Esthetic Anterior Space Closure

A patient presented requiring restoration of a postorthodontic space discrepancy involving teeth Nos. 7 and 10 (Figure 1). This is one of the most common dilemmas following orthodontic treatment, and there are really only two viable treatment options: indirect porcelain veneers or direct composite veneers. Arguments can be made for both options, but for adolescent teeth, such as those in this case, the preferred option is usually to use direct composite because it requires less tooth preparation.²

Alginate impressions were taken, and a diagnostic wax-up was fabricated from a silicone putty index (VP Mix^™ Putty, Henry Schein).³Next, teeth Nos. 7 and 10 were prepared with a pumice slurry to remove any plaque, then lightly air-abraded (MicroEtcher^™ II, Zest Dental Solutions). A small amount of local anesthetic (Lignospan^® standard [lidocaine HCl 2% solution with a 1:100 epinephrine concentration], Septodont) was infiltrated around tooth No. 10, and a radiosurgery unit was used to improve the gingival contour to allow for a more ideal emergence profile of the composite. The bonding protocol followed for this procedure used a total-etch dental adhesive (OptiBond^™ Solo Plus, Kerr) as the bonding agent. Using the silicone putty index as a backdrop, a supplementary resin-based blocking shade (OMNICHROMA BLOCKER, Tokuyama Dental America) was used to create the palatal shelf (Figure 2). Next, a single-shade universal composite (OMNICHROMA, Tokuyama Dental America) was layered just shy of the final facial contour, and a sable brush was used to place subtle internal characterizations with colored resins (Figure 3). To finish the restoration, a final thin layer of the single-shade universal composite was sculpted to just over the final desired contour, which would leave room for shaping and polishing (Figure 4). The patient was very happy with the final result, and the orthodontist was in disbelief that this was accomplished with a single-shade composite system (Figure 5).

A patient presented for re-treatment of a diastema between her maxillary central incisors (Figure 6). Approximately 6 months earlier, the patient had undergone restoration to have this space closed, but following treatment, her papilla had become very red and inflamed. In addition, when she flossed, the floss would shred and catch on a large overhang under the gums. Eventually, part of the composite fractured off of the mesial surface of tooth No. 9. During her presentation for a second opinion to see if the previous bonding was done properly, it was discovered that there was a significant amount of subgingival composite that was creating severe chronic papillary inflammation and even bone loss. An impression was taken, a diagnostic wax-up was completed, and a silicone putty index was fabricated. After infiltration with a local anesthetic was accomplished, soft-tissue modification was performed with a radiosurgery unit to create space for an ideal emergence profile (Figure 7). A space-closing technique was selected that allowed for the simultaneous layering of both teeth.⁴ The space was small enough that the supplementary blocking shade was not needed. First, a small layer of the single-shade universal composite was placed on the putty index in the location of the mesial aspect of both teeth Nos. 8 and 9. A clear Mylar strip was positioned in a cut within the putty index to help establish the interproximal contact and to create both a uniform mesiolingual contour and a straight midline (Figure 8). Next, the index was placed into position on the teeth and pressed to force out any excess composite facially. After the excess composite was removed with an interproximal carver (IPC Interproximal Carver, Hu-Friedy), the remaining material was light cured while holding the Mylar shim in the correct midline position (Figure 9). With the Mylar still in place, a final layer of the single-shade universal composite was placed on the mesiofacial aspect of each incisor and sculpted into the final facial contour. Finishing and polishing were then completed, ensuring that the gingival margins were flush and smooth so that the papilla could heal.⁵ Because this patient was from out of town, the final photograph was taken only a few days after the procedure, so the papilla was still in the process of healing (Figure 10). However, the patient reported that her gums were feeling much better already and that she loved being able to floss without it getting caught on any edges. When she returned 6 months later for a follow-up appointment, the restoration demonstrated excellent marginal integrity and esthetics, and her papilla was healthy (Figure 11).

To achieve the ultimate in macro- and microesthetics, polychromatic layering is still the gold standard. The benefit of a composite material that matches every tooth from A1 to D4 with a single shade is that it simplifies many aspects of anterior direct composite procedures. Too many dentists shy away from doing anterior direct composite restorations because of the complexities of shade selection or because they do not know how to properly layer the different colors. A versatile single-shade composite system resolves many of these concerns and should allow every dentist to perform conservative direct anterior composite restorations with confidence.

Kevin M. Brown, DMD
Private Practice
Bellevue, Washington