A clinical case by our Community member Dr. Nisha Deshpande
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.
Diastema closure with direct composites is one of the most minimally invasive, and commonly performed procedure in aesthetic and restorative dentistry. Yet, it remains a technique-sensitive procedure often yielding good results only in the hands of experienced and skilled clinicians. More often than not, clinicians struggle with techniques leading to issues ranging from unaesthetic restorations to cervical overhangs. In order to simplify direct diastema closures for everyday dentistry, Dr Jordi Manauta and the Style Italiano Group have devised a technique called the Front Wing Technique.
This article is a case report where we have utilized this technique for a midline diastema closure case. The Front Wing Technique as its name suggests advocates the building up of the restoration from the Buccal aspect as against the palatal aspect used for other layering procedures. The palatal index has been often used but with little effect since it does not allow us to adequately develop and contour the cervical part of the restoration.
The Front Wing Technique allows the clinician to have full control on the emergence profile and shape of the restorations. Once these front “wings” have been developed, posterior sectional matrices are used to achieve a good contact point. The palatal part can now be easily contoured against the buccal wings on one side and the proximal matrices on the other. A small amount of flowable resin is first placed and not cured. Next the composite is packed from the palatal aspect until no more material flows out from the buccal. This ensures good sealing of the space and helps in achieving a tight contact. Finishing and polishing is then carried out sequentially.
Fig.1
A patient aged 51 walked into our dental office with the desire to improve his smile. He was conscious of the gap between his front teeth, and expressed his hesitancy to smile freely. After considering all options, we decided to close the diastema with direct composite restorations as it was one of the most minimally invasive treatments for this situation since he refused to undergo orthodontic intervention.
Fig.2
Intra oral close-up of the anterior teeth.
Fig.3
Composite shade was selected using the button technique, where small balls of different shades and opacities are placed on the buccal surfaces of the two centrals and cured. The composite used was Brilliant Ever glow by Coltene, Shade A2/B2 and Trans.
Fig.4
Rubber dam isolation is mandatory to achieve a good clean and dry working field. For this case, two B4 Brinker clamps (KSK) were used to further retract the cervical region. This allows for good compression of the interdental papilla and helps in providing access to the cervical part of the tooth to better control the emergence profile of the restorations.
Fig.5
No preparation of the tooth surface is needed other than passing a coarse disc over the enamel to only remove the aprismatic layer, and provide a clean substrate for the adhesive procedures. There is no need to make any bevels on the proximal surface.
Additionally, an air abrasion device (Esthetrix Blaster) was used to further clean the enamel surface interproximally and mesial part of the buccal surface.
Fig.6
The enamel surface was treated with 37% orthophosphoric acid (D-tech Etchant Gel) for 20 seconds, followed by rinsing thoroughly with water.
Fig.7
A universal bonding agent, Scotchbond Universal (3M ESPE) was applied all over the etched enamel and gently air thinned. Multiple coats were applied according to manufacturer’s instructions and photocured (Curing Pen, Eighteeth) for 20 seconds.
Fig.8
The first step in the Front Wing Technique is the creation of the buccal wings. This picture shows the buccal wing sculpted on the right central incisor. As we are approaching the restoration from the buccal, where we tend to have better control on the cervical contour, emergence profile, as well as achieving a straight midline.
Fig.9
A composite brush can be used to model the composite especially in the cervical areas.
Fig.10
Both the buccal wings were created in the same way. As can be noticed, a small gap must be left open as preparation for the next step of the technique, which is the application of the sectional matrices and wedge.
Fig.11
Application of sectional matrices and wedge.
Fig.12
The view from the palatal aspect which shows the space that now needs to be filled.
Fig.13
The next step is to add a small amount of flowable resin (Filtek Flowable Restorative, 3M) from the palatal, and add an increment of composite A2/B2 Shade, Brilliant Everglow (Coltene) till the material starts flowing out from the buccal. After one tooth is completed, that matrix can be removed, and the same procedure repeated on the other tooth to achieve a tight proximal contact.
A final layer of Trans Shade, Brilliant Everglow (Coltene) was applied on the buccal surface with the matrix pull through technique to sculpt the transitional line angles. The final layer was cured under a layer of glycerine gel.
Fig.14
Immediate post op after removal of the rubber dam and gross finishing. Basic finishing was done with a red ringed tapered diamond point on slow speed and rubber polishers from Shape guard (Diatech).
Fig.15
Final polishing was done with Lucida Polishing System.
Fig.16
Palatal view of the completed restorations after checking occlusion and lateral excursions.
Fig.17
Final post-operative picture showing well integrated restorations with good emergence profiles.
Fig.18
Final smile of the happy and satisfied patient.
Conclusions
Skipping the palatal index and approaching the restorations from the buccal aspect allowed us to achieve a good emergence profile and contact without complicating the procedure. This technique is easy to adopt and work with, since it simplifies a seemingly complex and unachievable outcome.
Only those techniques that can consistently yield predictable results should be at the forefront of our skill sets for tackling commonly encountered clinical situations.
Bibliography
1.Manauta J. The Front Wing Technique. 2017. Styleitaliano.
2.Manauta J, Salat A, Monterubbianesi R, Tosco V, Devoto W, Orsini G, Putignano A. Advances in diastema closure and tooth shape change using direct composite restorations: the Front Wing Technique. Int J Esthet Dent. 2022 Nov 25;17(4):378-393. PMID: 36426611.
3. Manauta J, Salat A, Devoto W, Putignano A. Layers 2. Direct Composites: The Styleitaliano Clinical Secrets. Chapter 7. Quintessence Publishing, 2022.
4.Dietschi D. Optimizing smile composition and aesthetics with resin composites and other conservative aesthetic procedures. Eur J Esthet Dent 2008; 3(1):14-29.
3. 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
4. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Books, 2012
