Performing esthetic and affordable diastema closures with composite restoratives

By David J. Clark, DDS

Flowable restoratives are still relatively new to the dental materials world. Given that it often takes the dental community a decade or two to embrace a material, many dental professionals are of the opinion that the jury is still out on flowables. My personal observation is that flowables are either overutilized or underutilized, depending on the clinician. However, I believe that by finding the proper balance between flowable and paste composites, clinicians can make these materials an invaluable part of their repertoire.

The recent availability of an anatomic diastema closure matrix (Bioclear Matrix Systems) makes it possible to achieve porcelain-like contours with composite materials, allowing dentists to offer an alternative treatment to patients who wish to avoid the expense of porcelain. But with this new capability, it is extremely important that dentists select the proper flowable material. For maximum success, a flowable should:

1. Be strong enough to avoid wear and fracture.
2. Achieve and maintain a high level of polish to compete with porcelain.
3. Provide strong esthetics, and match the corresponding shades of paste composite.

The following case demonstrates an appropriate and balanced use of flowable and paste composites to perform diastema closures. Case descriptionThe patient had diastemas between both the upper central incisors and peg laterals (Fig. 1). Treatment plans were presented to restore the teeth with either porcelain or composite veneers, and the patient chose to move forward with the lower-cost composite treatment.

Fig. 1: The patient’s peg laterals presented a restorative challengeA rubber dam was placed in order to provide interproximal gingival retraction. An aluminum chloride astringent was placed underneath the dam and burnished into the sulci to control crevicular fluids. The centrals and canines were restored first in order to build out the areas surrounding the very small peg laterals, which were left for last. For each procedure, Bioclear DC203 diastema closure matrices were placed inciso-gingivally to the point where the gingival aprons on the matrices were near the depth of the sulcus (Fig. 2). The rubber dam provided sufficient lateral pressure in this step to seal the gingival margins. Alternately, dentists may use gentle approximating devices, such as an Interproximator (Bioclear). A traditional wooden or plastic wedge should not be used in this wedging step in order to avoid deforming the precurved matrix.

Fig. 2: Bioclear diastema closure matrices are placed inciso-gingivally A 37% phosphoric acid was applied to etch the area, then rinsed and dried. Next, a thin layer of bonding resin was placed. This bonding resin was air-thinned, but not cured. A small amount of 3M™ ESPE™ Filtek™ Supreme Ultra Flowable Restorative in shade B1 was placed into the interproximal form, both facially and lingually (Fig. 3). The flowable was not light-cured, but rather immediately followed with injection of 3M™ ESPE™ Filtek™ Supreme Ultra Universal Restorative in shade B1. The two restoratives were then light-cured together and the restorations were polished (Fig. 4).

Fig. 4: The diastemas were esthetically treated with the combination of paste and flowable compositesDiscussionThis case explains how an appropriate and balanced use of flowable and paste composites can be used to create the proper emergence profile to close space and regenerate papillae. The knife-edged emergence profile created by the anatomic matrix makes it virtually impossible for a paste composite to reach everywhere, but use of the flowable material both fills these tiny spaces and serves as a wetting agent for the subsequent application of paste, helping it get in hard-to-reach areas of the matrix. The spacing of the patient’s teeth in this case was such that the peg laterals could not be treated alone. Small amounts of bulk were added to both distals of the central incisors and the mesials of the canines to appropriately close the significant space left by the laterals. The same technique was applied to build each tooth with the combination of flowable and paste composites. For cases such as this where esthetics is vital, Filtek Supreme Ultra flowable restorative offers the shine and polishability necessary to rival a porcelain restoration. It also offers a strong shade match with its paste counterpart, helping further assure strong esthetics. The ability to restore cases such as this with a composite treatment, as opposed to only being able to offer porcelain, helps dentists offer patients a more economical option without compromising esthetics. I would recommend both this product and the unique technique described here for predictable and successful restorative outcomes.

David J. Clark, DDS, founded the Academy of Microscope Enhanced Dentistry to advance the art and science of microdentistry, micro-endodontics, micro-periodontics, and dental microsurgery. He is a course director at the Newport Coast Oral Facial Institute. He is on the editorial board for several journals. Dr. Clark has developed a matrix and interproximal management system, the Bioclear Matrix System that promises a real advancement for both bonded porcelain and direct composites.