Direct stratification for diastema closure

A clinical case by our Community member Dr Laura Mokhtari

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.

This patient was referred by her orthodontist to close the residual spaces and harmonize her smile. She wanted a «fuller» and brighter smile.

styleitaliano style italiano smile design

Fig.1
We can observe diastemata between lateral incisors and canines, and a difference in length and proportion between the two lateral incisors. The aesthetic study of the case showed that ideal space repartition would require to widen both the central and lateral incisors, but after discussion with the patient we chose to only close the spaces with a modification of the lateral incisors and canines with direct composite and prior bleaching.

styleitaliano style italiano lateral views showing symetrical diastemata

Fig.2
Lateral view of the residual spaces between the lateral incisors and canines.

styleitaliano style italiano home bleaching

Fig.3
Home bleaching with 10% carbamide peroxide for 3 weeks.

styleitaliano style italiano before and after bleaching

Fig.4
Before and after bleaching.

styleitaliano style italiano shade selection for direct composite restoration

Fig.5
Beginning of the composite bonding session. Composite shade is chosen before setting up the operative field to avoid dehydration of the teeth and shade modification. The selected composites are Kulzer Venus Pearl CL and Kulzer Venus Pearl B1.

styleitaliano style italiano selecting shade for direct restoration

Fig.6
Selected composites.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano split dam isolation

Fig.7
Set up of the operative field. A thick rubber dam is used. As the post-orthodontic retainer prevents from using an individualized rubber dam a split dam is used for the incisors.

styleitaliano style italiano silicone index

Fig.8
Try-in of the silicone key to transfer the wax up. Shapes are modified as your can see from the index, elongation of the 22, and widening of both laterals. Also, the shape of the e ridges of the canines is planned.

styleitaliano style italiano enamel etching

Fig.9
The surface of the teeth was prepared by sandblasting with 50μm aluminium oxide. Then etching of lateral incisors and canines was carried out with 35% orthophosphoric acid for 30 seconds.

styleitaliano style italiano bonding etched surfaces

Fig.10
Universal adhesive is applied on lateral incisors and canines.

styleitaliano style italiano palatal shells

Fig.11
Build up of the palatal shells using the silicone key, with enamel shade composite (CL).

styleitaliano style italiano palatal and proximal build-up

Fig.12
Close up view of the palatal shells and proximal walls.

styleitaliano style italiano modeling with fissura instrument

Fig.13
Build up with dentin shade composite (B1) and LM Arte Fissura instrument. Some blue translucent composite is used very sparingly to mimic the natural translucency of the adjacent teeth.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano polishing with venus supra polishing kit by kulzer

Fig.14
Polishing of the composite with the Venus Supra polishing kit, first bur to polish the proximal area.

styleitaliano style italiano polishing with venus supra plishing kit by kulzer

Fig.15
Second bur for proximal area.

styleitaliano style italiano polishing with venus supra plishing kit by kulzer

Fig.16
Polishing of the buccal side with a differently shaped bur.

styleitaliano style italiano diastema closure with composite right after rubber dam removal

Fig.17
Immediate post-op result after polishing and removing the rubber dam. Immediate result is satisfying but we need to wait for teeth rehydration.

styleitaliano style italiano month follow up after direct diastema closure

Fig.18
Final result at 1 month. The patient is happy with her new smile and the composite integration is satisfying.
This said, room for improvement can be found, regarding the width of teeth 12. and 22 which is too close to that of the centrals. As mentioned above, modifying the proportion of the centrals would have involved going back to orthodontics for space distribution, and the patient didn’t want a long or complex treatment.

styleitaliano style italiano before and after diastema closure

Fig.19
Before and after treatment.

styleitaliano style italiano before and after diastema closure

Fig.20
Before and after treatment.

Conclusions

Initial aesthetic analysis is key to plan a direct composite rehabilitation, following general aesthetic rules. An initial wax up is useful to respect the proportions and planned shapes when working on several teeth. Clean operative field and correct selection of composite shades are critical for a good aesthetic result, as well as polishing and finishing, which provide both immediate and long-lasting results.

Bibliography

  1. Devoto W.Clinical Procedure for producing aesthetic stratified composite resin restorations. Pract Proced Aesthete Dent 2002, 14:541-543.
  2. DIestchi D. Free-hand bonding in the aesthetic treatment of anterior teeth : creating the illusion. J Esthet Dent 1997;9:156-164.
  3. Frank AC. Comparison of the bleaching efficacy of different agents used for internal bleaching: a systematic review and meta-analysis. Journal of Endodontics, 2022.

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