No prep diastema closure approach

A no prep approach for restorative diastema closure after orthodontic treatment in patients with associated microdontia can involve direct techniques, with the modern composite resins, or indirect techniques, with composites, glass ceramics or the new hybrid materials, in an extremely conservative way.

The indirect techniques can be, nowadays, completely additive in various clinical situation, thanks to the gaps that have to be compensated. Most of the times a prosthetic preparation is, in fact, not necessary for those teeth that are very small and don’t have undercuts. The only peculiarity is the assessment of an insertion axis for the handwork which is, most of the times, buccal.

There are several advantages of not preparing the teeth, e.g. preservation of the present enamel, management and control on the emergence profile, reduction in time of the appointments.

In this scientific article a modern approach is proposed for the solution of microdontia and diastema of upper lateral incisors with a multidisciplinary approach.

styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.1

Front view, initial situation.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.2

The patient is affected by microdontia of teeth 12 and 22 and right posterior cross-bite.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.3

Rotation of tooth 13 associates with notable spaces between teeth 11, 12, 13 with right open bite.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.4

The patient is referred to the orthodontist for a treatment solution of the above listed problems.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.5

To facilitate the correct closure performed by the orthodontist in order to get the ideal situation for the definitive restorations, composite provisionals are made on 12 and 22 with no adhesive protocol in order to easily be removed after orthodontic treatment.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.6

Detail of provisional restorations (left) and after their removal after orthodontic treatment.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.7

Detail of the diastemas of lateral incisors after orthodontic treatment, front and occlusal view.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.8

Macro-view, detail of the diastemas.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.9

Macro-view, detail of the diastemas.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.10

Face bow and impression registrations for manufacturing of two additive veneers for 12 and 22.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.11

Lithium disilicate veneers, pressed and stained.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.12

Try-in with dedicated try-in pastes. For a correct color evaluation a viscous material layer is, in fact, to be interposed to cover the buccal surface, simulating the presence of the product chosen for cementation.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.13

Try-in of additive veneers, frontal and occlusal view. Note the complete compensation of diastemas and optimal esthetic integration.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.14

Veneers are once more tried in with the rubber dam positioned, then cemented one by one.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.15

Details of the etching procedure and protection of the adjacent teeth from contamination with a transparent matrix and then with teflon. To correctly carry out the adhesion procedure on aprismatic non-prepared enamel it is advisable to start with sand blasting with alumina 50 microns, or prolonged etching for 60 seconds of the buccal surface.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.16

Universal, last-generation adhesive agent application. The product is very viscous so it’s not polymerized immediately, but together with the chosen cement in order to prevent creation o potentially damaging thicknesses before application of the restoration.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.17

Etching of the internal surface is done with fluorhydric acid for 20 seconds. After etching and rinsing, the same universal bonding agent, which also contains silane, is applied without polymerizing.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.18

The chosen cement is applied on the internal surface of the restoration
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.19

Details of the final cementation procedures after removal of excess and finishing.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.20

Details of the finished restorations under rubber dam isolation.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.21

Before and after situations.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.22

The patient’s smile after treatment.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.23

One month follow-up.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.24

Details of morphology and diastema closure.
styleitaliano style italiano diastema microdontia after orthodontics close composite veneers indirect anteriors impression rubber dam

Fig.25

One year follow-up. Integration of the additive restorations in the front upper sextant is very good.

Conclusions

Additive techniques are more and more revolutionizing the way of thinking, designing and executing indirect restorative treatments. Preservation of sound dental tissues and of tooth structure that hadn’t been previously restored has to be one of the main goals in treatment planning of esthetic and functional cases, when – of course – it is indicated.

Aknowledgements
Thank to. Dr. Renato Cocconi for the ortho treatment and to DT Vincenzo Musella for the lab work.

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