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An Interdisciplinary Approach for Diastema Closure in the Anterior Maxilla: a Clinical Report

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An Interdisciplinary Approach for Diastema Closure in the Anterior Maxilla: a Clinical Report Case Report An Interdisciplinary Approach for Diastema Closure In the Anterior Maxilla: A Clinical Report Kai-Jung Chang, DDS, MS Abstract School of Dentistry, Taipei Medical Achieving a satisfactory anterior esthetic outcome is University, Taipei, Taiwan a considerable challenge for most dentists. Multiple interdisciplinary approaches are necessary to resolve esthetic defects, especially in cases of improper tooth Thin-Wen Chang, DDS, MS alignment and excessive space between anterior teeth. Fung-Chai Dental Clinic, Taichung, This case report describes an interdisciplinary approach Taiwan used for a 66-year-old male with diastema and peg-shaped lateral incisors. The interdisciplinary treatments included orthodontic and prosthodotic treatments. All ceramic crowns and porcelain laminate veneers were successfully Sheng-Wei Feng, DDS, MS School of Dentistry, Taipei Medical applied to correct esthetic problems and achieve improved esthetic and functional outcomes. University, Taipei, Taiwan Keywords: diastema, all ceramic crowns, porcelain laminate veneer Corresponding author: Sheng-Wei Feng, DDS, MS Introduction School of Dentistry, Taipei Medical he increasing demand for esthetic restorations has been University, Taipei, Taiwan T met around the world in recent years. However, the es- 250 Wu-Hsing Street, Taipei, Taiwan thetic appearances of cosmetic restorations are usually com- promised by many potential problems, such as a diastema Tel: 886-2-2736-1661 ext. 5148 in the midline region, asymmetry of tooth arrangement and Fax: 886-2-2736-2295 proportion, asymmetry of the gingival level and tooth dis- E-mail: [email protected] coloration. In such instances, an interdisciplinary approach including periodontic, endodontic, orthodontic, and prosth- odontic treatments is necessary to evaluate and solve esthetic problems.1-3 The presence of a midline diastema usually distorts a pleasing smile. A lot of treatment options have been pro- posed to close the space between maxillary anterior teeth. 3-5 A careful diagnosis of the causal element is important in determining the appropriate treatment plan. However, the etiology of diastema is complex and multifactorial. Several etiological factors have been proposed as the causes of dia- stema, including periodontal aachment loss, pressure from the inflamed tissue, occlusal factors such as trauma from occlusion, oral habits (such as bruxism, mouth breathing, tongue thrusting, sucking habits, pipe smoking, and playing of wind instruments), abnormal labial frenum, non-replace- ment of missing teeth, gingival overgrowth, and iatrogenic factors.4-6 In addition, a peg-shaped lateral incisor has also been regarded as a potential cause of diastema due to the dis- tal movement of the central incisor.7 22 Volume 2, Number 2, 2013 Case Report a b Fig. 1 Intra-oral frontal view showed Fig. 2 Pretreatment maxillary (a) and mandibular (b) occlusal view. large diastema between maxillary cen- tral incisors and peg-shaped maxillary lateral incisors. a b Fig. 3 Frontal view (a) and lateral view (b) of pretreatment mounted casts. In some instances, orthodontic treatment small peg-shaped maxillary lateral incisors, and can improve esthetic problems and the pa- occlusal enamel erosion over posterior teeth tient's satisfaction by correcting anterior open were all presented (Fig. 2). During the protru- bite and closing the diastema. However, when sive movement, the maxillary central incisors dentoalveolar and Bolton discrepancies are de- contacted evenly with the mandibular incisors. tected, orthodontic treatment alone is not suf- However, in the edge-to-edge position, only ficient to obtain ideal proximal contacts with the le maxillary central incisor contacted the satisfactory vertical and horizontal overlaps.8,9 mandibular incisors. Tooth 21 showed discol- In such instances, the orthodontic treatment oration and negative pulp vitality. e regular can be used to redistribute the adequate spaces gingival zenith and thick gingival biotype were between the maxillary anterior teeth prior to noted. In addition, the vertical overlap and the restorative treatment. The literature has horizontal overlap were 3 mm and 7 mm re- demonstrated that direct composite resin spectively according to the measurement on restorations, porcelain laminate veneers and the study cast (Fig. 3). e mesio-distal widths crowns are good treatment options for correct- of four maxillary incisors from tooth 12 to 22 ing anterior diastema.5,9 Therefore, the pur- were 5.9, 9.2, 9.0, and 5.8 mm respectively. e pose of this clinical case report was to present diagnosis of this case included diastema, peg- the interdisciplinary management (including shaped maxillary lateral incisor, and labial ar- orthodontic and prosthodontic treatment) of ing of maxillary central incisors. a patient who exhibits maxillary anterior dia- Aer communication and discussion with stema and peg laterals. this patient, the definitive treatment plan in- cluded closing the space between maxillary Case Report central incisors and aligning maxillary incisors A 66-year-old male came to Fung Chai to proper position with orthodontic treat- Dental Clinic (Taichung, Taiwan) for restor- ment. Furthermore, full ceramic crowns were ative treatment. His chief complaint was tooth recommended to restore the maxillary central spacing and improper appearance of the maxil- incisors and laminates for lateral incisors. e lary anterior teeth. No major systemic diseases preliminary treatment included oral hygiene or drug allergies were noted. Extra-oral exami- instructions, caries control, non-surgical peri- nation indicated the 3 mm of tooth display and odontal therapy, root canal treatment of tooth diastema between maxillary central incisors 21, and orthodontic treatment for 6 months. at rest. Intraoral examination revealed normal Orthodontic treatment included alignment dentition with mild gingival recession and of the maxillary and mandibular dental arch; cervical abrasion on the buccal side of teeth. correction of excessive horizontal overlap; and There was approximately 2.5 mm spacing be- creation of adequate space for further prosth- tween the maxillary central incisors (Fig. 1). odontic restorations (Fig. 4). Before removal of e labial aring of maxillary central incisors, brackets, tooth proportion and space distribu- Journal of Prosthodontics and Implantology 23 Case Report Fig 4. (a) Frontal view before the comple- tion of orthodontic treatment. Diastema between maxillary central incisors was closed and space was re-distributed. (b) Frontal view after the completion of orth- odontic treatment at the maxillary arch. a b Fig 5. (a) Provisional crowns and veneers in place. (b) The palatal splinting wire in place. a b Fig 6. (a) Frontal view of tooth preparation for all-ceramic crowns and porcelain lami- nate veneers. (b) Occlusal view of tooth preparation and soft tissue architecture. a b tion were reevaluated using recurring esthetic e master cast was mounted on a semi-adjust- dental (RED) proportion analysis. The calcu- able articulator (Artex, Girrbach, Germany). lated RED proportion was approximately 70%. Pressed ceramic crowns and veneers (IPS Maxillary and mandibular study cast were then e.max, Ivoclar-Vivadent, Schaan, Liechten- taken with alginate impression for provisional stein) were fabricated for the maxillary central restorations and palatal splinting wire. e pro- incisors and lateral incisors. visional restorations were fabricated according The definitive restorations were checked to the diagnostic wax up. The provisional res- and adjusted in order to obtain optimal torations were modied and adjusted until the proximal contact, ideal gingival contour, and phonetic, esthetic, and functional results were occlusal contact (Fig. 7). The definitive res- accepted by the patient (Fig. 5). torations were cemented with dual-cure resin A circumferential 1 mm width of shoulder cement (Variolink II, Ivoclar Vivadent, Schaan, margin was prepared for full ceramic crowns of Liechtenstein). Even contacts at maximum in- maxillary central incisors and a 0.3 mm width tercuspation and proper anterior guidance of of chamfer margin was designed for laminate the maxillary central and lateral incisors were veneers of maxillary lateral incisors. Fur- made. A maintenance plan, which included thermore, a 1 mm subgingival margin on the oral hygiene instruction and prosthesis home mesial finishing line of centrals was prepared care, was established. The patient and the in- to eliminate the occurrence of black triangles terdisciplinary team were satisfied with the (Fig. 6). To verify the adequate tooth length esthetic and functional outcomes of these de- and appearance, a phonetic test (including F nitive restorations. and S sounds) and an esthetic test (including tooth proportion, alignment, and color) were Discussion evaluated. After 3 months of wearing provi- e arrangement and proportion of maxil- sional restorations, the definitive impression lary anterior teeth are the major determinants was made using vinyl polysiloxane impression for a pleasing appearance. To evaluate and material (Aquasil, Dentsply/ Caulk, Milford, describe the ideal tooth-to-tooth proportion, DE). e impression was poured with type III Levin applied the golden proportion (pro- dental stone and a master cast was fabricated. portion of 1.618:1.0) to relate the successive 24 Volume 2, Number 2, 2013 Case Report Fig 7. (a) Post-treatment intraoral view of definitive restorations. (b) Frontal view of the anterior maxillary restorations.
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