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Show Your Work: Full-Contour Veneers and a Fantastic Hygienist by Dr. Arthur R. Volker

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Categories: Restorative Dentistry;
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist 

by Dr. Arthur R. Volker
with Shimaa Abdelhady and Chanda Tangabetani

New-patient emergency visits can be a stressful situation for both patient and clinician. Unless detrimental to the health of the patient, it’s imperative that their chief complaint be addressed. Even if future comprehensive treatment will be needed, a successful initial encounter can be a practice builder for the office and a confidence builder for the patient.

This article documents a case in which a new patient presented with a clinical emergency and from that experience became vested in his dental health and sought further comprehensive care. To address his chief complaint, which was a Class IV fracture on Tooth #9, an appropriate aesthetic outcome was needed.

Obtaining a perfect shade and overall appearance is not an easy process, because the color of the teeth is a combination of intrinsic and extrinsic effects. Intrinsic effects are generated from the enamel characteristics of light absorption and reflection, while extrinsic effects mainly occur from stains from foods, drinks or medications. As a result, trying to mimic all these effects to achieve the color matching using resin filling materials could be a sophisticated process. It includes shade selection and multilayering of different shades and opacities of composite.

This long, detailed technique is time-consuming and highly affected by each dentist’s skill level. The process is made infinitely more difficult if the patient presents with heavy staining and gross biofilm. As such, the chief complaint was prescribed to be repaired with a “universal shade” composite in the hopes that it would color-adapt to the shade of the teeth after the cleaning.

A universal shade solution
Omnichroma resin (Tokuyama) can resolve the overwhelming, technique-sensitive approaches of veneering teeth; the universal nanocomposite can match all 16 Vita shades, from A1 to D4. According to the manufacturer, this optical phenomenon occurs when light passes through proprietary 260-nanometer spherical filler particles, which creates a chameleon effect with the surrounding area.

Universal shade composites have shown good clinical outcomes in terms of shade matching to adjacent tooth structure.1–4 Because they are translucent by nature, care must be taken when working with areas of sharp contrast such as in a fracture case where the break, coupled with the dark recesses of the mouth, can combine to create an unnaturally gray appearance. To that end, an opaque blocker material is suggested that may help blending of the material.5

Though translucent, Omnichroma composite is radiopaque, which will not create radiographic issues.6 It exhibits good color matching of teeth both before and after bleaching procedures,7 which demonstrates that the material can adapt to a change in shade and still be clinically acceptable. Also, Omnichroma exhibits lower amounts of cytotoxicity to gingival tissues, compared with other composites.8,9 This can be potentially advantageous in full-contour veneer applications or interproximal restorations where the material will be in contact with the gingival areas.

Case study
Initial visit: Class IV
A 35-year-old patient in good general health presented with a chief complaint of a fractured Tooth #9 (Figs. 1 and 2). He had not been to a dentist for more than 15 years, and the clinical examination also revealed heavy calculus and staining with erythematous gingiva. No signs of pulpitis or necrosis were observed. Tooth #8 was observed to have a small carious lesion on the direct facial.
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 1
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 2

The patient was anesthetized with 3% mepivacaine without epinephrine. Tooth #9 was prepared with a 0.5-millimeter chamfer and an infinity bevel.10 A heavy nonlatex rubber dam was placed over the teeth, affixed with WedgeJets (Coltene), and a metal sectional matrix (Tor VM) was inserted into the mesial (Fig. 3). The matrix was stabilized with a wooden wedge (Fig. 4).
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 3
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 4

Omnichroma blocker was placed freehand on the palatal surface over the chamfer but short of the infinity bevel, then cured. A layer of Omnichroma was then overlaid on the tooth (Fig. 5). The matrix was removed to assess the interproximal profile (Fig. 6), and the excess material was then removed with a disc (Fig. 7). The shape was further honed with diamond burs (Figs. 8 and 9).
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 5
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 6
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 7
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 8
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 9

Fig. 10 shows the immediate postoperative result of the Class IV repair. A resin-reinforced glass ionomer (Activa, Pulpdent) was placed over the carious lesion of #8 until the final restoration was to be made.
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 10

Periodontal treatment
One week later, the patient returned for a full-mouth series of X-rays and a comprehensive examination, which also included periodontal charting (Fig. 11). The patient reported no pain or issues at #8 or #9. He was subsequently seen by the hygienist for treatment.
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 11

According to the hygienist, generalized 5 mm pseudopockets with red, heavily irritated gingival margins and bulbous papillae were noted. A thorough scaling and root planning was completed using Cavitron and hand scalers. After treatment, oral hygiene techniques were demonstrated and reinforced (modified Bass brushing and scoop flossing). The patient was placed on a three-month recare.

Full-contour veneers
One month later, the patient returned for removal of caries on #8 and placement of direct composite veneers on #8 and #9. He had complied with oral hygiene instruction, so his tissues demonstrated remarkable improvement. After caries removal, the veneers were injection-molded onto the teeth using heated Omnichroma and a flat Mylar matrix. Figs. 12 and 13 show the immediate postoperative result. On the follow-up photograph taken one week later demonstrating satisfactory integration (Fig. 14), pencil markings were placed on the teeth to help assess symmetry.
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 12
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 13
Show Your Work: Full-Contour Veneers and a Fantastic Hygienist
Fig. 14

Conclusion
Using a universal shade of composite can be advantageous in clinical circumstances where shade determination can be complicated because of heavy staining and or biofilm, especially in emergency situations. Omnichroma proved to be a reliable material that can be used in multiple situations, from a Class IV resolution to full-contour veneers.

References
1. Durand LB, Ruiz-López J, Perez BG, Ionescu AM, Carrillo-Pérez F, Ghinea R, Pérez MM. Color, lightness, chroma, hue, and translucency adjustment potential of resin composites using CIEDE2000 color difference formula. J Esthet Restor Dent. 2021 Sep; 33(6):836–843.
2. Hayashi K, Kurokawa H, Saegusa M, Aoki R, Takamizawa T, Kamimoto A, Miyazaki M. Influence of surface roughness of universal shade resin composites on color adjustment potential. Dent Mater J. 2023 Sep 29; 42(5):676–682.
3. Anwar RS, Hussein YF, Riad M. Optical behavior and marginal discoloration of a single shade resin composite with a chameleon effect: a randomized controlled clinical trial. BDJ Open. 2024 Feb 20; 10(1):11.
4. Kobayashi S, Nakajima M, Furusawa K, Tichy A, Hosaka K, Tagami J. Color adjustment potential of single-shade resin composite to various-shade human teeth: Effect of structural color phenomenon. Dent Mater J. 2021 Jul 31; 40(4):1033–1040.
5. De Abreu JLB, Sampaio CS, Benalcázar Jalkh EB, Hirata R. Analysis of the color matching of universal resin composites in anterior restorations. J Esthet Restor Dent. 2021 Mar; 33(2):269–276.
6. Agaccioglu M, Yilmaz MN. The radiopacity of single-shade composite resins: A comparative evaluation. J Esthet Restor Dent. 2024 Mar; 36(3):527–533.
7. Mohammed MA, Afutu R, Tran D Dunn K, Ghanem J, Perry R Kugel G. Shade -matching capacity of Omnichroma in anterior restorations. J Den Sci. 2020; 5(2):1–6.
8. Duzyol M, Bayram P, Duzyol E, Aksak Karamese S. Assessing the impact of dental restorative materials on fibroblast cells: Animmunohistochemical and ELISA analysis. Sci Rep. 2024 Feb 27; 14(1):4725.
9. Beltrami R, Colombo M, Rizzo K, Di Cristofaro A, Poggio C, Pietrocola G. Cytotoxicity of different composite resins on human gingival fibroblast cell lines. Biomimetics (Basel). 2021 Apr 20; 6(2):26.
10. Volker AR. The “Blank Canvas Technique”: Expedited Polychromatic Class IV Restorations. Dentaltown April 2023: 24(4):50–55.

Author Bio
Dr. Arthur Volker Dr. Arthur R. Volker graduated from the Columbia University School of Dental and Oral Surgery. He is a member of the continuing education committee for the New York State Academy of General Dentistry. Volker is a diplomate of the World Congress of Minimally Invasive Dentistry, and is a fellow of the Academy of General Dentistry and the American College of Dentists. He has also published articles and lectures on such topics as cosmetic dentistry, minimally invasive dentistry, dental materials and dental implants. He practices in Sunnyside, New York.
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