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.

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

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.

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.

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

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

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.

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.

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

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

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.

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.

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

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

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.

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

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

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

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

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

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

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.

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

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

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.

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

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

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

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

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.

Fig.31
Final result after finishing and polishing procedures.

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

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/)