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Midline diastema closure with direct composites

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CHF technique prevents common endodontic mishaps
Direct composites offer an advantage over other options due to its shortened treatment time & non-invasive nature
Dr. Usha Dadlani

Dr. Usha Dadlani

Wed. 14 June 2023

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A report published in the Journal of American Dental Association (JADA) estimates that around 1.6% to 25.4% of adults from various age groups and populations have midline diastema. Various treatment options, like orthodontics, direct composites, and indirect veneers, are in use for midline diastema correction. Direct composites offer an advantage over other options due to their shortened treatment time. One of the major advantages of direct composites over indirect veneers is their non-invasive nature. This case series discusses various techniques for diastema closure with direct composites.

Introduction

In this article, a case of midline diastema in a 24-year-old male patient that was closed in a single appointment with direct composite build-up is discussed in detail. This case report presents a step-by-step approach toward composite build-up under rubber dam isolation. Z350 Filtek from 3M was used with a universal bonding agent.

Fig 1 - 6: Evaluation and mock up

    Fig 1: Pre-op showing midline diastema.
    Fig 1: Pre-op showing midline diastema.
    Fig 2: Shade was evaluated with the “Button technique”. Various shades of composite to be used are applied in a button or disk shape on the tooth and light cured. The shade that is the most inconspicuous is selected. In this case, A3.5 Body for cervical region and A3 Body for middle and incisal thirds is selected. A point to be noted here is to select the shade before any procedure or rubber dam to avoid any discrepancy due to dehydration.
    Fig 2: Shade was evaluated with the “Button technique”. Various shades of composite to be used are applied in a button or disk shape on the tooth and light cured. The shade that is the most inconspicuous is selected. In this case, A3.5 Body for cervical region and A3 Body for middle and incisal thirds is selected. A point to be noted here is to select the shade before any procedure or rubber dam to avoid any discrepancy due to dehydration.
    Fig 3. A monochrome photograph helps evaluate the Value. A3 Enamel was chosen for this case.
    Fig 3. A monochrome photograph helps evaluate the Value. A3 Enamel was chosen for this case.
    Fig 4. Increasing the contrast and reducing the brightness of a photograph helps evaluate the internal characteristics. There were hypoplastic lines for example, in this case.
    Fig 4. Increasing the contrast and reducing the brightness of a photograph helps evaluate the internal characteristics. There were hypoplastic lines for example, in this case.
    Fig 5. Quick intra-oral mock up was performed without etching or bonding. Care was taken to divide the space equally between the two central incisors and the same was confirmed by measuring with vernier calliper. This can also be done with the chosen shades of composite to roughly evaluate the selected shade. It is also recommended to check occlusion at this point and remove any static/dynamic interferences.
    Fig 5. Quick intra-oral mock up was performed without etching or bonding. Care was taken to divide the space equally between the two central incisors and the same was confirmed by measuring with vernier calliper. This can also be done with the chosen shades of composite to roughly evaluate the selected shade. It is also recommended to check occlusion at this point and remove any static/dynamic interferences.
    Fig 6. Once verified, a putty index was made with A-Silicon to record the palatal surface.
    Fig 6. Once verified, a putty index was made with A-Silicon to record the palatal surface.

Fig 7 - 12: Bonding and palatal shell

    Fig 7. After thorough prophylaxis, the concerned site was isolated with rubber dam and further retraction of gingiva was achieved with the help of floss ties. A good retracted area gives good access and visibility for the restoration and hence the desired emergence profile.
    Fig 7. After thorough prophylaxis, the concerned site was isolated with rubber dam and further retraction of gingiva was achieved with the help of floss ties. A good retracted area gives good access and visibility for the restoration and hence the desired emergence profile.
    Fig 8. 37% Phosphoric acid was used to etch the enamel for 20 seconds and thoroughly washed after that.
    Fig 8. 37% Phosphoric acid was used to etch the enamel for 20 seconds and thoroughly washed after that.
    Fig 9. A single Bond Universal from 3M was used as the adhesive. The bond was applied and the excess was removed with a fresh applicator tip and light cured.
    Fig 9. A single Bond Universal from 3M was used as the adhesive. The bond was applied and the excess was removed with a fresh applicator tip and light cured.
    Fig 10. The silicon index is then used to build the palatal shell which will serve as the base to further layer composite.
    Fig 10. The silicon index is then used to build the palatal shell which will serve as the base to further layer composite.
    Fig 11. A3 Enamel was used in this step.
    Fig 11. A3 Enamel was used in this step.
    Fig 12. The sectional matrix for posterior teeth was used in a vertical direction and stabilized with wedge.
    Fig 12. The sectional matrix for posterior teeth was used in a vertical direction and stabilized with wedge.

Fig. 13 - 17: Contact build-up and stains

    Fig 13. The proximal wall was first built on right central incisor taking support from the matrix band. The desired contour is achieved on right central incisor.
    Fig 13. The proximal wall was first built on right central incisor taking support from the matrix band. The desired contour is achieved on right central incisor.
    Fig 14. Band and wedge is then stabilized for the left central incisor.
    Fig 14. Band and wedge is then stabilized for the left central incisor.
    Fig 15. And the proximal contour Is built for the left central.
    Fig 15. And the proximal contour Is built for the left central.
    Fig 16. Contact point is achieved at the desired level The main body is built with blending the A3.5 and A3 Body shades.
    Fig 16. Contact point is achieved at the desired level The main body is built with blending the A3.5 and A3 Body shades.
    Fig 17. Finally, white opaquer is used to mimic the hypoplastic lines and light cured.
    Fig 17. Finally, white opaquer is used to mimic the hypoplastic lines and light cured.

Fig. 18 - 22: Final layering and polishing

    Fig 18. Final Enamel layer is contoured with A3 Enamel and light cured.
    Fig 18. Final Enamel layer is contoured with A3 Enamel and light cured.
    Fig 19. A water soluble medium is applied and light cured under that to eliminate the Oxygen Inhibited Layer.
    Fig 19. A water soluble medium is applied and light cured under that to eliminate the Oxygen Inhibited Layer.
    Fig 20. Gross finishing was performed before removing the rubber dam.
    Fig 20. Gross finishing was performed before removing the rubber dam.
    Fig 21. The Line angles are defined first with the help of pencil marking and then fine tuned with the help of fine finishing burs.
    Fig 21. The Line angles are defined first with the help of pencil marking and then fine tuned with the help of fine finishing burs.
    Fig 22. And final polish was achieved with the help of Soflex Disks and Spirals from 3M.
    Fig 22. And final polish was achieved with the help of Soflex Disks and Spirals from 3M.

Fig. 23 - 28: Post-op documentation

    Fig 23. Post-op 7 Days shows the smooth finish and polish which integrated well with the surrounding soft tissues. The healthy papilla filled the interdental space leaving no black triangle.
    Fig 23. Post-op 7 Days shows the smooth finish and polish which integrated well with the surrounding soft tissues. The healthy papilla filled the interdental space leaving no black triangle.
    Fig 24. The white opaquer used just under the enamel layer blended well with the rest of the hypoplastic lines even after rehydration.
    Fig 24. The white opaquer used just under the enamel layer blended well with the rest of the hypoplastic lines even after rehydration.
    Fig 25. Defining line angles and their perfect contour helps establish an aesthetic shape and hence a pleasing end-result.
    Fig 25. Defining line angles and their perfect contour helps establish an aesthetic shape and hence a pleasing end-result.
    Fig 26. Defining line angles and their perfect contour helps establish an aesthetic shape and hence a pleasing end-result.
    Fig 26. Defining line angles and their perfect contour helps establish an aesthetic shape and hence a pleasing end-result.
    Fig 27. The textures were well replicated and gave the life-like appeal to final restoration.
    Fig 27. The textures were well replicated and gave the life-like appeal to final restoration.
    Fig 28 The textures were well replicated and gave the life-like appeal to final restoration.
    Fig 28 The textures were well replicated and gave the life-like appeal to final restoration.

Conclusion:

The success of these restorations depends on following the protocols for bonding and its integration with the surrounding soft tissues. Direct composites if handled well, by a skilled clinician, offer the best modality to transform the smile in a single visit with minimally invasive protocols.

Tags:
Adhesive bonding Adhesive dentistry Aesthetic dentistry Aesthetic restorations Anterior direct restoration Direct restoration Midline diastema
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