Introduction

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The presence of diastema in the anterior esthetic zone may be displeasing to a person”smile and many patients are motivated to improve their appearance either by orthodontic treatment or restoratively by veneers, crowns or composite resin bonding.

Composite bonding between teeth fills spaces and improves the appearance of diastemas. As part of a comprehensive esthetic treatment and part of an overall dental treatment plan, the result of diastema closure must produce a beautiful smile and fulfill the goals of overall smile design.

Increased patient demand for esthetic rehabilitation with less invasive procedures has led to extensive use of composite bonding in the anterior region. This resin bonding is conservative and relatively inexpensive means of enhancing one “s smile  and often carried out in a single visit in most dental practices.

In selecting composite resin materials certain features are essential

1. Scultability;Material should be easy to shape and sculpt with minimal slumping.

2. Fracture Toughness: Resistance to fracture in stress bearing areas.

3. Modulus of Elasticity: Similar modulus of elasticity to natural tooth substances.

4 .Polish ability; Easy to attain polish and maintain gloss for long time.

5. Shrinkage; Minimal polymerization shrinkage to reduce microleakage and stress at restorative/tooth interface.

IPS Empress Direct  by Ivoclar  Vivadent,  microhybrid composite resin was chosen as restorative material for this case. Use of this resin not only provides strength needed in these situations but also good polish ability and luster needed for aesthetics.

The Bis- GMA resin contains fillers consisting of barium almunium  boron fluoride, silica glass and  highly dispersed silicon dioxide.

To achieve a natural life like restorations, the clinician needs to establish a chromatic colour map and layer the restoration with successive layers of enamel, dentine and translucent effect s so that the final restoration has good optical properties that reflect ,refract and absorb light naturally.

This gives the restoration a polychromatic effect with depth of color  that looks like natural teeth.

Case Report(s)

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Case

The following case describes the use of direct composite resin to close diastemas in the anterior teeth to address the aesthetic concerns of the patient (Fig 1)

Restorative Sequence

1. Pre-operative assessment:Assessment of the patient should be made along with any contraindications to treatment. Special attention must be made if there are any occlusal concerns like bruxing or in “deep bite” situations. Shade selection is made prior to treatment to compensate for the elevated value of teeth if dehydrated. Due to the different opacities/translucencies of the different tooth substrate-with dentine more opaque and enamel translucent ,we need to a choose material that mimics these characterstics.

2. Mock-Up: It can be difficult to select the correct shade and opacity and it is the author’s preference to begin with a trial mockup of the different shades/opacities of materials to ensure correct colour and Translucency after matching the appropriate shade(Fig 2). This is a very quick buildup that gives the clinician a preview to the ?nal result with minimal time and effort.

3. Isolation: The teeth were isolated with non-latex rubber dam using a full arch approach.

4. Preparation: is completed with a pumice slurry, judicious use of a diamond bur to give necessary bevels and clean the surface for optimal adhesion.(Fig3)Teeth were  acid etched for 20 seconds with Ultra-Etch (Ultradent) (Fig. 4), rinsed and air dried. The enamel exhibited an excellent etch pattern. No dentin was exposed; therefore only Dentin/ Enamel resin (D/E resin, Bisco) was used. The D/E resin was applied in a thin layer, and lightly air- thinned. It is important not to allow the unfilled resin to pool around the gum tissue. If this occurs, the microfill will not be able to be placed subgingivally.

The putty made from the mock up was used to build up the incisal edges .(Fig 5)

The restorations were placed according to an anatomical technique that involved the use of a highly chromatic dentin shade composite overlaid with a colorless enamel value composite. In addition to a full complement of enamel and dentin shades that correspond to the A-D shade range, the selected composite system also features 3 unique value shades (high, medium, and low) that mimic natural enamel in the manner in which it diffuses the underlying dentin color to create a natural-looking depth and appearance. The restorations were shaped and contoured using medium, fine, and superfine discs (Sof-Lex XT, 3M ESPE( Fig6) , and the final contours were made with a finishing bur (TDF9 Finishing Bur, Axis ) .To achieve a nice, polished surface, a PoGo Wheel (DENTSPLY Caulk) and Astropol points (Ivoclar Vivadent) were used . The final restorations were photographed at completion. (Figures 7)

Discussion

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Bleaching is done before composite bonding to achieve color change; 10 to 14 days are allowed to pass before bonding as the bleaching material oxidizes the teeth, making bond strengths weaker. After the bleaching period, then composite can be bonded between teeth to increase the size of adjacent teeth and close  spaces.

The results of diastema closure must conform to the esthetic ideals of smile design.(1-2) Because tooth dimension is being changed, maintaining symmetry and tooth proportion (both in terms of height to width and tooth to tooth) is challenging. Symmetry and tooth proportion (one tooth compared to the next) is easier when multiple diastemas are being closed; however, it cannot always be accomplished depending on tooth position.

Psychological limitations include apprehension about composite strength and longevity as well as final appearance. Excessive force will shear and fracture composite. It is the author’s experience that diastema closure limits exposure to direct force on the incisal edge and little fracture occurs. Composite does slightly change color with time, and leakage around the margins can occur. Touch-ups to composite are usually required every 7 to 10 years.(3-4)There are several psychological advantages to composite bonding. Patients who worry that the results of diastema closure will result in teeth that look too large in comparison to the other teeth or compared to the framework of the lips and face have the option of composites being easily changed. Composite can be added or reduced to fit a patient’s desired goal. Indeed, it can be completely removed if necessary. Composite also can be placed without bonding to confirm patient acceptance. Flexibility is a very desirable feature. Patients also like that little to no tooth reduction is done and the dentistry can be completed without anesthetic.

References

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1. Morley J. Smile design—specific considerations. J Calif Dent Assoc. 1997;25(9):633-637.
2.  Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001; 132(1):39-45.
3. Ardu S, Braut V, Uhac I, et al. Influence of mechanical and chemical degradation on surface gloss of resin composite materials. Am J Dent. 2009;22(5):264-268
4. Heintze SD, Forjanic M, Ohmiti K, Rousson V. Surface deterioration of dental materials after simulated toothbrushing in relation to brushing time and load. Dent Mater. 2010;26(4):306-319.

Source(s) of Funding

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No Source of funding

Competing Interests

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None