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Inside Dentistry
January 2023
Volume 19, Issue 1
Peer-Reviewed

Cosmetic Treatment for Large or Multiple Diastemas

No-prep, direct composite veneers enable conservative, highly esthetic outcomes

Sandra Hulac, DDS

Diastema closures are commonly performed procedures in cosmetic dentistry. Although small maxillary midline diastemas are seemingly now in fashion, they still bother many of our patients. Orthodontic treatment to close diastemas or to correctly position the teeth prior to any restorative treatment is, of course, often the best solution in these situations, but many patients are reluctant to invest the additional money and time. Treating these cases indirectly with porcelain veneers is another option; however, without pre-restorative orthodontics, the biologic burden placed on the teeth through the invasive preparations needed to achieve correct alignment may be high. For patients with large or multiple diastemas who do not wish to undergo any additional orthodontic treatment at the time, no-preparation direct composite veneers are a very attractive alternative. Being solely additive, they also enable patients to pursue alternative treatment options in the future, including orthodontics.

Although diastemas can be easily remedied with direct composite restorations, difficulties can arise when treating larger and/or multiple diastemas with direct composite. These tend to occur in patients whose teeth are correctly sized but positioned with incorrect or flared axial inclinations. In these cases, if the only focus of restoration is space closure, the esthetic results can be poor with undesirable proportions regarding the width and length of the teeth and an even more flared appearance. One way to properly address these cases is with a full composite veneering approach, which allows the practitioner to adjust the placement of the proximal line angles, the width-to-height ratio, and the placement of the gingival zeniths. However, it should be emphasized that in order to achieve correct esthetic proportions, in most cases, the central and lateral incisors and sometimes even the cuspids have to be treated.

The squarish appearance of restored teeth can be overcome by adding length and by moving the proximal line angles mesially to create smaller zones of light reflection. In addition, highlighting vertical texture in the final shaping and polishing process can also be helpful because this creates small deflective areas that make teeth appear slimmer. Incorrect axial inclinations can be corrected by shifting the gingival zeniths as well as through correct proximal line angle placement. Oftentimes, this requires the placement of more composite in the middle and cervical areas of teeth to create correct heights of contour. Care should be taken to not create too much cervical convexity because this will make the teeth appear shorter. This article presents three diastema closure cases involving no-prep direct composite veneers that highlight these optical principles.

About the Author

Sandra Hulac, DDS
Private Practice
Hong Kong, China

Pretreatment smile photograph of a patient who had previously undergone treatment to close her large maxillary midline diastema but was very unhappy with the appearance of her smile. Note how guarded the smile is, which is often the case with patients who are self-conscious about the appearance of their teeth.

Figure 1

Pretreatment retracted view demonstrating that the teeth have divergent axial inclinations and that the central incisors have an unfavorable width-to-height ratio of 96%.

Figure 2

Posttreatment smile photograph of the no prep direct composite veneers (inspiro®, Edelweiss DR). The patient is now smiling confidently as evidenced by the natural drape of her lips. Note how the line angles were moved toward the centers of the teeth and developmental grooves were added to make the teeth appear slimmer.

Figure 3

Posttreatment retracted view demonstrating that the axial inclinations were corrected and that the teeth now exhibit a much more favorable width-to-height ratio of 83%.

Figure 4

Pretreatment smile photograph of a patient who previously underwent an esthetically unsuccessful attempt at midline diastema closure. Note how tooth No. 8 is shorter than tooth No. 9 and the treatment of undersized tooth No. 10.

Figure 5

Pretreatment right lateral view with the teeth apart demonstrating flaring of the maxillary anterior teeth.

Figure 6

Removal of the existing restorations under rubber dam isolation (Isodam®, Sigma Dental Systems) revealed the true size of the midline diastema, the difference in length of the central incisors, and the nature of undersized tooth No. 10. Prior to applying the dam, small amounts of flowable composite (inspiro®, Edelweiss DR) were placed at the cervical aspects of the teeth to create a convexity for the placement of floss ligatures.

Figure 7

Posttreatment smile photograph demonstrating that the diastema is now fully closed and that the teeth exhibit correct proportions.

Figure 8

Posttreatment right lateral smile photograph. By adding volume to the middle and cervical parts of the facial aspects of the teeth, the flared appearance was improved.

Figure 9

Pretreatment smile photograph of a patient who previously underwent midline diastema closure demonstrating a guarded smile with no reveal of the maxillary incisors.

Figure 10

Pretreatment retracted view demonstrating that the existing restorations are failing and that the maxillary central incisors appear extremely “squat” with width-to-height ratios of approximately 101%.

Figure 11

Retracted close-up view of the maxillary arch after the previous restorations were removed revealing a very large midline diastema as well as smaller diastemas distal to the central incisors.

Figure 12

The cervical outlines were built using curved matrix bands (Unica Anterior, Polydentia).

Figure 13

A rubber dam (Isodam®, Sigma Dental Systems) was secured over the cervical outlines, and a lingual stent (Lab-Putty, Coltene) based on the diagnostic wax-up was placed to layer the lingual shelves of the restorations.

Figure 14

After the application of a dentin layer and the development of the interproximal areas, flowable composite (inspiro®, Edelweiss DR) was used in a layering process to complete the restorations.

Figure 15

To develop the correct curvature of the cervical, middle, and incisal regions, it is important to look at the teeth from the side during the shaping process (3M™ Sof-Lex™, 3M Oral Care).

Figure 16

Developmental grooves and line angles were placed using a flame-shaped diamond bur (FLAME Diamond Bur, Meisinger USA).

Figure 17

During the initial polishing process, the polishers (Enhance®, Dentsply Sirona) were used in an up-and-down fashion to help highlight the elements of verticality.

Figure 18

Postoperative smile photograph of the final direct composite veneers. Note that the patient’s smile is less guarded and appropriately displays the maxillary incisors.

Figure 19

Posttreatment retracted view demonstrating that the central incisors now exhibit an acceptable width-to-height ratio of 90%.

Figure 20

Sandra Hulac, DDS

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