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Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 86-89

Diastema closure with restoratively influenced papilla regeneration

Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Abha 61471, Saudi Arabia

Date of Web Publication25-Oct-2016

Correspondence Address:
Mohammed A Alqarni
Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, P.O. Box 3263, Abha 61471
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0521.193005

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Midline diastema is the most common esthetic problem seen as a result of space discrepancy in the anterior region of the mouth. Closure of midline diastema will give the patient a better smile, good esthetics, and social confidence. Appropriate diagnosis and planning hold the key to the successful clinical outcome. The size of the diastema decides the closure with composite resin or indirect ceramic restorations that can yield excellent treatment alternative. This case reports the closure of diastema with ceramic veneer restoration from maxillary right first premolar to maxillary left first premolar except maxillary right central incisor were all ceramic restoration was considered the tooth had undergone root canal treatment. The case also highlights the closure of the black triangle or in other words restoratively driven papilla regeneration, which is a clearly visible at the 8 th month follow-up.

Keywords: Dental esthetics, dental laminates, dental restoration, dental veneer, diastemas, papilla regeneration

How to cite this article:
Alqarni MA. Diastema closure with restoratively influenced papilla regeneration. Saudi J Health Sci 2016;5:86-9

How to cite this URL:
Alqarni MA. Diastema closure with restoratively influenced papilla regeneration. Saudi J Health Sci [serial online] 2016 [cited 2021 Jan 18];5:86-9. Available from: https://www.saudijhealthsci.org/text.asp?2016/5/2/86/193005

  Introduction Top

Space discrepancy in the anterior region of the mouth is a recognizable major esthetic problem. Among the listed discrepancies of the anterior region in the literature, midline diastema has a pronounced effect and is promptly visualized by many. Midline diastema is the space or gap that exists between the central incisors. Space more than 0.5 mm between the central incisors accounts to true diastema. [1],[2] Diastema can be attributed to the following causes; dentoalveolar diastema, pernicious habits, muscular imbalances, physical impediment, abnormal maxillary arch structure, missing teeth, and dental anomalies. [3]

Appropriate diagnosis and planning hold the key to the successful clinical outcome. Such aspects define themselves in modern dentistry within the scope of the developing branches transpiring in the fraternity. The emergence and advent of esthetic dentistry in modern dental sciences has been a boon to patients demanding a pleasing esthetic appearance for due social adaptability, especially the ones with diastema. Depending on the size of the diastema - material based esthetically driven closure with composite resin or indirect ceramic restorations can make up an excellent treatment option of the available measures. [4] Composites demand extensive tooth reconstruction and have high failure rate averaging to 2.9% annually. [5] Reasons for failure being a loss of restoration, secondary caries, marginal defects, fracture, and pigment impregnation or a high degree of color instability. [6],[7] Advances in dental materials have made ceramic veneers the desired option in the indirect esthetic restorative procedure. [8],[9] Ceramics display properties such as compatible compressive strength, surface smoothness, abrasion resistance, gloss, and low plaque accumulation. Thus, ceramic stands as a promising material for closure of interdental spaces as compared to the conventional treatment alternatives.

The major challenge in the correction of diastema lay with the elimination of posttherapeutic open gingival embrasures. These open embrasures are also termed as black triangles. Hence, correction of the black triangle by papilla regeneration in diastema closure projects significant clinical modality. Restoratively, driven papillary regeneration is a concept that corrects black triangles or open embrasures with restorative procedures, especially in severe midline diastema presentations. Recently, revolutionary concepts such as Bioclear Matrix (Bioclear, Tacoma, WA, USA) are introduced for the esthetic closure of diastema followed by papilla regeneration. However, the system carries along itself the limitation of direct composite restoration as forestated. Papillary regeneration with an indirect restoration of a promising material like ceramic sounds more beneficial than the concept introduced. Hence, this case details the esthetic closure of diastema by indirect ceramic restoration driven papilla regeneration technique.

  Case report Top

A 31-year-old male reported to the Department of Restorative Dental Sciences, King Khalid University College of Dentistry, Abha, Saudi Arabia; with a chief complaint of space between his upper front teeth and wanted it to be closed for a pleasing and satisfactory smile. The patient gave a history of root canal treatment with upper right central incisor. Following a thorough examination, the patient presented with a midline diastema, teeth were symmetric on either side. The patient also presented with generalized plaque-induced gingivitis [Figure 1]. Clinical examination, photographs, radiographs, study casts, and diagnostic wax setup were performed [Figure 2] and [Figure 3]. The patient was comprehensively evaluated for smile esthetics in the dentolabial region along with smile line analysis and analysis of occlusal interferences.
Figure 1: Patient presented with midline diastema

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Figure 2: Preoperative diagnostic cast

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Figure 3: Radiograph presenting root canal treated right maxillary central incisor

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The patient was proposed with the possible treatment options thereby explaining advantages and disadvantages of each. With the consent of the patient, all ceramic restoration for right maxillary central incisor and ceramic veneer restorations from right first maxillary premolar to left first maxillary premolar except right maxillary central incisor were decided. A wax-up of treatment proposed in the cast model was outlined to the patient [Figure 4]. The patient underwent thorough oral prophylaxis, necessary restoration and occlusal corrections. Crown preparations were done; tooth preparation was kept in enamel at a depth of 0.5 mm deploying a depth cutting diamond, and a tapered diamond bur of 1 mm diameter. 0.25 mm chamfer in the cervical region was maintained. The chamfer finish lines were maintained equi-gingival for ceramic veneer restorations. The centric stops were carefully eluded while preparing the palatal finish line. The proximal preparation was extended beyond the contact area to prevent visibility of the tooth restoration junction. Gingival retraction cords were placed. Dual impression technique was followed, with the use of heavy body and light body elastomeric impression material (3M ESPE Express™ light and regular body, 3M ESPE, St. Paul, USA; 3M Gulf, Riyadh-Regional Centre, KSA; Dubai, UAE). Provisional restoration was placed as a temporary measure for all ceramic (3M ESPE Protemp™, 3M ESPE, St. Paul, USA; 3M Gulf, Riyadh-Regional Centre, KSA; Dubai, UAE) and temporary composite veneers by free-hand technique (3M Z250 Flowable Composite - 3M ESPE, St. Paul, USA; 3M Gulf, Riyadh-Regional Centre, KSA; Dubai, UAE) to avoid potential discrepancies before placement of final restorations.
Figure 4: Wax up of treatment proposed in the cast model

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The ceramic veneers (E-Max Ceram, Ivoclar Vivadent AG, Liechtenstein) and all ceramic restoration for tooth #11 (E-Max Zir CAD, Layered by E-max Ceram, Ivoclar Vivadent AG, Liechtenstein) were fabricated. The shade, size, and fit of the fabricated restorations were evaluated, and patient approval was taken. Luting composite system (Multilink Automix, Ivoclar Vivadent AG, Liechtenstein) was used for cementation of the right maxillary central incisor all-ceramic restoration. The inner surface of the ceramic veneers was etched, silaned, and bonded to the enamel surface after selection of appropriate shade of dual-cured composite resin cement. The ceramic veneer was etched with 5% hydrofluoric acid (IPS Ceramic Etching Gel, Ivoclar Vivadent AG, Liechtenstein) solution for 1 min. The etched surface is coated with silane coupling agent (Monobond Plus, Ivoclar Vivadent AG, Liechtenstein) that helps in chemical bonding of restoration with resin cement. Tooth surface is etched with 37% phosphoric acid (Total Etch, Ivoclar Vivadent AG, Liechtenstein) for 15-20 s which is followed by 30 s rinsing and drying with air. A layer of bonding agent (Monobond Plus, Ivoclar Vivadent AG, Liechtenstein) is applied and cured on the etched enamel surface. The appropriate color of the luting composite (Light Cure Variolink Veneer, Ivoclar Vivadent AG, Liechtenstein) is coated on the ceramic veneer and seated with finger pressure. Excess cement was removed and cured for 1 min with a curing light.

The patient was duly followed up as a routine for 3 and 8 months posttreatment, which clearly shows the papilla regeneration between the central incisors [Figure 5]. Pre- and post-treatment smile line analysis was carried out [Figure 6] to determine the outcome. Postoperative radiograph was made to analyze the treatment [Figure 7].
Figure 5: Frontal view; (a) before treatment; (b) on the day of cementation; (c) 3 months after cementation; and (d) 8 months after cementation

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Figure 6: Pre- and post-smile profile of the patient - (a) Preoperative right lateral view; (b) preoperative frontal view; (c) preoperative left lateral view; (d) postoperative right lateral view; (e) postoperative frontal view; and (f) postoperative left lateral view

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Figure 7: Postoperative radiograph

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  Discussion Top

Al-Balkhi and Zahrani, 1994, reported prevalence rates of midline diastema and associated discrepancy in local inhabitants of Saudi Arabia to be 32.8% and 30.7%, respectively. [10] A space between the maxillary central incisors was presented as unattractive by both Saudi Arabian dentists and layman people. Patient esthetics plays a vital role in the quality of life and social confidence. [11] Diastema closure can be carried out by orthodontic treatment followed by restorative treatment or direct restorative technique using composites or indirect restorative technique using all ceramic restorations or ceramic veneers. [12] Composite resins and ceramic veneers are the two most commonly used materials for the diastema closure. Micro filled and hybrid composites are used for smaller diastema measuring 1-1.5 mm. Composite resins are easy to use relatively require fewer appointments and are economical, but, on the other hand, have high failure rate due to marginal leakage, fracture of restoration and loss or change in color of the restoration as mentioned above. Ceramic veneer restoration has pleasing esthetic results, high wear resistance and better color stability which is long lasting. [5],[13]

The clinical rationale of gingival black space is multifactorial. Therefore, it is important to diagnose the etiological factor accurately to establish an appropriate treatment planning. In ceramic veneer or crown change in the point of contact can give a pleasing result. [14] In this study, papilla regeneration was achieved at 8 th month follow-up with a completely covered black triangle by papilla. Moreover, the case supported standard calculation concept of distance from contact area to crestal bone as highlighted by Tarnow et al., to determine papilla stability and adequacy. [15] The discussed distance in the present case was approximately 5 mm between maxillary central incisors and crestal bone level which duly supported the regeneration, stability, and adequacy of the papilla. The said distance was a benchmark stated by Tarnow et al. and, in this case, was demonstrated as well. [15] The results can be very well appreciated in the postoperative radiograph [Figure 7]. Advances in dentistry have brought about drastic changes in the options in treating esthetic problems, but the selection of appropriate treatment plan based on accurate analysis of clinical parameters holds the key to the successful outcome.

  Conclusion Top

Every meticulously worked out clinical situation demands a unique line of treatment for that particular case. The diastema closure, in this case report, depicts the appropriate selection of material, technique, and expertise to the long-term successful clinical outcome. Restoratively influenced papilla regeneration technique used in this case report, highlights the successful closure of the black triangle or regeneration of the papilla at the 8 th month of the clinical follow-up. The result achieved by this technique is mutually gratifying for the patient and esthetic dentist.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Keene HJ. Distribution of diastemas in the dentition of man. Am J Phys Anthropol 1963;21:437-41.  Back to cited text no. 1
Baum AT. The midline diastema. J Oral Med 1966;21:30-9.  Back to cited text no. 2
Oesterle LJ, Shellhart WC. Maxillary midline diastemas: A look at the causes. J Am Dent Assoc 1999;130:85-94.  Back to cited text no. 3
Baratieri LN, Araujo EM Jr., Monteiro S Jr. Composite Restorations in Anterior Teeth: Fundamentals and Possibilities. Chicago, USA: Quintessence; 2005.  Back to cited text no. 4
Tuncer D, Yazici AR, Özgünaltay G, Dayangac B. Clinical evaluation of different adhesives used in the restoration of non-carious cervical lesions: 24-month results. Aust Dent J 2013;58:94-100.  Back to cited text no. 5
Kopperud SE, Tveit AB, Gaarden T, Sandvik L, Espelid I. Longevity of posterior dental restorations and reasons for failure. Eur J Oral Sci 2012;120:539-48.  Back to cited text no. 6
Garoushi S, Lassila L, Hatem M, Shembesh M, Baady L, Salim Z, et al. Influence of staining solutions and whitening procedures on discoloration of hybrid composite resins. Acta Odontol Scand 2013;71:144-50.  Back to cited text no. 7
Guess PC, Stappert CF, Strub JR. Preliminary clinical results of a prospective study of IPS e.max Press- and Cerec ProCAD- partial coverage crowns. Schweiz Monatsschr Zahnmed 2006;116:493-500.  Back to cited text no. 8
Signore A, Kaitsas V, Tonoli A, Angiero F, Silvestrini-Biavati A, Benedicenti S. Sectional porcelain veneers for a maxillary midline diastema closure: A case report. Quintessence Int 2013;44:201-6.  Back to cited text no. 9
Al-Balkhi K, Zahrani A. The pattern of malocclusions in Saudi Arabian patients attending for orthodontic treatment at the College of Dentistry, King Saud University, Riyadh. Saudi Dent J 1994;6:138-44.  Back to cited text no. 10
Talic N, Alomar S, Almaidhan A. Perception of Saudi dentists and lay people to altered smile esthetics. Saudi Dent J 2013;25:13-21.  Back to cited text no. 11
Dlugokinski MD, Frazier KB, Goldstein RE. Restorative treatment of diastema. In: Goldstein RE, Hoywood VB, editors. Esthetic in Dentistry. 2 nd ed. Vol. 2. London, UK: BC Decker Inc.; 2002. p. 703-32.  Back to cited text no. 12
Cho GC, Donovan TE, Chee WW. Clinical experiences with bonded porcelain laminate veneers. J Calif Dent Assoc 1998;26:121-7.  Back to cited text no. 13
De Oliveira JD, Storrer CM, Sousa AM, Lopes TR, de Sousa Vieira J, Deliberador TM. Papillary regeneration: Anatomical aspects and treatment approaches. RSBO 2012;9:448-56.  Back to cited text no. 14
Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-6.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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