The patient underwent orthodontic treatment, improved aesthetics with composite Tetric Evo Ceram® veneers, and hyaluronic acid and botulinum toxin (Botox) were applied to correct and enhance the smile and lip contour

11/10/2023
14:50

Authors: Juan Pablo and Mauricio sanchez

From Braces to a Brilliant Smile: A Case Study in Composite Veneers at Facialia

When orthodontic treatment with metal brackets ends, patients often dream of their perfect smile. But what happens if the results don’t quite meet expectations? At Facialia, your trusted dental clinic in Silla, Valencia, we specialize in transforming smiles beyond orthodontics. In this case, a patient came to us looking for a solution to improve her post-braces aesthetics and address lingering dental sensitivity. The answer? Composite veneers, a minimally invasive and effective way to enhance both form and function.

The Patient’s Journey: Braces Were Just the Beginning

Our patient, having completed her orthodontic treatment with metal brackets, still felt her smile wasn’t as radiant as she had hoped. Discoloration and slight irregularities in her teeth left her dissatisfied. To meet her goals, we designed a personalized treatment plan using composite veneers, which not only improved her smile’s color and shape but also alleviated her dental sensitivity.

Composite veneers are an excellent option for patients looking for immediate aesthetic improvement without the invasiveness of porcelain veneers. Research by Peumans et al. (2000) confirms that composite veneers are a cost-effective, durable solution when performed with proper technique.

Step-by-Step Process for Composite Veneers

1. Selective Carving: Where Science Meets Art

The first step in the composite veneer process is careful selective carving. In this case, we focused more on areas where discoloration and deeper stains were present. Minimal enamel removal was necessary, as the patient’s natural color didn’t require significant adjustment. This conservative approach aligns with studies like those by Van Meerbeek et al. (2003), which emphasize the importance of preserving natural tooth structure in aesthetic treatments.

2. Cleaning and Preparing the Surface

Next, we thoroughly cleaned the teeth using alcohol to eliminate impurities and ensure optimal bonding.

Alcohol application: Left on for 20 seconds to sanitize and prime the surface.
Orthophosphoric acid (37%): Applied for 4–5 minutes to etch the surface, creating microscopic pores for better adhesion.
Adhesive layer: Carefully applied and air-thinned to prevent excess material, then photopolymerized for a secure bond.

3. Layering the Composite: The Secret to a Natural Look

Using Evo Ceram Bleach XL, we applied the composite in delicate layers. Transparent plastic bands were placed between the teeth to maintain separation, and in some cases, Teflon tape was used to enhance precision. Each layer was light-cured to build the ideal shape, mimicking the natural contours of enamel.

4. Sculpting Perfection: Contours, Profiles, and Angles

Once the composite was fully cured, we sculpted the teeth using an Arkansas bur and diamond bur. This step allowed us to refine:

Contours for a natural appearance.
Emergence profiles to ensure proper gum-to-tooth harmony.
Incisal inclination for that polished, symmetrical smile.

5. Polishing: The Final Flourish

The polishing stage is where the magic happens, transforming good work into perfection. Using polishing discs of varying grits (from coarse to fine), we smoothed and shined the composite until it flawlessly matched the patient’s desired color and shape. As this step can take several appointments, we worked closely with the patient to ensure complete satisfaction, echoing findings by Nakabayashi et al. (1982) on the importance of surface finishing for long-term veneer success.

The Results: A Radiant, Symmetrical Smile

After completing the treatment, the patient was thrilled with her new smile. Her teeth were brighter, more even, and completely free of sensitivity. Studies like those by Baratieri et al. (1998) confirm that properly bonded composite veneers offer not only immediate aesthetic benefits but also protect against further enamel wear and sensitivity.

Why Choose Facialia for Composite Veneers in Valencia?

At Facialia, we blend artistry with advanced techniques to deliver stunning results:

Personalized Care: Each smile is unique, and we tailor every treatment to your needs.
Minimally Invasive Techniques: We prioritize preserving your natural tooth structure while enhancing aesthetics.
State-of-the-Art Materials: Using high-quality composites ensures durability and a natural look.
Experienced Professionals: Our team is highly trained in aesthetic dentistry and uses evidence-based techniques.

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Transform Your Smile Today at Facialia

Whether you’ve just finished orthodontic treatment or want to enhance your smile, Facialia is here to help. Our composite veneers are designed to give you the confidence and radiance you deserve.

👉 Book your consultation today at Facialia.com or visit us in Silla, Valencia to start your smile transformation journey. Let us bring out the best in your smile! 😁

Photos of the realization of veneers

Initial photo after brackets

Photos during the preparation for veneers in composite Xl bleach Tetric Evo Ceram®

Maxilla

In the photo, it can be seen that there is a combination of a very light colour with yellow. This is because the patient disagreed with such a light colour. As the veneers were increasingly polished to reduce the tonality, the composite gradually diminished, appearing the dentin.

Hyaluronic acid

Hyaluronic acid is a great tool to improve facial aesthetics and skin health.

There are two types or two large groups and different variables within them.

These groups are:

1. Hyaluronic acid stiffer: Used to give support and lift functions to parts of the Face that have descended, such as the tip of the nose or the eyebrows. Another use is to restore or restore the strength of the tissues.

2. Hyaluronic acid softer: It is used to improve the contour of facial expressions, such as the front of the jawline. The idea is to achieve facial proportions.

The lip will be upper lip of 1 cm and the lower of 1,618 cm in women; this was written by Swift & Remington in 2011(Swift and Remington, 2011).

Some characteristics do not change. Instead, they are constant, such as the intercanthal distance, the forehead’s height, the nasal spine’s anterior position, genetics, age, and ethnic characteristics.

3. Injected botulinum toxin A (BTXA) into the normal contralateral smile muscles to weaken them and restore symmetry to active and passive movements by neutralizing these overacting muscles(Sadiq, Khwaja and Saeed, 2012).

Different Areas where can put hyaluronic acid in the Face.

Photo taken from the article by McKee et al. 2019(Mckee et al., 2019).

Referral

The patient attended the Doctor Lluch dental clinic (Valencia, Spain).

Patient Complain

« I want to have more striking lips and improve my profile without being artificial. My smile is not symmetrical when I laugh, and I want to improve it. »

Medical history

Age: 65 years old.

Actual diseases: None.

Allergies: Pollen, dust.

Family conditions: Her father died of cancer, and her mother died from systematic failure.

Tobacco history: Not smoker.

Alcohol intake: No, usually.

Treatments performed before Hyaluronic acid treatment:

1. Cleaning and applying airflow are carried out.

2. Radiological diagnostic method: Periapical radiographs and orthopantomography. A CBCT(Leonardi Dutra et al., 2016) was performed when even better image detail was needed to assess periodontal health.

3. Perio chart shows the deep pockets and soft tissue conditions:

A. CAL generalized were 2 mm in molars and 1 mm in anterior teeth.

B. Plaque localized.

C. Thin biotype.

D. Gingivitis induced by biofilm(Caton et al., 2018) localized in molars.

G. The CPITN code was 1 for the majority of her teeth.

4. The patient was taught the instructions and good brushing and flossing techniques. An electric toothbrush is recommended since, according to Ccahuana-Vasquez et al.(Ccahuana-Vasquez et al., 2019), 2019 reduces the level of plaque and gingivitis compared to the manual toothbrush.

To control plaque levels in the patients, it was recommended to use some tablets to detect plaque after brushing. Thus, they would know if the plaque is being removed and where they need to brush better.

5. Sistematic revaluation was recommended after four months to check the periodontal evolution.

Attitudes towards previous treatment

She did not want to do it to him; she did not want to seem artificial but knew I was missing a case of aesthetics, which is why she did it.

Systematic orofacial examination

Dolychofacial patient initially from Colombia, with upper and low maxilla facades.

Initial Face’s photos:

*Meso brachyfacial pattern.

*Thirds not provided; frontal are increased.

*Inter-labial distance in anterior un-occlusion of 4 mm.

*Pupillary and commissural lines are parallel.

*Labiomental angle open.

*Cheeks full.

*Deviation of the jaw 1 mm to the right when she closes her mouth.

*Facial and pupillary midline are not perpendicular.

*Inter-labial distance in anterior un-occlusion 4 mm.

*Effortless lip engagement.

*Lip competence.

*Inter-commissural width matches the middle limbus of the eyes.

* profile convex.

* flat union between the philtrum and Cupid’s bow.

* Nasal-labial angle of 100º.

* Lips contained within the aesthetic plane of Ricketts.

Lips photos

*Sup Lip 1 mm.

*Inf Lip 1.2 mm.

Smile photo:

Smile examination

* Lip smile line: When she smiles, a deviation of the smile line is seen on the left side, showing more lower than upper teeth.

* Lower line matches with the facial midline.

* Asymmetrical smile.

* Upper midline deviated 1 mm to the right concerning the facial and upper midline.

Diagnosis

1. The patient presents a loss of lip volume, which is more noticeable in the upper; the contours are not well defined, being more apparent when the patient is in profile.

The nasolabial angle is not very open, and the labial-chin angle is almost straight.

The tip of the nose is slightly drooping, and the grooves of the columella are distorted.

2. The patient does not have Hyperkinesis(de Sanctis Pecora and Shitara, 2021), which consists of static and dynamic asymmetry of the Face, leading to significant functional and aesthetic problems, such as a more pronounced nasolabial fold deviation of the corner of the mouth laterally up or down and a narrower eye-opening. Nevertheless, it does present an asymmetry when it smiles due to a greater intensity of the angle depressor muscle of the left mouth.

Alternatives to the treatment:

1. A combination with minor surgery or laser application achieves a natural look even in elderly patients with prolonged philtrum(Wollina and Goldman, 2018).

2. Plastic surgery.

Treatment

1. 4 mm deep was applied superficially with a 27G needle, deep hyaluronic acid from the Revolax brand, for the lip contour.

2. the Revolax TM soft brand was used for lip filling.

3. For the wings of the nose, philtrum, and tip of the nose, the Revolax TM deep was used.

4. Fill the peri-oral tissue around the mouth with Hyaluronic acid.

De Maio et al. 2017(De Maio et al., 2017) said that the perfect lip includes a visible transition line or border between the vermillion and skin, a V-shaped cupid’s bow, a full medial tubercle and vermillion, an ascendant line in the oral commissures; this is our aim, and also to get an aesthetic proportion between upper and down lips of 1:1618(Swift and Remington, 2011).

4. Botulinum toxin (BtXA) is applied to the depressor muscle of the left side commissure; 2 U was injected.

Options

Conveniences

Hyaluronic acid has many applications due to its excellent biodegradability, biocompatibility, nontoxicity, and non-immunogenicity. Sudha & Rose 2014(Sudha and Rose, 2014)
Long-term use.

Inconveniences

Apply hyaluronic acid inside the upper labial artery since it is 4.29±1.54 mm deep between the corner of the mouth and the Cupid’s bow(Wollina and Goldman, 2020).
Lip necrosis.

Application technique:

1. It must be done gently and slowly, causing minor damage, inflammation and pain. McKee and Lalonde 2017(McKee and Lalonde, 2017) published this.

2. The lips being an area with so much irrigation and nearby nerve endings, Benzocaine topical anaesthesia was applied in the vestibule of the upper and lower teeth from 2.4 to 1.4 and from 3.5 to 4.5.

3. After waiting two minutes, 2% lidocaine was applied to the infraorbital nerves, accessing intraorally at the level of the canines.

4. Then, anaesthesia is reinforced by placing the upper incisors in the vestibular and the vestibular fundus.

5. For the lower part, anaesthesia was applied at the level of the mental nerve. After this, In the lower lip, what was done was drawing a parallel line of the wings of the nose. It was filled by directly clicking between the red line and the skin area. The acid was applied to two points in the lower lip, with one point in each quadrant.

These points were located on the lip ridge; 5 ml and 10 ml were applied to fill the lip’s centre.

6. Soft hyaluronic acid was placed on the upper lip. The upper lip was applied at three points in each quadrant, 5 ml at each point to increase the nasal ridge and improve the Cupid’s bow and 10 ml for the lip filler.

In total, 80 ml was applied, 10 ml being for the tip of the nose and 10 ml in the columella.