CLINICAL ARTICLE
Conservative Approach for the Esthetic Management of Multiple Interdental Spaces: A Systematic Approach ABELARDO BÁEZ ROSALES, DDS, MS*, DIEGO DE NORDENFLYCHT CARVACHO, DDS†, RAMÓN SCHLIEPER CACCIUTOLO, DDS, MS‡, MANUEL GAJARDO GUINEO, DDS, MS‡, CLAUDIO GANDARILLAS FUENTES, DDS, MS‡
ABSTRACT Purpose: To describe a conservative approach using resin-based composites following a buccolingual layering technique with a customized silicon index for the management of multiple diastemas. Clinical Considerations: This clinical article describes the case of a patient with their anterior teeth esthetically compromised by multiple diastemas, incisal wear, and dull/low-value cervical composite resin restorations that were managed with nanofilled composite resin using the “buccolingual technique” with a customized silicon index made from a wax-up to build up the restorations. The first layer of composite placed lingually that represents the enamel replacement was placed directly on the silicon index so that it provides in one single step the lingual profile and the position of the incisal edge of the restoration. Then, dentine and effect composite resin can be applied in a precise three-dimensional configuration. Conclusions: To solve esthetic dental problems, as anterior diastemas, in a very conservative and even reversible way, the use of direct resin composites for layering is an excellent choice, but should be performed based on simple and reproducible techniques, as the buccolingual technique.
CLINICAL SIGNIFICANCE The clinical technique described in this paper shows the advantages of a conservative approach to correct diastemas on maxillary anterior teeth. The application of these techniques can not only help achieve optimal esthetics, but also avoid the removal of extensive dental hard tissue and achieve a predictable final result, especially in esthetically demanding cases. (J Esthet Restor Dent 27:344–354, 2015)
INTRODUCTION Cosmetics and esthetics are current trends of our society that also involve the dental profession, especially the restorative dentistry, and present a new problem to clinicians who have to provide highly esthetic results without increasing costs and clinical working time.1 The current approach for the management of esthetic problems includes conservative treatments, such as
enamel recontouring, bleaching, microabrasion, and resin-based composites. These treatments should be recommended since these can be practical, efficient, and predictable.2 Diastemas are spaces on anterior teeth that can be very unpleasant and may result from developmental, pathological, and iatrogenic factors. Determining the best way of closing an unwanted diastema must be
*Chief director, Department of Restorative Dentistry, Universidad Andrés Bello, Viña del Mar, Chile † Instructor, Department of Restorative Dentistry, Universidad Andrés Bello, Viña del Mar, Chile ‡ Assistant professor, Department of Restorative Dentistry, Universidad Andrés Bello, Viña del Mar, Chile
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predicated upon a diagnostic evaluation of the diastema size, the length and proportion of the clinical crowns of the teeth involved, wear factors, occlusion, and anterior guidance.3
achieved with relatively simple application and layering methods. Modern layering techniques include the use of dentin- and enamel-like masses that are completed with effect materials in selected indications.10,11
Today, a variety of techniques are available to manage diastemas, including orthodontic treatment, crowns, laminate veneers, and direct composite resin restorations.4,5 Indirect restorative options generally require preparation with destruction of healthy tooth structure. Direct techniques, however, embody the principles of minimally invasive restorative treatment, which balances need, damage, and risk; also, it can be done in a single appointment and it is very cost-efficient.5,6
Composites resin can be applied by different incremental techniques. The classical approach is the centrifugal technique, which implies the placement of one or two dentine layers (with an oblique position), followed by the enamel layer which covers the surface. The other approach is the “buccolingual technique,” which uses a silicon key (also described as silicon index or matrix) made from a free-hand mock-up or a wax-up. The first layer made of enamel is placed directly on the silicon key so that it provides in one single step the lingual profile, with and position of the incisal edge of the restoration. Then, dentine and effect materials can be applied in a precise three-dimensional configuration. This technique provides the conditions for an optimal esthetic result (such as natural translucency, opalescence, and halo effects).11
Direct resin-based composite layering is a biomimetic, functional, and biologically prudent treatment option for closing diastemas with clinically promising survival rates, especially in cases in which minimally invasive or noninvasive procedures on healthy teeth are indicated.5 Direct composite resin layering is a reliable treatment option for anterior teeth reconstructions (including diastemas closure), with a survival rate near 85% after 5 years, with the majority of restorations reaching excellent or good quality,7 which is similar to the survival rate exhibited by laminate veneers (above 90% in 10 years),8 although needing intervention in more than a third of the cases.9
Purpose The study aims to describe a conservative approach using resin-based composites following a buccolingual layering technique with a customized silicon index for the management of multiple diastemas.
Clinical Technique Some advantages offered by direct composite resin restorations are the following: (1) tooth shape, color, and position can be corrected in one treatment session; (2) noninvasive or minimally invasive technique; (3) the technique is reversible, restorations can be removed, and teeth can be returned to their original state; (4) in case of minor failure, the restoration can be repaired; (5) in case of major failure, other treatment options (laminate veneers, crowns) can be applied; and (6) cost-effective technique, requiring little or no laboratory work.5 Along with dramatic improvements in their physicochemical properties, modern resin composites present superior esthetic qualities and satisfactory color stability. They allow excellent esthetic results to be
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A 30-year-old woman presented with a chief complaint of unaesthetic appearance of her anterior teeth because of multiple diastemas, alteration of their natural anatomy, unpleasant appearance of the incisal edge (result of past experience of sleep bruxism), and unsatisfactory shade on cervical composite fillings (Figures 1 and 2). She did not report any medical history or use of medical drugs. During the clinical examination, a substantial loss of tooth structure was evident, especially on the incisal border of the anterior teeth. Additionally, multiple diastemas and composite filling with a slight change in color were found. Giving the patient demand for esthetic, a restorative treatment was performed using
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direct composite resin on her anterior teeth in order to recover a natural anatomy and closure of the diastemas. Before beginning the restorative treatment, and because of a localized gingivitis, a periodontal treatment (consisting in education, oral hygiene instructions, and ultrasonic plaque-calculus removal) was performed in order to obtain healthy and stable periodontal soft tissues. Once the periodontal treatment was realized, an at-home bleaching (4 hours/day for 15 days) procedure was performed on both arches to homogenize the color of the teeth (Opalescence PF 10% Regular, Ultradent Products Inc., South Jordan, UT, USA) (Figure 3). The initial shade was A3 and the after-bleaching shade was A2. After that, dental arches impressions were taken, and a diagnostic wax-up was made to analyze the occlusal relationships and esthetic parameters based on biomimetic principles.12 No contributory occlusal factors that would require functional rehabilitation were
FIGURE 1. Preoperatory view of all her front teeth depicting the presence of diastemas and cervical dull/low value resin-based composite restorations.
shown. After the analysis, silicon guides were prepared for the anatomic reconstruction (Figure 4). During the first session of treatment, an optical color measurement procedure was performed using a color guide (Vitapan classic, VITA Zahnfabrik H. Rauter, Bad Säckingen, Germany), and then it was reevaluated by adding a small amount of the selected composite resin directly over the tooth surface, light-cured, and moistened with saliva. Once the composite resin shades were selected (Filtek Supreme XT, 3M ESPE, St. Paul, MN, USA), a chromatic map was designed, as shown in Figure 5. After that, field isolation was achieved with cotton rolls and retraction cords (Ultrapak #0, Ultradent Products Inc., Salt Lake City, UT, USA). All enamel surfaces were bur-roughened with a diamond bur (Komet Gerb Brasseler GmbH & Co., Lemgo, Germany) followed by application of 35% phosphoric acid for 30 seconds (Ultra-etch, Ultradent Products Inc., Salt Lake City, UT, USA), rinsed with air–water spray and gently dried. Whenever possible, a Teflon tape was used to protect adjacent teeth while etching or applying the adhesive system. A two-step etch-and-rinse adhesive system (Adper Single Bond Plus, 3M ESPE) was generously applied over the etched enamel for 15 seconds with gentle agitation using a fully saturated microbrush, air-thinned with the triple syringe for 10 seconds and light-cured for 30 seconds with an LED light-curing unit (Coltolux LED, Coltene Whaledent, Cuyahoga Falls, OH, USA) with an irradiance of 600 mw/cm2 (Figure 6). Then, a second layer of adhesive was applied following the same protocol. Once the second adhesive layer was cured, the anatomic reconstruction with composite resin was
FIGURE 2. Lateral preoperatory side-by-side views that show diastemas between most of her front teeth.
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FIGURE 3. After bleaching front view which depicts the change in value of her teeth.
FIGURE 4. Frontal image of the diagnostic wax-up with the customized silicon index.
this layer and to fill possible voids on the composite resin layer. Then, the polymerization is completed with light-curing for 40 seconds at 500 mW/cm2. After the first layer of composite resin is set, several increments of dentin and effects composite resin were applied according to the chromatic map.
FIGURE 5. Individualized chromatic map that shows the shades of composite resin (Filtek Supreme XT, 3M ESPE) that were used for each zone: White Enamel (WE) for incisal edge, palatal and buccal surfaces, Body A2 for dentinal mamelons, and Amber Translucent for opalescent effect below the incisal edge.
performed following a lingual-to-buccal layering (described as buccolingual technique by Dietschi11), as in Figure 7. In this technique, the first layer of enamel composite resin (Filtek Supreme XT, WE Shade) is applied on the palatal surface using a customized silicon index previously made from the diagnostic wax-up that will help to support the following layers of composite resin. This first increment of enamel composite resin should not be thicker than 0.5 mm in order to avoid reduced space for the following composite resin layers (Figures 8 and 9). After that, the first composite resin layer was light-cured for 5 seconds, and then a small amount of flowable resin of the same shade (Filtek Supreme XT Flow, 3M ESPE) was placed over the resin–tooth interface because of the possible frailness of
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The increments of dentin composite resin were inserted cervical-to-incisal direction. A special attention should be given to dentin mamelons, which must be reproduced according to the patient’s anatomy because it will determine the overall appearance of the final restoration (Figure 10). During this, the space for incisal characterization and effects should be taken care of (Figure 11). The incisal halo was created using a thin spindle of composite resin of high value (Filtek Supreme XT, WE Shade), whereas the opalescent effect was made using an effect composite resin (Filtek Supreme XT, Amber Translucent). Every resin increment was applied with spatulas and adapted with a small brush, and light-cured for 5 seconds. The final layer was an enamel composite resin (the same used for the palatal surface) that was applied in a round-sphere shape and distributed over the buccal surface with instruments for composite resin (IPC-T, American Eagle, Missoula, MT, USA) and sculpting brush (Micerium S.p.A, Genova, Italy), leaving just a small excess to be removed during the polishing. This final layer should produce the same degree of translucency as the natural teeth (Figure 12). The restoration should be seen from different angles to make sure that there is
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FIGURE 6. Adhesive procedure for central incisors; the images show the protection of the lateral incisors with Teflon tape, application of 35% phosphoric acid, washing the acid away after etching time is complete, application of the adhesive system, and light-curing.
FIGURE 8. Silicon index positioned at the back of front teeth with WE composite resin layer. FIGURE 7. Buccolingual layering technique scheme; drawings in line A show the sequence of the diagnostic wax-up, the confection of the silicon index, and the reposition of the silicon index on the teeth. Drawings in line B show the layering procedure, from palatal enamel to dentin mamelons, to the buccal enamel and effects.
no lack or excess of composite resin. During this phase of the restorative procedure, the macro-anatomy should be shaped with instruments for composite resin (IPC-L, American Eagle), creating texture details over the last
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layer of composite resin before its polymerization. After that, the polymerization was complete after 60 seconds of light-curing at 500 mW/cm2 to ensure a high degree of monomer conversion. Upon completion of the central incisor, lateral incisor and canine (in that order) were restored using the same procedures (Figures 13–15). Thereafter, the polishing procedure of the fillings was realized; in the first step, the excess of composite resin
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FIGURE 9. Palatal layer of enamel composite resin after removal the silicon index. The lateral incisor was covered with Teflon tape to avoid binding the central incisor restoration to the lateral incisor.
FIGURE 10. Incisal dentin resin layering (A2 Body).
FIGURE 11. Resin dentin mamelons and opalescence effect placed against the palatal enamel resin reconstruction. Note that the rendering of the dentin mamelons and opalescent effect should be performed in this step of the layering.
FIGURE 12. Final layer of composite resin applied to the central incisors (White Enamel shade) before finishing and polishing the restorations. This layer reproduces the same degree of translucency as the natural teeth.
was removed using diamond burs (Komet Gerb Brasseler GmbH & Co.) and abrasive discs (Sof-lex XT, 3M ESPE), improving the macro-anatomy.
were defined using fine diamond burs (Komet Gerb Brasseler GmbH & Co.), enhancing the vertical and horizontal details. Finally, the restorations were finished with foam cups (Enhance Polishing Cups, Dentsply Caulk, Milford, DE, USA) and polishing paste (Prisma Gloss, Dentsply Caulk) to obtain a natural gloss without losing the micro-anatomy of the fillings (Figures 17–23).
In sequences, the shape and dimensions of the restorations were defined with special emphasis on the anatomical conformation of incisal edge of all restored teeth. Then, proximal and occlusal contacts were checked and the palatal/buccal surfaces were smoothened with silicon cups polishers in decreasing grit (Astropol F, P, and HP, Ivoclar Vivadent AG, Schaan, Liechtenstein) (Figure 16). The approximal surfaces were polished using abrasive discs and strips in decreasing grains. The final micro-anatomy and texture
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DISCUSSION The described clinical case illustrates a conservative approach for the management of unaesthetic anterior teeth. The combination of bleaching and direct
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FIGURE 13. Adhesive procedure for lateral incisors and canines (the same as for central incisors).
FIGURE 14. Dentin composite resin layering in lateral and canine.
FIGURE 15. Application of buccal enamel resin layer.
composite resin restoration allows a satisfactory, predictable, minimally invasive, and little time-consuming clinical procedure.
in the literature.5 The durability rate of anterior composite resin buildups is near 85% after 5 years, which means that these restorations have a very good long-term prognosis.7 Some of the reasons for a possible failure are: (1) fracture of composite resin (chipping); (2) unsatisfactory color; (3) marginal gaps; (4) secondary caries; and (5) fracture of enamel.5
Wolff and colleagues stated that the objectives for direct composite resin buildups are the following: (1) color, shade, and character of the composite buildup should imperceptibly match the tooth substance; (2) proper opposing and proximal contacts should be established; (3) trauma to the gingival attachment should be avoided; (4) the subjective and objective appearances of the treated teeth should be improved; and (5) the longevity of the restoration should be maximized by using elaborate clinical techniques diversely described
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When a composite resin restoration is made for esthetics reasons, most of the times this involves the addition of composite resin to previously untreated healthy enamel rather than enamel removal procedures. This allow the composite resin to be bonded only to the enamel surface of the tooth, and due to the low
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FIGURE 16. Finishing and polishing procedures: a sequence of silicon cups in decreasing grit for palatal/buccal surfaces, abrasive strips for approximal surfaces, and final gloss with foam cups and polishing paste.
FIGURE 17. Final right lateral view.
FIGURE 18. Final left lateral view.
configuration factor of the restorations no relevant stress will arise during polymerization shrinkage, making the microleakage less probable.6
and allow transmission of the orange waves of visible light bestows its opalescent properties. When translucent enough, modern incisal composite masses also exhibit opalescence-like effects.10 The Filtek Supreme XT translucent shades achieve that effect, allowing a very natural and esthetic final appearance.
Fluorescence is fundamental to give the restoration some “vitality” and contributes to giving it the correct value. A nonfluorescent material tends to have a grayish appearance and will appear as a “black hole” when seen under ultraviolet illumination.10 Filtek Supreme XT dentin shade has shown fluorescence that is significantly lower than dentin, and the enamel shade had fluorescence that is significantly greater than enamel; translucent shade and enamel have similar fluorescence.13 The ability of enamel to preferentially reflect the blue waves
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The buccolingual layering technique used in this clinical case looks to achieve the combination of an immediate esthetic resolution of the diastemas and restorations with a high degree of predictability in time. The buccolingual layering technique was first reported by Didier Dietschi.10 In this layering technique, the “missing” palatal enamel and dentin masses are replaced
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FIGURE 19. Final frontal view.
FIGURE 20. Incisal detail with transmitted light. This result is achieved due to the use of the layering technique with different shades and effect composite resins.
FIGURE 21. Right lateral final smile of the patient.
FIGURE 22. Frontal final smile of the patient.
with enamel and dentin composites (in an additive nonreplacing mode), whereas for the thin buccoproximal enamel layer an effect composite resin is used. Ideally, a nanofilled composite resin should be used for buccolingual layering technique that can provide good optical properties, before-curing slumping resistance, and after-curing wear resistant. The composite resin selected for this case was Filtek Supreme XT (3M ESPE), which is a nanofilled resin that contains a 59.5 vol%/78.5 wt% of zirconia and silica particles (clusters of 0.6–1.4 μm; particle size of 5–20 nm), and a mixture of organic monomers that includes Bis-GMA, Bis-EMA, UDMA, and TEGDMA.14
clinical case. Whereas central (midline) diastemas usually need to be closed from both adjacent teeth for symmetrical reasons, lateral (nonmidline) diastemas can be successfully handled in a unilateral approach.6
Whether a unilateral or bilateral approach is chosen mainly depends on the esthetic requirements of the
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Sometimes, the use of rubber dam can hamper the repositioning of the silicon index, even with a rubber dam-splint technique. In the present case, an appropriate control of saliva/humidity was achieved with cotton rolls and saliva ejector, although it is a difficult procedure and it requires a skilled clinician. There is some recent evidence that shows that the use of rubber dam may not influence the longevity of restorations in comparison to cotton rolls/saliva ejector,15 so that the latter approach may be sufficient
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FIGURE 23. Lateral left close-up smile of the patient.
for restoring upper front teeth. Given that rubber dam isolation still is a “gold standard” approach for restorative procedures because it keeps the operatory field dry and free of contaminants, the recommendation of the authors is to use rubber dam isolation whenever it is possible. In this case, the proximal contour was given with the silicon key plus a very careful free-hand sculpting, separating the adjacent tooth with Teflon tape instead of other commercially available matrix systems. Teflon tape has been shown to produce relatively homogeneous restorations in vitro.16 To achieve a strong interdental contact, the thickness of commercially available matrix systems is usually compensated by the use of interdental wedges, which not only adapt the matrix at the tooth but also temporarily separate the adjacent teeth. However, the use of wedges when closing diastemas usually results in an inadequate emergence profile, leaving black triangles underneath the contact area which will severely compromise the esthetic outcome of the treatment.6 Black triangles are spaces that appear between teeth when the gingival tissue does not follow the respective tooth contour and exposes the black background of the oral cavity.4 For this reason, it is important to consider the periodontal health and gingival contour when planning the restorative technique. In the light of the presented case, the authors strongly recommend a minimally invasive approach with adhesive direct restorations for the management of
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esthetics problems of the anterior teeth. This approach using a buccolingual layering technique allows a reversible restorative procedure, allows an exact transfer of the anatomic shapes of the diagnostic wax-up, preserves healthy dental structure, have relatively lower costs (than prosthodontics or indirect veneers), simple implementation with minimal laboratory requirements, very satisfying esthetic final result, have good esthetics predictability, and have good long-term prognosis. However, this approach requires a trained professional in restorative dentistry to optimize the results, to follow an appropriate treatment sequence, to devote the necessary time to execute this sequence of treatment (which probably would be less than prosthodontics or other invasive approaches), and like most dental treatments requires periodic controls.
DISCLOSURE The authors do not have any financial interest in the companies whose materials are included in this article.
REFERENCES 1.
2.
3.
4.
5.
6. 7.
8.
Ardu S, Krejci I. Biomimetic direct composite stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167–74. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent 2008;3:14–29. Rao R, Vishwanath BT. Esthetic enhancement with diastema closure-a case report. Indian J Dent 2011;2:184–6. De Araujo EM Jr, Fortkamp S, Baratieri LN. Closure of diastema and gingival recontouring using direct adhesive restorations: a case report. J Esthet Restor Dent 2009;21:229–40. Wolff D, Kraus T, Schach C, et al. Recontouring teeth and closing diastemas with direct composite buildups: a clinical evaluation of survival and quality parameters. J Dent 2010;38:1001–9. Lenhard M. Closing diastemas with resin composite restorations. Eur J Esthet Dent 2008;3:258–68. Frese C, Schiller P, Staehle HJ, Wolff D. Recontouring teeth and closing diastemas with direct composite buildups: a 5-year follow-up. J Dent 2013;41:979–85. Layton D, Walton T. An up to 16-year prospective study of 304 porcelain veneers. Int J Prosthodont 2007;20:389–96.
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9.
10. 11.
12.
13.
354
Peumans M, De Munck J, Fieuws S, et al. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent 2004;6:65–76. Dietschi D. Layering concepts in anterior composite restorations. J Adhes Dent 2001;3:71–80. Dietschi D. Optimising aesthetics and facilitating clinical application of free-hand bonding using the “natural layering concept”. Br Dent J 2008;204:181–5. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition—a biomimetic approach. 1st ed. Chicago (IL): Quintessence; 2002. Takahashi MK, Vieira S, Rached RN, et al. Fluorescence intensity of resin composites and dental tissues before and after accelerated aging: a comparative study. Oper Dent 2008;33:189–95.
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14. Cetin AR, Unlu N. One-year clinical evaluation of direct nanofilled and indirect composite restorations in posterior teeth. Dent Mater J 2009;28:620–6. 15. Cajazeira MR, De Sabóia TM, Maia LC. Influence of the operatory field isolation technique on tooth-colored direct dental restorations. Am J Dent 2014;27:155–9. 16. Kwon SR, Oyoyo U, Li Y. Influence of application techniques on contact formation and voids in anterior resin composite restorations. Oper Dent 2014;39:213–20.
Reprint requests: Abelardo Báez Rosales, DDS, MS, Department of Restorative Dentistry, Universidad Andrés Bello, Av. Valparaíso 1560 Viña del Mar, Chile; Tel.: 56-9-8299 7995; email: [email protected]
DOI 10.1111/jerd.12175
© 2015 Wiley Periodicals, Inc.
Conservative Approach for the Esthetic Management of Multiple Interdental Spaces: A Systematic Approach ABELARDO BÁEZ ROSALES, DDS, MS*, DIEGO DE NORDENFLYCHT CARVACHO, DDS†, RAMÓN SCHLIEPER CACCIUTOLO, DDS, MS‡, MANUEL GAJARDO GUINEO, DDS, MS‡, CLAUDIO GANDARILLAS FUENTES, DDS, MS‡
ABSTRACT Purpose: To describe a conservative approach using resin-based composites following a buccolingual layering technique with a customized silicon index for the management of multiple diastemas. Clinical Considerations: This clinical article describes the case of a patient with their anterior teeth esthetically compromised by multiple diastemas, incisal wear, and dull/low-value cervical composite resin restorations that were managed with nanofilled composite resin using the “buccolingual technique” with a customized silicon index made from a wax-up to build up the restorations. The first layer of composite placed lingually that represents the enamel replacement was placed directly on the silicon index so that it provides in one single step the lingual profile and the position of the incisal edge of the restoration. Then, dentine and effect composite resin can be applied in a precise three-dimensional configuration. Conclusions: To solve esthetic dental problems, as anterior diastemas, in a very conservative and even reversible way, the use of direct resin composites for layering is an excellent choice, but should be performed based on simple and reproducible techniques, as the buccolingual technique.
CLINICAL SIGNIFICANCE The clinical technique described in this paper shows the advantages of a conservative approach to correct diastemas on maxillary anterior teeth. The application of these techniques can not only help achieve optimal esthetics, but also avoid the removal of extensive dental hard tissue and achieve a predictable final result, especially in esthetically demanding cases. (J Esthet Restor Dent 27:344–354, 2015)
INTRODUCTION Cosmetics and esthetics are current trends of our society that also involve the dental profession, especially the restorative dentistry, and present a new problem to clinicians who have to provide highly esthetic results without increasing costs and clinical working time.1 The current approach for the management of esthetic problems includes conservative treatments, such as
enamel recontouring, bleaching, microabrasion, and resin-based composites. These treatments should be recommended since these can be practical, efficient, and predictable.2 Diastemas are spaces on anterior teeth that can be very unpleasant and may result from developmental, pathological, and iatrogenic factors. Determining the best way of closing an unwanted diastema must be
*Chief director, Department of Restorative Dentistry, Universidad Andrés Bello, Viña del Mar, Chile † Instructor, Department of Restorative Dentistry, Universidad Andrés Bello, Viña del Mar, Chile ‡ Assistant professor, Department of Restorative Dentistry, Universidad Andrés Bello, Viña del Mar, Chile
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predicated upon a diagnostic evaluation of the diastema size, the length and proportion of the clinical crowns of the teeth involved, wear factors, occlusion, and anterior guidance.3
achieved with relatively simple application and layering methods. Modern layering techniques include the use of dentin- and enamel-like masses that are completed with effect materials in selected indications.10,11
Today, a variety of techniques are available to manage diastemas, including orthodontic treatment, crowns, laminate veneers, and direct composite resin restorations.4,5 Indirect restorative options generally require preparation with destruction of healthy tooth structure. Direct techniques, however, embody the principles of minimally invasive restorative treatment, which balances need, damage, and risk; also, it can be done in a single appointment and it is very cost-efficient.5,6
Composites resin can be applied by different incremental techniques. The classical approach is the centrifugal technique, which implies the placement of one or two dentine layers (with an oblique position), followed by the enamel layer which covers the surface. The other approach is the “buccolingual technique,” which uses a silicon key (also described as silicon index or matrix) made from a free-hand mock-up or a wax-up. The first layer made of enamel is placed directly on the silicon key so that it provides in one single step the lingual profile, with and position of the incisal edge of the restoration. Then, dentine and effect materials can be applied in a precise three-dimensional configuration. This technique provides the conditions for an optimal esthetic result (such as natural translucency, opalescence, and halo effects).11
Direct resin-based composite layering is a biomimetic, functional, and biologically prudent treatment option for closing diastemas with clinically promising survival rates, especially in cases in which minimally invasive or noninvasive procedures on healthy teeth are indicated.5 Direct composite resin layering is a reliable treatment option for anterior teeth reconstructions (including diastemas closure), with a survival rate near 85% after 5 years, with the majority of restorations reaching excellent or good quality,7 which is similar to the survival rate exhibited by laminate veneers (above 90% in 10 years),8 although needing intervention in more than a third of the cases.9
Purpose The study aims to describe a conservative approach using resin-based composites following a buccolingual layering technique with a customized silicon index for the management of multiple diastemas.
Clinical Technique Some advantages offered by direct composite resin restorations are the following: (1) tooth shape, color, and position can be corrected in one treatment session; (2) noninvasive or minimally invasive technique; (3) the technique is reversible, restorations can be removed, and teeth can be returned to their original state; (4) in case of minor failure, the restoration can be repaired; (5) in case of major failure, other treatment options (laminate veneers, crowns) can be applied; and (6) cost-effective technique, requiring little or no laboratory work.5 Along with dramatic improvements in their physicochemical properties, modern resin composites present superior esthetic qualities and satisfactory color stability. They allow excellent esthetic results to be
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A 30-year-old woman presented with a chief complaint of unaesthetic appearance of her anterior teeth because of multiple diastemas, alteration of their natural anatomy, unpleasant appearance of the incisal edge (result of past experience of sleep bruxism), and unsatisfactory shade on cervical composite fillings (Figures 1 and 2). She did not report any medical history or use of medical drugs. During the clinical examination, a substantial loss of tooth structure was evident, especially on the incisal border of the anterior teeth. Additionally, multiple diastemas and composite filling with a slight change in color were found. Giving the patient demand for esthetic, a restorative treatment was performed using
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direct composite resin on her anterior teeth in order to recover a natural anatomy and closure of the diastemas. Before beginning the restorative treatment, and because of a localized gingivitis, a periodontal treatment (consisting in education, oral hygiene instructions, and ultrasonic plaque-calculus removal) was performed in order to obtain healthy and stable periodontal soft tissues. Once the periodontal treatment was realized, an at-home bleaching (4 hours/day for 15 days) procedure was performed on both arches to homogenize the color of the teeth (Opalescence PF 10% Regular, Ultradent Products Inc., South Jordan, UT, USA) (Figure 3). The initial shade was A3 and the after-bleaching shade was A2. After that, dental arches impressions were taken, and a diagnostic wax-up was made to analyze the occlusal relationships and esthetic parameters based on biomimetic principles.12 No contributory occlusal factors that would require functional rehabilitation were
FIGURE 1. Preoperatory view of all her front teeth depicting the presence of diastemas and cervical dull/low value resin-based composite restorations.
shown. After the analysis, silicon guides were prepared for the anatomic reconstruction (Figure 4). During the first session of treatment, an optical color measurement procedure was performed using a color guide (Vitapan classic, VITA Zahnfabrik H. Rauter, Bad Säckingen, Germany), and then it was reevaluated by adding a small amount of the selected composite resin directly over the tooth surface, light-cured, and moistened with saliva. Once the composite resin shades were selected (Filtek Supreme XT, 3M ESPE, St. Paul, MN, USA), a chromatic map was designed, as shown in Figure 5. After that, field isolation was achieved with cotton rolls and retraction cords (Ultrapak #0, Ultradent Products Inc., Salt Lake City, UT, USA). All enamel surfaces were bur-roughened with a diamond bur (Komet Gerb Brasseler GmbH & Co., Lemgo, Germany) followed by application of 35% phosphoric acid for 30 seconds (Ultra-etch, Ultradent Products Inc., Salt Lake City, UT, USA), rinsed with air–water spray and gently dried. Whenever possible, a Teflon tape was used to protect adjacent teeth while etching or applying the adhesive system. A two-step etch-and-rinse adhesive system (Adper Single Bond Plus, 3M ESPE) was generously applied over the etched enamel for 15 seconds with gentle agitation using a fully saturated microbrush, air-thinned with the triple syringe for 10 seconds and light-cured for 30 seconds with an LED light-curing unit (Coltolux LED, Coltene Whaledent, Cuyahoga Falls, OH, USA) with an irradiance of 600 mw/cm2 (Figure 6). Then, a second layer of adhesive was applied following the same protocol. Once the second adhesive layer was cured, the anatomic reconstruction with composite resin was
FIGURE 2. Lateral preoperatory side-by-side views that show diastemas between most of her front teeth.
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FIGURE 3. After bleaching front view which depicts the change in value of her teeth.
FIGURE 4. Frontal image of the diagnostic wax-up with the customized silicon index.
this layer and to fill possible voids on the composite resin layer. Then, the polymerization is completed with light-curing for 40 seconds at 500 mW/cm2. After the first layer of composite resin is set, several increments of dentin and effects composite resin were applied according to the chromatic map.
FIGURE 5. Individualized chromatic map that shows the shades of composite resin (Filtek Supreme XT, 3M ESPE) that were used for each zone: White Enamel (WE) for incisal edge, palatal and buccal surfaces, Body A2 for dentinal mamelons, and Amber Translucent for opalescent effect below the incisal edge.
performed following a lingual-to-buccal layering (described as buccolingual technique by Dietschi11), as in Figure 7. In this technique, the first layer of enamel composite resin (Filtek Supreme XT, WE Shade) is applied on the palatal surface using a customized silicon index previously made from the diagnostic wax-up that will help to support the following layers of composite resin. This first increment of enamel composite resin should not be thicker than 0.5 mm in order to avoid reduced space for the following composite resin layers (Figures 8 and 9). After that, the first composite resin layer was light-cured for 5 seconds, and then a small amount of flowable resin of the same shade (Filtek Supreme XT Flow, 3M ESPE) was placed over the resin–tooth interface because of the possible frailness of
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The increments of dentin composite resin were inserted cervical-to-incisal direction. A special attention should be given to dentin mamelons, which must be reproduced according to the patient’s anatomy because it will determine the overall appearance of the final restoration (Figure 10). During this, the space for incisal characterization and effects should be taken care of (Figure 11). The incisal halo was created using a thin spindle of composite resin of high value (Filtek Supreme XT, WE Shade), whereas the opalescent effect was made using an effect composite resin (Filtek Supreme XT, Amber Translucent). Every resin increment was applied with spatulas and adapted with a small brush, and light-cured for 5 seconds. The final layer was an enamel composite resin (the same used for the palatal surface) that was applied in a round-sphere shape and distributed over the buccal surface with instruments for composite resin (IPC-T, American Eagle, Missoula, MT, USA) and sculpting brush (Micerium S.p.A, Genova, Italy), leaving just a small excess to be removed during the polishing. This final layer should produce the same degree of translucency as the natural teeth (Figure 12). The restoration should be seen from different angles to make sure that there is
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FIGURE 6. Adhesive procedure for central incisors; the images show the protection of the lateral incisors with Teflon tape, application of 35% phosphoric acid, washing the acid away after etching time is complete, application of the adhesive system, and light-curing.
FIGURE 8. Silicon index positioned at the back of front teeth with WE composite resin layer. FIGURE 7. Buccolingual layering technique scheme; drawings in line A show the sequence of the diagnostic wax-up, the confection of the silicon index, and the reposition of the silicon index on the teeth. Drawings in line B show the layering procedure, from palatal enamel to dentin mamelons, to the buccal enamel and effects.
no lack or excess of composite resin. During this phase of the restorative procedure, the macro-anatomy should be shaped with instruments for composite resin (IPC-L, American Eagle), creating texture details over the last
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layer of composite resin before its polymerization. After that, the polymerization was complete after 60 seconds of light-curing at 500 mW/cm2 to ensure a high degree of monomer conversion. Upon completion of the central incisor, lateral incisor and canine (in that order) were restored using the same procedures (Figures 13–15). Thereafter, the polishing procedure of the fillings was realized; in the first step, the excess of composite resin
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FIGURE 9. Palatal layer of enamel composite resin after removal the silicon index. The lateral incisor was covered with Teflon tape to avoid binding the central incisor restoration to the lateral incisor.
FIGURE 10. Incisal dentin resin layering (A2 Body).
FIGURE 11. Resin dentin mamelons and opalescence effect placed against the palatal enamel resin reconstruction. Note that the rendering of the dentin mamelons and opalescent effect should be performed in this step of the layering.
FIGURE 12. Final layer of composite resin applied to the central incisors (White Enamel shade) before finishing and polishing the restorations. This layer reproduces the same degree of translucency as the natural teeth.
was removed using diamond burs (Komet Gerb Brasseler GmbH & Co.) and abrasive discs (Sof-lex XT, 3M ESPE), improving the macro-anatomy.
were defined using fine diamond burs (Komet Gerb Brasseler GmbH & Co.), enhancing the vertical and horizontal details. Finally, the restorations were finished with foam cups (Enhance Polishing Cups, Dentsply Caulk, Milford, DE, USA) and polishing paste (Prisma Gloss, Dentsply Caulk) to obtain a natural gloss without losing the micro-anatomy of the fillings (Figures 17–23).
In sequences, the shape and dimensions of the restorations were defined with special emphasis on the anatomical conformation of incisal edge of all restored teeth. Then, proximal and occlusal contacts were checked and the palatal/buccal surfaces were smoothened with silicon cups polishers in decreasing grit (Astropol F, P, and HP, Ivoclar Vivadent AG, Schaan, Liechtenstein) (Figure 16). The approximal surfaces were polished using abrasive discs and strips in decreasing grains. The final micro-anatomy and texture
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DISCUSSION The described clinical case illustrates a conservative approach for the management of unaesthetic anterior teeth. The combination of bleaching and direct
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FIGURE 13. Adhesive procedure for lateral incisors and canines (the same as for central incisors).
FIGURE 14. Dentin composite resin layering in lateral and canine.
FIGURE 15. Application of buccal enamel resin layer.
composite resin restoration allows a satisfactory, predictable, minimally invasive, and little time-consuming clinical procedure.
in the literature.5 The durability rate of anterior composite resin buildups is near 85% after 5 years, which means that these restorations have a very good long-term prognosis.7 Some of the reasons for a possible failure are: (1) fracture of composite resin (chipping); (2) unsatisfactory color; (3) marginal gaps; (4) secondary caries; and (5) fracture of enamel.5
Wolff and colleagues stated that the objectives for direct composite resin buildups are the following: (1) color, shade, and character of the composite buildup should imperceptibly match the tooth substance; (2) proper opposing and proximal contacts should be established; (3) trauma to the gingival attachment should be avoided; (4) the subjective and objective appearances of the treated teeth should be improved; and (5) the longevity of the restoration should be maximized by using elaborate clinical techniques diversely described
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When a composite resin restoration is made for esthetics reasons, most of the times this involves the addition of composite resin to previously untreated healthy enamel rather than enamel removal procedures. This allow the composite resin to be bonded only to the enamel surface of the tooth, and due to the low
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FIGURE 16. Finishing and polishing procedures: a sequence of silicon cups in decreasing grit for palatal/buccal surfaces, abrasive strips for approximal surfaces, and final gloss with foam cups and polishing paste.
FIGURE 17. Final right lateral view.
FIGURE 18. Final left lateral view.
configuration factor of the restorations no relevant stress will arise during polymerization shrinkage, making the microleakage less probable.6
and allow transmission of the orange waves of visible light bestows its opalescent properties. When translucent enough, modern incisal composite masses also exhibit opalescence-like effects.10 The Filtek Supreme XT translucent shades achieve that effect, allowing a very natural and esthetic final appearance.
Fluorescence is fundamental to give the restoration some “vitality” and contributes to giving it the correct value. A nonfluorescent material tends to have a grayish appearance and will appear as a “black hole” when seen under ultraviolet illumination.10 Filtek Supreme XT dentin shade has shown fluorescence that is significantly lower than dentin, and the enamel shade had fluorescence that is significantly greater than enamel; translucent shade and enamel have similar fluorescence.13 The ability of enamel to preferentially reflect the blue waves
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The buccolingual layering technique used in this clinical case looks to achieve the combination of an immediate esthetic resolution of the diastemas and restorations with a high degree of predictability in time. The buccolingual layering technique was first reported by Didier Dietschi.10 In this layering technique, the “missing” palatal enamel and dentin masses are replaced
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FIGURE 19. Final frontal view.
FIGURE 20. Incisal detail with transmitted light. This result is achieved due to the use of the layering technique with different shades and effect composite resins.
FIGURE 21. Right lateral final smile of the patient.
FIGURE 22. Frontal final smile of the patient.
with enamel and dentin composites (in an additive nonreplacing mode), whereas for the thin buccoproximal enamel layer an effect composite resin is used. Ideally, a nanofilled composite resin should be used for buccolingual layering technique that can provide good optical properties, before-curing slumping resistance, and after-curing wear resistant. The composite resin selected for this case was Filtek Supreme XT (3M ESPE), which is a nanofilled resin that contains a 59.5 vol%/78.5 wt% of zirconia and silica particles (clusters of 0.6–1.4 μm; particle size of 5–20 nm), and a mixture of organic monomers that includes Bis-GMA, Bis-EMA, UDMA, and TEGDMA.14
clinical case. Whereas central (midline) diastemas usually need to be closed from both adjacent teeth for symmetrical reasons, lateral (nonmidline) diastemas can be successfully handled in a unilateral approach.6
Whether a unilateral or bilateral approach is chosen mainly depends on the esthetic requirements of the
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Sometimes, the use of rubber dam can hamper the repositioning of the silicon index, even with a rubber dam-splint technique. In the present case, an appropriate control of saliva/humidity was achieved with cotton rolls and saliva ejector, although it is a difficult procedure and it requires a skilled clinician. There is some recent evidence that shows that the use of rubber dam may not influence the longevity of restorations in comparison to cotton rolls/saliva ejector,15 so that the latter approach may be sufficient
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FIGURE 23. Lateral left close-up smile of the patient.
for restoring upper front teeth. Given that rubber dam isolation still is a “gold standard” approach for restorative procedures because it keeps the operatory field dry and free of contaminants, the recommendation of the authors is to use rubber dam isolation whenever it is possible. In this case, the proximal contour was given with the silicon key plus a very careful free-hand sculpting, separating the adjacent tooth with Teflon tape instead of other commercially available matrix systems. Teflon tape has been shown to produce relatively homogeneous restorations in vitro.16 To achieve a strong interdental contact, the thickness of commercially available matrix systems is usually compensated by the use of interdental wedges, which not only adapt the matrix at the tooth but also temporarily separate the adjacent teeth. However, the use of wedges when closing diastemas usually results in an inadequate emergence profile, leaving black triangles underneath the contact area which will severely compromise the esthetic outcome of the treatment.6 Black triangles are spaces that appear between teeth when the gingival tissue does not follow the respective tooth contour and exposes the black background of the oral cavity.4 For this reason, it is important to consider the periodontal health and gingival contour when planning the restorative technique. In the light of the presented case, the authors strongly recommend a minimally invasive approach with adhesive direct restorations for the management of
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esthetics problems of the anterior teeth. This approach using a buccolingual layering technique allows a reversible restorative procedure, allows an exact transfer of the anatomic shapes of the diagnostic wax-up, preserves healthy dental structure, have relatively lower costs (than prosthodontics or indirect veneers), simple implementation with minimal laboratory requirements, very satisfying esthetic final result, have good esthetics predictability, and have good long-term prognosis. However, this approach requires a trained professional in restorative dentistry to optimize the results, to follow an appropriate treatment sequence, to devote the necessary time to execute this sequence of treatment (which probably would be less than prosthodontics or other invasive approaches), and like most dental treatments requires periodic controls.
DISCLOSURE The authors do not have any financial interest in the companies whose materials are included in this article.
REFERENCES 1.
2.
3.
4.
5.
6. 7.
8.
Ardu S, Krejci I. Biomimetic direct composite stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167–74. Dietschi D. Optimizing smile composition and esthetics with resin composites and other conservative esthetic procedures. Eur J Esthet Dent 2008;3:14–29. Rao R, Vishwanath BT. Esthetic enhancement with diastema closure-a case report. Indian J Dent 2011;2:184–6. De Araujo EM Jr, Fortkamp S, Baratieri LN. Closure of diastema and gingival recontouring using direct adhesive restorations: a case report. J Esthet Restor Dent 2009;21:229–40. Wolff D, Kraus T, Schach C, et al. Recontouring teeth and closing diastemas with direct composite buildups: a clinical evaluation of survival and quality parameters. J Dent 2010;38:1001–9. Lenhard M. Closing diastemas with resin composite restorations. Eur J Esthet Dent 2008;3:258–68. Frese C, Schiller P, Staehle HJ, Wolff D. Recontouring teeth and closing diastemas with direct composite buildups: a 5-year follow-up. J Dent 2013;41:979–85. Layton D, Walton T. An up to 16-year prospective study of 304 porcelain veneers. Int J Prosthodont 2007;20:389–96.
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CONSERVATIVE MANAGEMENT OF MULTIPLE INTERDENTAL SPACES Báez Rosales et al
9.
10. 11.
12.
13.
354
Peumans M, De Munck J, Fieuws S, et al. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent 2004;6:65–76. Dietschi D. Layering concepts in anterior composite restorations. J Adhes Dent 2001;3:71–80. Dietschi D. Optimising aesthetics and facilitating clinical application of free-hand bonding using the “natural layering concept”. Br Dent J 2008;204:181–5. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition—a biomimetic approach. 1st ed. Chicago (IL): Quintessence; 2002. Takahashi MK, Vieira S, Rached RN, et al. Fluorescence intensity of resin composites and dental tissues before and after accelerated aging: a comparative study. Oper Dent 2008;33:189–95.
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14. Cetin AR, Unlu N. One-year clinical evaluation of direct nanofilled and indirect composite restorations in posterior teeth. Dent Mater J 2009;28:620–6. 15. Cajazeira MR, De Sabóia TM, Maia LC. Influence of the operatory field isolation technique on tooth-colored direct dental restorations. Am J Dent 2014;27:155–9. 16. Kwon SR, Oyoyo U, Li Y. Influence of application techniques on contact formation and voids in anterior resin composite restorations. Oper Dent 2014;39:213–20.
Reprint requests: Abelardo Báez Rosales, DDS, MS, Department of Restorative Dentistry, Universidad Andrés Bello, Av. Valparaíso 1560 Viña del Mar, Chile; Tel.: 56-9-8299 7995; email: [email protected]
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