There’s much more to a smile than space closure

A clinical case by our Community member Dr. Mohammed Shaga

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

In today’s interdisciplinary dental world, treatment planning must begin with well-defined esthetic objectives. By beginning with esthetics, and taking into consideration the impact on function, structure, and biology, the clinician will be able to use the various disciplines in dentistry to deliver the highest level of dental care to each patient. The presence of a maxillary diastema is one of the main aesthetic concerns for patients during dental appointments but large midline diastema, it leads us to an orthodontic treatment as a first step to correct distribute the midline spacing between anterior teeth before restorative approach.
In this article we will present a combined approach to obtain the highest result of esthetic treatment, using disciplinary approach of orthodontics, periodontics and minimal invasive direct restorative treatment.

smile of patient with very large diastema style italiano styleitaliano

Fig.1
An 18-year-old female patient was complaining about the esthetic appearance of her smile in terms of spacing between central incisors and teeth stains. A complete dataset was fabricated to evaluate the clinical outcome for accurate treatment plan.

large midline diastema style italiano styleitaliano

Fig.2
Initial image of intra-oral frontal view with midline diastema 3.5 mm.

calculated reduction of diastema before restoration styleitaliano style italiano

Fig.3
The space was too large to be closed with a restorative treatment alone, therefore, the treatment plan consisted of three main steps. Firstly, an orthodontic approach would correct the large midline diastema with proper distribution of this space by movement of the central incisors to properly distribute the large midline space.

digital smile design prior to multidisciplinary dental treatment style italiano styleitaliano

Fig.4
Digital Smile Design is very important in these cases used as a guide in all steps. The Golden Proportion (proportion of 1.618:1.0:0.618) was used to determine adequate distribution of the spaces between teeth and to guide the orthodontic and restorative intervention.

space distribution for aesthetic treatment style italiano styleitaliano

Fig.5
This image explains spacing distribution that us will obtain it with orthodontic treatment to create a good tooth to tooth proportions.

orthodontic treatment style italiano styleitaliano

Fig.6
Final phase of the orthodontic treatment. Spaces were distributed according to the Golden Proportion after six months.

final result after orthodontic and periodontal treatment style italiano styleitaliano

Fig.7
Secondly, gingival contouring was done. The interdental papillae must reproduce the natural architecture after the alignment and leveling promoted by the orthodontic mechanics. Therefore, periodontics also be included in the multidisciplinary approach for the correction of diastemata. A gingivectomy was performed before removal of the orthodontic appliance, to improve the relationship between height and width of the dental crowns.

smile before veneer restorations styleitaliano style italiano

Fig.8
As a last step, two months after surgery, the teeth were ready to receive direct restorations. Direct composite resin restorations are a good treatment option because of the little preparation required. Moreover, the longevity of adhesion to enamel is well documented and may enhance both esthetics and function.

intraoral situation before direct composite restorations style italiano styleitaliano

Fig.9
Post-ortho-periodontics intra-oral situation.

rubber dam isolation and veneer preparation style italiano styleitaliano

Fig.10
Rubber-dam isolation with knot ligatures after minimal preparation.

enamel total etching before composite veneering style italiano styleitaliano

Fig.11
Etching with 37% phosphoric acid for 30 seconds and washing with water for 60 seconds to ensure complete removal of the etching gel residues.

bonding of veneer preparations style italiano styleitaliano

Fig.12
Multiple coats of bonding agent are applied, air-blown using oil-free syringe to let the solvent evaporate and cured for 40 seconds.

silicone index and palatal shells for direct veneering style italiano styleitaliano

Fig.13
The 0.5 mm thick palatal shells were built using a silicone index.

shape build up with composite resin styleitaliano style italiano

Fig.14
The proximal walls were built by using metallic sectional matrices.

layering of dentine composite shade style italiano styleitaliano

Fig.15
As you can see, layering of the dentin shade is easy if your working framework is accurate. With the help of an explorer, or a sharp instrument, we start shaping the mamelons, maintaining a small space for the incisal effects with the transparent masses.

mamelons shaped within the dentin composite layer styleitaliano style italiano

Fig.16
Dentin shade of composite resin applied in the incisal edge to create the halo effect.

translucent composite in the incisal area style italiano styleitaliano

Fig.17
The small space between the mamelons and the incisal halo will be covered with a translucent shade, slightly covering the mamelon tips.

packing of composite resin style italiano styleitaliano

Fig.18
Translucent small masses were adapted in between the mamelons first by a spatula.

brushing composite masses styleitaliano styleitaliano

Fig.19
Then, the composite was smoothened by dental brush to ensure adaption and reduce void.

direct veneers before finishing procedures style italiano styleitaliano

Fig.20
Then a chromatic enamel shade was applied all over the surface of the restoration.

split dam before finishing composite veneers style italiano styleitaliano

Fig.21
For finishing, isolation was changed to a split dam for better control over the cervical area.

angle line definition by abrasive disc styleitaliano style italiano

Fig.22
After drawing line angles with a pencil, a blue disc (most abrasive) was used at 45 degrees with respect to the tooth surface.

buccal thirds for anatomical finishing of composite veneers style italiano styleitaliano

Fig.23
To correct the labial contour, dividing it into three thirds, cervical, middle, and incisal, is very helpful to achieve a natural anatomy.

modeling buccal area with abrasive disc styleitaliano style italiano

Fig.24
The labial contour can be shaped with an abrasive disc by following the three thirds of the labial surface.

perio bur creating macro-texture on composite veneers style italiano styleitaliano

Fig.25
To create the vertical macro-texture (V-shape grooves) a low speed grain diamond bur can be used following the pencil trace. Here, the perio bur from the Styleitaliano finishing kit was used.

abrasive rubber tip polishing composite styleitaliano style italiano

Fig.26
The macro-grooves can then be smoothened out by the tip of a flame-shaped rubber.

soft rubber polishing composite style italiano styleitaliano

Fig.27
It is necessary to go through the entire polishing system, starting at the most abrasive rubber and finishing at the less abrasive rubber

spiral wheel polishing composite restorations style italiano styleitaliano

Fig.28
After having created the micro-texture details we should soften the surface of the composite resin with spiral tools.

composite aluminum oxide polishing paste style italiano styleitaliano

Fig.29
Aluminum oxide pastes are ideal to give the composite resin a natural enamel-like glossy look.

silicone brush polishing with aluminum oxide paste styleitaliano style italiano

Fig.30
A silicone carbide brush was used to polish the composite resin. This brush can be used effectively, yet, it is necessary to control pressure as it may scratch the surface.

polished direct composite veneers style italiano styleitaliano

Fig.31
Final result after finishing and polishing procedures.

smile after direct veneer restoration style italiano styleitaliano

Fig.32
The patient was very satisfied with her new smile.

detail of incisal composite veneer anatomy style italiano styleitaliano

Fig.33
Surface texture with a natural halo effect.

Conclusions

In this multidisciplinary article, a maxillary midline diastema was solved including orthodontic resolutions combined with periodontics and restorative dentistry. The success of a cosmetic treatment depends on accurate diagnosis and multidisciplinary treatment planning to obtain the best combination of minimal invasiveness and aesthetics.

Bibliography

1. Hwang, S. K., Ha, J. H., Jin, M. U., Kim, S. K., & Kim, Y. K. (2012). Diastema closure using direct bonding restorations combined with orthodontic treatment: a case report. Restorative dentistry & endodontics, 37(3), 165-169.
2. Furuse, A. Y., Franco, E. J., & Mondelli, J. (2008). Esthetic and functional restoration for an anterior open occlusal relationship with multiple diastemata: a multidisciplinary approach. The Journal of prosthetic dentistry, 99(2), 91-94.
3. Şen, N., & Işler, S. (2019). Multidisciplinary management of a severe maxillary midline diastema: a clinical report. Journal of Prosthodontics, 28(3), 239-243.
4. Shaalan O. A combined approach for diastema closure. StyleItaliano. (LINK https://www.styleitaliano.org/acombined-approach-for-diastema-closure/)
5. Monteiro P. The step by step in finishing and polishing: anterior direct composite restorations. StyleItaliano. (LINK https://www.styleitaliano.org/the-step-by-step-in-finishing-and-polishing-part-i/)

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