A clinical case by our Community member Dr. Lisa Fernandes Gonçalves
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Orthodontic treatment is frequently the treatment of choice to close anterior diastemata. However, when a Bolton discrepancy is detected, orthodontic treatment alone cannot establish proximal contacts with proper overlaps making restorative treatment mandatory to close the spaces.
Several treatment options are available for minimally invasive diastema restoration, including the recently introduced injectable composite resin technique, normal composite techniques or the use of laminated veneers.
However, direct composite restoration and indirect ceramic veneers are still the most popular minimally invasive treatment options to close the anterior spacing and restore the natural appearance of the smile. Direct composites can produce a very life-like diastema restoration in a convenient single appointment with no need for tooth preparation. However, the technique requires advanced sculpting and finishing skills to achieve an optimally polished restoration with an ideal anatomic form. It is also a technique that requires an appointment every 6 months for polishing. Because of these limitations, some dentists prefer ceramic veneers, especially for large diastemas that are more challenging to close with direct composite. Ceramic veneers can produce a diastema restoration with exquisite esthetics and excellent longevity, but the technique requires a technically demanding and time-consuming clinical procedure, not to mention the sacrifice of a healthy tooth structure to allow space for the restorative material.
Sometimes, a noninvasive veneer preparation is possible where the buccal surface remains intact in order to produce effective space management and soft tissue contouring. Ultimately, either direct composites or indirect ceramic veneers can serve very well for the purpose of diastema restoration.
This case presents a laminated veneer technique for diastema closing.
Fig.1
This young female patient was seeking an aesthetic improvement of her smile. On our first appointment we started by taking photos so that we could plan the case correctly. Here we can see the diastemas between the anterior upper teeth.
Fig.2
In this lateral view we can see a huge gap that goes from her first premolar to her canine. Since she only accepted to do 6 veneers and this side greatly impacted on her aesthetics, we decided to proceed with a flowable injection technique using the same wax up.
Fig.3
From this side we can see an implant crown placed on her first premolar few years earlier.
Fig.4
Close up showing a very good level of the gingival margins on each tooth.
Fig.5
With the keynote software we can draw the correct proportions for each tooth, the curvature of the ideal smile, as well as the ideal midline. This way the dental technician can have a guide for the wax up.
Fig.6
This is the mock up placed in our patient’s mouth. For this we used Protemp 4, color A1. During this appointment, approval of the esthetic project is obtained by the patient. If minor adjustments are needed, we should always take an impression to keep it as a reference.
Fig.7
The first set of burs will define the thickness of the veneers, and so, depending on the volume of the wax-up and how conservative we need to be, we choose the best fit for each case.
Fig.8
With a pencil we marked the grooves made by those initial burs. With this technique we can control the depth of the preparation.
Fig.9
A silicone guide was fabricated to check the hight of the incisal edge and the overall thickness.
Fig.10
After polishing, we take our conventional impressions.
Fig.11
Non-invasive veneer preparation.
Fig.12
This is the model that we get after taking the impressions.
Fig.13
As a first step, we try the veneers and see if the adaptation of the margins is correct, as well as contact points.
Fig.14
After placing the rubber dam, adaptation of the veneers is checked again before conditioning the tooth with orthophosphoric acid and Optibond FL.
Fig.15
Since these were made from feldspathic ceramic, we prepare our veneers with 10% hydrofluoric acid during 60 seconds, then we clean with alcohol and place orthophosphoric acid. After etching, silane is applied for 1 minute with a source of heat. Bonding was done with Optibond FL (Kerr) on the veneer before placing Variolink (Ivoclar Vivadent) neutral LC cement.
Fig.16
Before and after cementation.
Fig.17
Final smile.
Fig.18
Final outcome.
Conclusions
The concept of successful restoration in contemporary dentistry embraces not only the traditional criteria of minimal biological cost, good longevity and successful esthetic integration, but also other factors, including the uncomplicated technique, possible intraoral repair, reduced soft tissue trauma and affordable financial cost. It is up to the dentist to balance all these factors and select the best treatment for the patient. However, the wider the choice of treatment options, the easier for the dentist to select the best treatment based on the clinical needs and for the patient to choose the one that can satisfy their esthetic expectations and financial possibilities.
Bibliography
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