Q U I N T E S S E N C E I N T E R N AT I O N A L

RESTORATIVE DENTISTRY

Sectional porcelain veneers for a maxillary

midline diastema closure: A case report
Antonio Signore, DDS, PhD1/Vassilios Kaitsas, DDS, PhD2/Alessandra
Tonoli, DDS3/Francesca Angiero, MD4/Armando Silvestrini-Biavati, MD4/
Stefano Benedicenti, DDS5

Diastema closure is a frequently requested, technique-sensitive cosmetic procedure.

There are many techniques and materials that can be employed to close diastemas. While
direct composite techniques can be economical and successful, they do present chal-
lenges in achieving satisfactory clinical and esthetic results. Traditional porcelain veneer
placement may offer an excellent esthetic result, but typically requires the removal of tooth
structure; as such, this is an irreversible procedure. The present article reports the case of
a maxillary midline diastema closure in a healthy dentition by means of sectional porcelain
veneers simply cemented onto the natural teeth and without tooth preparation. A step-by-
step procedure is proposed for illustrating the proper implementation of an additive-only
and noninvasive indirect technique that yields a satisfactory clinical and esthetic outcome
for clinician and patient. (Quintessence Int 2013;44:201–206; doi: 10.3290/j.qi.a29058)

Key words: adhesion, diastema, diastema closure, esthetic dentistry, porcelain

veneer, sectional veneer

A common feature found in the maxillary
anterior dentition is the presence of single
or multiple diastema between teeth, which
can strongly affect the appearance of a
smile and may be displeasing to the patient.
A diastema can be transient owing to the
mixed and early permanent dentition stage
and thus requires no active treatment.
diastema between adjacent anterior teeth
may occur frequently in certain ethnic
groups, may be due to anatomical tooth
size discrepancies, tooth angulations, the
presence of a high labial frenal attachment,
as well as many other developmental, path-
1
Assistant Professor, Department of Biophysics, Medicine and
Dentistry, University of Genoa, Italy; Private practice, Rome,
Italy.
ological, or iatrogenic factors.2 The man-
agement of a diastema in the permanent
dentition requires a detailed examination
and appropriate care; an accurate diagno-
sis and careful consideration of the contrib-
uting factors is necessary before treatment
can be initiated.3
1
A The current literature suggests a variety
of approaches for the closing of diastemas,
such as orthodontic treatment, restorative
treatment, or the combination of both.4
Orthodontic treatment almost always
requires the use of fixed appliances, which
means a longer, complex, and more uncom-
fortable procedure for the patient. On the
other hand, the orthodontic treatment is a
very conservative option.2 Prosthodontic
replication of tooth tissue and form, such as
full ceramic crowns or porcelain laminate
veneers, as well as direct adhesive restor-

2
ations with composite resins, have been
Assistant Professor, Department of Biophysics, Medicine and
Dentistry, University of Genoa, Italy. described as successful restorative treat-
3
ments for the closure of diastemas.4,5
Private Practice, Rome, Italy.

4
Researcher, Department of Biophysics, Medicine and Dentistry,
University of Genoa, Italy.
5
Associate Professor, Department of Biophysics, Medicine and
Dentistry, University of Genoa, Italy.
Correspondence: Dr Antonio Signore, Via Fulcieri Paulucci dè
Calboli, 54 I – 00195 Rome, Italy. Email: dr.signore@tiscali.it
Progress in adhesive material technolo-
gies has made possible a variety of more
conservative indirect restoration tech-
niques.6 In recent years “no-preparation”
also called “additional” or “minimal prep-
aration” porcelain veneers have been pro-

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Fig 1a Ceramic buildup.
Fig 1b Sectional veneer after firing and glazing.
posed as a conservative option compared
to conventional veneers.7–9 These restor-
ations have an ultra-thin thickness of 0.3 to

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0.5 mm for which conservative tooth prep-
aration or no preparation at all is suggested.
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and the patient’s oral hygiene was good.
indicated for selected cases where strict
criteria as to suitability may be met.10,11
More recently, “sectional” veneers, also
called “partial” veneers, have been referred
to in the dental literature.12 As with no-prep-
aration veneers, very thin ceramic partial
veneers require no tooth preparation,
although currently there is a lack of detailed
information about this technique (Fig 1).
A step-by-step procedure is described

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in which a maxillary midline diastema clo-
sure in a healthy dentition was performed
using sectional porcelain veneers. As an
alternative to direct resin composites and to
porcelain laminate veneers, the restorations
were simply cemented on to the natural
teeth without any prior tooth preparation.
CASE REPORT
A 34-year-old woman was referred to the
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spective restorative results (Fig 3).
Dentistry of the University of Genoa, Italy,
complaining about the presence of a maxil-
lary midline diastema between her anterior
202
Fig 2 Patient’s smile appearance exhibiting a den-
tal midline diastema.
teeth and the appearance of her smile. The
clinical examination revealed a moderate
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lesions were found. Periodontal examination
revealed no pocketing or gingival recession
Despite the desire to improve her smile,
the patient had rejected prior treatment
options such as full-ceramic crowns or por-
celain veneers in order to preserve the
existing tooth structure. In view of this, a
non-invasive option of sectional veneers
was proposed and a schematic description
of the clinical procedures presented to the
patient.
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radiographs, photographs, diagnostic cast,
and facebow records were taken. In an
esthetic rehabilitation in which the patient
has high expectations, a mock-up can help
in evaluating the patient’s esthetic demands.
In this case a diagnostic wax-up was per-
formed by the addition of wax to the pre-
liminary model so that a silicone index and
a corresponding acrylic “mock-up”, as
described in literature could be made.13 The
acrylic resin mock-up also allowed simplifi-
cation of the in vivo visualization of the pro-
Moreover, a plan of proposed esthetic treat-
ment could be presented so that the addi-
tive tooth volume was approved by the
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a b
Figs 3a and 3b The acrylic mock-up is used by the patient to evaluate the effect on the expression of the
smile within her face.
patient and her complete agreement was
obtained regarding the final tooth size and
shape. Phonetics, occlusal lateral, latero-
protrusive, and protrusive excursions were
also evaluated during this phase. The maxil-
lary central incisors were cleaned with pum-
ice and the shade of the sectional veneers
was determined prior to definitive impres-
sion. To aid in communication with the cera-
mist regarding final shade selection for the
sectional veneers, numerous digital photo-
graphs were taken with shade tabs adja-
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ation was necessary and gingival
displacement was obtained using a retrac-
tion cord (Ultrapack, Ultradent Products). A
definitive full arch impression was taken
using a single impression-double mixing
technique polyvinyl-siloxane material
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loid (Kromopan 100, Lascod) impression of
the opposing dentition was made and inter-
occlusal bite registrations were recorded
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the master casts were mounted on a semi-
adjustable articulator (SAM 3, SAM
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ations were required.
After placement of rubber dam for tooth
isolation during adhesive procedures, the

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marginal fit and adaptation at the proximal
contacts of each veneer was checked
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under microscopic examination. The fit sur-
faces of the sectional veneers were first
etched for 1 minute with 9.6% hydrofluoric
acid (Ena Etch, Micerium), rinsed off and
dried with oil-free air, then silanized with a
silane coupling agent (Silane, DMG Dental-
Material). Following this, each was wetted
with a single coat bonding resin (Mono,
DMG Dental-Material), thinned out with oil-
free air but not light-cured at this time.
Prior to cementation the central incisors
were cleaned with a non-fluoridated clean-
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Vivadent) on a rotating prophylaxis brush.
After the try-in procedures and color evalu-
ation, enamel surfaces were etched with
37% phosphoric acid for 30 seconds, fol-
lowed by a thorough 30 seconds rinsing
with water and gently air dried for 15 sec-
(Mono, DMG Dental-Material) was applied
and not light-cured.
As luting agent, a nano-hybrid compos-
and the enamel shade Universal Enamel 2
was chosen. Prior to application on the
sectional veneers, the composite resin was
preheated by means of a composite heat-
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ommendations; this was to obtain greater
203
Q U I N T E S S E N C E I N T E R N AT I O N A L
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flowing properties of the material for cemen-
tation.
The sectional veneers were gently
seated and the final adaptation was con-
trolled under microscopic examination. The
excess composite was removed with a
brush and dental floss interproximally. The
restoration margins were covered with gly-
cerin gel to prevent the formation of an
oxygen inhibited layer. The luting agent was
then light-cured by means of an LED light-
curing unit with a light-intensity of 1,200
mW/cm2
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decades as a number of researchers
for 40 seconds (Fig 4).
Occlusion was evaluated and interfer-
ences in lateral, latero-protrusive, and pro-
trusive excursions were identified and
removed.
All finishing and polishing procedures
were performed and evaluated with the use
of 4.3 × 400 surgical head-worn loupes
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still required to respect the geometric and
care for subgingival and interproximal fin-
ishing lines and contours. The incisal edge
and the margins were finished with a suc-
cession of fine and an ultrafine diamond
burs, followed by rubber points. A 3-μm to
1-μm diamond paste (EnaShine, Micerium)
was used for polishing, followed by an alu-
minum oxide paste with a felt disk working
at first without water at a very low speed,
then increasing the speed but using copi-
ous water spray to achieve a high-gloss
finish. The interproximal walls were finished
with a scaler to remove excess material,
finally polished using abrasive strips with
decreasing grain and diamond pastes


(Fig 5).
DISCUSSION
For each of the more conservative options
for diastema closure, from orthodontic treat-
ment to freehand composite resin bonding,
there are more invasive prosthetic alterna-
tives available including veneers and
crowns.2 It is recommended that a conser-
vative approach should be used wherever
possible as an alternative to treatment
options that may sacrifice tooth structure.14
In this context, as an alternative to direct
composite resin restorations and porcelain
laminate veneers, an indirect treatment
204
approach using noninvasive partial porce-
lain veneers simply cemented onto the nat-
ural teeth providing maximum preservation
of tissues was applied in the current case.
It is generally agreed that bonded por-
celain restorations such as porcelain
veneers have matured into a predictable
restorative concept in terms of longevity,
periodontal response, and exceptional
esthetic characteristics.15 The indications for
the use of bonded porcelain restorations
broadened significantly during the last two
expressed confidence in these restorations.6
As a result, innovative preparation designs
emerged and these were rationalized
accordingly by clinical and laboratory inves-
tigation.16,17 Despite modern and more con-
servative tooth preparation principles for
bonded porcelain restorations, the removal
of a minimum amount of sound enamel is
mechanical parameters of the tooth prepa-
ration, to facilitate placement and position-
ing of the ceramic during the final bonding
procedure, and to ensure marginal accu-
racy. The closure of diastemas through
ceramic veneers allows for excellent esthetic
and convincing long-term clinical results,
but cannot be considered a very conserva-
tive or even a noninvasive treatment.
Moreover it is an irreversible procedure,
which in case of failure would require com-
plete replacement of the restoration.
Porcelain veneers are a favored option
when the entire vestibular surface must be
replaced.14
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in an intact dentition conservative esthetic
corrections are increasingly mandated.
The closure of diastemas through direct
adhesive restorations with composite resins
represents a conservative alternative treat-
ment, which possesses some major advan-
tages compared to indirect ceramic restor-
ations. It is absolutely noninvasive, with
practically no tissue sacrifice, it can be
performed in a single appointment, and is
cost-efficient.14
Along with remarkable improvements in
their physicochemical properties, modern
composite resins present satisfactory
esthetic qualities and provide long-term
satisfactory clinical service.18,19 They allow
optimal esthetic results to be obtained by
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a b
Figs 4a and 4b Rubber dam placement for tooth isolation and etching during adhesive procedures.
Fig 4c Restorations in place before finishing and
polishing procedures.
applying an anatomical layering technique,
involving the use of dentin- and enamel-like
masses, completed with effect-materials.20
In case of failure, composite resin restor-
ations can easily be repaired and a com-
plete replacement of the restoration is often
not necessary.12
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mance of direct adhesive restorations is a
highly technique sensitive cosmetic proce-
dure. The incorrect use of interdental matrix
and wedges for temporary tooth separation
may compromise the emergence profile of
the composite resin restorations.5 A black
triangle underneath the interdental contact,
poor contacts points, or gingival irritation
from subgingival overhangs may be the
consequence.5
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freehand may represent a challenge in this
particular clinical situation, which may be
considered a disadvantage.
While it is an indirect technique and no
prior tooth preparation is needed, gingival
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Fig 5 Final intraoral view after placement of the
sectional veneers.
displacement as well as impression proce-
dures do not present any particular difficul-
ties and no temporization is needed.
Furthermore, it is a reversible procedure, as
in case of failure the partial veneer can be
easily removed and replaced without addi-
tional sacrifice of sound enamel.11,12 An
anatomical emergence profile, adequate
contact points, as well as color accuracy
and favorable esthetic results can be
obtained in the laboratory after adequate
clinical evaluation. To avoid imbalance in
the “golden proportion” of the anterior teeth,
there should be a suitable dental width/
length proportion for the execution of the
partial veneer. Thus, additive wax-up and
mock-up restoration are fundamental and
well-established tools of analysis.13
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attention is required for details of interproxi-
mal emergence by the technician; more-
over the clinician should dedicate particular
care for subgingival finishing and polishing
205
Q U I N T E S S E N C E I N T E R N AT I O N A L
S i g n o re e t a l
of the interproximal finishing lines and con-
tours, which can be difficult to accomplish.
Laboratory studies and long-term clini-
cal results for this new technique are not yet
available. While sectional veneers in dia-
stema closure have more of an esthetic
than functional consideration, biomechani-
cal investigations and longitudinal trials will
provide additional data to support the clini-
cal effectiveness of this technique. In this
regard, it should be mentioned that a study
group is under observation, with the aim of
collecting long-term survival data.
CONCLUSION
In the presence of a maxillary midline dia-
stema, an accurate diagnosis and ade-
quate esthetic evaluation as well as a
careful consideration of the treatment
options are recommended for obtaining a
predictable result. The use of sectional por-
celain veneers takes into account the con-
servation of healthy tooth structure and may
represent a suitable alternative to conven-
tional prosthetic approaches or direct adhe-
sive restorations.
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