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Whenever there is an opportunity to use Minimally Invasive Dentistry (MID) or minimal intervention, the choice should be obvious. These opportunities come along daily. The case below is an example of how an orthodontist correctly left space for complementing cosmetic enhancement.

A 15-year-old female patient presented following removal of her orthodontic brackets a week previously. She was missing tooth No. 11 and the laterals were small. The teeth had been orthodontically repositioned with No. 12 shifted into the No. 11 position (Fig. 1). The orthodontist had balanced the interdental spaces to maintain a natural inter-canine distance.

The patient’s mother did not want to spend too much money at this stage as she was still dealing with the financial aspects of the orthodontic treatment. The age of the patient precluded the use of indirect porcelain veneers, as tissue resolution was still occurring and the orthodontist wanted to get her into a vacuum-formed retainer as soon as possible. The obvious, most minimal and non-invasive way to complete the resolution of the esthetics following ortho was to place bonded, direct composite restorations. This treatment option did not preclude the placement of something like Lumineers (Den-Mat) in the future, once gingival maturation had occurred and the patient’s financial options increased.

The decision was made to close the spaces with direct placement composites using Gradia Direct X (GC America). Following meticulous cleaning of all the interproximal surfaces, the enamel was acid etched and G-Bond (GC America) was placed, air thinned and cured (Fig. 2). One of the esthetic problems of placing direct interproximal composite veneers is translucent shine-through between the composite veneers and the interproximal enamel, creating a vertical shadow adjacent to the bonded interproximal composite. To prevent this, the initial increment of composite is placed using an opaque shade (AO2) that is wrapped around onto the palatal surface to reduce light transmission through the interproximal enamel. This opaque layer was then covered with A2, followed by enamel translucent shades neutral and white (Fig. 3).

Tooth No. 7 was built up first and contoured, ensuring good contour of the mesial and distal labial embrasures (Figs. 4-5). The distal of No. 8 (Fig. 6) and mesial of No. 6 (Fig. 7) were then built up using the same layering technique. When the left side was built up and contoured, care was taken to create balanced embrasure contours on the two laterals to create a similar natural light reflection off the labial faces to the mesial embrasures. When this effect is obtained, the teeth have a natural, balanced appearance, even if it has not been possible to establish identical proportions due to interproximal space discrepancies.

Following initial contouring, a photo was taken and downloaded to allow close observation of the labial and incisal embrasure symmetry (Fig. 8). It was obvious that the distal labial embrasure of No. 7 was slightly rounder than that on No. 22, and the distal incisal edge embrasures of the No. 7 and No. 10 were too sharp. Simple modification with a fine disc created acceptable symmetry before the veneers were polished (Fig. 9). Care was taken to establish natural labial contours and hollows to create realistic light reflection.

Fig. 1 Immediate post orthodontic case. Tooth No. 12 has been moved into the No. 11 position and the spaces balanced for a natural inter-canine distance.		Fig. 2 After meticulous cleaning of all the interproximal surfaces, the enamel was acid etched and G-Bond was placed, air thinned and cured.
Fig. 3 Following the first interproximal increment of opaque composite A02, a second increment using A2 was placed.	Fig 4. A final layer of enamel translucency was placed. Neutral translucent was placed in the gingival 2/3 and white translucent in the incisal 1/3.
Fig. 5 The distal of No. 7 was built up using the same layering technique. The tooth was contoured using fine diamond burs and polishing discs to create a natural size, shape and proportion.	Fig. 6 The distal of No. 8 was built up, once again using the same layering technique of AO2, A2, NT and WT.	Fig. 7 The mesial of No. 6 was restored using the same technique to fill in the open embrasure, also placing composite into the palatal aspect to allow control of the embrasure contours.
Fig. 8 The left side was restored using the same concepts and a photo was taken and uploaded to allow close observation of the veneer contours. This photo allows a comparison of both the labial and incisal embrasure shapes. At this point, the distal labial embrasure of No. 7 is too bulbous in the gingival 1/3 and the distal incisal embrasures of Nos. 7 and 10 are too square.
Fig. 9 Completed case two weeks after revision of contours. Note the light reflection pattern from the mesial embrasure planes of both laterals is similar.
Photos courtesy of Dr. Graeme Milicich, BDS

	This monthly column is co-sponsored by DPR and  The World Congress of Minimally Invasive Dentistry. It is edited by Congress past-president Dr. Joseph Whitehouse.
	Dr. Graeme Milicich, BDS Dr. Milicich lives in Hamilton, New Zealand and lectures internationally in the fields of minimal intervention, caries risk assessment and management, minimal intervention restorative techniques, and on the physics and clinical applications of dental lasers. He is a Fellow, Diplomate and founding board member of the WCMID, and has produced several educational CDs.