Minimal direct approach in anterior shape modification

Re-establishing a patient’s natural dental esthetics is one of the most requested and important topics of today’s dentistry. Many patients with a diastema complain it affects the aesthetics of their smile. In addition to function and phonation, color, shape, and structural and position abnormalities of anterior teeth might lead to important esthetic problems for patients. In order to solve such problems, the most frequently preferred solution is full coverage by means of dental crowns, which requires a very aggressive approach. In this case report the Authors, according to the philosophy of the Styleitaliano group, want to drive all the colleagues through a simplified approach system directly to the final outcome, with an appropriate working time.
Direct composite restorations are today feasible and teachable, and being efficient and predictable are a must for any practicing clinician. Additionally, direct composites provide functional, long lasting, and esthetically pleasing results in the most conservative fashion. New materials on the market require a completely new approach if want to be successful with them.

style italiano styleitaliano intraoral picture of large diastema

Fig.1
A female patient, 55 years old, came to the office complaining about her smile and the big black triangle. She asked to get a fast and easy solution to improve her smile. After clinical evaluation, we decided to perform a no prep shape modification on mesial 21, and mesial and distal 11, with a direct veneering of tooth 12.

style italiano styleitaliano rubberdam isolation of anterior sextant

Fig.2
Field isolation, inverting the rubber dam to improve access to the cervical areas of the teeth, and to better manage the emergence profiles.

style italiano styleitaliano surface sandblasting

Fig.3
The old composite third class restoration on tooth 12 was removed by just sandblasting the surface with 53µm Aluminium Oxide (AquaCare). No anesthesia was needed.

style italiano styleitaliano unica mini deep matrix on lateral incisor

Fig.4
After cavity preparation the new Unica Mini Deep matrix was used to restore tooth 12. This matrix perfectly hugs the cervical and interproximal margins, especially of smaller teeth. This is a significant help as it makes final shape predictable, allowing for time management and limiting chair time. We can exploit a complete contour in just one step.

style italiano styleitaliano polydentia matrix
style italiano styleitaliano polydentia matrix
style italiano styleitaliano occlusal view of matrix adaptation

Fig.5
It’s mandatory to check the matrix fit from the occlusal.

style italiano styleitaliano etching the enamel

Fig.6
The Unica Mini Deep matrix was kept in place during the whole adhesive procedure, starting with etching of the enamel surface with 37% H3PO4 (Coltene Etchant Gel), for 20 seconds.

style italiano styleitaliano bonding of dental surface

Fig.7
The the surface was bonded using a universal adhesive (Coltene One Coat 7 Universal). Keeping the matrix in place helps to avoid accidental contamination of the adjacent teeth during the adhesive procedure.

style italiano styleitaliano composite cartridge

Fig.8
95% of the restoration on teeth 12 was made using a single shade (A3/D3, Brilliant Everglow, Coltene) using a spatula and brushes (Styleitaliano LM Modella & Styleitaliano CompoBrush). The color was chosen in the preliminary investigative phase, before putting the dam on, before teeth dehydration.

coltene brilliant everglow style italiano styleitaliano
coltene brilliant everglow style italiano styleitaliano
style italiano styleitaliano coated non-stick spatula

Fig.9
The new LM Arte Modella Dark Diamond non-stick edition which offers the great sensitivity and flexibility of stainless steel with a non-stick coating to improve composite handling.

styleitaliano style italiano LM Arte Dark Diamond instruments
styleitaliano style italiano LM Arte Dark Diamond instruments
style italiano styleitaliano layering of composite veneer

Fig.10
A very thin high-value enamel composite layer (0.3-0.4 mm approximately), was spread over the A3/D3 mass to increase the depth and the brightness of the restoration.

style italiano styleitaliano compobrush spreading composite on tooth surface

Fig.11
Using a very soft brush to follow the already designed anatomy and contour.

smileline compobrush banner style italiano styleitaliano
smileline compobrush banner style italiano styleitaliano
style italiano styleitaliano light curing of composite veneer

Fig.12
The enamel mass was cured for 40 seconds with an high power multi-led lamp (Spec 3, Coltene).

style italiano styleitaliano curing under glycerine air block

Fig.13
Once the restoration was complete, a 60-second final curing under glycerine was carried out. This step prevents oxygen from inhibiting the outer layer of composite from completely being cured.

style italiano styleitaliano sandblasting of enamel surface

Fig.14
Air abrasion of teeth 11 and 21 using Aquacare (29µm aluminium oxide particles) was carried out. The purpose of this step is cleaning and improving the bond strength.

style italiano styleitaliano etching diastema area

Fig.15
Enamel etching using 37% H3PO4 for 30 seconds, followed by a 60 second rinse. This is very important to ensure that all the etchant is washed off the tooth surface.

style italiano styleitaliano extended etching area

Fig.16
The etched area should be a little larger than the working area, to get the best bond strength quality, and the transition between composite and tooth surface.

style italiano styleitaliano brushing adhesive agent

Fig.17
Bonding with One Coat 7 Universal (Coltene). Multiple adhesive layers were applied until surface was shiny. Then the adhesive was air-blown until no movement was detectable on the surface.

style italiano styleitaliano light curing of bonding agent

Fig.18
Light curing for 40 seconds.

style italiano styleitaliano modeling front wing with non stick spatula

Fig.19
The same composite mass used on tooth 12 was applied by using the new coated LM Arte Modella (LM Arte™ Dark Diamond non-stick edition, powered by StyleItaliano) to build the proximal walls, free-hand.

style italiano styleitaliano modeling front wing with non stick spatula

Fig.20
The buccal wings of both 11 and 21 were first modeled.

style italiano styleitaliano composite front wings

Fig.21
I work with composite until symmetry between the two incisors is satisfactory.

style italiano styleitaliano sectional matrices in place

Fig.22
Two pre-contoured sectional metal matrices (Quickmat FLEX, Polydentia) were inserted vertically and stabilized by a plastic wedge to achieve a tight contact point.

polydentia banner style italiano
polydentia banner style italiano
style italiano styleitaliano palatal view of front wing diastema closure

Fig.23
Palatal view.

style italiano styleitaliano placement of flowable composite at midline

Fig.24
The cavities were then filled from the palatal by placing a drop of flowable composite (A2/B2 Coltene Brilliant Everglow) first, which was left uncured, near the proximal margin.

style italiano styleitaliano packing composite from the palata

Fig.25
Then the palatal cavity was filled with packable composite.

style italiano styleitaliano closed diastema before finishing

Fig.26
As a last step, to improve symmetry, some packable composite was added on the distal buccal side of tooth 11.

style italiano styleitaliano finishing of the emergence profile

Fig.27
Finishing started by refining the cervical margin using the StyleItaliano New finishing burs kit (Intensiv).

style italiano styleitaliano perIo bur for surface texturing Intensiv finishing kit STYLE FINALE

Fig.28
Then, macro and micro-texture were reproduced using the perio coarse grain bur (Styleitaliano New Finishing kit, Intensiv), at low speed, without any water, in order to obtain more light-reflecting areas and to enhance the final value.

style italiano styleitaliano intensiv burs stylefinale banner
style italiano styleitaliano intensiv burs stylefinale banner
style italiano styleitaliano lucida polishing paste and star felt

Fig.29
Final polishing is mandatory to the esthetic success of the restorations, as a shiny smooth surface reduces plaque accumulation, and prevents the teeth from discoloring. The polishing is performed with a disposable felt charged with diamond paste (Lucida).

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
style italiano styleitaliano polished composite restorations

Fig.30
Final result after finishing and polishing, before removing the rubber dam.

style italiano styleitaliano occlusal view of composite anterior restorations

Fig.31
Aspect from the palatal side.

style italiano styleitaliano composite restorations before rehydration

Fig.32
Immediate post-op smile. The slight discoloration cause by dehydration will improve soon.

style italiano styleitaliano composite restorations after rehydration

Fig.33
At check-up, two weeks later.

style italiano styleitaliano intraoral picture of composite diastema closure

Fig.34
Two months recall. We can appreciate that the composite has integrated very well with the natural dentition and the papilla has filled the small gap.

style italiano styleitaliano occlusal view of diastema closure

Fig.35
Aspect from the palatal side.

style italiano styleitaliano xray after composite diastema closure

Fig.36
X-ray aspect of the restorations.

Conclusions

The evolution of restorative materials, pushed by dental practitioners themselves, has led dental companies to the manufacturing of new composite masses with a balanced degree in terms of translucency that, based on the thickness applied, make it possible to appropriately masque both the preparation limit and the restoration itself, without resorting to complex stratification techniques and providing a good esthetic result with a limited number of shades at the same time.
The use of the Front Wing Technique can represent a useful solution for closing diastemas in a few steps. With non-invasive, purely additive, we can radically change patient smile.

Bibliography

Monteiro P. The step by step in finishing and polishing: anterior direct composite restorations. 2017, Styleitaliano.org
Devoto W, Saracinelli M, Manauta J. Composite in every day practice: How to choose the right material and simplify techniques in the anterior teeth. Eur J Esthet Dent 2010 Spring;5(1):102-24.
W. Devoto, L. Vanini. Rifinitura e lucidatura dei restauri in composito. Il Dentista Moderno, Dossier, 5-13, 1999
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
Villares CF. Diastema closure a single shade opacity aesthetic approach. 2019, Styleitaliano.org. Devoto W, Pansecchi D. Composite restorations in the anterior region: clinical and aesthetic performances. PPAD; 19 (8): 465-470, 2007
Devoto W. Clinical procedures for producing aesthetic stratified composite resin restorations PPAD, vol.14 n.7, 541-544 2002

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style italiano styleitaliano Essential Dentistry kit online on demand course

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