Extremely large diastemas

20 Sep 2016 - 132304

Clinical cases with a large diastemas always represent an issue in any dentist’s daily practice. The main question is: how can we create a truly good tooth-to-tooth proportion? Not of less worry and difficulty is how to position the material between the central incisors – because there is a very large gingival papilla. In this article I will try to answer these questions with the example of a clinical case.

Fig. 1

Initial situation

Fig. 2

Before treatment, was made a plaster model of the jaws, which were rehearsed future work, and a wax-up. On the base of waxed models were made of silicone indices of the palatal surface of the teeth.

Fig. 3

Note the very large diastema.

Fig. 4

Initial situation.

Fig. 5

Initial situation.

Fig. 6

Side view.

Fig. 7

Very large gingival papilla.

Fig. 8

A small abrasion of the cutters.

Fig. 9

When planning such clinical cases, which means envisioning the shape of the future teeth, it is important to understand what makes proportions harmonious, hence the need to increase not only the width of the teeth, but also their height. In most clinical cases, the dentist can increase the height of a tooth towards the cutting edge. However, in order to protect the edges against overloads, in such cases it is also necessary to increase the height of the canines.
In order to create this form, it is necessary to get the material is actually under the gum between the teeth. So how can we do that?

Fig. 10

The selection of shade.

Fig. 11

The first stage of treatment. Isolating one of the two central incisors.

Fig. 12

Without preparation – sandblasting of the mesial surface of enamel, application of etching and adhesive preparation.

Fig. 13

Then use a Mylar matrix with a rounded shape, a small portion of the composite was added on the lateral surface of the tooth with a small compression to the gum.

Fig. 14
Fig. 15

The same procedure was carried out on the other central incisor.

Fig. 16

As a result, with a little effort, the parts of the restoration that were more challenging to mold were created. In addition, these composite add-ins allow to keep the floss at the neck of the tooth after positioning the rubber dam.

Fig. 17

The second phase of treatment – teeth preparation.

Fig. 18

During this procedure, it is desirable to control the amount of removed tissue on the silicone index, based on the wax-up.

Fig. 19

Isolation

Fig. 20

Sandblasting

Fig. 21

Dynamic etching using UltraEtch.

Fig. 22

Dynamic etching using UltraEtch.

Fig. 23

Bonding by OptiBond FL.

Fig. 24

Bonding by OptiBond FL.

Fig. 25

Applying of composite Ceram-X Duo E2 as palatal enamel layer on the silicone key.

Fig. 26

The procedure is performed on the four incisors.

Fig. 27

Slit-like space between the palatal enamel layer and a tooth is filled with a small amount of flowable composite shade OA3.

Fig. 28

This allows you to fill this space without the formation of air pores.

Fig. 29

The introduction of the composite mass  Ceram-X DUO D2 to simulate dentin.

Fig. 30

Simulation of the dentinal body and mamelons.

Fig. 31

Simulation of the dentinal body and mamelons.

Fig. 32

Simulation of the dentinal body and mamelons.

Fig. 33

Simulation of the dentinal body and mamelons.

Fig. 34

Modeling additional mamelons composite Esthet-X A3.

Fig. 35

Modeling additional mamelons composite Esthet-X A3.

Fig. 36

Applying shade OBN composite Enamel Plus for greater transparency of the cutting edge. This shade is laid between mamelon.

Fig. 37

OBN, Enamel plus.

Fig. 38

Applying a layer of body enamel Esthet-X A1.

Fig. 39

Applying a layer of body enamel Esthet-X A1.

Fig. 40

Applying a layer of translucent enamel Esthet-X CE.

Fig. 41
The introduction of the composite on the side surface with the use of thin transparent plates.
Fig. 42

To get the access into the most difficult places – under the gingival papilla, we used the following method. Metal sectional matrix for posterior teeth with a semi-circular shape was introduced between the teeth. One edge of the matrix trod on and pushed the gingival papilla, freeing up space in the area where we need to enter the composite. First, the procedure is performed with the first center cutter, then the second.

Fig. 43

Extremely important condition for successfully adding material in this area is the careful polishing of the composite under the gums, in the place of transition of the composite material at the root.

Fig. 44

This is done with abrasive strip.

Fig. 45

Abrasive stripping.

Fig. 46

At the end of the first visit was carried out rough contouring of the restorations. All subsequent steps were taken in the next visit.

Fig. 47

The next visit took place 3 days later.

Fig. 48
A large, overhanging, sharp edge was found on the palatal surface of one of the cutters.
Fig. 49

This visit was the correction of defects of restoration, slightly displaced Central line and carried out the whole complex of works on finishing of restorations.

Fig. 50

This stage is devoted to the video.

Fig. 51

The condition of the teeth before recording the video.

Fig. 52
Fig. 53

Final result.

Fig. 54
Fig. 55
Fig. 56
Fig. 57
Fig. 58
Fig. 59
Fig. 60
Fig. 61

Before and after.

 

Conclusions

Restoration of large diastemas in the direct method using composite material has great potential. To make an indirect ceramic restoration is much more difficult in such situations. However, this technique can only be used with strict observance of all stages. Finishing is very important.

Bibliography

Atlas of tooth shape, Shigeo Karaoke