Closing multiple diastemata. From digital project to direct Front Wing restorations

Everyone would agree that a well-established set of manual skill is required for smile makeovers with direct composite, which constitute one of the challenges in aesthetic dentistry. When closing diastemata, a smart technique making life easier for the restorative dentist, such as the Front Wing technique is, is key to a good result. Bonus: no wax-up is needed.
Of course, a good technique for shaping can’t do it if we don’t have the right color strategy to close diastemata.The Front Wing Technique is a technique in which a buccal wing is created freehand and then the buccal gap is filled afterwards.
For good masking of the underlying anatomy in shape modification, using a so-called Body mass, one that is not too opaque, nor too transparent, is highly recommended. New composites of course give the best performance when approaching the aesthetic areas.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.1
This 28 year old male patient complained about the multiple diastemata. After discussing treatment options he chose the most conservative – and the cheapest – way to fix his smile, the partial composite coverage without tooth preparation.
Digital planning helped us to better understand the limits of this treatment option.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.2
Initial intraoral picture.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.3
A screenshot of the digital design in progress with the free 3D software to make digital mock-ups, the Meshmixer.
As a general rule when closing diastemata we don’t need a wax-up, but the palatal references are very much appreciated when lengthening multiple teeth. The diagnostic wax-up helps you get a clearer picture of the limits of the case. In this clinical case, I realized that to proceed to a partial coverage, a little asymmetry of the laterals was the compromise, because of the slight rotation of tooth 12. I also precisely measured the quantity of tissue remodelling needed for the perfect gingival symmetry.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.4
After completion of the design, two resin models were 3D printed with the Formlabs Form 2.
On the left, the model to guide the restorations and gingival surgery. On the right the model is made from a second design. The second design is the same design, but it is digitally moved approximately 1 mm more buccally. For the fact that it is more buccally it can be used as a motivational mock-up. The mock-up is performed in the patients mouth with composite to obtain the instant preview smile used for motivational purposes.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.5
With the digital planning we understood that we needed to remove gingival tissue to correct uneven gingival zeniths.
We first removed gingival tissue, simple gingivectomy guided by the digital planning.
Removing the gingival tissue is not sufficient to predictably expose the clinical crown over long follow-up periods. (1) The North Carolina probe was used to measure the distance from the new gingival level to the bone.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.6
Minimally invasive flapless osteotomy was performed by Dr. Ioan “Sefu” Cofar (Dentcof) using a piezoelectric ultrasound (Dent Surg Device) and the bur pk1 until there was a 2.5mm distance from the top of the bone crest to the new gingival margin.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.7
The Nic Tone dental dam (MDC) was placed from the right first premolar to the left one with 2WA wingless clamps (Ivory), immediately after the surgery.
The surgery and composites were performed the same day because the bleeding was minimal, and the right dental dam seals perfectly when holes are the right size Moreover, flapless surgery allows to keep the papillae, so partial composite coverage can be done in the same session, without contacting the area of the surgery.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.8
Soflex disc (3M) was used to clean and polish the surface for a better adhesion.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.9
Etching with phosphoric acid gel, 37% for 30 seconds (Etching gel, DMG) for the performance of the incisal edges. We overextend the etching area to half of the buccal surface at least, as we want to avoid non-etched areas in case we want to apply the composite further. We always use two matrices (LumiContrast matrix, Polydentia) to protect the neighboring teeth from the adhesive steps. Then we used the universal bond (Ecosite bond, DMG.) following the manufacturers instructions.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.10
With a silicone index we recreated the palatal shells with EM shade from the Ecosite Elements Layer set, DMG.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.11
Lateral view of the thin composite shells (Ecosite Elements, Layers EM shade, DMG).

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.12
For the incisors, the Ecosite Elements A3 Pure shade was used, while the A3,5 shade was used for the canines, over the natural enamel, extended to the half the buccal area, finishing with a very thin layer over the enamel. The Pure masses were layered leaving a spacing at the incisal edge to recreate opalescence. It is important the choose the right color for the opaque mass of any composite system to achieve invisible restorations. Selecting the correct opaque shade allows us to mask the junction between the natural tooth and the restoration. For the opalescence of the incisal borders we applied the Ecosite Elements Highlight INC composite, DMG on the free of opaque mass area on the incisal edge with the thin Fissura instrument (LM Arte kit, LM).

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.13
An enamel layer (Ecosite Elements, Layers mass EM, DMG) was applied on top with the thin and delicate LM Arte Applica spatula (LM).

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.14
This is the result after lengthening of the incisal edges.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.15
The layering technique is the Characterized Single Shade. This technique is ideal to lengthen teeth, as it brings together all the benefits of single-shade restorations while allowing incisal translucency and any kind of characterization of the incisal edge. This technique makes diastema closure much easier compared to the Controlled Body thickness technique. When optimizing color matching and opacity selection, this technique can be the best in a wide range of situations. Many masses on the market are suitable for the Characterized Single Shade concept as their opacities and optical properties are perfect for the technique in many clinical situations. An example is the composite I used for this case, the Ecosite Elements, DMG.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.16
Now it’s time for the Front Wing technique (2) to close the diastemata one by one with the brinker B4 retraction clamps Hygienic to build an anatomical emergence profile.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.17
From the palatal view and you can appreciate the extra retraction given by these clamps which allow us to create a good emergence profile from buccal and palatal.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.18
We overextend the etching approximately one third of the buccal and palatal surface.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.19
We begin with the Front Wing Technique (2). We recreated freehand the buccal wings first on the canine and on the lateral. Then we used the Pure shade A3,5 Ecosite Elements, DMG for the canine and a less chromatic A3 Ecosite Elements, DMG for the lateral. Using a single composite shade greatly simplifies the procedure (3).

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.20
In the Front Wing Technique (FWT) we make sure we are creating an excellent contour, emergence profile and dimension altogether before curing. The space between the two front wings is the space of the thin brown LM Arte Applica instrument (LM).

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.21
With the occlusal mirror, we can work with great visibility on the palatal side. We placed two sectional matrices (myCustom Rings kit, Polydentia) and we filled the gaps with the same color we used for the buccal area.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.22
Palatal view after filling the palatal side, after removing the matrices and wedge, and photocuring.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.23
Once the palatal side is closed and the composite is photocured, metallic and transparent finishing and polishing strips can be used to achieve a perfectly shaped and polished emergence profile. It’s better to do the proximal finishing before removing the clamps for better access.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.24
The finishing steps are always performed with low speed without water with the flame diamond bur from the Finishing Style bur kit by Styleitaliano and Komet. The Styleitaliano finishing and polishing protocol provides a good control during finishing.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.25
The pre-polishing was made for 30 seconds with water with the Sof-Lex™ Spiral Finishing Wheel, 3M

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.26
The final polishing was performed with the felt wheel and the polishing paste Lucida paste, Diashine.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.27
Check-up appointment, 1 week after.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.28
Lateral views.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.29
Smile at the end of the procedure.

style italiano styleitaliano Closing multiple diastemata anna salat

Fig.30
The patient was extremely satisfied with the result.

Conclusions

1. The diastema closure in anterior teeth using direct adhesive restorations and gingival re-contouring is a viable option for the clinician because it restores esthetic harmony between soft and hard tissues.
2. When modifying incisal length with a direct restoration technique, the wax-up and the silicone key are very useful so we are able to easily characterize the incisal edges to achieve the best aesthetic result.
3. When closing diastemata, the Front Wing Technique is a smart idea because it is less time consuming, easy to learn, and simple compared to the other techniques. According to many doctors that have learnt and practiced the technique in our Daily Menu courses, it’s the techniques that provides the best aesthetic result.
4. It is advantageous for practitioners to use the Single Mass Technique with materials that has excellent blending properties when performing diastema closures, because controlling thickness, shape, emergence profiles and measures at the same time is extremely difficult.
5. We need materials which are able to match the opacity-translucency of the natural tooth. In many cases the Pure colors from the Ecosite system by DMG are ideal for this purpose.
6. The 3D digital diagnostic for planning is the winning strategy vs the old wax technique, because it requires less labor and eliminates mistakes and rework, and specially because it cuts turnaround time from 2-3 days to a few hours.
7. The digital diagnostic wax-up is very convenient when changing smiles with composites:
• Very useful when lengthening teeth.
• Very useful when gingival surgery is needed as 3D printed guide is easily made.
8. The benefits of the diagnostic wax up when changing smiles with composites:
• It allows you to stratify from palatal to buccal direction guided by a silicone and obtain the best aesthetic results in the area most
needed: the incisal area.
• It gives a clearer picture of the limits of the case

Bibliography

1. Ribeiro FV, Hirata DY, Reis AF et al. Open-flap versus flapless esthetic crown lengthening: 12-month clinical outcomes of a randomized controlled clinical trial,” Journal of Periodontology, vol. 85, no. 4, pp. 536–544, 2014.
2. Manauta J. The Front Wing Technique. 2017 styleitaliano.org
3. Manauta J. Single Shade Everyday. 2020 styleitaliano.org
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 2010; 5: 102-124
5. De Araujo EM Jr., Fortkamp S, Baratierri LN. Closure of diastema and gingival recontouring using direct adhesive restorations: a case report. J Esthet Restor Dent. 2009;21(4):229-40.
6. Lacy AM. Application of composite resin for single- appointment anterior and posterior diastema closure. Pract Periodont Aesthet Dent. 1998;10(3):279-86

RELATED CASES

Fiber post reconstruction. Update and clinical protocol

Adhesive reconstruction of dental structure has become the new standard since the 90’s. See, through this clinical case, the updated clinical concept for fiber post reconstruction in order to make it accessible in the everyday practice.