Fig.1
A retracted view of the diastema between the two upper central incisors. A chair-side direct mock-up was done to assess the shade, and to build the palatal aspects in order to make a silicone index. The patient was happy with the result and shade.

Fig.2
Teeth were isolated using a rubber dam. As you can see, despite the good inversion of the rubber dam, the upper centrals needed further retraction.

Fig.3
A couple of floss ties were used to displace the papilla and retract all the tooth surface needed enabling us to achieve a better emergence profile.
TIP: bond some resin tags disto-gingivally to help keep the floss ties distal and apical throughout the treatment.

Fig.4
Air-abrasion of the tooth surface using Aquacare (29µm aluminium oxide particles) was carried out to remove any residual plaque deposits or stains.

Fig.5
Enamel etching using 37% phosphoric acid for 30 seconds, followed by a 60 second rinse. This is very important to ensure that all the etchant has been washed off the tooth surface.

Fig.6
After drying the teeth, Scotchbond Universal (3M) was used as a bonding agent. It was rubbed onto the tooth surfaces and left for 30-60 seconds to air dry. Once the bond was cured, the silicone index was used to build up the palatal aspect of the teeth.
Then two sectional matrix bands were placed mesially. Using two matrices is meant to prevent overbuilding or over-extending one of the restorations thus affecting the proportions and overall aesthetic outcome. Once the first tooth had been restored, the sectional band used to build that tooth was removed, while the other one was kept in place. Leaving a single matrix before building the second restoration helps ensure a tight contact between the two restorations. In this case 3M Filtek B1 Universal composite was used for the restorations.

Fig.7
Once the restorations were complete, a final cure under glycerine was carried out.

Fig.8
This is very important as curing under glycerine prevents oxygen from inhibiting the outer layer of composite from completely being cured. An incompletely-cured composite layer can be stained and make the restorations discolor very quickly.

Fig.9
A Soflex disc (3M) was used to remove excess composite and to better define the final shape.

Fig.10
A clean rose-head bur (on a slow hand piece) was then used to add secondary anatomy.

Fig.11
The 831 (perio bur) is also a great bur to use for added secondary and or tertiary anatomy (the perikymata).

Fig.12
A two rubber wheel finishing protocol was used. Here we used ASAP steps 1 and 2 to polish. However, the spiral are also very good for this step.

Fig.13
The ASAP step 2 is used to give the restorations a beautiful shine and lustre.

Fig.14
The restorations after polishing.

Fig.15
Immediate post-op. It is important to warn the patient beforehand that the restorations could appear slightly darker than the teeth immediately after the procedure because of dehydration that occurs under rubber dam isolation. This is also why it is critical to take the shade before starting any treatment!

Fig.16
Immediate post op smile. As well as telling the patient that the slight discoloration will improve, in this case we also advised that the slight gap between the gum will be filled up by the papilla.

Fig.17
One month recall. You can see that the composite has integrated very well with the natural dentition and the papilla has filled the small gap.

Fig.18

Conclusions

Composite materials are a great alternative treatment modality when it comes to restoring a diastema where the patient has refused or cannot afford orthodontics.
Universal composites such as the 3M filtek universal are fantastic materials that can mask the opacity and provide a natural blend with the natural tooth shade. This can simplify the work process both for the clinician and assistant whilst remaining predictable. The use of the Polydentia posterior matrices or now the UNICA matrix can be invaluable tools to help make the process easier and predictable ever time.

Bibliography

1. Monteiro P. The step by step in finishing and polishing: anterior direct composite restorations on styleitaliano.org – 2017
2. Fahl N Jr. Achieving ultimate anterior esthetics with a new microhybrid composite. Compend Contin Educ Dent Suppl. 2000;(26):4-13; quiz 26.
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. Manauta J, Salat A. Layers, An atlas of composite resin stratification.Quintessence Books, 2012
5. C. F. Villares Diastema closure a single shade opacity aesthetic approach on styleitaliano.org – 2019
6. 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.