CLINICAL REPORT

A multidisciplinary approach to the management of a

maxillary midline diastema: A clinical report
Mario F. Romero, DDS,a Courtney S. Babb, DMD,b Christian Brenes, DDS, MS,c and Fernando J. Haddock, DDSd

Anterior maxillary spacing has ABSTRACT

been shown to be one of the
A maxillary midline diastema (MMD) is a common complaint of dental patients. An MMD can be
most negative influences on closed with treatment from different disciplines, including operative dentistry and orthodontics. A
self-perceived dental appear- comprehensive smile analysis is also a necessity before beginning treatment. This article highlights
ance,1 and a maxillary midline the closure of a 3-mm MMD by using a combination of orthodontics and direct composite resin
diastema (MMD) is commonly restorations. (J Prosthet Dent 2017;-:---)
cited by patients as a primary
concern during dental consultations.2 MMD has been different dental disciplines.” Therefore, complex esthetic
defined as a space greater than 0.5 mm between the dilemmas may require more than one dental discipline, for
mesial surfaces of the 2 maxillary central incisors.3 An example, operative dentistry and orthodontics, to establish a
MMD greater than 2 mm in the mixed dentition is un- functional, maintainable, and pleasant smile.13
4
likely to spontaneously close. African Americans are This article illustrates a clinical situation in which an
more than twice as likely to have an MMD than whites or MMD was addressed by first completing a comprehensive
Hispanics. 5 smile analysis, followed by closure using limited orthodon-
In esthetic situations, without a comprehensive smile tics and direct composite resin restorations.
analysis and proper planning, overtreatment and undesirable
effects can occur.6 Tooth size especially has been emphasized CLINICAL REPORT
as the primary element of an esthetic smile design.7 One A caries-free, 32-year-old African American woman pre-
method of establishing tooth size is tooth biometry as
7
sented to the Eastman Institute for Oral Health Advanced
described by Chu. He reported that maxillary anterior tooth
Education in General Dentistry (AEGD) program clinic
widths average 8.5 mm for central incisors, 6.5 mm for lateral
expressing unhappiness with her smile because of the
incisors, and 7.5 mm for canines and that 80% of the patient
spaces between her anterior teeth (Fig. 1). The smile
population falls within ±0.5 mm of these values. Other
important elements of smile analysis include the dental analysis revealed a 3-mm diastema between the maxillary
midline, tooth morphology, axial inclinations, and the soft central incisors, 0.5-mm diastemas between the maxillary
tissue components of gingival health, levels, and harmony. 8 canines and lateral incisors, an average smile line with
The direct bonding technique is a straightforward, con- 75% to 100% of the clinical crown height of the maxillary
servative method for diastema closure. 9,10
However, artistic incisors displayed,14 scalloped periodontal tissue with
skills, a knowledge of tooth morphology, and the appro- long thin interdental papillae except for the blunted area
priate selection and use of composite resin materials are between the central incisors, disharmony in the shape of
11
essential for success. According to Spear and Kokich, 12 the central incisors (square) compared with the other
“some existing dentitions simply cannot be restored to a maxillary anterior teeth (triangular), and an appropriate
more pleasing appearance without the assistance of several axial inclination of all 6 maxillary anterior teeth (Fig. 2).

a
Assistant Professor, Department of Restorative Sciences, Dental College of Georgia at Augusta University, Augusta, Ga.
b
Instructor, Department of General Dentistry, Dental College of Georgia at Augusta University, Augusta, Ga.
c
Assistant Professor, Department of General Dentistry, Dental College of Georgia at Augusta University, Augusta, Ga.
d
Assistant Professor, Department of Restorative Sciences, Dental College of Georgia at Augusta University, Augusta, Ga.

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Figure 1. Preoperative view. Note 3-mm maxillary midline diastema. Figure 2. Preoperative smile view illustrating correct axial angulation but
disharmonic shape of maxillary anterior teeth.

Figure 3. Composite resin trial restorations. Placing composite resin Figure 4. Limited orthodontic treatment at placement of appliance.
restorations without orthodontics would lead to excessively wide
maxillary central incisors and black triangle.

A trial restoration demonstrated that treatment with

composite resin increments would only create excessive width
of the central incisors and a black triangle (Fig. 3). Therefore, a
multidisciplinary treatment plan was formulated that included
limited orthodontic treatment for interproximal space distri-
bution, followed by diastema closure with direct composite
restorations for all maxillary anterior teeth to develop a pro-
portionately pleasant tooth morphology.
Since the patient presented with a Class I dental rela-
tionship, orthodontic treatment focused on reducing the
MMD from 3 mm to 1 mm. After bonding standard edge-
wise brackets (Mini Master Series Diagonal Twin .022
Bracket; American Orthodontics) to the maxillary central
incisors, the MMD closure was carried out by using form I
round 0.018-inch stainless steel wire (Natural Arch Form I; Figure 5. Maxillary cast after completion of orthodontics showing
American Orthodontics) combined with a short (H6) remaining MMD of 1 mm. MMD, maxillary midline diastema.
memory chain (Memory Chain; American Orthodontics)
(Fig. 4). The patient was evaluated every 15 days, at which
time the memory chain was replaced. After 6 weeks of The initial shade was selected (VITA Classical Shade
treatment, the MMD measured 1 mm (Fig. 5), and even Guide; VITA North America) and evaluated directly on
spaces had been created between the maxillary central and the teeth. The diastemas between the lateral incisors
lateral incisors (Fig. 6). and canines were first restored using a free-handed layering

THE JOURNAL OF PROSTHETIC DENTISTRY Romero et al

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Figure 6. Space created after orthodontic treatment. A, Between right maxillary central and lateral incisor. B, Between left maxillary central and lateral incisor.
Figure 7. Polyvinyl siloxane matrix seated and followed by application of
lingual layer of A1 body microhybrid composite resin to form lingual
shell.
composite resin technique, with no preparation of the teeth
needed.15 The teeth were cleaned with a slurry of pumice
(Pumice Preppies; Whip Mix Corp), followed by acid etching
with 37% phosphoric acid (Uni-Etch w/BAC; Bisco) for 30
seconds. A 1-step adhesive system (OptiBond Solo Plus;
Kerr Corp) was used. With the aid of a Mylar strip (Matrix
Strips; Crosstex), the mesiolingual layer of the maxillary
right canine was developed by using A1 body microhybrid
composite resin (Renamel Microhybrid; Cosmedent Inc),
followed by the application of a mixture of gray and violet
color intensifiers (Renamel Creative Color; Cosmedent Inc)
in the incisal third.
A final facial increment of A1 enamel microfilled com-
posite resin (Renamel Microfill; Cosmedent Inc) was
sculpted to optimal contours. These steps were repeated to
restore the mesial aspect of the lateral incisors and left
canine. A polyvinyl siloxane (PVS; Reprosil Putty; Dentsply
Sirona) lingual matrix was fabricated to restore the central
incisors from a new diagnostic waxing created after the or-
thodontics. After completing the bonding protocol, the
lingual PVS matrix was seated, followed by application of
the lingual layer of A1 body microhybrid composite resin to
form a lingual shell (Fig. 7). After light-polymerizing, the
PVS matrix was removed, and a polyester film strip was
Romero et al
3
Figure 8. After application of final increment of microfilled composite
resin layer and before finishing and polishing.
placed to restore the interproximal walls and contact area. A
final 1-mm A1 enamel microfilled composite resin layer was
applied to the facial surface.
Both of the restorations were assessed as this was the
optimal time to modify the restorations if needed (Fig. 8).
The finishing process was initiated with coarse and
medium-coarse disks (Sof-Lex Contouring and Polishing
Discs; 3M ESPE), by following the natural contours of the
teeth. Fine and extra-fine diamond rotary instruments
(8888.31.012 FG Fine Flame Diamond, DET6EF FG Extra-
fine Needle Diamond; Brasseler USA) were used for
texture and microanatomy. Finishing strips (EPITEX; GC
America) were used interproximally to eliminate flash and
obtain smooth line angles, and silicone polishing points
(Enhance Finishing Points; Dentsply Sirona) were used on
the lingual surface after occlusal adjustment. The final
esthetic evaluation of shade and texture of the restoration
was done 15 days postoperatively (Fig. 9).
DISCUSSION
All treatment options for diastema closure should be
considered and presented to the patient. This patient
was previously aware of indirect restorations as the only
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Figure 9. Patient’s smile 15 days postoperatively.
treatment option and expressed reservations about cost
and tooth preparation. To close the diastemas with or-
thodontics alone would have required comprehensive
orthodontic treatment, which would not have addressed
the tooth shape discrepancy and which was an unap-
pealing option for the patient in terms of time and fi-
nances. The option of both limited orthodontics and
direct restorations was attractive to the patient in terms
of finances, timeliness, and conservation of tooth
structure.
The esthetic smile analysis was imperative in the
formulation of a treatment plan, and establishing proper
tooth proportions presented a challenge. The central incisor
width was 8 mm. If the MMD of 3 mm was closed with
composite resin restorations alone, the central incisors
would have been 9.5 mm wide, which would have been
excessive. With limited orthodontics, the MMD was reduced
to 1 mm. Using the principles described by Chu,7 the central
incisors were restored to an 8.5-mm width with composite
resin restorations. Thus, the patient’s resulting central
incisor width was equal to the mean value of that of the
population7 and was harmonious with the adjacent teeth
and the patient’s face.
Using limited orthodontics for MMD closure with
segmental arch wire from central incisor to central incisor in
conjunction with an elastomeric chain is predictable, as long
as retraction of the incisors is not required.5 After ortho-
dontic treatment, composite resins were used not only to
close the remaining MMD but also to stabilize the teeth.16 A
posttreatment frenectomy was considered unnecessary
because there was no residual tissue excess.5
The presence of a diastema is one of the causes of
deficient or absent interdental papillae.17 While periodontal
surgery is an option for creating a papilla,9 for this patient,
the interdental gingiva between the central incisors was
“squeezed” together with movement of the teeth, physically
displacing the tissue coronally to create a papilla,18 as
another benefit of the orthodontic treatment. After
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treatment, the patient’s smile displayed harmonious gingival
contours and appropriate tooth size and shape.
SUMMARY
In esthetic dilemmas such as diastema closure, a
comprehensive smile analysis is essential prior to treat-
ment. When maximal tooth conservation is required,
direct composite resin restorations, with their combined
benefits of esthetics, minimal invasiveness, and longevity
are the favored treatment option.19 Together with or-
thodontics, direct composite resins offered this patient a
cost-effective, conservative resolution of her MMD.
REFERENCES
1. Bernabe E, Flores-Mir C. Influence of anterior occlusal characteristics on self-
perceived dental appearance in young adults. Angle Orthod 2007;77:831-6.
2. Chu CH, Zhang CF, Jin LJ. Treating a maxillary midline diastema in adult
patients: a general dentist’s perspective. J Am Dent Assoc 2011;142:1258-64.
3. Keene H. Distribution of diastemas in the dentition of man. Am J Phys
Anthropol 1963;21:437-41.
4. Edwards JG. The diastema, the frenum, the frenectomy: a clinical study. Am J
Orthod 1977;71:489-508.
5. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 5th ed. St.
Louis: Mosby/Elsevier; 2013. p. 7, 451-2.
6. Kuljic BL. Merging orthodontics and restorative dentistry: an integral part of
esthetic dentistry. J Esthet Restor Dent 2008;20:155-63.
7. Chu SJ. Range and mean distribution frequency of individual tooth width of
the maxillary anterior dentition. Pract Proced Aesthet Dent 2007;19:209-15.
8. Bhuvaneswaran M. Principles of smile design. J Conserv Dent 2010;13:
225-32.
9. De Araujo EM Jr, Fortkamp S, Baratieri LN. Closure of diastema and gingival
recontouring using direct adhesive restorations: a case report. J Esthet Restor
Dent 2009;21:229-40.
10. Heymann HO, Hershey HG. Use of composite resin for restorative and or-
thodontic correction of anterior interdental spacing. J Prosthet Dent 1985;53:
766-71.
11. Heymann HO. The artistry of conservative esthetic dentistry. J Am Dent
Assoc 1987;Spec No:14E-23E.
12. Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry.
Dent Clin North Am 2007;51:487-505, x-xi.
13. Francisconi LF, Freitas MC, Oltramari-Navarro PV, Lopes LG,
Francisconi PA, Mondelli RF. Multidisciplinary approach to the establishment
and maintenance of an esthetic smile: a 9-year follow-up case report.
Quintessence Int 2012;43:853-8.
14. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent
1984;51:24-8.
15. Dietschi D. Optimising aesthetics and facilitating clinical application of
free-hand bonding using the ‘natural layering concept’. Br Dent J 2008;204:
181-5.
16. Mussig E, Lux CJ, Staehle HJ, Stellzig-Eisenhauer A, Komposch G. Appli-
cations for direct composite restorations in orthodontics. J Orofac Orthop
2004;65:164-79.
17. Blatz MB, Hurzeler MB, Strub JR. Reconstruction of the lost interproximal
papillaepresentation of surgical and nonsurgical approaches. Int J Peri-
odontics Restorative Dent 1999;19:395-406.
18. Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol
2000 1996;11:65-8.
19. Wolff D, Kraus T, Schach C, Pritsch M, Mente J, Staehle HJ, et al. Recon-
touring teeth and closing diastemas with direct composite buildups: a clinical
evaluation of survival and quality parameters. J Dent 2010;38:1001-9.
Corresponding author:
Dr Courtney S. Babb
Department of General Dentistry
Dental College of Georgia at Augusta University
1120 15th St, GC-3090
Augusta, GA 30912
Email: cbabb@augusta.edu
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
Romero et al