diastema with rubber dam isolation before composite restorations

Midline diastema closure using the Front Wing technique

Closing diastemata with composite resin is considered one of the big challenges, mainly because of dealing with the cervical part of the diastema (the emergence profile) which may sometimes lead to overhangs or improper contours that may cause food stagnation and inflammation. Using the Front Wing technique developed by Jordi Manauta makes the whole procedure very easy for the very reasons mentioned in his article:
– Skipping the wax-up (NOT to be confused with not doing a project) closing diastema just one visit .
– Giving the user the chance of building and selecting the emergency profile and contour of one or multiple diastemata
– The chance of working with single shade or multi shade approach
– Tight contacts are easier to get
– Ideal cervical fit
– Aesthetics of the restoration

crooked smile with diastema

Fig.1

20 years old young lady came to the clinic complaining of her midline diastema. The patient said she want to close the diastema and to enhance the shape of upper anterior segment.

smile symmetry analysis

Fig.2

Retracted view shows a midline diastema with genesis of upper lateral incisors. Implants were placed in the canine area after extraction of the deciduous canines.
Her permanent natural canines, right next to the central incisors, were small in size which made it easier to modify in shape, yet, note the inclination of the natural canines.

direct restoration digital project for composite fillings

Fig.3

A simple design was enough find the proper dimensions for both centrals and laterals. We decided to close the diastema symmetrically between centrals, and to change the inclination of canines by adding composite in the selected red areas to appear as laterals.

button color try for composite direct restoration

Fig.4

Shade was selected with a composite button try before rubber dam isolation to keep teeth hydrated and prevent faulty shade selection due to dehydration.

color matching by cross-polarisation

Fig.5

A cross-polarised picture was taken with the MDP Smilelite to ensure color matching.

rubber dam isolation before retraction

Fig.6

Rubber dam isolation is mandatory for the whole procedure. Rubber dam inversion and extra retraction are required for diastema closure.

b4 clamps for maximum retraction of rubber dam

Fig.7

B4 clamps are used to achieve maximum retraction to expose the mesial cervical part to guarantee a perfect emergence profile.

coarse paper discs for debris removal

Fig.8

A coarse grit disc is used to clean the mesial surface, and to remove the debris for better bonding.

extended enamel etching of central incisors

Fig.9

Enamel etching for 30 seconds with safe margin over-extension is highly advised for diastema closure. Water rinsing for 60 seconds to remove all the remnant of etching gel.

etched frosty dental enamel

Fig.10

Frosty white appearance after enamel etching.

bonding rubbing with microbrush

Fig.11

Multiple coats of universal adhesive were rubbed on the surface 20 seconds and air-blown for 5 seconds to remove the solvent. Light curing for 60 seconds to ensure complete polymerization.

composite front wings

Fig.12

The first step of Front Wing technique is creating the buccal wings (red arrows) freehand as precisely as possible. Multiple layers can be added. SI2 Composite WDB was used in this case.

sectional matrices for mesial anatomy of incisors

Fig.13

After building the from wings, it is time to focus on the sealing of the restorations and on the achievement of a tight contact, by placing two sectional matrix with a wedge.

palatal voids to be filled with composite

Fig.14

Matrices in place, it is time to fill the palatal void. Note the adaptation of the matrix fitting in the sulcus.

lateral view of probe with flowable composite near incisor

Fig.15

A small drop of flowable composite resin is placed and left uncured. This helps the wettability of the following composite increment.

composite paste on spatula during layering

Fig.16

A composite increment is placed to fill the palatal part and condensed until excess material stops flowing from the buccal.

palatal cavities filled with composite

Fig.17

Both palatal cavities are perfectly sealed. Always check that the matrices still lay on the cervical.

diastema closed with composite before finishing

Fig.18

A layer of enamel is added before final polymerization.

direct restoration of upper incisors with composite resin

Fig.19

After the centrals are complete, it is time to shape the canines as we mentioned before.

perio bur for finishing of composite surface

Fig.20

Finishing procedures remove the excess and surface irregularities while correcting the buccal contour.

pencil marks to define angle lines in composite shaping

Fig.21

To correct the angle lines, after having drawn them with a pencil, a yellow coded diamond needle bur is used.

rubber wheel polishing composite surfaces

Fig.22

After shape is complete , polishing is done with rubber wheels.

teeth after direct diastema closure

Fig.23

Immediately after restoration and rubber dam removal.

smile after midline dental gap closure

Fig.24

At two-week follow-up.

direct closure of diastema

Fig.25

Surface texture.

surface texture of composite restorations

Fig.26

Surface texture.

Conclusions

With the Front Wing technique we can simplify direct diastema closure and obtain immediate, single-visit results. Moreover, skipping the wax-up is cost-saving and freehand modeling is much easier and more precise than methods involving a palatal silicone index.

Bibliography

1. Fahl N Jr. Achieving ultimate anterior esthetics with a new microhybrid composite. Compend Contin Educ Dent Suppl. 2000;(26):4-13; quiz 26.
2. 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.
3. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent 2008; 3(1):14-29.