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Rubber dam isolation –
key to success
in diastema closure technique
with direct composite resin
Paulo Ricardo Barros de Campos, DDS
Rodrigo Rocha Maia, DDS, MS, PhD
Livia Rodrigues de Menezes, DDS, MS, PhD student
Isabel Ferreira Barbosa, DDS, MS, PhD student
Amanda Carneiro da Cunha, DDS, MMS, PhD student
Gisele Damiana da Silveira Pereira, DDS, MS, PhD

Correspondence to: Paulo Ricardo Barros de Campos, DDS
Rua Professor Paulo Rocco 325/2° andar, Ilha da Cidade Universitária, Rio de Janeiro, RJ, 21.941-913, Brazil;


two diastema closure cases are of paramount importance as it prevents presented using direct composite resin moisture contamination and ensures in- with rubber dam isolation.&t/6. creased gingival retraction compared to (Int J Esthet Dent 2015.10:564–574) access to the cervical area of the tooth. avoiding a space be- without the removal of sound tooth struc- tween the papilla and the restored tooth. This provides better The use of direct composite resin for facilitating proper placement of resin to diastema closure has technique ad- recreate the natural anatomical contours vantages. there is a more procedure can be carried out in one natural adaptation of the restoration to appointment at a reasonable cost and the gingival tissue. ture.BARROS DE CAMPOS ET AL Abstract other techniques. including that the restorative and contact point.#&3t8*/5&3 . The use of a rubber dam for clos- To illustrate the advantages of this tech- ing diastemas with composite resin is nique. Thus. 565 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.

7.2 Dental professionals need to an indirect procedure. and facial shape. and habits. Diastemas are resin create esthetic restorations without more prevalent in females.9 Orthodon- as atypical insertion brake lip. and low cost.#&3t8*/5&3 . more com- the removal of healthy tooth structure. physiological or from the palatine using direct or indirect procedures.13 Options to resolve diastemas can These results are mainly due to the de- involve various specialties. presence of mesiodens. The 566 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. functional. ures. it requires more strive for continuous improvement in or- invasive removal of tooth structure and der to offer esthetic solutions that satisfy is more expensive than direct proced- these expectations. however. a careful examination and the strated excellent results with direct com- correct diagnosis of diastemas helps the posite restorations based on the bio- clinician to make the appropriate treat- logical. The main advantages of well as improved composite resin ma- treatment through the direct procedures terials. the more con- dentition stage.1 Closure of diastemas with por- years1 Orthodontic diastema closure requires fixed orthodontic braces.3 These teeth correctly for proper occlusion and spaces can be classified as pathologi- size. and and compositions of these systems. in- due to the high expectations of celain veneers or crowns also provides patients. One consequence of a diastema be- predictability.&t/6.8 Diastemas are characterized by the An interdisciplinary approach can presence of interdental spaces that be taken.10 Restorative procedures populations varies according to gender. who want to have beautiful excellent results.4 The presence of diastemas in other factors. such prioritized by professionals. speed. while the pathological servative treatment should always be one can have numerous etiologies. acteristics of each patient’s teeth. mon between the ages of 14 and 34. orthodontics. as in cases where orthodon- can be seen to constitute an inharmoni- tic treatment is carried out to align the ous factor in a patient’s smile. size. agene- tics is a conservative treatment but can sis.6 of the closure of interdental spaces. such periodontal disease. absence of a maxillary be difficult due to the individual char- lateral incisor. because it is smiles. height/width ratio. The physiological spacing cording to the current concept of mini- commonly occurs during the primary mally invasive dentistry. and can improve some of the individual and occur more in mesofacial patients characteristics.CLINICAL RESEARCH Introduction sults. and deleterious as shape.12. The demand for esthetic excellence volving the greatest amount of time and in dental care has increased in recent cost. microdontia.11 growth. using direct bonding with composite age.5 Recent clinical studies have demon- Therefore. and then space closure is finalized cal. as prosthodontics. Ac- disjunction. and esthetic aspects who ment have balanced facial choice. of operative dentistry include simplicity.6 with tween the maxillary central incisors is the reversible and almost imperceptible re- absence of the interdental papilla. including velopment of the adhesive techniques operative dentistry.

thus increasing the Fig 3 Cervicoincisal height (blue line). when it was 6 mm.#&3t8*/5&3 . Clinical case descriptions Case 1 A 22-year-old Caucasian female patient to the cervicoincisal dimension. presented for esthetic enhancement of her smile. In a study conducted in 1992.BARROS DE CAMPOS ET AL distance between the interdental contact point of these teeth and the alveolar bone crest has significant influence in interdental papilla presence. gingival papilla level (pink line). evaluation of teeth measurements. it was present in only 27% or less of Fig 1 Preoperative smile view. After the patient’s medical and dental histories were reviewed. The recommended treatment plan involved closing the diastema with composite resin.&t/6. and when it was 7 mm or more. the papilla was 100% present in almost all cases. and the following results were obtained: when the distance was less than 5 mm. the papilla was present in 56% of cases. Clinical examination revealed the presence of a diastema between the maxillary central incisors. which included an assessment of tooth size relationships. a clinical and radiographic examination was performed. A smile analysis was done. phonetic evaluation. this distance was estimated for 200 interproximal sites. The teeth were found to have a small mesiodistal width in relation to the cervicoincisal dimension (Figs 1 and 2). the factors that are essential for obtaining a successful result are good diagnosis and treatment planning (including functional assessment). and preparation of a diagnostic wax-up. Fig 2 Note the small mesiodistal width in relation cases. 567 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. dental positioning.14 Despite the numerous treatment options.

15 Measurements accurate determination of color. provide the correct space for la. placing and sculpting 568 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. and allow com- would naturally form between the cervi- posite addition with a gradual contour cal contours of the restored teeth. gingival Fig 5 Volume of resin corresponding to the space papilla level before rubber dam (red line). Embrasure and proximal tooth surface inclination before restoration (yellow line). while opalescence is based on without damaging tooth structure. tooth width between 75% and the teeth were still moist to facilitate an 85% of tooth height.#&3t8*/5&3 . ing multiple layers and the “pull trough” The value is the brightness. ie. mesiodistal dimension of the incisors tooth.&t/6.CLINICAL RESEARCH Fig 4 Cervicoincisal height (blue line). The adhesive system Single selection was made by first choosing Bond 2 (3M ESPE) was then applied ac- chromaticity. while enamel incisal characteristics. tion. then value and opales- cording to manufacturer’s instructions. cence. which should be chosen at the was closed by freehand technique us- middle and cervical thirds of the tooth. also required that this contact be 4 mm A total-etch technique was selected or less from the interdental crestal bone for the bonding procedure. The were made using a digital caliper. to ensure that the interdental papilla interproximal contact. The shade air dried. The chromaticity is the dentin and polymerized for 20 s. then gently ations was color mapping. space achieved by papilla retraction with rubber dam isola- obtained by gingival tissue retraction (green line). was etched with 35% phosphoric acid The next step in planning the restor- for 15 s.16 achieving the ideal esthetic propor- Shade selection was performed while tions. which should technique from lingual to facial with clear be determined at the middle third of the celluloid matrix. as well based on the ideal distance between as to allow greater gingival retraction the incisal edge and the gingival papil- (Fig 4). Each tooth level (Fig 3). The diastema color. rinsed with water. This similar to that of the natural tooth (Fig 5). Ref- operative field was isolated with rubber erence points for the desired proximal dam to permit ideal moisture control for contact in the final restorations were an adhesive dental procedure. embrasure and proximal tooth surface inclination after the restoration (pink line). embrasure and proximal tooth surface inclination without absolute isolation (green line).

This helps to obtain a (3M ESPE) and rubber finishing cups smoother contour between the restored and points (Edenta). an air-inhibited layer. after polymerization of this ing technique was used for the direct increment. To sep- “free” polychromatic incremental layer- arate them. more ideal space Using the technique 569 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. Proper erated some debris on the surface of the contouring of the gingival embrasure first restoration and after the removal of provides a smaller. FGM) to teeth toration therefore did not adhere to the the nanohybrid composite 8 and 9 to achieve the desired restora- adjacent tooth.&t/6. finishing was done with excellent gingival retraction compared a surgical blade No. After the conclusion of tive outcome. Dentsply) at an intensity in the same way as the first restoration. These steps gen- cervical and proximal surfaces.BARROS DE CAMPOS ET AL Fig 6 A small black triangle at the apex of the interdental papilla. rubber dam isolation provides sial of tooth 11).#&3t8*/5&3 . 12. followed by a to other techniques. with both of 450 to 490 nm to ensure adequate restorations able to receive the immedi- polymerization. described In addition to offering absolute field above. The resin material was the first buildup. 4 (Tigre). A that touched the adjacent tooth. (Opallis. ate final finishing and polishing. The second res- shades A1/T-Neutral/VH. a small torque with an IPC or composite buildup. the second (mesial of contoured using composite resin instru- tooth number 21) was done initially by NFOUT 4VQSBGJMM 448IJUF BOEBSUJTUT creating a thin wall of dental composite Sable Touch Brush 486 No. PGN8DN2 and a wavelength range creating the proximal contact. each increment of similar instrument is sometimes neces- nanohybrid composite was light-cured sary to achieve the correct matrix place- for 20 s using a blue LED light source ment and to pull through the composite (SmartLite PS. Fig 7 Another image showing the small black space. such as the use of pre-polish with ultrafine finishing discs retraction cord. after the first tooth buildup (me- control.

Once the restorations were finished. The patient was cautioned regarding harmful habits (such as biting the lips or hard objects.&t/6. 570 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. nail biting.CLINICAL RESEARCH to be occupied by the gingival papilla. ultrafine finishing discs (3M ESPE). 12 blade. a small black triangle was observed at the apex of the interdental papilla (Figs 6 and 7) due to the gingival tissue not completely filling the embrasure. and rubber finishing cups and points (Edenta). The appearance of the papilla 1 week Six months later. Upon completion of the restorative work. 6 months the papilla occupied the entire space (Figs 9 and 10). KG Sorensen). opening objects with the teeth. observe the final aspect later showed that it had nearly filled the of the restorative treatment. etc). and it was emphasized that proper care is closely related to treatment longevity.#&3t8*/5&3 . The rubber dam was removed and the restorations finished using diamond burs (2200 F and 3168 F. forming a step in relation to the original tooth contour (yellow line). a No. nearly filling the gingival embrasure. the resin addition might follow the outline indicated by the green line.17 Fig 10 Final result at 6-month clinical follow-up. An adequate balance gingival embrasure (Fig 8). Figure 5 shows that without rubber dam isolation and retraction. is possible to obtain a more appropriate contact and symmetrical contours in the final restoration (pink line). By using the isolation and retraction offered by the rubber dam. and after Fig 9 between soft and hard tissues is evident. it Fig 8 The papilla 1 week after the restoration. the patient was given instructions regarding oral hygiene and maintenance of the restorations. which is then slightly compressed to fill the entire interdental space in the final restoration.

the application of the Single Bond 2 adhesive system according to the manufacturer’s instructions.#&3t8*/5&3 . which also allowed for effective gingival retraction. Total rubber dam isolation of the maxillary 571 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. resulting in a black triangle with the absence of an adequate interdental papilla (Fig 11). Observe the inadequate proximal contours in the restoration. the proximal restor- Fig 11 Preoperative smile view. Total isolation of the maxillary anterior teeth was achieved using rubber dam (Fig 13). and the placement of composite resin (Opallis). ations were removed (Fig 12). After color mapping of the teeth had been performed. anterior teeth. This facilitated the completion of a new restoration with ideal contour and contacts. For this case. the rubber dam was ligated at the cervix of each tooth using dental floss. it was observed that inadequate proximal contours existed in the restoration. During examination and case analysis.&t/6. Clinical examination revealed the presence of a diastema between the maxillary central incisors. After the proximal restorations had been the previous case: acid etching. but also provided esthetic improvement by modifying the angle between the cervical and proximal surface to close the gingival embrasure (Figs 14 and 15) in a manner that provided proper space for the interdental papilla to fill the embrasure for a natural Fig 13 and esthetic result. The newly completed restoration not only reproduced the ideal contours and contact of the teeth. To enhance isolation. the restorative procedure also made use of the freehand technique and continued according to Fig 12 the exact same steps as described for removed.BARROS DE CAMPOS ET AL Case 2 A 23-year-old Caucasian male patient presented for esthetic enhancement of his smile. which resulted in a black triangle with the absence of an adequate interdental papilla.

and the patient’s desires.12 The ing diastemas is that the rubber might treatment choice for the two cases de- interfere with proper cervical adapta- scribed in this article was direct bonding tion of the restoration. It is known that with composite resin. Interdental pa- ducing the ideal contours and contact of the teeth. rubber dam proach to diastema closure. time avail- regarding rubber dam isolation for clos- ability. with sev- isolation is advantageous to obtain bet- eral authors advocating the use of di- ter gingival retraction without moisture rect composite resin as the material of contamination.&t/6. as the size of the interdental sive movement. compared to the use of choice due to its good clinical longevity. in- composite resin.12 572 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. Further.CLINICAL RESEARCH Fig 14 The newly completed restorations repro- Fig 15 Postoperative frontal view. a direct approach to diastema Obtaining good gingival retraction is closure is a less expensive and less in- crucial to enable composite addition in vasive treatment option compared to areas previously occupied by gingival indirect techniques. as well The proper location of the contact ar- spaces. economics. remaining sound tooth structure. retraction cord.18-21 tissue.22 ea in relation to the level of the alveolar It has been suggested to use microfilled crest might determine that the interden- resins in smaller spaces without occlusal tal papilla will completely fill the gingival contact. pilla fills the embrasure for a natural and esthetic and resulting in improved esthetics. as a means of field control and to achieve it is thought that restorative material gingival retraction for the placement of choice is based on several factors. Proper isolation and retraction The type of composite resin selected is essential to achieve the correct ana- depends on the amount and condition of tomical location of the proximal contact. and microhybrid and nanopar- embrasure and prevent the unesthetic ticle composites in larger spaces or in black triangle that can occur if the proxi- areas of occlusal contact during excur- mal contact is located too far incisally.#&3t8*/5&3 Achieving anatomically correct contact . result. One of the questions cluding etiology. Discussion The technique used in the cases presented here uses rubber dam isolation Given the numerous treatment options.12 Therefore. composite resin requires a moisture-free The literature supports a direct ap- environment.

The second step gery being avoided.24. These measurements are made vantages of this technique include: to ensure that after the accomplishment Needing fewer clinical sessions com- of absolute isolation. which serves as a proper contact. The proper location of the restorations. The spacing an advantage in adhesive restorative is then closed with a new direct compos- techniques. Another factor to be considered is the it demands more clinical hours. where a Obtaining excellent field and moisture scalpel blade is used to carve the region control. reference to the pared to the technique that uses pro- DPOUBDUQPJOUMPDBUJPOJTOPUMPTU8JUIPVU visional restorations for gingival re- these procedures.25 priate proximal contours and contacts Another technique requires four ses- at the tooth restorative interface. where a dry and clean sur- ite resin.23 The apex of the interdental papilla is used as a reference to determine the optimum height for the contact point. to ensure the gingival papilla. sions to close diastemas.1 Although good re- long-lasting esthetic restoration. thus preventing the conditioning of the papilla. provisional restoration to perform a grad- Contours and an emergence profile ual compression of the gingival area. rubber dam isolation offers ite that had been cemented. the use of rubber dam iso- digital caliper. Moreo- distance from the proximal contact point ver. ity of forming a step between tooth and Obtaining optimal gingival retraction composite due to a lack of a significant that is superior to that obtained by us- gingival retraction.3.12. The ad- papilla. and the space is closed Obtaining better access to create with composite resin. and plaque accumulation contact point in relation to the bone crest causes local inflammation. The that mimics the natural tooth and al- third step is to anesthetize the patient and low accommodation of the natural cement the restorations. Thus.14. Conclusions Measurement is made with a probe or In this article. mon in cases where the cord retraction Preparing the restoration with appro- technique is used. which makes avoids the appearance of a black triangle it difficult to obtain an appropriate field.23 sults are obtained using this technique. the impression is made and the pa- techniques such as periodontal sur- tient model is obtained.BARROS DE CAMPOS ET AL and contour is essential for the esthet- returns after 1 or 2 weeks for the fourth ics and longevity of any restorative tech- step. takes place in the laboratory. In the first ses- Greater patient comfort. The patient appearance of black triangles. 573 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6. of the papilla. which is very com- ing the cord retraction technique.26 between the teeth and gingival tissue. without using absolute isolation gical field provides the foundation for a and cord retraction.&t/6.#&3t8*/5&3 . sometimes oral hygiene is difficult and the height of the alveolar bone crest for patients who have these temporary interdentally. there is the possibil- traction. with invasive sion. measuring from the in- lation for direct diastema closure with cisal edge of the tooth to the tip of the composite resin is presented. which is the removal of the compos- nique.

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