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 Thenchique 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
Img. 1 – Multiple diastemas in young girl after orthodontic treatment.
Img. 2 – A simplified DSD grid was made in order to individuate how much material to add and where. Facial midline (solid line) was shifted importantly 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 lenghthen 1.5mm the incisal edge, and the diastema of 21 at the expense of 21 distal and 22 mesial with an incisal lenghthening on 21.
Img. 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 apporach we will follow a one-by-one tooth reconstruction.
Img. 4 – Maximum retraction is achieved with a 212A clamp. Rubberdam 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 diastime 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.
Img. 5 – Acid etching of the enamel. In this kind of extensive restorations, it is common to end up with composite in areas where it migh 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.
Img. 6 – In this case, all the buccal and proximal surfaces were etched.
Img. 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.
Img. 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 usually very used to go "free hand" in several modalities of restorations with wonderful results.
Img. 9 – Achieving a right contour is easy when the only thing we need to focus on is in the shape.
Img. 10 – Working with stiff modelling composites allows us to get the shape in only one shot. Multiple layers can be added.
Img. 11 – Once the buccal part is done, the palatal and the precision of the restoration are very far from ideal, but this has a ridiculousely easy solution.
Img. 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 NOT TOUCH the already bonded enamel, but only composite.
Img. 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.
Img. 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.
Img. 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
Img. 16 – The black matrix placed, and the palatal cavity access
Img. 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.
Img. 18 – After polymerization, matrix is pulled off. It is very easy to obtain tight contacts and good contours.
Img. 19 – The possible obtained excess (as the one visible in the palatal) are located in areas where trimming them is extremely easy.
Img. 20 – The incisal edge was constructed 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.
Img. 21 – A correction was made immediatele as the incisal edge effects were not very good.
Img. 22 – Immediate post-operative image.
Img. 23 – Oblique view of the texture and morphology.
Img. 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 lenghthening area, it was decided not to touch them at all.
Img. 25 – The initial situation, as a reminder of the departure point.
Img. 26 – Digital composition of the before and after, where all the added material can be perceived.
Img. 27 – Lateral view of 11, 12 and 21, 22.
Img. 28 – Close up of 21 and 22
Img. 29 – Close up of 11 and 12. Further controls will be made and posted in this article. Special thanks to Leandro Martins.
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.