The Use of Gingivoplasty,

Direct Composite Resin

Restorations, and Minor Tooth
Movement to Close Maxillary
Anterior Diastemata
André Luis Faria-e-Silva, MS, PhD
Professor, Department of Dentistry, Federal University of Sergipe, Aracaju, Brazil.

Adriano Augusto Melo de Mendonça, MS, PhD

Professor, Department of Dentistry, Federal University of Sergipe, Aracaju, Brazil.

Alaíde Hermínia de Aguiar de Oliveira, MS, PhD

Professor, Department of Dentistry, Federal University of Sergipe, Aracaju, Brazil.

Margarete Aparecida Menezes de Almeida, MS, PhD

Professor, Department of Dentistry, Federal University of Sergipe, Aracaju, Brazil.

The closure of a large anterior diastema is a challenging task for

dental clinicians. This case report describes the closure of a large
midline diastema with associated shorter diastemata using crown-
lengthening surgery, direct composite resin restorations, and minor
tooth movement. To significantly lengthen the incisors, 2 mm of gin-
gival tissue was removed. A wax-up was fabricated to determine the
adequate height-to-width ratio of the teeth. Diastemata were closed
using direct composite resin restorations completed over two ap-
pointments. Between these visits, the incisors were slightly moved
toward the midline using elastomeric separators. At the 6-month
follow-up, complete diastema closure and the absence of black
spaces were observed. (Am J Esthet Dent 2012;2:136–143.)

Correspondence to: Dr André Luis Faria-e-Silva

Department of Dentistry, Rua Claudio Batista, s/n, Sanatório, Aracaju, Sergipe, Brazil 49.060-100.
Email: faria_silva@ufs.br

136
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
A diastema is an undesirable space created by the absence of contact
between adjacent teeth.1 Tooth-to-tooth contact plays an important role in
protecting the soft tissues from the accumulation of food particles during masti-
cation.2 Further, diastemata in the anterior region can negatively affect the har-
mony of the smile.3 The presence of a diastema is mainly related to the absence
of teeth, discrepancies between the size of the dental arch and the width of the
teeth, the presence of supernumerary teeth, proclination of the maxillary labial
segment, or a prominent frenum.4
Diastema closure presents a challenge for clinicians. Several techniques have
been used to close diastemata, including orthodontic treatment, indirect resto-
rations (crowns or laminate veneers), and direct restorations using composite
resin.5 Orthodontic treatment requires the use of fixed appliances and is a com-
plex, longer, and more expensive treatment. Indirect restorations generally require
tooth preparation, resulting in the loss of sound dental structure. Additionally,
laboratory procedures for indirect restorations can increase the cost of treat-
ment. Direct restorations, in contrast, offer satisfactory esthetics, easier repairs,
reduced working time and costs, and minimally invasive clinical procedures.
Regardless of the technique used, successful diastema closure in the esthetic
zone requires careful treatment planning.  The restorative procedure must aim
to establish or maintain a harmonious smile. Since tooth widths are altered in
diastema closure, the height of the teeth must also be altered to obtain a proper
height-to-width ratio.6 However, excessive increase of maxillary tooth height can
compromise the excursive movements of the mandible. An alternative method is
to increase the clinical crown height followed by gingivoplasty. Gingivoplasty is
required to obtain an esthetic gingival contour. Moreover, to maintain the esthetics
of the smile, restorative procedures must be used to fill the space underneath the
contact area with interdental papilla.2
This case report describes the closure of several diastemata using a combination
of periodontal and direct restorative procedures.

137
VOLUME 2 • NUMBER 2 • SUMMER 2012

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 FARIA-E-SILVA et al

Fig 1   Preoperative smile. Fig 2   Preoperative view showing the large mid-
line diastema, altered height-to-width ratio of the
central incisors, and fractured composite resin
restorations with excess restorative material.

CASE REPORT Impressions of both arches were tak-

en using irreversible hydrocolloid im-
A 23-year-old man was referred to the pression material to facilitate treatment
dental clinic of the Federal University planning. A stone cast was used to plan
of Sergipe, Aracaju, Brazil, with com- the height of each tooth using the gold-
plaints about the appearance of his en proportion based on the width of the
smile. The patient reported that he anterior teeth needed to permit diaste-
had undergone restorative treatment ma closure. Due to the extensive mid-
using composite resin several years line diastema, the plan was to reduce
prior to close his diastemata. How- this space with a slight movement of the
ever, this procedure had not achieved central incisors toward the midline. The
adequate esthetics, and the restora- treatment plan specified the use of elas-
tions had fractured during function. tomeric separators after increasing the
Clinical examination revealed a large widths of the central incisors. This pro-
midline diastema between the maxil- cedure would allow the composite resin
lary central incisors (Figs 1 and 2). used to close the diastema to be divid-
Smaller spaces were also observed ed between the mesial and distal as-
between the central and lateral incisors pects. The same procedure was
and between the lateral incisors and planned for the lateral incisors.
canines on both sides of the maxilla. The height of the central incisors was
The preexisting restorations showed planned for an increase of 4 mm, while
excess composite resin along with the the height of the lateral incisors would
fracture. The restored crowns on the be increased by 3.5 mm. Thus, the
central incisors presented an unes- crown would be lengthened before re-
thetic height-to-width ratio because the storative procedures were conducted
restored teeth were too wide. to reduce the amount of composite

138
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 FARIA-E-SILVA et al

Fig 3   Intraoral view immediately after gingivo- Fig 4   Maxillary anterior teeth 1 week after peri-
plasty. odontal surgery. The fractured restorations were
removed, and the enamel was polished.

resin inserted at the incisal edge. Ade- would only be achieved after tooth
quate positioning of the gingival zeniths movement. To create sufficient space
was also considered during treatment for the insertion of composite resin at
planning. It was decided to remove the buccal aspect, a vinyl polysiloxane
2 mm of gingival tissue for each tooth. index was created based on the wax-
Under local anesthesia, a gingivec- up. This index was positioned over the
tomy was performed with a sulcular buccal surfaces of the anterior teeth to
incision and a full-thickness mucoperi- guide the tooth preparation (Fig 6). The
osteal flap, followed by removal of the buccal surfaces were prepared using a
buccal gingival tissues, with preser- diamond bur (no. 2135F, KG Sorensen)
vation of the papilla (Fig 3). No bone and sandpaper aluminum oxide disks
tissue was removed once the distance (Soflex Pop-On, 3M ESPE).
between the gingival margin and the The enamel was etched with 35%
alveolar bone crest was longer than phosphoric acid for 30 seconds, fol-
2 mm for all teeth. One week after sur- lowed by rinsing with water and drying.
gery, the unsatisfactory composite res- The adhesive system (Adper Single
in restorations were removed, and the Bond 2, 3M ESPE) was applied in two
enamel was polished (Fig 4). consecutive layers. A gentle airstream
Thirty days after periodontal surgery, was then applied, and the adhesive
adequate healing had occurred, and was light cured for 20 seconds. Another
the gingival contour was examined. A index based on the wax-up was used
second impression of the maxilla was to guide the restoration of the palatal
taken using vinyl polysiloxane impres- surface (Fig 7). For the restoration of all
sion material. A diagnostic wax-up was maxillary incisors, the composite resin
fabricated based on the restorative plan (shade CT, Filtek Z350XT 2, 3M ESPE)
(Fig 5). Complete diastema closure was placed on the index positioned

139
VOLUME 2 • NUMBER 2 • SUMMER 2012

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 FARIA-E-SILVA et al

Fig 5   The diagnostic wax-up. The midline dia­ Fig 6   Vinyl polysiloxane index used to guide
stema remains since this space would be closed the tooth preparation.
later using elastomeric separators.

Fig 7   Vinyl polysiloxane index used to guide Fig 8   Composite resin was used to simulate
the restoration of the palatal surfaces. the opaque halo.

over the palatal surface. After the first Direct) was used as the last increment
increment was light cured, dentin (Fig 8). Figures 9 and 10 show the
composite resin (shade A2 dentin, IPS completed restorations.
Empress Direct, Ivoclar Vivadent) was After these restorative procedures,
applied over the abraded enamel and elastomeric separators were placed
1.0 to 1.5 mm over the incisal edge. between the central and lateral incisors
Next, composite resin (shade CT, Filtek and between the lateral incisors and the
Z350XT) was applied between the canines (Fig 11). Complete closure of
mamelons created with the dentin the midline space was observed after
composite resin as well as incisally 48 hours, leaving only the restoration
to this increment. Enamel composite of the distal aspects of the central
resin (shade A1 enamel, IPS Empress and lateral incisors to be completed

140
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 FARIA-E-SILVA et al

Figs 9 and 10   The completed composite resin restorations.

Fig 11   Elastomeric separators placed between Fig 12   Complete closure of the midline space
the central and lateral incisors and between the 48 hours after placement of elastomeric separa-
lateral incisors and canines. tors.

(Fig 12). The Levin grid was used to performed using a 12-blade finish-
confirm the golden proportion be- ing bur (KG Sorensen) and sandpa-
tween the widths of the anterior teeth per aluminum oxide disks. Polishing
(Fig 13). The elastomeric separators was performed after 24 hours using a
were individually replaced by wood silicon carbide brush (Astrobrush,
wedges to maintain the obtained posi- Ivoclar Vivadent) and felt disks with dia-
tions. After the adhesive procedures, mond paste (Universal Polishing Paste,
composite resin (shade A1 enamel, Ivoclar Vivadent). Figure 14 shows the
IPS Empress Direct) was inserted at the final result 15 days after polishing.
distal aspect of the central and lateral The 6-month follow-up revealed well-
incisors to close the proximal space. maintained esthetics and complete
Immediate finishing procedures were closure of all diastemata (Fig 15).

141
VOLUME 2 • NUMBER 2 • SUMMER 2012

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 FARIA-E-SILVA et al

Fig 13 (left)  Levin grid used to confirm the

proper proportions between the widths of the
teeth.

Fig 14   Postoperative view 15 days after final Fig 15   Six-month follow-up. The esthetics were
polishing. Adequate harmony of the smile was well maintained, and no diastemata between the
achieved. teeth were evident.

DISCUSSION ite resin resulted in inflammation of the

gingival tissue. Patients may present
Larger diastemata negatively affect gingival margins positioned coronally
the appearance of the smile, and their to the cementoenamel junction due to
closure remains a clinical challenge. In alterations in the eruption process, re-
such cases, restorative treatment plan- sulting in wide teeth. This alteration is
ning must consider the proper height-to- observed in 12.5% of children between
width ratio of the anterior teeth. Further, 6 and 16 years of age,7 whereas pas-
the gingival architecture, including the sive dental eruption can be observed
presence of interdental papillae, is im- until the age of 19.8 In the present case,
portant to the esthetic outcome. the crown lengthening achieved by the
In the present case, a previous at- removal of gingival tissue was sufficient
tempt to close the diastema had re- to improve the height-to-width ratio
sulted in an inadequate height-to-width without exposing the cemento­
enamel
ratio. Additionally, the excess compos- junction.

142
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 FARIA-E-SILVA et al

Despite the esthetic improvement 0.16 mm within 12 or 24 hours of use.8

obtained solely by the surgical proce- Two elastomeric separators were used
dures, diastema closure was required on the same side of the arch to improve
to achieve a harmonious smile. The this effect. Further, the longer duration
dental width was increased by the in- of use (48 hours) was sufficient to ob-
sertion of composite resin in the incisal tain complete closure of the midline
area. This procedure was difficult be- space.
cause the composite resin must not The location of the contact point must
hinder the excursive movements of the also be observed during restorative
mandible, thus limiting the amount of procedures. It has been reported that
composite resin that can be inserted. a distance of 5 mm between the con-
Canine guidance must be observed. tact point and the bone crest results in
In this case, the canine guidance pre- almost 100% interdental papilla devel-
sented by the patient permitted an opment.9 This percentage is reduced
approximately 2-mm increase in the to 56% or 27% when the distance is
height of the incisors. This increase increased to 6 or 7 mm, respectively.
was sufficient to close the gap without The movement of teeth with elasto­
compromising the proper height-to- meric separators allows the clinician
width ratio of the teeth. to restore the contact point to an ade-
Another important aspect of this case quate position. Correct treatment plan-
was the need to move the incisors to- ning is an important tool for increasing
ward the midline to distribute the space the predictability of esthetic restorative
required for closing the diastema. It has procedures. Furthermore, the use of a
been demonstrated that elastomeric wax-up and periodontal treatment can
separators can move teeth more than help to enhance the final results.

REFERENCES
  1. Boushell LW. Diastema. J Esthet   5. Oquendo A, Brea L, David S.   8. Davidovitch M, Papanicolaou S,
Restor Dent 2009;21:209–210. Diastema: Correction of Vardimon AD, Brosh T. Duration
  2. Sharma AA, Park JH. Esthetic excessive spaces in the of elastomeric separation and
considerations in interdental aesthetic zone. Dent Clin North effect on the interproximal
papilla: Remediation and Am 2011;55:265–268. contact point characteristics.
regeneration. J Esthetor Restor   6. Moskowitz ME, Nayyar A. Deter- Am J Orthod Dentofacial
Dent 2010;22:18–28. minants of dental esthetics: A Orthop 2008;133:414–422.
  3. Chu FC, Siu AS, Newsome PR, rationale for smile analysis and   9. Tarnow DP, Magner AW,
Wei SH. Management of treatment. Compend Contin Fletcher P. The effect of the
median diastema. Gen Dent Educ Dent 1995;16:1164–1186. distance from the contact point
2001;49:282–287.   7. Morrow LA, Robbins JW, Jones to the crest of bone on the
  4. Huang WJ, Creath CJ. The DL, Wilson NHF. Clinical crown presence or absence of the
midline diastema: A review of length changes from age interproximal dental papilla.
its etiology and treatment. 12–19: A longitudinal study. J Periodontol 1992;63:995–996.
Pediatr Dent 1995;17:171–179. J Dent 2000;28:469–473.

143
VOLUME 2 • NUMBER 2 • SUMMER 2012

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Copyright of American Journal of Esthetic Dentistry is the property of Quintessence Publishing Company Inc.
and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.