A clinical case by our Community member Dr. Elissa Nasr
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
Some patients feel like having a diastema between their maxillary central incisors may reduce the attractiveness of their smile, which makes it an aesthetic concern they often wish to eliminate. Direct composite resin restoration is the biomimetic treatment of choice for localized missing tooth structure as diastema closure. Computer-aided design (CAD) and computer-aided manufacturing (CAM) technology allows for accurate planning for a correct aesthetic and functional restoration in this kind of cases.
Additionally, Digital Smile Design (DSD) integrates the 2D facial image with the 3D wax-up in order to improve the aesthetic outcome and facilitate the communication of the expected results with the patient.
This case presents a digital workflow for midline diastema closure and a small restoration on the left lateral incisor using composite resin.
The chief complaint of our 23 years old patient was the diastema between her maxillary central incisors, and the chipping of her maxillary left lateral incisor. She wouldn’t have an orthodontic treatment as she previously had two, so she asked for a restorative option. A digital planning of composite resin restorations was executed. A contrasted photo was taken with a Flexipalette (SmileLine, Switzerland).
Intra-oral scans were taken in order to perform a digital wax-up.
DSD extra-oral photographs were taken. These pictures require cooperation of the patient. Two photographs were were taken, one with the retractors on and the other one smiling without the retractors keeping the same separation of the teeth and a straight head position.
The previous 2D pictures (Fig. 3) were superimposed with the 3D scans (Fig. 2) in order to perform a digital wax-up respecting the facial midline and the correct dental proportions. The wax-up model was 3D printed and a palatal silicone key was fabricated.
The shade was selected taking regular and cross-polarized photographs. Two composite resin materials were selected, UE2 as an enamel material (Dentsply Sirona, USA) and UD2 as a dentin component (Mycerium, Italy).
Interdental surfaces and the incisal edge of the 22 were roughened using Sof-lex discs (3M, USA) in order to improve adhesion.
Ligatures were used to retract the rubber dam in order to achieve maximum exposure of the cervical enamel for optimum adhesion and for better fitting of the silicone index.
Try-in of the silicone index generated from the digital wax-up. This stent will serve as the layering base for the palatal walls, followed by the layering of the selected masses.
Teeth were prepared following the golden standard 4th generation 3 steps (etch-and-rinse) with a total etching by 37% orthophosphoric acid followed by primer and bonding (Optibond FL, Kerr, USA). StyleItaliano’s LM Arte spatulas (LM, Finland) were used for modeling. Finishing and polishing were done using Enhance (Dentsply, Sirona), Sof-lex discs (3M, USA) and Optident’s polishing pastes (Optident, UK).
Final result, after rehydration of the teeth.
Initial situation, digital wax-up and the final result after rehydration of the teeth.
Meticulous treatment planing is extremely important in everyday dentistry. Aiming to optimum aesthetics, it is necessary to take sufficient photographs in order to select the optimal shades in composite restorations.
Digital tools help with patient-oriented communication, predicting results, and speeding up the process.
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