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SMILE DESIGN - MINDING THE GAP

Sunita Verma of the Sparkle Dental Boutique shows how diastema closure can be successfully carried out using composite resin

MATERIALS USED	TREATMENT LIST
Zoom 2! Whitening Enamel etchant 37% phosphoric acid Bonding agent; Optibond FL2 Heavily filled hybrid composite: Z250 Microfill composite, Durafill	Teeth whitening UL2 and UR2 distal-incisal composite resin restorations UL3 and UR3 mesial surface composite resin restorations

A gap between upper front teeth can be a quirky individual characteristic that defines a personality. However, for many people, gaps between front teeth can be a source of embarrassment, and the focus for insensitive taunts and comments from their family and friends. It is not unusual for a patient to attend the dental practice requesting the closure either completely or at least partially of spaces between front teeth. Depending on the size of the space, significant skill is needed to close the gap, taking into consideration, the size, shape and emergence profiles of the restored teeth, in order for them to look like a natural extension of the existing dentition.

HISTORY AND CHIEF COMPLAINT

The patient was a healthy 28-year-old woman. Her main complaint was the colour of her teeth and the gaps present in her upper arch between the lateral incisors and canines. She had worn braces as a child, but was unhappy with the outcome as the residual spaces caused her embarrassment and she was not fully confident when she smiled.

CLINICAL ExAMINATION

Her medical history revealed she was in excellent health, while a dental examination revealed an excellent dentition with no restorations, except a fissure sealant on UL7. The LR5 was missing and a gap existed between LL5 and LL6, but she was not concerned about anything in the lower arch. Radiographic evidence confirmed she was caries free and had excellent bone levels. Her oral hygiene was excellent and periodontal tissues were healthy. The diastema on the left side was 3mm compared with the smaller gap on the right side of 1mm.

DIAGNOSIS

It is generally accepted that diastema of up to 3mm can be closed and still maintain a natural looking appearance. We decided that the best way would be to mock-up the diastema closures in composite resin to show the patient how the end result would look. This was done fairly quickly in one shade of composite, to obtain the correct shape and occlusion of the final restorations. The patient was delighted to see the immediate difference in her smile and I was satisfied that the shape of the final result would be acceptable within smile-design parameters. Silicone putty was then used to create a palatal putty index stent of the mock-ups, which would be used as a matrix for the definitive composite resin restorations.

TREATMENT PLAN

The patient was given the choice of indirect porcelain veneers to reduce the space or to have her diastema reduced using direct composite resin restorations. Following an in-depth discussion of the advantages and disadvantages of each approach, the patient decided that direct composite resin restorations on the distal-incisal aspects of the upper lateral incisors and mesial surfaces of the canines, would suit her aims.

As she was unhappy with the colour of the teeth, it was agreed that she would undergo a combination of in-surgery whitening and home whitening before definitive diastema closure. She was given permission to ask final questions, sign paperwork including an itemised treatment plan and consent forms and agree an appointment schedule.

TREATMENT

At the start of the definitive appointment, the treatment plan was outlined once again to ensure the patient understood the proposed work we were about to provide.

TEETH WHITENING

The upper and lower teeth were whitened using the Zoom2! proprietary system, followed by continuous home whitening twice daily, using 7.5% concentration of hydrogen peroxide dispensed in vacuum-formed trays applied for 30 minutes, for the next two weeks. Home care instructions were given and emphasised to ensure the best results and she was advised to carry out the whitening, twice a day for 30 minutes, over the next two weeks. She was scheduled to see me again for the veneer preparations in three weeks to allow the lightened colour of the teeth to stabilise.

SHADE MAPPING

The shade of the existing teeth was recorded at the follow-up appointment, once the patient was satisfied with the improved colour of her teeth. She confirmed that she had stopped the whitening process a week before, so I could be sure the colour was stable and ensure the bond strengths of the composite resin to the enamel surfaces were maximised. The whitening procedure highlighted fine white horizontal ‘striations’ within the enamel, which would need to be replicated in the final restorations.

It was vital to consider the effects of dehydration on the tooth shade once the rubber dam was placed, as the tooth tissue itself becomes lighter and lighter as it dehydrates. I spent some time creating an accurate shade map which included details about the surface texture of the teeth. The surface texture of enamel in younger patients can vary quite dramatically depending upon factors such as acidity in the diet,

toothbrush abrasion and even natural variations. I recorded that the surface of the incisors and canines was remarkably smooth, with no secondary or tertiary anatomy.

TEETH PREPARATION

The distal surfaces of the lateral incisors and the mesial surfaces of the canines were lightly abraded to remove the enamel pellicle and facilitate full and effective enamel surface etching right to the gingival tissue margin. The rubber dam was placed and non-impregnated retraction cord (Ultradent) was carefully packed into the gingival sulcus of the teeth concerned, to retract tissue and reduce crevicular tissue flow and to aid in placing the finishing line slightly subgingivally. The area was thoroughly cleansed with 2% chlorhexidine scrub (Consepsis Scrub, Ultradent).

The upper lateral incisors and canines were etched with 37% phosphoric acid. The etch was applied for 30 seconds covering half the labial enamel, the contact point areas, around to the palatal areas and then thoroughly rinsed with copious amounts of water. The teeth were dried gently with the three-in-one air syringe, making sure all the etched surfaces displayed a frosty appearance.

The etched enamel surfaces were then painted with unfilled, clear, light-cured bonding resin using a sable brush, and the excess resin removed with suction then thinned out with a gentle air stream. As there was no exposed dentine to consider, it was not necessary to use a dentine-bonding agent. The unfilled resin was then light-cured until fully set using a halogen curing light.

RESTORATION PLACEMENT

To avoid duplication, I am describing the procedure I carried out to restore the left diastema, as the procedure was identical on the right. I decided to use Filtek Z250 to create the overall shape and colour of the restorations. Being a heavily filled hybrid composite material, it would give better support and strength to the restorations and its ease of handling made it easy to utilise a stratified layering technique, using a combination of shades.

The putty matrix was placed in position, and the palatal surfaces of each tooth were built up with a very thin layer of composite resin, being very closely adapted to the internal contours of the matrix with the sable brush and then cured. The proximal wall and also the incisal edge of the lateral incisor was also built up using the stent, creating a wafer thin ‘shell’ of set composite resin which made the building of the remainder of the restoration shape within this shell a relatively easy task.

By using the stent in this way, the palatal, proximal and incisal

anatomy were reproduced exactly as in the mock-up so little adjustment was anticipated. The body of the restoration was then built up in stratified layers (Vannini, 1996) to produce a gradual transition from the solid ‘chroma’ of the cervical third of the tooth through the less dense middle third of the tooth up to the higher ‘value’ of the incisal third. The incisal edge halo was then applied using a translucent shade in a very thin roll from mesial margin, along the incisal edge of the restoration to the tooth.

For the final layer on the labial non-occluding surface, I used a microfill composite (Durafill, Shade A1, Heraeus Kulzer) thinly to achieve a high polish with a long-lasting lustre. This was placed on the tooth and I created very shallow fine channels, using a carver in the unset material, to provide a reservoir where I could replicate the white ‘hues’ present on the teeth. The material was then cured and these channels were filled with shade B1 and cured again.

To close the gaps and avoid ‘black triangles’ at the gingival embrasures, especially between the UL2 and UL3, I measured (under local anaesthetic), where the level of the crestal bone was beneath the soft tissue, using Dennis Tarnow’s principles (Tarnow et al, 1992), making sure the contact point was no further than 5mm from the crest of the bone beneath the tissue.

Now the lateral incisor was complete, a mylar strip was adapted and secured with a wedge between the lateral and canine, to allow the canine to be restored. A similar technique was used as described above, with the exception of the shade of composite used to reflect the higher chromatic value of the canine. Composite resin tints Corrective Color (Cosmedent) were used to ‘warm’ up the neck colour of the canine.

Final cure was through a layer of K-Y Jelly (Johnson and Johnson) to deal with any oxygen-inhibited layer still uncured. The rubber dam was then removed in preparation for final polishing.

FINISHING AND POLISHING

Occlusion was checked to ensure there were no issues. Little alteration was needed except to subtly refine the shape and surface form with Soflex ET contouring and polishing discs (3M Espe). This was followed by aluminium oxide polishing discs (Cosmedent) and completed with graded aluminium oxide impregnated rubber polishers (Flexipoints and Flexicups, blue and pink; Cosmedent).

with fine-grade Epitex strips (GC Industries). The final contoured restoration surface was gently polished with five-micron diamond paste (Luminescence) in a rubber-polishing cup, in a slow-speed, contra-angle handpiece, and then further polished with a silicone brush (Occlubrush, Kerr Hawe). Final polishing was completed using aluminium oxide composite polishing paste (Enamelize, Cosmedent) applied with Flexibuff felt polishing points and discs (Cosmedent).

Interstitially, the restorations were refined and smoothed with diamond strips (Visonflex) of progressive smoothness and finished with fine-grade Epitex strips (GC Industries). The final contoured restoration surface was gently polished with five-micron diamond paste (Luminescence) in a rubber-polishing cup, in a slow-speed, contra-angle handpiece, and then further polished with a silicone brush (Occlubrush, Kerr Hawe). Final polishing was completed using aluminium oxide composite polishing paste (Enamelize, Cosmedent) applied with Flexibuff felt polishing points and discs (Cosmedent). As expected, the shade did not fully match the rest of the teeth once the rubber dam was removed. Although pre-warned, the patient was shown a mirror and this phenomenon was explained once again. A review appointment was arranged a week later.

REVIEW

The patient returned the next week and the tooth had rehydrated, so the colour match was satisfactory. All surfaces were again checked and photographs were taken. She was told how to care for the restorations and informed there would also need to be annual reviews for polishing and smoothing to keep them looking their best.

CONCLUSION

This case is reflective of many of the patients and situations we see in our practices. The patient would like the confidence that a beautiful smile can generate and the dentist must ensure that the restorations meet the patient’s expectations both in terms of aesthetics and function. Known for their versatility, modern composite restorations combine maximum function with ideal aesthetics in a multitude of clinical situations and with the materials available today, it is possible to place virtually invisible restorations that rival the translucency and lustre of natural teeth.

Although composite resin does deteriorate aesthetically over time and does not perhaps have the longevity of indirect porcelain restorations, there are still significant biological advantages to be gained when using this material, especially when coupled with bonding directly to enamel. The strongest bond in adhesive dentistry remains the bond between etched enamel and resin, despite increasing improvements within the field of dentine bonding

technology, and there is much to be gained if we can take advantage of this strong bond. Together with a minimally invasive approach completed at one visit, often without the use of anaesthetic at a much reduced cost, composite resin restorations gives our patients a suitable alternative to indirect porcelain restorations in many situations.