January 2012 - Vol.6 105 European Journal of Dentistry Considerable advancements in communication technology have made a significant contribution to the patient’s knowledge, expectations, and demands regarding the esthetic possibilities that this profes- sion has to offer. As a result, professionals have improved their knowledge and qualifications to per- form the most varied and innovative forms of dental treatment. Consistent with this survey, multidisci- plinary treatment has become increasingly neces- sary and common in dental offices, particularly for the resolution of more complex clinical cases.1-6 AbstrAct The following is a clinical case report of a patient whose chief complaint was the presence of generalized spacing in the maxillary anterior segment following orthodontic treatment. After me- ticulous clinical analyses and discussions of the clinical procedures to be adopted, dental bleaching was performed in both arches with 10% hydrogen peroxide (Opalescence Trèswhite Supreme 10% Hydrogen Peroxide - Ultradent Products, Inc., South Jordan, USA) after the conclusion and stabiliza- tion of orthodontic treatment. Then, the orthodontic appliance was removed and the diastemas in the maxillary anterior teeth were closed with Amelogen Plus (Ultradent Products, Inc., South Jordan, USA) resin composite. It was observed that the association of orthodontic, bleaching, and restorative procedures was capable of restoring dental shape, function, and esthetics, allowing the patient to smile without hesitation. (Eur J Dent 2012;6:105-109) Key Words: Orthodontics; diastema; dental bleaching; composite resin. Renato Herman Sundfeld1 Lucas Silveira Machado1 Fernanda Garcia de Oliveira1 Eduardo Almada Santos2 Isabel Cristina Prado Torres Lugato3 Daniel Sundfeld Neto4 Conservative reconstruction of the smile by orthodontic, bleaching, and restorative procedures 1 Discipline of Restorative Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. 2 Department of Pediatric and Community Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. 3 Orthodontic Trainee at the Araçatuba School of Dentistry, São Paulo State University, Araçatuba, Brazil. 4 Discipline of Dental Materials, Piracicaba Dental School–Campinas University, Piracicaba, Brazil. Corresponding author: Dr. Renato Herman Sundfeld Faculdade de Odontologia de Araçatuba – Departamento de Odontologia Restauradora – UNESP Rua José Bonifácio 1193, CEP - 16015-050, Araçatuba - São Paulo - Brazil     E-mail: sundfeld@foa.unesp.br INtrODuctION European Journal of Dentistry 106 A clinical condition that can lead to making this association is related to the presence of inter- proximal spaces, which detract from the esthetic appearance of the patient’s teeth to a large ex- tent. Due to this possibility and with the intention of obtaining satisfactory esthetics, professionals can use conservative esthetic procedures, includ- ing dental bleaching and adhesive restorations, or even an combination of them.7 It is important to point out that contemporary adhesive esthetic dentistry has, among other things, enabled the obtainment of esthetic adhesive restorations strongly bonded to the dental structure, particu- larly when they are made in tooth enamel. Never- theless, there is a need for a well-formulated plan and well-qualified professional to perform such restorations. Our aim was to present a clinical protocol for the esthetic reconstruction of a patient’s smile af- ter the conclusion and stabilization of an orthodon- tic treatment. For this purpose, dental bleaching with 10% hydrogen peroxide and diastema closure with direct resin composite were performed. cLINIcAL cAsE The 23-year-old patient presented with gener- alized spacing in the maxillary anterior segment following orthodontic treatment. It was observed that after the leveling and aligning of the teeth, ac- cording to the correct position of the canines, pre- molars, and molars, it was not possible to obtain closure of the diastemas because it characterized a model of positive discrepancy. Specifically, the perimeter of the dental arch was larger than the sum of the mesio/distal diameters of the teeth. Therefore, these spaces were closed with resin composite (Figure 1). The orthodontic, bleaching, and restorative pro- cedures were performed at the post-graduation clinic of a dental office at the Araçatuba School of Dentistry – UNESP, after the conclusion and es- tablishment of an orthodontic treatment (i.e., pri- or to removal of the orthodontic appliance in the maxillary and mandibular arched). In-office den- tal bleaching was performed in the maxillary and mandibular arches with the application of 10% hy- drogen peroxide (Opalescence Trèswhite Supreme 10% Hydrogen Peroxide - Ultradent Products, Inc., South Jordan, USA) (Figure 2). The bleaching pro- cedures complied with the clinical sequence pre- sented in Table 1. Eight consecutive bleaching treatments were performed over eight days. Immediately after den- tal bleaching 7 topical applications of 2% neutral pH sodium fluoride gel were accomplished, for 4 minutes, with one application per day.6 After obtaining the desired color and waiting for a period of seven days,8,9 the orthodontic ap- pliances were removed from the maxillary and mandibular arches (Figure 3) so that the diaste- mas between the maxillary anterior teeth could be closed with Amelogen Plus composite resin (Ultradent Products, Inc., South Jordan, USA). The resin composite was applied to the tooth enamel surface after prophylaxis with pumice stone and water using a Robinson-type brush (KG Sorensen Ind. & Com., Alphaville, São Paulo, Brazil). Then, the appropriate resin composite shade was se- lected by performing absolute isolation. Complete isolation was achieved using rubberdam (Meide- tex, São José dos Campos, São Paulo, Brazil). The teeth to be reconstructed were etched with 37% phosphoric acid (Dentsply - De Trey Gmbh, Konstanz, Germany) on the entire dental clinical Figure 1. After conclusion and stabilization of orthodontic treatment. Figure 2. Performing dental bleaching with Opalescence Trèswhite Supreme (10% Hydrogen Peroxide - Ultradent Products, Inc., South Jordan, USA). Conservative reconstruction of the smile January 2012 - Vol.6 107 European Journal of Dentistry crown for 30 seconds. Immediately after washing and drying the etched dental enamel, two layers of the adhesive system Adper Single Bond 2 (3M ESPE Dental Products St. Paul, MN, USA) were applied and subsequently light polymerized for 10 seconds using an Ultralux halogen light appliance (Dabi Atlante, Ribeirão Preto, São Paulo, Brazil) with a power of 450mW/cm². Amelogen Plus resin composite (Ultradent Products, Inc., South Jor- dan, USA) in dentin shades A1 and A2 and enamel shade EN was used with a metal spatula, polyester strip, and wooden wedge in the proximal regions of teeth that were reconstructed. Light polymeriza- tion was performed for 20 seconds for each layer inserted and with the aforementioned light polym- erizing appliance (Figure 4). Marginal excesses were removed and the inci- sal height was adjusted with the use of a diamond tip 1190 F (KG Sorensen Ind. & Com., Alphaville, São Paulo, Brazil) (Figure 5). Occlusal adjustment was performed, as well as in working and non- working excursions, and in protrusion. During the following session, the margins, shape, and color of restorations were again observed for immedi- ately after the finishing and final polishing were performed with Sof-Lex Pop-On (3M ESPE Dental Figure 3. After performing dental bleaching with 10% hydrogen peroxide and re- moval of the orthodontic brackets. Figure 4. Insertion of Amelogen Plus composite resin (Ultradent Products, Inc., South Jordan, USA). Figure 5. Finishing the composite resin restoration with the application of a 1190 F diamond tip (KG Sorensen Ind & Com, Alphaville, São Paulo, Brazil). Figure 7. Polishing the restoration with a tip for polishing Jiffy Polisher Cups (Ultra- dent Products, Inc., South Jordan, USA). Figure 6. After finishing the restoration. Figure 8. Polishing the restoration with a tip for polishing Jiffy Composite Polishing Brushes (Ultradent Products, Inc., South Jordan, USA). Sundfeld, Machado, Oliveira, Santos, Lugato, Sundfeld Neto European Journal of Dentistry 108 Products St. Paul, MN, USA). Abrasive discs were used for resin composite finishing and polishing tips, with a tip for polishing Jiffy polisher cups (Ultradent Products, Inc., South Jordan, USA) and Jiffy composite polishing brushes (Figures 6, 7, 8). Figures 9 and 10 show the final result. DIscussION Closure of diastemas in the anterior region de- mands a careful approach and adequate planning by the professional to include multidisciplinary concepts in order to achieve a satisfactory result.2 As Mendonça et al,2 we found that the orth- odontic objectives related to the correct position of the molars, premolars, and canines further, verti- cal and horizontal overlaps were achieved within the normal range. At this time, clinical reasoning must prevail. If we are faced with adequate oc- clusion from the static and dynamic aspects and there are still diastemas to be closed, the most ad- vantageous solution for the patient is obtained by means of restorative resources. Due to the fact that the patient presented yel- lowed dental elements, dental bleaching with 10% hydrogen peroxide was proposed. This was performed after tooth movement and orthodontic stabilization; however, the brackets were not yet removed from the teeth. This clinical management enabled the closing of the diastemas with resin composite immediately after the removal of the orthodontic brackets, since the dental elements already had the ideal color to the achievement of the restorations. The manner in which the bleaching product was presented and inserted into the dental arch promoted its adaptation to the teeth and permit- ted the orthodontic brackets to bond to them, as well as allowing a whitening effect in only 8 days, with one application per day. We observed no den- tal sensitivity arising from its use. Another op- tion for teeth whitening is the in-office bleaching with hydrogen peroxide at higher concentrations. However, we decided upon the protocol we used because the bleaching of the final result was con- siderably faster. We utilized topical fluoride after bleaching because we believed that this clinical procedure could promote the remineralization of dental enamel.7 To achieve the desired dental esthetics, the golden proportion could be used to construct the dental harmony with regard to the size and shape of the teeth involved in the diastema.1,2,10 Moreover, the choice of an effective restorative material for direct use must be made using certain criteria so Figure 9 and 10. Final composite resin restorations. Conservative reconstruction of the smile Bleaching Product Application in the Dental Office 1. After prophylaxis with pumice stone and water, if necessary, protect exposed dentinal tissue with a conventional or self-etching adhesive sys- tem before applying the hydrogen peroxide-based bleaching material. 2. Apply the molded tray that contains the bleaching product to the dental arch to be bleached, adapting it well to the teeth. Instruct the patient to apply suction to it and to fix it against the teeth to be bleached. 3. Remove the molded tray and use the fingers to press the plastic tray that holds the bleaching product to make it fit better against the teeth to be bleached. 4. Use the bleaching product for a period of 60 minutes 5. After this time, remove the plastic tray that holds the bleaching product and rinse the mouth with water. 6. If necessary, the professional can repeat the process in the dental office on the following day for the same period of time (i.e., 30 to 60 minutes). 7. While the volunteer is undergoing treatment, s/he should avoid sweets, foods that contain any type of coloring agent (e.g., coffee, soda, grape or currant juice), and acidic fruits (e.g., orange, lemon) by the end of bleaching. Table 1. Clinical procedures for dental bleaching with Opalescence Trèswhite Supreme (10% Hydrogen Peroxide - Ultradent Products, Inc., South Jordan, USA). January 2012 - Vol.6 109 European Journal of Dentistry Sundfeld, Machado, Oliveira, Santos, Lugato, Sundfeld Neto that we can safely and satisfactorily establish the new mesio/distal dimensions and widths, as well as the color, texture, and strength of the dental el- ements involved.1,2,3,5,7 The choice of direct restorations with resin composite over other indirect restoration options was made primarily due to the fact that the treat- ment used was more affordable and did not involve any wear of dental structure. In addition, it is work more inexpensive.1,2,11 It is worth considering that the clinical success of anterior resin composite restorations is directly related to the use of an ex- tremely accurate technique. Adhesive system pen- etration into the dental enamel surface depends not only on the efficacy of acid etching, but also on the surface cleanliness of the enamel and the conditions of operative field isolation. In this case, priority was given to absolute isolation. However, if this cannot be done, relative isolation may be used, provided that it is carefully performed. Once the enamel surface has been etched, if it is con- taminated by saliva or oral humidity, it interferes with tag formation by reducing it number and size, thus affecting retention of the resinous material on the etched surface.12,13 The composite resin used was Amelogen Plus (Ultradent Products, Inc., South Jordan, USA), which is a direct restorative composite developed for restoring anterior and posterior teeth. Among other attributes, it presents smooth surface after finishing and polishing. Performing adequate oc- clusal adjustment in both habitual maxim inter- cuspidation and working and nonworking excur- sion and protrusion movements will undoubtedly contribute to the longevity of the restorations per- formed.1 Periodic controls of the orthodontic con- ditions established and restorations performed must be made by visits to the professional respon- sible for the treatment provided.1,2 cONcLusION We can affirm that the association of orthodon- tic, bleaching, and restorative procedures was capable of restoring dental shape, function, and esthetics and contributed to our patient’s esthetic appearance. rEFErENcEs 1. Garcia AR, Sundfeld RH, de Alexandre RS. Reestablishment of occlusion with prosthesis and composite resin restora- tions. Bull Tokyo Dental Coll 2009;50:91-96. 2. Mendonça MR, Koyama NS, Machado LS, Guedes APA, Oliveira FG, Sundfeld Neto D, Sundfeld RH. Associação de procedimentos ortodônticos e restauradores na recu- peração do sorriso de um paciente adolescente. Dent Bras 2009;1:14-16. 3. Sundfeld RH, Croll TP, Rahal V, De Alexandre RS, Briso AL, Sundfeld Neto D. Smile restoration by use of enamel microabrasion associated with tooth bleaching. Compend Contin Educat Dent 2008;29:2-9. 4. Sundfeld RH, Rahal V, Croll TP, De Aalexandre RS, Briso AL. Enamel microabrasion followed by dental bleaching for patients after orthodontic treatment-case reports. J Esthet Restor Dent 2007;19:71-77. 5. Furuse AY, Franco EJ, Mondelli J. Esthetic and functional restoration for an anterior open occlusal relationship with multiple diastemata: a multidisciplinary approach. J Pros- thet Dent 2008;99:91-94. 6. Sundfeld RH, Croll TP, Briso AL, De Alexandre RS, Sundfeld Neto D. Considerations about enamel microabrasion after 18 years. Am J Dent 2007;20:67-72. 7. Sundfeld RH, Rahal V, Croll TP, De Aalexandre RS, Briso AL. Enamel microabrasion followed by dental bleaching for patients after orthodontic treatment-case reports. J Esthet Restor Dent 2007;19:71-77. 8. Da Silva Machado J, Cândido MS, Sundfeld RH, De Alexan- dre RS, Cardoso JD, Sundefeld ML. The influence of time interval between bleaching and enamel bonding. J Esthet Restor Dent 2007;19:111-119. 9. Sundfeld RH, Briso AL, De Sá PM, Sundfeld ML, Bedran- Russo AK. Effect of time interval between bleaching and bonding on tag formation. Bull Tokyo Dent Coll 2005;46:1-6. 10. Levin EI. Dental esthetics and the golden proportion. J Pros- thet Dent 1978; 40:244-252. 11. Almog D, Sanchez Marin C, Proskin HM, Cohen MJ, Kyr- kanides S, Malmstrom H. The effect of esthetic consulta- tion methods on acceptance of diastema-closure treatment plan: a pilot study. J Am Dent Assoc 2004;135:875-881. 12. Komatsu J, Russo M. Restaurações estéticas em dentes anteriores sem preparo cavitário convencional: estudo clínico. Rev Assoc Paul Cir Dent 1979;33:386-392. 13. Komatsu J, Russo M, Takayama S, Holland Junior C, Sa- saki T, Quintella LA. Influência da contaminação do es- malte dental descalcificado pelo ácido na retenção de res- taurações de resinas compostas. Rev Assoc Paul Cir Dent 1980;34:476-479.