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CLINICAL REPORT

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A multidisciplinary approach to the management of amaxillary midline diastema: A clinical report

Mario F. Romero, DDS,a Courtney S. Babb, DMD,b Christian Brenes, DDS, MS,c and Fernando J. Haddock, DDSd

ABSTRACTA maxillary midline diastema (MMD) is a common complaint of dental patients. An MMD can beclosed with treatment from different disciplines, including operative dentistry and orthodontics. Acomprehensive smile analysis is also a necessity before beginning treatment. This article highlightsthe closure of a 3-mm MMD by using a combination of orthodontics and direct composite resinrestorations. (J Prosthet Dent 2017;-:---)

Anterior maxillary spacing hasbeen shown to be one of themost negative influences onself-perceived dental appear-ance,1 and a maxillary midlinediastema (MMD) is commonlycited by patients as a primary

concern during dental consultations.2 MMD has beendefined as a space greater than 0.5 mm between themesial surfaces of the 2 maxillary central incisors.3 AnMMD greater than 2 mm in the mixed dentition is un-likely to spontaneously close.4 African Americans aremore than twice as likely to have an MMD than whites orHispanics.5

In esthetic situations, without a comprehensive smileanalysis and proper planning, overtreatment and undesirableeffects can occur.6 Tooth size especially has been emphasizedas the primary element of an esthetic smile design.7 Onemethod of establishing tooth size is tooth biometry asdescribed by Chu.7 He reported that maxillary anterior toothwidths average 8.5 mm for central incisors, 6.5 mm for lateralincisors, and 7.5 mm for canines and that 80% of the patientpopulation falls within ±0.5 mm of these values. Otherimportant elements of smile analysis include the dentalmidline, tooth morphology, axial inclinations, and the softtissue components of gingival health, levels, and harmony.8

The direct bonding technique is a straightforward, con-servative method for diastema closure.9,10 However, artisticskills, a knowledge of tooth morphology, and the appro-priate selection and use of composite resin materials areessential for success.11 According to Spear and Kokich,12

“some existing dentitions simply cannot be restored to amore pleasing appearance without the assistance of several

ofessor, Department of Restorative Sciences, Dental College of Georgia atepartment of General Dentistry, Dental College of Georgia at Augusta Univofessor, Department of General Dentistry, Dental College of Georgia at Augofessor, Department of Restorative Sciences, Dental College of Georgia at

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different dental disciplines.” Therefore, complex estheticdilemmas may require more than one dental discipline, forexample, operative dentistry and orthodontics, to establish afunctional, maintainable, and pleasant smile.13

This article illustrates a clinical situation in which anMMD was addressed by first completing a comprehensivesmile analysis, followed by closure using limited orthodon-tics and direct composite resin restorations.

CLINICAL REPORT

A caries-free, 32-year-old African American woman pre-sented to the Eastman Institute for Oral Health AdvancedEducation in General Dentistry (AEGD) program clinicexpressing unhappiness with her smile because of thespaces between her anterior teeth (Fig. 1). The smileanalysis revealed a 3-mm diastema between the maxillarycentral incisors, 0.5-mm diastemas between the maxillarycanines and lateral incisors, an average smile line with75% to 100% of the clinical crown height of the maxillaryincisors displayed,14 scalloped periodontal tissue withlong thin interdental papillae except for the blunted areabetween the central incisors, disharmony in the shape ofthe central incisors (square) compared with the othermaxillary anterior teeth (triangular), and an appropriateaxial inclination of all 6 maxillary anterior teeth (Fig. 2).

Augusta University, Augusta, Ga.ersity, Augusta, Ga.usta University, Augusta, Ga.Augusta University, Augusta, Ga.

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Figure 1. Preoperative view. Note 3-mm maxillary midline diastema. Figure 2. Preoperative smile view illustrating correct axial angulation butdisharmonic shape of maxillary anterior teeth.

Figure 3. Composite resin trial restorations. Placing composite resinrestorations without orthodontics would lead to excessively widemaxillary central incisors and black triangle.

Figure 4. Limited orthodontic treatment at placement of appliance.

Figure 5. Maxillary cast after completion of orthodontics showingremaining MMD of 1 mm. MMD, maxillary midline diastema.

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A trial restoration demonstrated that treatment withcomposite resin increments would only create excessive widthof the central incisors and a black triangle (Fig. 3). Therefore, amultidisciplinary treatment plan was formulated that includedlimited orthodontic treatment for interproximal space distri-bution, followed by diastema closure with direct compositerestorations for all maxillary anterior teeth to develop a pro-portionately pleasant tooth morphology.

Since the patient presented with a Class I dental rela-tionship, orthodontic treatment focused on reducing theMMD from 3 mm to 1 mm. After bonding standard edge-wise brackets (Mini Master Series Diagonal Twin .022Bracket; American Orthodontics) to the maxillary centralincisors, the MMD closure was carried out by using form Iround 0.018-inch stainless steel wire (Natural Arch Form I;American Orthodontics) combined with a short (H6)memory chain (Memory Chain; American Orthodontics)(Fig. 4). The patient was evaluated every 15 days, at whichtime the memory chain was replaced. After 6 weeks oftreatment, the MMD measured 1 mm (Fig. 5), and evenspaces had been created between the maxillary central andlateral incisors (Fig. 6).

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The initial shade was selected (VITA Classical ShadeGuide; VITA North America) and evaluated directly onthe teeth. The diastemas between the lateral incisorsand canines were first restored using a free-handed layering

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Figure 6. Space created after orthodontic treatment. A, Between right maxillary central and lateral incisor. B, Between left maxillary central and lateral incisor.

Figure 7. Polyvinyl siloxane matrix seated and followed by application oflingual layer of A1 body microhybrid composite resin to form lingualshell.

Figure 8. After application of final increment of microfilled compositeresin layer and before finishing and polishing.

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composite resin technique, with no preparation of the teethneeded.15 The teeth were cleaned with a slurry of pumice(Pumice Preppies; Whip Mix Corp), followed by acid etchingwith 37% phosphoric acid (Uni-Etch w/BAC; Bisco) for 30seconds. A 1-step adhesive system (OptiBond Solo Plus;Kerr Corp) was used. With the aid of a Mylar strip (MatrixStrips; Crosstex), the mesiolingual layer of the maxillaryright canine was developed by using A1 body microhybridcomposite resin (Renamel Microhybrid; Cosmedent Inc),followed by the application of a mixture of gray and violetcolor intensifiers (Renamel Creative Color; Cosmedent Inc)in the incisal third.

A final facial increment of A1 enamel microfilled com-posite resin (Renamel Microfill; Cosmedent Inc) wassculpted to optimal contours. These steps were repeated torestore the mesial aspect of the lateral incisors and leftcanine. A polyvinyl siloxane (PVS; Reprosil Putty; DentsplySirona) lingual matrix was fabricated to restore the centralincisors from a new diagnostic waxing created after the or-thodontics. After completing the bonding protocol, thelingual PVS matrix was seated, followed by application ofthe lingual layer of A1 body microhybrid composite resin toform a lingual shell (Fig. 7). After light-polymerizing, thePVS matrix was removed, and a polyester film strip was

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placed to restore the interproximal walls and contact area. Afinal 1-mm A1 enamel microfilled composite resin layer wasapplied to the facial surface.

Both of the restorations were assessed as this was theoptimal time to modify the restorations if needed (Fig. 8).The finishing process was initiated with coarse andmedium-coarse disks (Sof-Lex Contouring and PolishingDiscs; 3M ESPE), by following the natural contours of theteeth. Fine and extra-fine diamond rotary instruments(8888.31.012 FG Fine Flame Diamond, DET6EF FG Extra-fine Needle Diamond; Brasseler USA) were used fortexture and microanatomy. Finishing strips (EPITEX; GCAmerica) were used interproximally to eliminate flash andobtain smooth line angles, and silicone polishing points(Enhance Finishing Points; Dentsply Sirona) were used onthe lingual surface after occlusal adjustment. The finalesthetic evaluation of shade and texture of the restorationwas done 15 days postoperatively (Fig. 9).

DISCUSSION

All treatment options for diastema closure should beconsidered and presented to the patient. This patientwas previously aware of indirect restorations as the only

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Figure 9. Patient’s smile 15 days postoperatively.

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treatment option and expressed reservations about costand tooth preparation. To close the diastemas with or-thodontics alone would have required comprehensiveorthodontic treatment, which would not have addressedthe tooth shape discrepancy and which was an unap-pealing option for the patient in terms of time and fi-nances. The option of both limited orthodontics anddirect restorations was attractive to the patient in termsof finances, timeliness, and conservation of toothstructure.

The esthetic smile analysis was imperative in theformulation of a treatment plan, and establishing propertooth proportions presented a challenge. The central incisorwidth was 8 mm. If the MMD of 3 mm was closed withcomposite resin restorations alone, the central incisorswould have been 9.5 mm wide, which would have beenexcessive. With limited orthodontics, the MMD was reducedto 1 mm. Using the principles described by Chu,7 the centralincisors were restored to an 8.5-mm width with compositeresin restorations. Thus, the patient’s resulting centralincisor width was equal to the mean value of that of thepopulation7 and was harmonious with the adjacent teethand the patient’s face.

Using limited orthodontics for MMD closure withsegmental arch wire from central incisor to central incisor inconjunction with an elastomeric chain is predictable, as longas retraction of the incisors is not required.5 After ortho-dontic treatment, composite resins were used not only toclose the remaining MMD but also to stabilize the teeth.16 Aposttreatment frenectomy was considered unnecessarybecause there was no residual tissue excess.5

The presence of a diastema is one of the causes ofdeficient or absent interdental papillae.17 While periodontalsurgery is an option for creating a papilla,9 for this patient,the interdental gingiva between the central incisors was“squeezed” together with movement of the teeth, physicallydisplacing the tissue coronally to create a papilla,18 asanother benefit of the orthodontic treatment. After

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treatment, the patient’s smile displayed harmonious gingivalcontours and appropriate tooth size and shape.

SUMMARY

In esthetic dilemmas such as diastema closure, acomprehensive smile analysis is essential prior to treat-ment. When maximal tooth conservation is required,direct composite resin restorations, with their combinedbenefits of esthetics, minimal invasiveness, and longevityare the favored treatment option.19 Together with or-thodontics, direct composite resins offered this patient acost-effective, conservative resolution of her MMD.

REFERENCES

1. Bernabe E, Flores-Mir C. Influence of anterior occlusal characteristics on self-perceived dental appearance in young adults. Angle Orthod 2007;77:831-6.

2. Chu CH, Zhang CF, Jin LJ. Treating a maxillary midline diastema in adultpatients: a general dentist’s perspective. J Am Dent Assoc 2011;142:1258-64.

3. Keene H. Distribution of diastemas in the dentition of man. Am J PhysAnthropol 1963;21:437-41.

4. Edwards JG. The diastema, the frenum, the frenectomy: a clinical study. Am JOrthod 1977;71:489-508.

5. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 5th ed. St.Louis: Mosby/Elsevier; 2013. p. 7, 451-2.

6. Kuljic BL. Merging orthodontics and restorative dentistry: an integral part ofesthetic dentistry. J Esthet Restor Dent 2008;20:155-63.

7. Chu SJ. Range and mean distribution frequency of individual tooth width ofthe maxillary anterior dentition. Pract Proced Aesthet Dent 2007;19:209-15.

8. Bhuvaneswaran M. Principles of smile design. J Conserv Dent 2010;13:225-32.

9. De Araujo EM Jr, Fortkamp S, Baratieri LN. Closure of diastema and gingivalrecontouring using direct adhesive restorations: a case report. J Esthet RestorDent 2009;21:229-40.

10. Heymann HO, Hershey HG. Use of composite resin for restorative and or-thodontic correction of anterior interdental spacing. J Prosthet Dent 1985;53:766-71.

11. Heymann HO. The artistry of conservative esthetic dentistry. J Am DentAssoc 1987;Spec No:14E-23E.

12. Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry.Dent Clin North Am 2007;51:487-505, x-xi.

13. Francisconi LF, Freitas MC, Oltramari-Navarro PV, Lopes LG,Francisconi PA, Mondelli RF. Multidisciplinary approach to the establishmentand maintenance of an esthetic smile: a 9-year follow-up case report.Quintessence Int 2012;43:853-8.

14. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent1984;51:24-8.

15. Dietschi D. Optimising aesthetics and facilitating clinical application offree-hand bonding using the ‘natural layering concept’. Br Dent J 2008;204:181-5.

16. Mussig E, Lux CJ, Staehle HJ, Stellzig-Eisenhauer A, Komposch G. Appli-cations for direct composite restorations in orthodontics. J Orofac Orthop2004;65:164-79.

17. Blatz MB, Hurzeler MB, Strub JR. Reconstruction of the lost interproximalpapillaepresentation of surgical and nonsurgical approaches. Int J Peri-odontics Restorative Dent 1999;19:395-406.

18. Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol2000 1996;11:65-8.

19. Wolff D, Kraus T, Schach C, Pritsch M, Mente J, Staehle HJ, et al. Recon-touring teeth and closing diastemas with direct composite buildups: a clinicalevaluation of survival and quality parameters. J Dent 2010;38:1001-9.

Corresponding author:Dr Courtney S. BabbDepartment of General DentistryDental College of Georgia at Augusta University1120 15th St, GC-3090Augusta, GA 30912Email: [email protected]

Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.

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