CASE REPORT

Cosmetic recontouring for achieving

anterior esthetics

Juan Carlos Pontons-Melo, DDS, MS

PhD Student, Department of Conservative Dentistry, School of Dentistry,
Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
Professor, Department of Esthetic and Restorative Dentistry, School of Dentistry,
Universidad Científica del Sur, Lima, Peru

Giorgio Atzeri, DDS

Private Practice in Esthetics and Conservative Dentistry, Olbia, Sardinia, Italy

Fabrício Mezzomo Collares, DDS, MS, PhD

Professor, Department of Conservative Dentistry, School of Dentistry,
Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil

Ronaldo Hirata, DDS, MS, PhD

Professor, Department of Biomaterials and Biomimetics, College of Dentistry,
New York University, New York, USA

Correspondence to: Prof Juan Carlos Pontons-Melo

Department of Esthetic and Restorative Dentistry, School of Dentistry, Universidad Científica del Sur,
Av. Guillermo Prescott 260 San Isidro, Lima 27, Peru; Tel: +51 422 2481; Email: drjcpontons@spaziooral.com

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 PONTONS-MELO ET AL

Abstract ite resin that improves the esthetic outcome of the

final treatment. Of the various types of treatment
Cosmetic recontouring based on the enameloplas- that can be offered in the dental clinic, cosmetic
ty of natural teeth is a treatment with esthetic ben- recontouring is a conservative one with low bio-
efits that can be considered both economical and logical and financial cost that obtains good func-
safe. Not only does the clinician need to restore tional and esthetic results. This article describes a
the harmony of the smile, but treatment planning clinical case including enameloplasty and the addi-
must also take the functional aspects of the restor- tion of direct composite resin to improve the bal-
ation into consideration. One way to recontour is ance and harmony of the smile and dentition.
through an additive technique with direct compos- (Int J Esthet Dent 2019;14:134–146)

The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019 | 135
CASE REPORT

Introduction Teeth that have an altered shape or posi-

tion affect proper alignment, smile harmo-
In restorative dentistry, esthetics is defined ny, and dentofacial composition. One way
as the art of creating, reproducing, copying, to treat these issues is with cosmetic recon-
and harmonizing restorations with contigu- touring through minor enameloplasty or the
ous dental and anatomical structure.1 Cos- addition of restorative materials. In many
metic dentistry can be defined as the set of cases, this treatment option compares fa-
operative procedures and the application of vorably to others that are significantly more
dental materials that aim to restore esthetic laborious, prolonged, and expensive3,4 as
beauty and harmony.1 Cosmetic recontour- well as poorly accepted by patients.
ing is considered to be conservative, eco- One frequently observed misconception
nomical, and capable of providing benefits is that cosmetic recontouring only involves
not only for esthetics and hygiene, but also the wearing down or leveling of the teeth.
for the optimization of occlusal function.2 Clinicians must be knowledgeable about
dental anatomy, esthetic proportions, and
optical illusions to perform an analysis of
dental facial harmony, which could have a
direct impact on the shape, position, and/or
size of the teeth.1,5,6 It is therefore essential
to carry out proper planning to determine
the need to perform additive techniques, re-
modeling (enameloplasty), or both.
Composite resins are the first choice as
direct restorative materials and for cosmetic
recontouring. In recent decades, their evo-
lution and improvement has increased pre-
diction and longevity and has enabled more
conservative and repairable procedures.5,7-13
a The aim of this article, therefore, is to de-
scribe a clinical case where a simple ap-
proach for cosmetic enamel recontouring
was followed, based on enameloplasty and
the additive technique with composite resin
to restore and enhance the esthetic appear-
ance of the maxillary anterior teeth and the
smile.

Case report

A 34-year-old female presented for treat-

ment complaining about the position of her
b misaligned maxillary central incisors, the
form and reduced size of her lateral inci-
Fig 1 (a) Preoperative image showing an inadequate incisal display and sors, and the wear of her canines. She also
misalignment of the teeth. (b) Preliminary intraoral view of the maxillary anterior expressed dissatisfaction with her smile. Af-
teeth, with the presence of peg lateral incisors. ter all the options had been explained and

136 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
 PONTONS-MELO ET AL

discussed, the patient and the clinician de-

cided on a cosmetic treatment of the six
maxillary teeth using an additive technique
with direct composite resin and enamelo-
plasty.

Diagnostic approach
and treatment planning

The initial clinical procedure included a

careful analysis of the occlusion, a dental
and periodontal examination, and a study of
extra- and intraoral photographs. The radio-
graphic evaluation showed no alteration of Fig 2 Diagnostic wax-up model mounted on the semi-adjustable articulator.
bone or dental (or any other) structure. The
clinical examination revealed an imbalance
in the harmony of the smile caused by
crowding of the two maxillary central inci-
sors, the alteration in size and shape of the Diagnostic wax-up
peg lateral incisors, and the position and in- and bis-acryl mock-up
cisal wear of the canines (Fig 1).
The evaluation of the incisal edge with A wax-up is fundamental for precise treat-
the lips at rest allowed for the visualization ment planning. The new heights, shapes,
of approximately 3.5 mm of tooth structure. and contours of the anterior teeth are
Photographs were taken and an assessment planned based on the analysis of the occlu-
made with the patient’s upper lip at rest. Us- sion, the phonetics, the dentolabial relation-
ing a periodontal probe, the position of the ship, and the esthetic proportions of height/
incisal edge of the maxillary central incisors width (Fig 2).9,15-19 Once the model with the
relative to the upper lip was determined. diagnostic wax-up had been verified and ac-
Previous studies have shown that the cepted by the clinician and patient, the
amount of incisal display decreases propor- planning was transferred to the mouth for
tionally with advancing age.14 For example, clinical evaluation (Fig 3). This was made
in a 30-year-old, 3 mm of incisal display at with an index of laboratory condensation
rest is usual, whereas in a 60-year-old, the silicone (Zetalabor; Zhermack) filled with a
incisal display could be 1 mm or less. The bis-acrylic resin (Protemp 4; 3M ESPE) for
change in incisal display with time suggests the try-in stage. This step was aided by es-
that the resilience and tone of the upper lip tablishing effective communication with the
tends to decrease with advancing age.15 patient by means of a visual language, which
Initially, dental arch impressions were also allowed us to verify, correct, and im-
taken with PVS material (Silagum; DMG) and prove the final configuration (Fig 4).20-22 Res-
models were made with type IV dental torations with new lengths, shapes, and in-
stone (Fujirock EP; GC). The casts were then cisal edges were planned and projected
duplicated and mounted on a semi-adjust- based on facial and dentolabial analysis,
able articulator (PROTARevo; KaVo), with phonetic tests, evaluation of the anterior
analysis and simulation of how the dental guidance (excursive movements), and tooth
structures would be modified. size (width/length ratios).20,21

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CASE REPORT

a b

Fig 3 (a) Silicone guides fabricated over the wax-up to elaborate the mock-up. (b) Frontal view with the mock-up in place.

a b

Fig 4 (a) Lateral view of the smile with the new tooth shapes and positions. (b) Some details that needed to be corrected to improve the
harmony of the smile were adjusted in the mock-up.

a b

Fig 5 (a) Areas to be modified were demarcated. Cosmetic recontouring was performed to better align the maxillary central incisors prior to
starting the definitive restorations. (b) Abrasive strips for redefining the interproximal areas.

138 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
 PONTONS-MELO ET AL

Cosmetic enamel recontouring

(enameloplasty)

After a phase of careful diagnosis, cosmet-

ic recontouring was performed to correct
the alignment of the maxillary central and
peg lateral incisors. The most prominent
areas of the vestibular aspects to be modi-
fied were demarcated with a Pitt perma-
nent artist pen. To improve the alignment
of the maxillary incisors, the abrasion was
carried out with an 864.FG.014 diamond a
bur (Komet) and stainless steel abrasive
strips (Fig 5). This procedure should be per-
formed without anesthesia, as this mea-
sure is an indicator of the possible degree
of sensitivity of the patient. To eliminate
accentuated surface roughness, finishing
was carried out with a carbide bur on a 1:4
increaser contra angle (T2 REVO; Sirona)
for better operative control. The facial sur-
faces were polished with a coarse silicone
cup (Jiffy; Ultradent). Finally, a desensitiz-
ing agent (5% potassium nitrate, and 2% so-
dium fluoride, Desensibilize 2%; FGM) was
b
applied for 10 min. The gel was removed
with cotton and plenty of water. Fig 6 (a) After prophylaxis, modified rubber dam isolation was established.
(b) Silicone guide in position to verify its position and adaptation.
Additive technique
with composite resin

Remodeling was carried out with compos- 20 s, followed by a water rinse and light air
ite resin. After tooth prophylaxis, modified drying. The surfaces of the adjacent teeth
rubber dam isolation and a retraction cord were protected with teflon tape during
were placed (Fig 6a). To enhance the pre- blasting and etching. Next, an adhesive sys-
dictability of the treatment, an impression of tem (Bond Force II; Tokuyama) was applied
the palatal and incisal thirds of the teeth sur- in accordance with the manufacturer’s
faces from the waxed-up cast was obtained guidelines (Fig 7a). Light curing was per-
and used as a dimensional guide for com- formed for 20 s with a LED light source
posite placement and symmetry. Prior to (VALO; Ultradent).
the restorative procedures, the adaptation Using a composite resin instrument, a thin
of the silicone guide was verified (Fig 6b). layer of translucent composite (NE, Estelite
Initially, the enamel surface was sand- Asteria; Tokuyama) was placed onto the sili-
blasted with 53 μ aluminum oxide (AquaCare cone guide as a lingual shelf to establish
Dental Air Abrasion; Medivance Instruments). the palatal/proximal contour and the new
Then, 35% phosphoric acid was applied for incisal edge. The excess material was

The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019 | 139
CASE REPORT

a b

c d

Fig 7 (a) After etching with phosphoric acid, a bonding agent was applied and light cured. (b) Highly translucent enamel composite placed
between the mamelons to obtain the opalescence characteristic of this area. (c) Interproximally, a tight contact point and the correct facial
embrasure forms were created. (d) The incisal and facial height was verified with the silicone matrix.

a b

Fig 8 (a) Composite for dentin was applied to the peg lateral incisors due to the lack of contour and volume. (b) View after the application
of the layer that corresponded with the artificial enamel.

140 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
 PONTONS-MELO ET AL

removed and the composite resin light mally and pulled through (Fig 7c). Finally,
cured in position for 20 s. The artificial body both the buccal and palatal surfaces were
(Shade A2B and A3B; Estelite Asteria) was cured for 40 s. The facial and incisal height
placed over the facial portion and sculpted was verified with the silicone matrix (Fig 7d).
into the shape of the lobes and develop- A similar stratification technique was ap-
mental depressions. To recreate the trans- plied to the peg lateral incisors, but with the
lucency of the natural enamel, a small addition of composite resin for dentin (Shade
increment of highly translucent enamel A2B and A1B) in the lateral zones due to the
composite (TE; Estelite Asteria) was applied lack of contour and volume (Fig 8). Before
to the region of the incisal third between polishing, excess material at the margins
the body mamelon spaces and extremities was removed with a no. 12 surgical scalpel
(Fig 7b). The final layer, which corresponded blade (Swann-Morton). A coarse-gritted disc
with the artificial enamel, was restored with (FlexiDisc; Cosmedent) was used to pro-
translucent enamel (NE; Estelite Asteria) for duce the primary anatomy and to achieve
the middle and incisal thirds. Composites symmetry between similar teeth. After the
were carefully applied with a large-bladed desired cervicoincisal and mesiodistal
instrument and smoothed with the aid of a lengths were reached, symmetric light-re-
no. 4 flat-tipped brush (Ivoclar Vivadent). In- flection areas and light-deflecting zones
crements of composite resin were light were outlined with a pencil, and the distance
cured according to the manufacturer’s in- was checked with a sharp-ended caliper.
structions. To aid in creating a tight contact In addition, tissue remodeling of the
point and the correct facial embrasure maxillary right central incisor was performed
forms, a Mylar strip was placed interproxi- to position the gingival margin at the same

Fig 9 (a) Teflon tape

and a thin retractor
cord were placed in
the sulcus for
visualization of the
cervical region.
(b) Acid etching
performed only on a
restricted area. (c) A
gingival protector
a b instrument was used
to enable the
adaptation of the
composite. (d) Appli-
cation of the
composite to
remodel the gingival
margin.

c d

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CASE REPORT

Fig 10 Frontal view

of the maxillary
anterior teeth after
the restorative
procedure.

height as the maxillary left central incisor Occlusal bite splint

and to improve the gingival architecture.
This simple and rapid technique1,5 involves After the restorative procedure, the use of
the direct application of composite. There- an occlusal bite splint was indicated as a
fore, Teflon tape and a thin retractor cord temporary protection for the restorations
were placed in the sulcus for protection and (Fig 11a). The splint was indicated for night
better visualization of the cervical region. A use during sleep for a period of 6 months.
gingival protector instrument (Zekrya; Dent- After this period, the patient will be reeval-
sply Sirona) was used for the application. uated to verify her dental status and restor-
This instrument favors the adaptation of the ations, as well as the situation regarding
composite resin, as shown in Figure 9. the bite splint. Upon completion of the
The facial and palatal surfaces were fin- treatment, the patient was given instruc-
ished in sequence with a coarse silicone tions regarding oral hygiene, periodic fol-
cup (Jiffy). To prepare for the macro sur- low-ups, and the maintenance of the res-
face texture, the facial surfaces were creat- torations. She was cautioned against
ed with the aid of a no. H48LF and no. harmful habits such as biting her lips or
H48LUF carbide finishing bur (Komet) on a hard objects, nail biting, etc. It was also
1:4 increaser contra angle. The final natural emphasized that proper oral care is closely
gloss was achieved using the Astrobrush related to treatment longevity. The final as-
system (Ivoclar Vivadent) and a goat hair pect of the teeth and smile is shown in Fig-
brush (Jiffy Goat; Ultradent), followed by a ure 11b and c.
felt wheel (FlexiBuff; Cosmedent), alumi-
num oxide polishing paste (Enamelize; Discussion
Cosmedent), and abrasive strips (Polyden-
tia) for refining and polishing the interprox- In recent years, cosmetic recontouring has
imal areas (Fig 10). been increasingly indicated due to its im-

142 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
 PONTONS-MELO ET AL

mediate and permanent results and is pre-

sented as a valuable alternative to more ex-
pensive treatments that demand greater
operative technique.3 Recontouring can
provide quick and efficient treatment for the
patients for whom it is indicated. In the case
presented here, esthetic and functional re-
sults were achieved based on sound plan-
ning and execution.
In cases of misaligned teeth, the proced-
ure of choice is orthodontic treatment.
However, in cases where dental misalign-
ment is minimal, orthodontic treatment a
may not be appropriate. In these cases, oth-
er methods may be chosen, ranging from
treatments such as cosmetic recontouring
with composite resin to less-conservative
treatments such as indirect veneers. These
treatments can be highly successful at a
lower cost with a greater commitment to
the maintenance of tooth structure.1
Cosmetic recontouring can be consid-
ered a safe form of treatment with few or no
side effects.22 Zachrisson and Mjör,23 after
performing extensive cosmetic recontour-
ing on healthy premolars, emphasized that
the patients did not show permanent pain-
b
ful symptoms, except in some cases where
increased sensitivity in the first days after
treatment was observed. In the case pre-
sented here, no collateral effect or symp-
toms associated with pain caused by sensi-
tivity were observed. Mondelli1 suggests that
this type of treatment should be previously
planned on study models. Additionally, judi-
cious clinical analysis using intra- and extra-
oral photographs to visualize the initial den-
tal situation and its relationship with the face
is recommended. These are always very im-
portant steps for proper planning. Frequent-
ly, the clinician is challenged to modify the
c
configuration of the smile by applying a re-
storative material to rearrange the disposi-
Fig 11 (a) Maxillary bite splint in position. (b) Final outcome after recontouring
tion of the teeth. A good treatment should and restoring the anterior teeth. (c) Postoperative view showing a new arrange-
respect and simulate the spatial arrange- ment of the teeth and the harmony of the smile. This case illustrates the potential
ment, relation, and appearance of the natu- of conservative dentistry.

The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019 | 143
CASE REPORT

ral tissue.24,25 The success of these proced- esthetics and behavior under functional
ures, however, depends on an understanding loads.32 Nanoparticle and hybrid compos-
of the intimate structure of the natural teeth. ites have sufficient fracture toughness for
The evolution of adhesive dentistry has Classes I, II, III, IV, and V, and even for ve-
increased the indication of esthetic restora- neers and large buildup restorations, com-
tive procedures, especially those using pared with microfilled composites that ex-
composite resins5,26 and improved reinfor- hibit low fracture toughness and should
cing fillers that have greater wear resistance only be considered for nonstress-bearing
and are more easily and effectively pol- areas.32 A retrospective evaluation yielded
ished.24 Compared with indirect restor- an estimated 5-year survival rate of almost
ations, these new technologies offer good 80% for direct composite resin buildups.12
predictability and load resistance, accept- This outcome supports the results of a pro-
able longevity, and the preservation of spective clinical evaluation of 87 direct
healthy dental tissue at a lower financial composite buildups over 5 years with a sur-
cost.9,12,21,26,27 Also, reintervention is relatively vival rate of 89%,8 compared with survival
easy and inexpensive, and fractures or de- data on Class III, IV, and V composites that
fects that may appear over time are repair- were similar in location, dimension, and
able without the need to remake the whole method of placement (8-year survival rate:
restoration, which is an advantage to pa- 73%).33 Also, for building up worn anterior
tients both in terms of conservative dentist- mandibular dentitions, direct composite
ry and financial cost.12,28 restorations have shown a good survival
As this case report shows, several condi- rate (94% restorations in 18 patients).34 In
tions are potential indications for conserva- this respect, clinical studies have shown
tive additive treatment through a simplified positive outcomes, with few limitations or
approach that can extend the benefits of problems.26,29,30
composite resin to a larger number of pa- Patients should be made aware that the
tients and clinicians. shade and texture of the material changes
Composites as anterior restoratives are over time. Restorations also require periodic
the material of choice for most restorations. maintenance.21 In addition, patients should
Several studies such as those by van Dijken be advised about diet and environmental
and Pallesen29 and Wolff et al30 found that factors. One important factor is superficial
the most frequent threat to direct compos- staining, which increases when surface tex-
ite buildups is the fracture of composite res- ture is created during the polishing proce-
in restorations. Fracture toughness is there- dure.35 Clinicians should be aware that re-
fore an important property, which correlates polishing a stained surface could reduce it
with intraoral chipping of surfaces and mar- without returning the restoration to its origi-
gins.31 The best current composites have a nal color.35
fracture toughness < 2.0 MPa1/2, which is Occlusal appliances such as hard occlu-
similar to amalgam and better than porce- sal stabilization splints are reversible inter-
lain. As there are differences in the fracture ventions.21 The use of occlusal splints should
toughness values of various composites not be considered a lifetime treatment,
recommended for anterior restorations, a although they may reduce teeth grinding,
more detailed classification of materials muscular activity, and myofascial pain.36,37
used for anterior restorations would be ben- Holmgren et al38 surmised that the thera-
eficial in order to select the appropriate ma- peutic mechanism of a splint must at least
terials for a specific restoration in terms of have a relationship to factor that modifies

144 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
 PONTONS-MELO ET AL

and reduces parafunctional activity and/or lar joint disorder factors as well as the use of
redistributes the overload in the masticatory other types of treatment that help improve
system. In this case, an occlusal appliance the patient’s quality of life.
was made for the purpose of preventing re-
storative treatment failure. Clinical relevance

Conclusion The cosmetic recontouring based on ena-

meloplasty and the additive technique with
In dentistry, achievement should not be composite resin allowed a conservative
measured solely by immediate results or es- treatment with a low biological and financial
thetic appearance but also by good stability cost. This simple approach was viable and
and harmony of the stomatognathic system obtained reliable functional and esthetic re-
and the long-term results of the treatment. sults.
These factors depend directly on a number
of variables, including proper maintenance Disclaimer
of restorations (eg, periodic controls, the
use of an occlusal bite splint), the increase The authors declare that there are no con-
or decrease of etiologic temporomandibu- flicts of interest.

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