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

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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.

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 FARIA-E-SILVA et al
Fig 1   Preoperative smile.
CASE REPORT
A 23-year-old man was referred to the
dental clinic of the Federal University
of Sergipe, Aracaju, Brazil, with com-
plaints about the appearance of his
smile. The patient reported that he
had undergone restorative treatment
using composite resin several years
prior to close his diastemata. How-
ever, this procedure had not achieved
adequate esthetics, and the restora-
tions had fractured during function.
Clinical examination revealed a large
midline diastema between the maxil-
lary central incisors (Figs 1 and 2).
Smaller spaces were also observed
between the central and lateral incisors
and between the lateral incisors and
canines on both sides of the maxilla.
The preexisting restorations showed
excess composite resin along with the
fracture. The restored crowns on the
central incisors presented an unes-
thetic height-to-width ratio because the
restored teeth were too wide.
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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.
Impressions of both arches were tak-
en using irreversible hydrocolloid im-
pression material to facilitate treatment
planning. A stone cast was used to plan
the height of each tooth using the gold-
en proportion based on the width of the
anterior teeth needed to permit diaste-
ma closure. Due to the extensive mid-
line diastema, the plan was to reduce
this space with a slight movement of the
central incisors toward the midline. The
treatment plan specified the use of elas-
tomeric separators after increasing the
widths of the central incisors. This pro-
cedure would allow the composite resin
used to close the diastema to be divid-
ed between the mesial and distal as-
pects. The same procedure was
planned for the lateral incisors.
The height of the central incisors was
planned for an increase of 4 mm, while
the height of the lateral incisors would
be increased by 3.5 mm. Thus, the
crown would be lengthened before re-
storative procedures were conducted
to reduce the amount of composite

Fig 3   Intraoral view immediately after gingivo-
plasty.
resin inserted at the incisal edge. Ade-
quate positioning of the gingival zeniths
was also considered during treatment
planning. It was decided to remove
2 mm of gingival tissue for each tooth.
Under local anesthesia, a gingivec-
tomy was performed with a sulcular
incision and a full-thickness mucoperi-
osteal flap, followed by removal of the
buccal gingival tissues, with preser-
vation of the papilla (Fig 3). No bone
tissue was removed once the distance
between the gingival margin and the
alveolar bone crest was longer than
2 mm for all teeth. One week after sur-
gery, the unsatisfactory composite res-
in restorations were removed, and the
enamel was polished (Fig 4).
Thirty days after periodontal surgery,
adequate healing had occurred, and
the gingival contour was examined. A
second impression of the maxilla was
taken using vinyl polysiloxane impres-
sion material. A diagnostic wax-up was
fabricated based on the restorative plan
(Fig 5). Complete diastema closure
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FARIA-E-SILVA et al
Fig 4   Maxillary anterior teeth 1 week after peri-
odontal surgery. The fractured restorations were
removed, and the enamel was polished.
would only be achieved after tooth
movement. To create sufficient space
for the insertion of composite resin at
the buccal aspect, a vinyl polysiloxane
index was created based on the wax-
up. This index was positioned over the
buccal surfaces of the anterior teeth to
guide the tooth preparation (Fig 6). The
buccal surfaces were prepared using a
diamond bur (no. 2135F, KG Sorensen)
and sandpaper aluminum oxide disks
(Soflex Pop-On, 3M ESPE).
The enamel was etched with 35%
phosphoric acid for 30 seconds, fol-
lowed by rinsing with water and drying.
The adhesive system (Adper Single
Bond 2, 3M ESPE) was applied in two
consecutive layers. A gentle airstream
was then applied, and the adhesive
was light cured for 20 seconds. Another
index based on the wax-up was used
to guide the restoration of the palatal
surface (Fig 7). For the restoration of all
maxillary incisors, the composite resin
(shade CT, Filtek Z350XT 2, 3M ESPE)
was placed on the index positioned
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VOLUME 2 • NUMBER 2 • SUMMER 2012
 FARIA-E-SILVA et al
Fig 5   The diagnostic wax-up. The midline dia­
stema remains since this space would be closed
later using elastomeric separators.
Fig 7   Vinyl polysiloxane index used to guide
the restoration of the palatal surfaces.
over the palatal surface. After the first
increment was light cured, dentin
composite resin (shade A2 dentin, IPS
Empress Direct, Ivoclar Vivadent) was
applied over the abraded enamel and
1.0 to 1.5 mm over the incisal edge.
Next, composite resin (shade CT, Filtek
Z350XT) was applied between the
mamelons created with the dentin
composite resin as well as incisally
to this increment. Enamel composite
resin (shade A1 enamel, IPS Empress
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Fig 6   Vinyl polysiloxane index used to guide
the tooth preparation.
Fig 8   Composite resin was used to simulate
the opaque halo.
Direct) was used as the last increment
(Fig 8). Figures 9 and 10 show the
completed restorations.
After these restorative procedures,
elastomeric separators were placed
between the central and lateral incisors
and between the lateral incisors and the
canines (Fig 11). Complete closure of
the midline space was observed after
48 hours, leaving only the restoration
of the distal aspects of the central
and lateral incisors to be completed
 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
confirm the golden proportion
tween the widths of the anterior teeth
(Fig 13). The elastomeric separators
were individually replaced by wood
wedges to maintain the obtained posi-
tions. After the adhesive procedures,
composite resin (shade A1 enamel,
IPS Empress Direct) was inserted at the
distal aspect of the central and lateral
incisors to close the proximal space.
Immediate finishing procedures were
performed using a 12-blade finish-
be- ing bur (KG Sorensen) and sandpa-
per aluminum oxide disks. Polishing
was performed after 24 hours using a
silicon carbide brush (Astrobrush,
Ivoclar Vivadent) and felt disks with dia-
mond paste (Universal Polishing Paste,
Ivoclar Vivadent). Figure 14 shows the
final result 15 days after polishing.
The 6-month follow-up revealed well-
maintained esthetics and complete
closure of all diastemata (Fig 15).

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 FARIA-E-SILVA et al
Fig 14   Postoperative view 15 days after final
polishing. Adequate harmony of the smile was
achieved.
DISCUSSION
Larger diastemata negatively affect
the appearance of the smile, and their
closure remains a clinical challenge. In
such cases, restorative treatment plan-
ning must consider the proper height-to-
width ratio of the anterior teeth. Further,
the gingival architecture, including the
presence of interdental papillae, is im-
portant to the esthetic outcome.
In the present case, a previous at-
tempt to close the diastema had re-
sulted in an inadequate height-to-width
ratio. Additionally, the excess compos-
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Fig 13 (left)  Levin grid used to confirm the
proper proportions between the widths of the
teeth.
Fig 15   Six-month follow-up. The esthetics were
well maintained, and no diastemata between the
teeth were evident.
ite resin resulted in inflammation of the
gingival tissue. Patients may present
gingival margins positioned coronally
to the cementoenamel junction due to
alterations in the eruption process, re-
sulting in wide teeth. This alteration is
observed in 12.5% of children between
6 and 16 years of age,7 whereas pas-
sive dental eruption can be observed
until the age of 19.8 In the present case,
the crown lengthening achieved by the
removal of gingival tissue was sufficient
to improve the height-to-width ratio
without exposing the cemento­
enamel
junction.
 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-
dures, diastema closure was required
to achieve a harmonious smile. The
dental width was increased by the in-
sertion of composite resin in the incisal
area. This procedure was difficult be-
cause the composite resin must not
hinder the excursive movements of the
mandible, thus limiting the amount of
composite resin that can be inserted.
Canine guidance must be observed.
In this case, the canine guidance pre-
sented by the patient permitted an
approximately 2-mm increase in the
height of the incisors. This increase
was sufficient to close the gap without
compromising the proper height-to-
width ratio of the teeth.
Another important aspect of this case
was the need to move the incisors to-
ward the midline to distribute the space
required for closing the diastema. It has
been demonstrated that elastomeric
separators can move teeth more than
Two elastomeric separators were used
on the same side of the arch to improve
this effect. Further, the longer duration
of use (48 hours) was sufficient to ob-
tain complete closure of the midline
space.
The location of the contact point must
also be observed during restorative
procedures. It has been reported that
a distance of 5 mm between the con-
tact point and the bone crest results in
almost 100% interdental papilla devel-
opment.9 This percentage is reduced
to 56% or 27% when the distance is
increased to 6 or 7 mm, respectively.
The movement of teeth with elasto­
meric separators allows the clinician
to restore the contact point to an ade-
quate position. Correct treatment plan-
ning is an important tool for increasing
the predictability of esthetic restorative
procedures. Furthermore, the use of a
wax-up and periodontal treatment can
help to enhance the final results.

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