Innovative, Indirect Mock-Up Technique: Predictable Diastema Closure Using An

I clinical technique _ diastema closure
Predictable diastema
closure using an innovative,
indirect mock-up technique
Authors_ Prof So Ran Kwon & Prof Gerald E. Denehy, USA
Diastemas can vary in number and

size (Fig. 1). Causative factors include
periodontal disease; traumatic oc-
clusion; abnormal fraenulum; habits,
including tongue thrust, tongue bit-
ing, nail biting; missing teeth (owing
to accident or the congenital ab-
sence of a tooth bud); and hereditary
factors.1
Treatment options for diastema

closure depend on the number and
size of the spaces and on the
aesthetic demands of the patient.
Fig. 1
Orthodontic space closure should be
considered, and is often the treat-
Fig. 1_Pre-op view of diastema. _Diastema closure with direct composite ment choice, particularly for young patients.2
restorations can be a conservative treatment However, there are many situations where or-
modality to improve the appearance of a thodontic treatment is not an option. Resto-
smile. However, without proper diagnosis and rative treatment modalities range from very
Fig. 2_Photo-imaging technique to treatment planning even the simplest looking conservative direct composite resin restorations,
simulate space closure. diastema can turn into a very disappointing through less conservative porcelain veneers, to
Fig. 3_Diagnostic wax-up situation for the patient, as well as for the den- more invasive indirect full-coverage restora-
on a study model. tist. tions.
Fig. 2 Fig. 3
12 I cosmeticdentistry 3_ 2011
clinical technique _ diastema closure I
Fig. 4 Fig. 5
Direct composite resin bonding may lack outcome and present it to the patient (Fig. 3). Fig. 4_Fast setting VPS material is
the permanency of indirect veneers and full- The technique is easy to use and helpful in eval- poured into the alginate impression.
coverage restorations. However, conservation of uating the anticipated shape and anatomy of Fig. 5_Gingival contour is trimmed
sound tooth structure, less treatment time, ease the tooth. Disadvantages of diagnostic wax-ups with a #12 blade to prevent formation
of repair and the low cost of the treatment com- are lack of relevance of waxing technique to of a black triangle in the gingival
pared with other treatment modalities are very the composite application technique, inability to embrasure area.
distinct advantages of direct bonding. match colours and difficulty on the patient’s side
to relate it to the clinical outcome on his/her
Visualisation of the final result is an important teeth.
factor in the patient’s acceptance of the treat-
ment of diastema closures. Prior to direct resin An innovative indirect mock-up technique
bonding, several diagnostic steps and commu- with composite resin on a vinyl-polysiloxane
nication tools are available to present the anti- (VPS) model allows the clinician to practice the
cipated treatment outcome to the patient. The diastema closure case, and assess the final shape
simplest method of assessing the final outcome and colour of the restoration. The indirect mock-
of a diastema closure is by means of using photo- up can then easily be placed on the patient’s
imaging techniques of before and after images teeth to present the anticipated outcome with-
of the space closure (Fig. 2). Patients can then ap- out taking too much clinical time. This indirect
preciate the outcome by looking at the modified mock-up also allows the patient to truly appre-
image. However, photo imaging may pose a chal- ciate the final outcome on his/her actual teeth.
lenge to the clinician to reproduce exactly the The procedure involves an alginate impression of
modified after-image clinically or the final resto- the patient’s teeth poured with a VPS material, Fig. 6_Application of composite
ration will result in patient disappointment. upon which composite mock-ups of the anti- material with an IPC instrument.
cipated restorations are done. These mock-up Fig. 7_Pull-through technique
A diagnostic wax-up on a study model is a shells are then transferred to the patient’s with a celluloid strip from facial
commonly used method to assess the treatment mouth for evaluation. towards lingual.
Fig. 6 Fig. 7
cosmetic
dentistry 3 _ 2011 I 13
I clinical technique _ diastema closure
Fig. 8 Fig. 9
Fig. 8_Smoothening of the surface _Step-by-step procedure for gual marginal ridge. Light-cure the restora-
with a #3 synthetic sable brush. the indirect mock-up technique tion (Fig. 6).
Fig. 9_Careful removal of the 6. Continue the composite build-up on the oppo-
butterfly-shaped indirect mock-up 1. Take an alginate impression of the patient’s site central incisor. Attach the resin material to
from the VPS model. diastema during the initial visit. The impres- the tooth and while maintaining a hold on the
sion needs only to be of the anterior quadrant celluloid strip with a fingertip on the facial side,
containing the diastema and a quadrant tray pull the strip from the facial towards the lingual
may be used if desired. to push the resin material through the proximal
2. Immediately pour the alginate impression to form a smooth contour adapted properly in
using fast set VPS material (Aquasil Ultra XLV, the gingival area of the tooth (Fig. 7). Use a #3
DENTSPLY), taking care to avoid bubbles (Fig. 4). brush to shape the material to the desired con-
3. Measure width and length of central incisors tour proximally and to form contact with the
and the diastema space on the VPS model. Typ- adjacent tooth. Use a brush to refine the facial
ically, central incisors should be mirror images and gingival embrasures, and light-cure (Fig. 8).
of each other, with similar width. 7. Remove the polymerised resin restorations
4. Trim the gingival tissue contour with a #12 and transfer the butterfly-shaped indirect
scalpel blade to prevent formation of a black mock-up to the patient’s mouth (Fig. 9).
triangle in the gingival embrasure area (Fig. 5). 8. The mock-up allows the patient to evaluate
5. Place and contour a sculptable composite the aesthetic outcome of the proposed treat-
resin on one central incisor with a Gold Micro- ment (Figs. 10 & 11).
Fig. 10_Pre-op view of fil instrument or IPC instrument, and smooth
patient’s smile. the surface with a #3 synthetic sable brush. _Step-by-step procedure for the direct
Fig. 11_Placement of indirect The contour of the placed resin should pro- build-up of composite resin
mock-up into the patient’s mouth duce the desired facial and proximal con-
to evaluate the outcome of tours and extend lingually to just beyond the 1. Isolate the operative field with a retractor
the proposed treatment. contact. It should not extend over the lin- (OptraGate, Ivoclar Vivadent) and place re-
Fig. 10 Fig. 11
14 I cosmetic
dentistry 3_ 2011
clinical technique _ diastema closure I
Fig. 12 Fig. 13
traction cords (Ultrapak Cord, Ultradent) on

teeth #8 and 9 after thoroughly pumicing the
teeth. The proximal surfaces may be carefully
cleaned with a sandpaper disc (Sof-Lex XT, 3M)
or a contouring strip (Epitex, GC). Care must
be taken not to damage the soft tissue and
cause field control problems.
2. It is generally not necessary to prepare the
teeth with a bur, but a Sof-Lex contouring disc
can be used to roughen the enamel surface
(Fig. 12).
3. The direct build-up of composite resin is per-
Fig. 14
formed according to the same sequence used
on the VPS model (Fig. 13). The difference is
that the portions of the restorations lingual to tice may help in providing a predictable and Fig. 12_Roughening of enamel
the contact and over the marginal ridge are successful clinical outcome._ surface with a Sof-Lex disc.
established in a secondary step with the cellu- Fig. 13_Direct build-up of
loid strip pulling the material from the lingual Editorial note: A complete list of references is available composite resin on tooth #8.
to the facial. from the publisher. Fig. 14_Final diastema closure
4. The final diastema closure with composite with composite resin.
resin should have natural contours at the gin-
giva–tooth interface without a black triangle _contact cosmetic
dentistry
and smooth sub-gingival margins with no
catch on flossing (Fig. 14).3 Prof So Ran Kwon
Associate Professor
_Discussion Department of Restorative
Dentistry, Center for Dental
Presentation of the final treatment outcome Research
is essential for proper communication with the School of Dentistry
patient. Several diagnostic tools are available; Loma Linda University
however, the illustrated innovative indirect
mock-up technique with composite resin on [email protected]
a VPS model allows the patient to visualise the
anticipated results in the mouth before agreeing Prof Gerald E. Denehy
to treatment. It also allows the clinician to ac- Professor and Chairman
tually practise the diastema closure case, and Department of Operative
assess the final shape and colour of the restora- Dentistry
tion prior to performing direct bonding on the College of Dentistry
patient. University of Iowa
Since free-hand direct composite build-ups [email protected]

are often challenging to the clinician, this prac-
cosmetic
dentistry 3 _ 2011 I 15

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I clinical technique _ diastema closure

Diastemas can vary in number and

Treatment options for diastema

traction cords (Ultrapak Cord, Ultradent) on

Since free-hand direct composite build-ups [email protected]

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