Simple multi-shade approach for closure of multiple diastemata

The presence of multiple diastemata in anterior teeth is one of the challanges of clinical estheitcs dentistry. There are multiple options for the treatment of diastema, but not all diastemata can be treated using one single approach. Proper case selection and diagnosis are crucial for success of the treatment. In this article multiple diastemata closure was performed using a direct, multi-shade composite resin layering technique.

smile with multiple diastemata

Fig.1
This 23-year-old female patient was not satisfied with her existing smile because of multiple diastemata. She refused orthodontic treatment because of long duration and financial constraint, so, after discussing treatment options she preferred an alternative, cost-effective treatment with direct composite resin as a minimally-invasive approach.

occlusion of patient with multiple diastemas

Fig.2
Retracted view show multiple diastema between anterior teeth with composite restoration on 21 and 22 .

digital project for smile makeover

Fig.3
After simulating the suitable proportions of width and height between teeth, it became clear that a good length-width ratio would be achieved by gingivectomy before proceeding to the restorations.

superimposition of gingivectomy and esthetic restoration project

Fig.4
After gingivectomy and increase in length of anterior teeth.

isolation with rubber dam and floss ligatures

Fig.5
Rubber dam is placed for isolation, and floss ligatures were used to retract the papillae laterally and enable better management of the emergence profile. If the papillae are not well retracted the result is the presence of an interdental black triangle.

bevel preparation on margin of upper left incisor

Fig.6
Only tooth 22 required preparation. A 2-3 mm fine bevel preparation using a diamond bur and afterwards the finishing of the preparation with coarse and medium abrasive discs were done on tooth 21.

acid etching of enamel from canine to canine

Fig.7
Enamel etching for 30 seconds, and 15 seconds for dentin. The etchant was then rinsed for 60 seconds.

microbrush rubbing bonding agent on incisor

Fig.8
Multiple coats of bonding agent are applied, and after 20 seconds air is blown using oil-free syringe to let the solvent evaporate. Light curing is carried out for and extended time of 60 seconds to ensure perfect polymerization.

palatal shells layered with the help of a silicone index

Fig.9
The 0.3-0.5 mm thick palatal shells were built using a silicone index and WE Filtek Z350 XT composite (3M).

composite boxes for direcy veneering ready to fill

Fig.10
Building the proximal walls by using metallic sectional matrices with WE Filtek Z350 XT (3M) composite shade.
This is an important step during work. If we control the outer shape, it’s easier to control layering of the inside dentin shade. Also finishing and polishing steps are made easier.

outer shape of direct veneers defined

Fig.11
Layering opaque dentin A2 Filtek Z350 XT (3M).

modeling of tmamelons and internal anatomical features on upper incisors

Fig.12
1- Body dentin A1 Filtek Z350 XT (3M).
2- CE Filtek Z350 XT (3M) between mamelons to create the opalescence effect.
3- White opaque tint at the incisal edge to recreate the incisal halo.

raw composite layered on front teeth

Fig.13
Layering of the final enamel layer WE Filtek Z350 XT (3M).

marks of line angle definition before composite finishing

Fig.14
Finishing started by correction of the angle lines with a fine needle diamond bur.

tooth thirds visual separation for anatomical finishing

Fig.15
Correction of the buccal contour following the three thirds of the labial surface with a fine long taper diamond bur.

composite restorations on upper front teeth before polishing

Fig.16
Labial view of upper anterior region after diastema closure and shape correction.

texturing of composite veneers with carbide bur

Fig.17
To create the vertical macro texture and V-shape grooves we can use a finishing carbide bur.

polishing composite direct veneers with rubber wheel

Fig.18
After having created the texture details we should soften the surface of the composite resin with a rubber Eve twist polisher.

polished composite veneers on upper front teeth

Fig.19
After initial finishing and polishing. The patient rescheduled for a second visit for minor modifications and repairs according to patient wishes and for a more detailed finishing and polishing.

diamond paste for composite polishing

Fig.20
On the second appointment, restorations were polished using 3 and 1 micron diamond paste (Micerium) with Shiny G (Micerium), and a natural goat-hair brush used at 1,000 rpm with no water and at 10,000 rpm with abundant irrigation.

felt wheel and fine diamond polishing paste for composite veneers

Fig.21
1-μm aluminum oxide paste (Shiny F, Micerium) paste was used with a soft felt disk. is used with a to achieve a very high gloss used at 1,000 rpm with no water and at 10,000 rpm with abundant water.

side view of composite veneers

Fig.22
After final finishing and polishing. Two-week follow up side view.

smile after teeth makeover with direct composite makeovers

Fig.23
Final result at 2-weeks check up appointment.

before and after diastema closure

Fig.24
Before and after.

Conclusions

We should always consider simple treatment approach if it gave the same aethetic result compared to other alternative treatment options, especially in cases of diastema closure.

Bibliography

1.Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 10 Surface and polishing Quintessence Books, 2012
2.Monteiro P. The step by step in finishing and polishing: anterior direct composite restorations.https://www.styleitaliano.org/the-step-by-step-in-finishing-and-polishing-part-i/
3.Mangani F, Cerutti A, Putignano A , Bollero R, Madini L. Clinical approach to anterior adhesive restorations using resin composite veneers, Eur. J. Esthet. Dent. Off. J. Eur. Acad. Esthet. Dent. 2 (2007) 188–209.
4.Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent 2011;23(2):73-87.

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