smile with small teeth

Closing Diastemas and Re-Centering a Midline Deviation

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

 

Multiple diastemas in between the anterior teeth affect many patients’ self-perception, and they constitute one of the challenges in clinical aesthetic dentistry. As you’ll see in this case, the midline position and inclinatio) is often affected in these situations, which is an example of how these cases can’t all be treated the same. Although many treatment options are available, proper case selection and diagnosis is key to achieving success. In this article a direct composite approach was chosen to close the diastemas and correct the midline deviation.

intraoral picture of diastema

Fig.1

This 20-year-old female patient was not satisfied with her existing smile because of the multiple diastemas. She wouldn’t undergo an orthodontic treatment both because of the duration of treatment and of financial constraints. So after discussing treatment options she chose a direct approach to fix her smile through a cost-effective and minimally invasive approach.

smile midline deviation

Fig.2

The challange here was the prescence of a deviation of the midline to the left, in addition to the uneven spaces in between the teeth.

digital smile design project before treatment

Fig.3

Digital Smile Design was used to preview the proportions and the space available The DSD was also used to make a project to correct the midline and evaluate on which side to close the diastemas to center the new midline.

resin composite shade button try

Fig.4

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 the color by choosing one that’s whiter than is appropriate.

polarized picture for composite shade matching

Fig.5

A polarized picture was also taken using the MDP SmileLite polarising filter to verify the shade selected was appropriate.

rubber dam isolation with floss ligatures

Fig.6

The teeth were isolated with the rubber dam and the papillae were retracted with floss ligatures to improve visibility and access to the emergence profile, to prevent mistakes in cervical embrasure design. The teeth were cleaned off with pumice (no fluoride) and the dental surface was slightly abraded with a coarse disc to remove the aprismatic outer enamel, to ensure a stronger bond .

orthophosphoric acid enamel etching

Fig.7

I protected the adjacent teeth with teflon tape before etching the enamel for 30 seconds. Then I rinsed the etchant for 60 seconds to perfectly remove the acid.

chalky teeth after acid etching

Fig.8

After the etching procedure all the enamel should look chalky white.

microbrush bonding the enamel

Fig.9

After applying the adhesive it is important to gently air-blow the bonded layer to make the solvent evaporate. Long light curing time (being careful not to overheat the teeth) ensures the maximum monomer-polymer conversion, and a stronger bond.

silicone key for palatal composite shell

Fig.10

I fabricated a silicone index to place the palatal composite shells (E White Dental Beauty CompoSite System).

direct composite contouring

Fig.11

Building the proximal walls is easy with metallic sectional matrices. The SI2 shade from the White Dental Beauty CompoSite kit was used. Controlling the outer frame of our restoration is a crucial step to make layering a predictable step and to minimise final shape corrections.

composite layering with rubber dam

Fig.12

As you can see, layering our SI2 White Dental Beauty CompoSite shade is easy if your working framework is accurate.

incisal composite mass layering

Fig.13

An SI1 dentine shade layer was used afterwards, and the layering was finished with the Enamel shade and some blue stain in between the tmamelons for better characterization.

correcting cervical embrasures with composite resin

Fig.14

I had to correct the contact to prevent a black cervical embrasure from appearing and spoiling the whole smile makeover.

pencil mark for line angles

Fig.15

The finishing procedures are crucial to get an amazing result. First, I corrected the angle lines with a fine grain diamond bur and the labial contour with fine grained long taper diamond bur.

eve twist polisher for composite veneers

Fig.16

The I polished the composite surface with an eve twist rubber polisher.

goat brush polishing composite

Fig.17

When polishing with pastes (Shiny G) I go water-free at 1,000 rpm and with water at 10,000 rpm afterwards.

felt disc direct veneer polishing

Fig.18

More paste (1 micron aluminium oxide paste) is used to polish with a soft felt at 1,000 rpm and no water first, and then at 10,000 rpm and water to achieve a highly glossy surface.

composite resin restorations

Fig.19

Immediately after finishing and polishing.

direct white veneers on teeth

Fig.20

One week follow-up after correction of the midline.

seamless direct veneers

Fig.21

One week follow up, side view.

before and after direct composite veneers

Fig.22

Before and After.

result after smile makeover

Fig.23

The patient’s satisfied smile.

Conclusions

Even in complex cases, the simplest treatment option should always be considered, especially if it’s the one meeting the patient’s needs and wishes. The simplest option might fit best both the patient’s and the clinician’s needs.

Bibliography

1. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent 2008; 3(1):14-29.
2. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 10 Surface and polishing. Quintessence Books, 2012
3. 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.
4. Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application
techniques in the anterior teeth. Eur J Esthet Dent Off J Eur Acad Esthet Dent. 2010; 5:102–124.