Digital Smile Design for diastema closure

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.

style italiano styleitaliano intraoral picture of smile with central diastema

Fig.1
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).

style italiano styleitaliano smileline dental photography flexipalette
style italiano styleitaliano smileline dental photography flexipalette
style italiano styleitaliano digital model

Fig.2
Intra-oral scans were taken in order to perform a digital wax-up.

style italiano styleitaliano extraoral pictures for digital smile design DSD

Fig.3
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.

style italiano styleitaliano superimposition of photographs and digital wax up

Fig.4
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.

style italiano styleitaliano photos and polarized pictures of composite button try

Fig.5
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).

style italiano styleitaliano roughening of enamel surface before adhesion

Fig.6
Interdental surfaces and the incisal edge of the 22 were roughened using Sof-lex discs (3M, USA) in order to improve adhesion.

style italiano styleitaliano 3m sof lex discs and diamond spirals polishing
style italiano styleitaliano 3m sof lex discs and diamond spirals polishing
style italiano styleitaliano retracted rubber dam

Fig.7
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.

style italiano styleitaliano try in of silicone index

Fig.8
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.

style italiano styleitaliano etching the enamel

Fig.9
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).

style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano result after direct diastema closure

Fig.10
Final result, after rehydration of the teeth.

style italiano styleitaliano before and after diastema closure with digital wax up

Fig.11
Initial situation, digital wax-up and the final result after rehydration of the teeth.

Conclusions

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.

Bibliography

1. Reis PMP, Lima P, Garcia FCP, Faber J. Effect of maxillary median diastema on the esthetics of a smile. Am J Orthod Dentofacial Orthop. 2020 Oct ;158:37–42.
2. Pascal Magne , Urs C. Belser. Biomimetic Restorative Dentistry. Quintessence Publishing company. 2022; 308-339.
3. Scattarelli P, Smaniotto P, Leuci S, Cervino G, Gisotti M. The Digital Integrated Workflow in the Aesthetic Management of the Smile: A Case Report. Prosthesis. 2020 Sep;2:196–210.
4. Cervino G, Fiorillo L, Arzukanyan AV, Spagnuolo G, Cicciù M. Dental Restorative Digital Workflow: Digital Smile Design from Aesthetic to Function. Dent. J. 2019 Jun;7:30.
5. Stanley M, Paz AG, Miguel I, Coachman C. Fully digital workflow, integrating dental scan, smile design and CAD-CAM: case report. BMC Oral Health. 2018 Aug 7;18:134.

style italiano styleitaliano Essential Dentistry kit online on demand course
style italiano styleitaliano Essential Dentistry kit online on demand course

RELATED CASES

Smile improvement in a single appointment using direct restorations

Nowadays, direct composite restorations represent a feasible and teachable treatment, with a predictable and satisfactory result for everyone. Discover how Anna Salat uses tricks and technical skills to make a difference and simplify a direct restoration in a single appointment.