

young patients with healthy dentitions, par-

the long-term repercussions of retreatment

ticularly following orthodontic treatment. A

and maintenance must also be taken into

more comprehensive case analysis in-

consideration during treatment planning.

cluding long-term prognoses should be

Pulpal or endodontic complications and

undertaken to offer the patient the best

mechanical failures (global biomechani-

available solution with minimal tissue sac-

cal risk) have a higher incidence with full

rifice. A global and reasonable treatment

Therefore, the

approach should include bleaching tech-

possibility of fulfilling patient expectations

niques, microabrasion, recontouring, and

and meeting current esthetic standards

resin composite bonding. Ideally, the appli-

with conservative procedures should al-

cation of nonconservative, nonadditive

ways be considered.

procedures should be postponed when-

prosthetic restorations.

ever possible. Today, it is often preferable

to use conservative treatments with minor,
foreseen esthetic limitations that will clearly benefit the long-term biomechanical behavior of concerned teeth.

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