big incisor diastema

A combined approach for diastema closure

A clinical cases by our Community member Dr. Osama Shaalan.

 

Challenging diastemas might require some orthodontic treatment before restoration. Wise space management and smart esthetic orthodontics changed the whole restorative game in this case.

The presence of a maxillary diastema is an aesthetic problem that can spoil a pleasing smile by concentrating the observer’s eye not on the overall dental composition, but on the large central diastema. Many treatment options are available for closing diastemas including orthodontics or restorative treatment. In this article we will present a combined approach for large diastema closure, using both minor orthodontics and minimal invasive direct restorative treatment.

smile with big diastema

Fig.1

A 35-year-old female came to the dental clinic complaining of her large diastema, as she was embarrassed while smiling and speaking. She wanted to fix her smile.

intraoral picture of diastema between incisors

Fig.2

Retracted view of upper and lower arches, showing a large (4.5 mm) diastema between teeth 11 and 21.

measurement of diastema

Fig.3

Black contrast; due to the very large diastema there would be a discerpancy in tooth to tooth ratio if the diastema was closed without managing the space. Among the different treatment options for this case, we selected the most conservative because of patient’s desire for quick results and her financial constraints.

design of space distribution for golden ratio

Fig.4

The treatment plan consisted of two steps main steps.
First, a minor orthodontic treatment to distribute the space between the upper incisors to create good tooth to tooth proportions creating multiple small diastemas with expected duration of two months.

3m style italiano composite bulk fill styleitaliano filtek universal
3m style italiano composite bulk fill styleitaliano filtek universal
DSD before orthodontics for space management

Fig.5

Second, direct closure of the multiple diastemas we created using composite resin restorations, thus eliminating the need for tooth preparation.

orthodontic diastema closure kit

Fig.6

ORTHODONTIC PHASE
Using a simple diastema-closure kit (American Orthodontics) can help distribute the midline spacing. This kit contains active spring and tubes, and it was chosen because of its high acceptance rate by patients thanks to its palatal position. Moreover, it’s hygienic and allows for easy flossing and cleaning of teeth.
Direct bonding the tubes on the cervical part of the palatal crown and tubes should be at the same incisal-gingival height and centered mesio-distally. Insert each side of the spring into the tubes separately to prevent distortion then crimp or secure both ends of the spring with flowable composite to prevent dislodging. Patient should be rescheduled in 7 – 10 days for observation.

intraoral picture of big diastema

Fig.7

After two weeks, the middle space began to decrease.

tooth movement towards diastema closure

Fig.8

After two weeks space appeared between teeth 11 and 12.

lateral view of space management

Fig.9

And the same thing happened between teeth 21 and 22.

space distribution for diastema closure

Fig.10

After two months the midline space is reduced and distributed on both sides to the laterals.

spacing for restorative diastema closure

Fig.11

After two months a 1.2 mm space was achieved between teeth 11 and 12.

orthodontic spacing before restorative treatment

Fig.12

After two months a space of 1.1 mm was available between 21 and 22.

before and after orthodontic treatment

Fig.13

Before and after the orthodontic phase of the treatment.

before and after orthodontic space management

Fig.14

Before and after side views.

digital smile design for restorative diastema closure

Fig.15

RESTORATIVE PHASE
DSD was used to simulate the suitable proportions of width and height between teeth. The spaces can be closed without preparing the teeth.

composite button try for multiple diastema restoration

Fig.16

The restorative phase was carried out with direct composite resin restorations, after removing the palatal spring.
Color matching and analysis must be performed before rubber dam isolation, when the teeth are fully hydrated; otherwise there is a high risk of mismatching color by choosing a whiter one than is appropriate.

rubber dam isolation for composite multiple restorations

Fig.17

Rubber dam is placed for isolating the teeth. Floss ligatures retract the papillae laterally and enable the clinician to better manage the emergency profile of the restoration. If the papillae are not laterally retracted the result is the presence of an interdental black triangle.

bonding procedure under rubber dam isolation

Fig.18

After etching and rinsing the teeth. Multiple coats of bonding agent are applied air-blown using oil-free syringe to let the solvent evaporate and cured for 60 seconds.

palatal composite wall layering technique

Fig.19

The palatal wall (CE , Filtek Supreme 3M Espe) was created with aid of a silicone index which had been previously fabricated on a wax up.

composite shell for direct anterior restoration

Fig.20

Building the proximal walls by using posterior sectional matrix with WE.

dentin composite resin stratification

Fig.21

A2 dentine filtek Supreme 3M Espe was used to control the opacity in spaces bigger than or equal to 2 mm.

Fig.22

Layering A1 Body dentin Filtek Supreme 3M Espe.

final layer of composite resin

Fig.23

A final enamel layer is applied on the proximal and buccal surfaces to complete the restoration using enamel shade WE.

composite resin restorations after polishing

Fig.24

After rough finishing and polishing.

composite resin incisor restorations

Fig.25

Immediatly after removal of the rubber dam. A second appointment was scheduled for more detailed finishing and polishing. Minor modifications were planned according to the patient’s wishes.

polishing paste and goat brush for composite

Fig.26

Final polishing using 3 micron diamond paste (Shiny G, Micerium). A natural goat-hair brush was used at 1,000 rpm with no water and at 10,000 rpm with abundant water.

polishing for gloss of composite with felt

Fig.27

Gloss is given by polishing with a soft felt disk, used at 1,000 rpm with no water and then at 10,000 rpm with abundant water, and a 1-μm aluminum oxide paste (Shiny F Micerium).

composite resin incisor restorations

Fig.28

One week later, after finishing and polishing. The final session should be at least 3 days after restoration to allow the composite to rehydrate.

composite restorations 3d shape

Fig.29

Surface gloss after finishing and polishing, side view.

polished composite resin direct restorations

Fig.30

Two weeks follow up. The contrast with the black background enhances the new anatomy.

details of composite resin on incisors

Fig.31

Two weeks follow up, side view.

before and after orthodontic and restorative treatment of diastema

Fig.32

Before and after.

smile with composite restorations on incisors

Fig.33

The patient very satisfied by the final result.

Conclusions

The presence of a diastema between teeth is a common feature found in the anterior dentition. Many treatment options are viable for diastema closure. A carefully documented diagnosis and treatment plan are mandatory for the clinician to apply the most effective approach to respect the patient’s needs.

Bibliography

1-Orthodontic-restorative treatment of maxillary midline diastema Mahboobe Dehghani1, Farzin Heravi2
2- The midline diastema: a review of its etiology and treatment Wen-Jeng Huang, DDS Curtis J. Creath, DMD, MS.
3- Juneja A. Invisible Margins in Anterior Composites, Tips & Tricks. StyleItaliano. (LINK https://styleitaliano.org/invisible-margins-in-anterior-composites-tips-tricks/)
4-Manauta J, Salat A. Layers, An atlas of composite resin stratification. , Quintessence Books, 2012.

Where to learn the technique?

You can participate at one of our Daily Menu courses, we will teach you the technique in practice. Dr. Walter Devoto and Prof. Angelo Putignano have organized courses rich of hands-on, and they can teach you also many more techniques to become a master of restoration.

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