The Front Wing Technique

Direct diastema closure is often a nightmare, starting from the wax-up which, even in skilled technician hands, is very likely not to be perfectly precise; then comes the little application that the silicone indexes have in the actual procedure, and the difficulty in selecting the right matrix among the ones they put in fancy systems that do all the opposite of simplification, and, finally,  end up with loose contact points and dangerous overhangings at the cervical level.

For all of the above reasons, a new strategy for diastema and shape modifications is proposed by the Styleitaliano team. The Front Wing Technique offers the following advantages:

– Skipping the wax-up (NOT to be confused with not doing a project)

– Giving the user the chance of building and selecting the emergency profile and contour of one or multiple diastemas

– The chance of working with single shade or multi shade approach

– Tight contacts are easier to get

– Ideal cervical fit

– Aesthetics of the restoration

styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.1

Multiple diastemas in young girl after orthodontic treatment.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.2

A simplified DSD grid was made in order to identify how much material to add and where. Facial midline (solid line) was consistently shifted from the dental midline (dotted line), making this diastema closure even more difficult. According to the project, it was decided to close the distema of 11 at the expense of the mesial area and lengthen 1.5mm the incisal edge, and the diastema of 21 at the expense of 21 distal and 22 mesial with an incisal lengthening on 21.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.3

In the classic technique, isolation is an enormous challenge, generally consisting of complicated retraction systems in order to place a multi-tooth silicone guide, in a very unreliable way. In this approach we will follow a one-by-one tooth reconstruction.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.4

Maximum retraction is achieved with a 212A clamp. The rubber dam retracts very efficiently the papilla as well, making the whole mesial area visible up to the desired emergence profile point of departure. This area is critical and is where most mistakes happen. When working on a diastema with two walls to restore, two B4 (Brinker) clamps are used in order to retract both teeth at the same time and build-up both front wings at the same time.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.5

Acid etching of the enamel. In this kind of extensive restorations, it is common to end up with composite in areas where it might not be expected to have restorative material: the risk of this happening is big, and it is preferred to etch beyond the limits, sometimes much further than needed.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.6

In this case, all the buccal and proximal surfaces were etched.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.7

Bonding application is made with a flat Compobrush (Smile Line by Styleitaliano) in order to have high precision, especially in the extremely narrow areas in the mesio-cervical region.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.8

TIP #1
This is the beginning of the project (and where the name of the technique comes from). The key is to model free hand the buccal part of the diastema, making this shape as efficient and precise as possible. Colleagues are often used to go “free hand” in several modalities of restorations with wonderful results.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.9

Achieving an appropriate contour is easy when the only thing we need to focus on is the shape.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.10

Working with stiff modeling composites allows us to get the shape in only one shot. Multiple layers can be added.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.11

Once the buccal part is done, the palatal and the precision of the restoration are very far from ideal, but this has a ridiculously easy solution.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.12

Application of an addition of the first hand-free buccal layer in order to optimize the shape. After modeling, mechanical trimming can be done in order to optimize the shape, it is mandatory when doing that you don’t touch the already bonded enamel, but composite only.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.13

Now it is time to focus on the sealing of the restoration and on the achievement of a tight contact, by placing an anatomical matrix (Lumicontrast, Kit MyCustomRings, Polydentia) and a wedge.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.14

All the matrices needed for most of the anterior and posterior cases were selected by the Styleitaliano members and placed in the MyCustomRings kit.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.15

TIP #2
A small – I mean, really small – drop of flowable resin is placed and NOT cured yet. This helps the wettability of the following composite increment as described by Opdam et al. in 2003
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.16

The black matrix in place, and the palatal cavity access.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.17

An increment of composite is placed on the palatal side, displacing all the flowable resin towards the buccal one. It is mandatory to keep condensing until there’s excess material flowing on the buccal. For the experienced operator, this step is not necessary, just condensing the composite mass until excess is found is more than enough.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.18

After polymerization, the matrix is pulled out. It is very easy to obtain tight contacts and good contours.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.19

The possible obtained excess (as the one visible on the palatal side) is located in areas where trimming it is extremely easy.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.20

The incisal edge was built with a dual layering technique according to the Styleitaliano recipes. Teeth 21 and 22 were built with the exact same technique and one at a time.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.21

A correction was made immediately as the incisal edge effects were not very good.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.22

Immediate post-operative image.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.23

Oblique view of the texture and morphology.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.24

One month control, shows perfect soft tissue healing and integration thanks to the contours created. Very small white lines (which correspond to the past incisal halo) can be perceived in the incisal lengthening area, it was decided not to touch them at all.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.25

The initial situation, as a reminder of the starting point.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.26

Digital composition of the before and after, where all the added material can be perceived.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.27

Lateral view of 11, 12 and 21, 22.
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.28

Close up of 21 and 22
styleitaliano style italiano jordi manauta anterior restoration direct diastema close space between teeth front wing technique composite rubber dam clamp

Fig.29

Close up of 11 and 12. Further controls will be made and posted in this article. Special thanks to Leandro Martins.

Conclusions

In an era in which conservative dentistry is almost a universal choice, the actions we do and apply everyday must be fast, easy and economical, incorporating advantages to the already existing techniques. The front wing technique has had an amazing acceptance immediately after being taught, and the immediate results we could se from the participants in their hands-on exercises in models was stunning. A series of community cases will be published in www.styleitaliano.org
The author wishes to thank Walter Devoto and Angelo Putignano for the co-authoring and inspiration in the development of this technique. Thanks to Leandro Martins (Manaus, Brazil) for sharing and helping during the clinical case performance in his training center in Brazil. To Dan Lazar and Louis Hardan for helping in the graphics and technique improvements and collaboration.

Bibliography

Devoto W, Saracinelli M., Manauta J.Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur. J. Esthet Dent 2010; 5: 102-124
Opdam NJ, Roeters JJ, de Boer T, Pesschier D, Bronkhorst E. Voids and porosities in class I micropreparations filled with various resin composites. Oper Dent. 2003 Jan-Feb;28(1):9-14.
Fahl N Jr. Achieving ultimate anterior esthetics with a new microhybrid composite. Compend Contin Educ Dent Suppl. 2000;(26):4-13; quiz 26.
Coachman, C., Calamita, M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. QDT 2012.
Manauta J, Salat A. Layers, An atlas of composite resin stratification.Quintessence Books, 2012
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http://styleitaliano.hime.host/synchro-matrix
http://styleitaliano.hime.host/diastema-tips-and-tricks