Multiple diastemas can be quite a big deal for patients. “I don’t like the space in between my teeth”, they usually say. When approaching this problem, many aspects need to be evaluated, such as what the patient’s main concern actually is. What does the patient want? We should always understand that our idea of aesthetics might not match the patient’s. Some patients might have unrealistic expectations. So, for an accurate esthetic check-up a well-established communication is mandatory.
Once the need of closing gaps is agreed, we should choose the most appropriate way to do it. Sometimes we need to move teeth with orthodontics, sometimes we need to enlarge them, or even a combination of the two.
Enlarging teeth might have some influence on harmony and proportions, improving the ratio between height and width. Having an incorrect ratio will give the appearance of heavy, large and ugly teeth.
This patient, a young woman, had multiple diastemas from 13 to 23. She complained about the aesthetic appearance of her smile, and she asked for space closure.
We can easily see that, especially for the central incisors, we have a lack of width, so we can imagine that enlarging teeth to close diastemas will improve the aesthetic outcome. The fact is that we can’t just improvise, we need to make a good project together with the dental technician. So we must send to the lab some good impressions, bite registration, pictures, videos and a treatment plan hypothesis.
Pictures of the face are really useful to properly plan a wax-up.
On the following appointment we transferred the wax-up directly in the mouth of the patient, thanks to the mock-up.
The mock-up is an extremely important tool. It gives us a lot of information about the feasibility of the treatment plan, and provides an immediate means of communication with the patient who can pre-visualize the result. Moreover, it can become a precise guide for the preparation phase. In this case, the mock-up was done with a self-curing resin (DMG Luxatemp star), and it was immediately clear that the project was good; this resin is almost “selfpolishing”, so you just need to remove resin excess and use a silicone tip to polish. The new proportions are nice, the patients is really happy with them.
On the operative appointment, the mock-up procedure was repeated. At this stage, the mock-up is a real preparation guide.
Preparing through the mock-up is a simple and reliable way to control the thickness of the final veneer, and the quantity of tooth structure we are removing. Horizontal depth grooves were made with a round diamond bur of known size.
Depth grooves on the incisal edge of lateral and central incisors (canine received a window preparation).
Marking the grooves with a pencil is helpful to highlight them.
With a diamond bur, following the 3 different planes of the buccal surface, teeth were prepared through the mockup in order until the grooves were completely removed.
Incisal edges were prepared.
After preparation, the mock-up can be removed. At this point, the undercuts were removed and preparations polished to give the lab smooth and regular surfaces.
Vertical silicone keys are very helpful to check the available thickness (A: tooth 23; B: tooth 22; C: tooth 21) and to guide us through the second part of the preparation. The same keys were used to check the result (D: tooth 23; E: tooth 22; F: tooth 21)
Same situation on quadrant I. A-D: 13; B-E: 12; C-F: 11
Final preparations, finished and polished. No finishing line was used, everything was based on vertical preparation.
Because of the vertical preparation, we needed to give the lab information about the physiological gum contour and position, so an impression was taken with an A-silicone (DMG Honigum Pro Heavy and Light) before any cord is positioned.
Two retraction cords (#000 and #1) were used to displace the gums prior to taking the working impression.
Pictures with shade references, to give the lab important information about the color of the substrate.
The silicone key was used again to print another mock-up, that worked as a temporary restoration (DMG Luxatemp Star)
The following appointment was very important to try the veneers one by one, to check if they were sitting properly and were precise. In multiple veneer cases, we need to try all the veneers together, to understand if we have an order of insertion. Eventually we can proceed to the aesthetic trial, using a try-in paste (DMG Vitique B1)
Rubber dam isolation is mandatory, speaking about adhesive procedures.
The isolation was completed with a B4 clamp, then the veneer was tried again, to be sure there was no interference with its sitting.
The lithium disilicate veneer was etched with hydrofluoric acid for 20 seconds, then carefully washed and dried. Then a layer of silane was applied (DMG Vitique Silane).
Tooth 21 was ready for the same procedure.
Light curing of 21.
The same cementation protocol was applied to each veneer. As a last step, a layer of transparent gel was used to remove the oxygen inhibition layer, and better light cure the resin cement.
All the excess was carefully detached after rubber dam removal.
10 days check-up. Tissues were perfectly healed. Central papilla was still growing back.
A detail of the incisors.
The patient was very happy of her new smile.
A detail of the smile.
The mock-up is an essential tool for several parts of the treatment plan when it comes to esthetics. Is the easiest way to show to our patient what the project we have in mind looks like in reality. It’s also very useful to understand if our project is actually feasible. Then it becomes an incredible guide during the preparation. Last, but not least, it can be used to create a temporary restoration until the final restorations are in.
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