Fig.1
The initial situation. The patient came to the clinic with the desire to repair teeth 11-21 that were filled with composite 2 years ago. The patient told that she had a large gap between teeth 11 and 21 before, and was then filled with composite, but now the filling is no longer aesthetic, so she wants to do it again. In addition, the patient also wants to fill the gaps between tooth number 12-13-22-23.

Fig.2
The first step is isolating the teeth with the rubber dam, this is a very important step to have a clean environment, free from contaminants, and with a clear vision. When done correctly, the gum will be pulled down and revealed the boundary of the old composite filling. In this case, the patient wants to fill the 6 front teeth, so the rubber dam will be used to expose the first premolar tooth on both sides of the upper jaw.

Fig.3
Use the bur to clean the old composite fillings. Note at this step, when the old composite filling was removed, a special attention should be done to not grind too much into the teeth tissue.

Fig.4
The remnant composite can be checked again by blowing the surface dry.

Fig.5
Use an AquaCare sandblaster with 29-micron Al2O3 sand to clean and create a rough surface on enamel. When using a sandblaster, the invasion of teeth enamel will be minimized while ensuring the durability of the filling.

Fig.6
Etching enamel surface with H3 PO4 acid for 30s and then washing for 60s to ensure complete removal of the etching gel.

Fig.7
Blow dry the enamel surface after etching, the frosty white appearance is a good indicator of enough etching.

Fig.8
The surface was bonded using a universal adhesive (Scotchbond Universal Adhesive, 3M ESPE). Keeping the matrix in place helps to avoid accidental contamination of the adjacent teeth during the adhesive procedure.

Fig.9
In this case, a customized matrix is created from a traditional matrix band. A curve at the tip was cut, so that this part of the matrix can hug the cervical part of the tooth in the labial-lingual direction. Then, the top of the matrix is warped to create the emergence profile wanted. Finally, a hole was drilled in the bottom part of the matrix so that the clinician can attach the 2 customized matrices together with the flow composite.

Fig.10
2 customized matrices attached together by composite seen from the side.

Fig.11
A1 shade from the Filtek Z250 (3M ESPE) was used to fill all of the space. First, 2 emergence profiles were created in one-third of the cervical part of 2 central incisors.

Fig.12
Then, orange wedges (Garrison) were used to fix the matrices at the gingival triangle and continue filling the entire diastema area. The composite was applied by using LM Arte Applica (LM Arte kit, powered by Styleitaliano) to build the proximal wall, while making sure the contact between the composite and the matrix is nicely curved. If this contact area is too sharp, it is very difficult to make the right transition lines.

Fig.13
After filling the entire diastema area between 2 central incisors.

Fig.14
The same procedure for the remaining teeth was repeated. In tooth 12, since the diastema area is small and the patient wanted the tooth 12 to have a better shape, only the mesial part of the tooth 12 was filled.

Fig.15
Perform the same procedure with teeth 13-22-23.

Fig.16
After removing all the matrices, the finishing and polishing step was crucial.

Fig.17
The Sof-lex extra-thin contouring and polishing discs (3M ESPE) were used to remove the excess composite and create the transition lines.

Fig.18
Firstly, the polishing was done with a blue rubber polisher.

Fig.19
Then, the polishing wheel was used to make the surface glossy.

Fig.20
The surfaces of the composites after polishing.

Fig.21
Immediate final result with dehydration which makes the teeth look whiter than natural. Shade selection should be performed at the beginning of any restorative procedure. Complete rehydration of the enamel can take between 24 and 48 hours.

Fig.22
7 days after, the teeth look more natural and the gingiva is healthy.

Fig.23
Patient’s new smile after 7 days.

Fig.24
Another side view of the new smile.

Fig.25
Another side view of the new smile.

Conclusions

Diastema closure is a technique that is widely applied in clinical practice, with the development of dental instruments, the performance of diastema closure is no longer difficult.
The customized matrix is one of the options that can be used in simple cases, it also helps dentists to perform diastema closure cases accurately and with high efficiency. Besides, the customized matrix can also be flexible in creating the desired emergence profile in some cases. As a result, whenever a clinical instance of diastema was encountered, the proper matrix must be selected for that scenario.

Bibliography

1. De Araujo EM, Fortkamp S, Baratieri LN. Closure of Diastema and Gingival Recontouring Using Direct Adhesive Restorations: A Case Report. J Esthet Rest Dent 2009; 21:229-240.
2. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent 2008; 3(1):14-29.
3. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 5. Quintessence Books, 2012.