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CLINICAL RESEARCH

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 Universitria, Rio de Janeiro, RJ, 21.941-913, Brazil;
E-Mail: estetica@paulocampos.odo.br

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Abstract

other techniques. 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, including that the restorative

and contact point. Thus, 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, avoiding a space be-

without the removal of sound tooth struc-

tween the papilla and the restored tooth.

ture. The use of a rubber dam for clos-

To illustrate the advantages of this tech-

ing diastemas with composite resin is

nique, 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.

creased gingival retraction compared to

(Int J Esthet Dent 2015;10:564574)

access to the cervical area of the tooth,

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Introduction

sults.

The demand for esthetic excellence

volving the greatest amount of time and

in dental care has increased in recent

cost.1 Closure of diastemas with por-

years1

Orthodontic

diastema

closure

requires fixed orthodontic braces, in-

due to the high expectations of

celain veneers or crowns also provides

patients, who want to have beautiful

excellent results; however, because it is

smiles.2

Dental professionals need to

an indirect procedure, 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.

ures.7,8

Diastemas are characterized by the

An interdisciplinary approach can

presence of interdental spaces that

be taken, as in cases where orthodon-

can be seen to constitute an inharmoni-

tic treatment is carried out to align the

ous factor in a patients smile.3 These

teeth correctly for proper occlusion and

spaces can be classified as pathologi-

size, and then space closure is finalized

cal, physiological or from the palatine

using direct or indirect procedures. Ac-

disjunction. The physiological spacing

cording to the current concept of mini-

commonly occurs during the primary

mally invasive dentistry, the more con-

dentition stage, while the pathological

servative treatment should always be

one can have numerous etiologies, such

prioritized by professionals.9 Orthodon-

as atypical insertion brake lip, agene-

tics is a conservative treatment but can

sis, microdontia, absence of a maxillary

be difficult due to the individual char-

lateral incisor, presence of mesiodens,

acteristics of each patients teeth, such

periodontal disease, and deleterious

as shape, size, height/width ratio, and

habits.4

The presence of diastemas in

other factors.10 Restorative procedures

populations varies according to gender,

using direct bonding with composite

age, and facial shape. Diastemas are

resin create esthetic restorations without

more prevalent in females, more com-

the removal of healthy tooth structure,

mon between the ages of 14 and 34,

and can improve some of the individual

and occur more in mesofacial patients

characteristics.11

growth.5

Recent clinical studies have demon-

Therefore, 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, functional, and esthetic aspects

who

ment

have

balanced

facial

choice.6

of the closure of interdental spaces.12,13

Options to resolve diastemas can

These results are mainly due to the de-

involve various specialties, including

velopment of the adhesive techniques

operative dentistry, orthodontics, and

and compositions of these systems, as

prosthodontics. The main advantages of

well as improved composite resin ma-

treatment through the direct procedures

terials.

of operative dentistry include simplicity,

One consequence of a diastema be-

predictability, speed, and low cost,6 with

tween the maxillary central incisors is the

reversible and almost imperceptible re-

absence of the interdental papilla. The

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distance between the interdental contact point of these teeth and the alveolar
bone crest has significant influence in
interdental papilla presence. In a study
conducted in 1992, this distance was
estimated for 200 interproximal sites,
and the following results were obtained:
when the distance was less than 5 mm,
the papilla was 100% present in almost
all cases; when it was 6 mm, the papilla
was present in 56% of cases; and when
it was 7 mm or more, it was present in
only 27% or less of

Fig 1

Preoperative smile view.

Fig 2

Note the small mesiodistal width in relation

cases.14

Despite the numerous treatment options, the factors that are essential for
obtaining a successful result are good
diagnosis and treatment planning (including functional assessment), evaluation of teeth measurements, dental
positioning, phonetic evaluation, and
preparation of a diagnostic wax-up.

Clinical case descriptions


Case 1
A 22-year-old Caucasian female patient

to the cervicoincisal dimension.

presented for esthetic enhancement of


her smile. Clinical examination revealed
the presence of a diastema between
the maxillary central incisors. After the
patients medical and dental histories
were reviewed, a clinical and radiographic examination was performed. A
smile analysis was done, which included an assessment of tooth size relationships. The teeth were found to have a
small mesiodistal width in relation to
the cervicoincisal dimension (Figs 1
and 2). The recommended treatment
plan involved closing the diastema with
composite resin, thus increasing the

Fig 3

Cervicoincisal height (blue line); gingival

papilla level (pink line).

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Fig 4

Cervicoincisal height (blue line); gingival

Fig 5

Volume of resin corresponding to the space

papilla level before rubber dam (red line); space

achieved by papilla retraction with rubber dam isola-

obtained by gingival tissue retraction (green line).

tion. Embrasure and proximal tooth surface inclination before restoration (yellow line); embrasure and
proximal tooth surface inclination without absolute
isolation (green line); embrasure and proximal tooth
surface inclination after the restoration (pink line).

mesiodistal dimension of the incisors

tooth, while opalescence is based on

without damaging tooth structure, while

enamel incisal characteristics.16

achieving the ideal esthetic propor-

Shade selection was performed while

tions, ie, tooth width between 75% and

the teeth were still moist to facilitate an

85% of tooth height.15 Measurements

accurate determination of color. The

were made using a digital caliper. 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, as well

based on the ideal distance between

as to allow greater gingival retraction

the incisal edge and the gingival papil-

(Fig 4), provide the correct space for

la, to ensure that the interdental papilla

interproximal contact, and allow com-

would naturally form between the cervi-

posite addition with a gradual contour

cal contours of the restored teeth. This

similar to that of the natural tooth (Fig 5).

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. Each tooth

level (Fig 3).

was etched with 35% phosphoric acid

The next step in planning the restor-

for 15 s, rinsed with water, then gently

ations was color mapping. The shade

air dried. The adhesive system Single

selection was made by first choosing

Bond 2 (3M ESPE) was then applied ac-

chromaticity, then value and opales-

cording to manufacturers instructions,

cence. The chromaticity is the dentin

and polymerized for 20 s. The diastema

color, which should be chosen at the

was closed by freehand technique us-

middle and cervical thirds of the tooth.

ing multiple layers and the pull trough

The value is the brightness, which should

technique from lingual to facial with clear

be determined at the middle third of the

celluloid matrix, placing and sculpting

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Fig 6

A small black triangle at the apex of the

interdental papilla.

Fig 7

Another image showing the small black

space.

(Opallis,

an air-inhibited layer. The second res-

shades A1/T-Neutral/VH; FGM) to teeth

toration therefore did not adhere to the

the

nanohybrid

composite

8 and 9 to achieve the desired restora-

adjacent tooth. After the conclusion of

tive outcome. The resin material was

the first 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. 4 (Tigre). A

that touched the adjacent tooth. To sep-

free polychromatic incremental layer-

arate them, after polymerization of this

ing technique was used for the direct

increment, a small torque with an IPC or

composite buildup; 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, Dentsply) at an intensity

in the same way as the first restoration,

PGN8DN2 and a wavelength range

creating the proximal contact, with both

of 450 to 490 nm to ensure adequate

restorations able to receive the immedi-

polymerization.

ate final finishing and polishing.


described

In addition to offering absolute field

above, after the first tooth buildup (me-

control, rubber dam isolation provides

sial of tooth 11), finishing was done with

excellent gingival retraction compared

a surgical blade No. 12, followed by a

to other techniques, such as the use of

pre-polish with ultrafine finishing discs

retraction cord. This helps to obtain a

(3M ESPE) and rubber finishing cups

smoother contour between the restored

and points (Edenta). These steps gen-

cervical and proximal surfaces. Proper

erated some debris on the surface of the

contouring of the gingival embrasure

first restoration and after the removal of

provides a smaller, more ideal space

Using

the

technique

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to be occupied by the gingival papilla,


which is then slightly compressed to fill
the entire interdental space in the final
restoration.
Figure 5 shows that without rubber
dam isolation and retraction, the resin
addition might follow the outline indicated by the green line, forming a step
in relation to the original tooth contour
(yellow line). By using the isolation and
retraction offered by the rubber dam, it
Fig 8

The papilla 1 week after the restoration,

nearly filling the gingival embrasure.

is possible to obtain a more appropriate


contact and symmetrical contours in the
final restoration (pink line).
The rubber dam was removed and
the restorations finished using diamond
burs (2200 F and 3168 F, KG Sorensen),
a No. 12 blade, ultrafine finishing discs
(3M ESPE), and rubber finishing cups
and points (Edenta).
Once the restorations were finished,
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.
The appearance of the papilla 1 week

Six months later, observe the final aspect

later showed that it had nearly filled the

of the restorative treatment. An adequate balance

gingival embrasure (Fig 8), and after

Fig 9

between soft and hard tissues is evident.

6 months the papilla occupied the entire


space (Figs 9 and 10).
Upon completion of the restorative
work, the patient was given instructions
regarding oral hygiene and maintenance of the restorations. The patient
was cautioned regarding harmful habits
(such as biting the lips or hard objects,
nail biting, opening objects with the
teeth, etc), and it was emphasized that
proper care is closely related to treatment longevity.17

Fig 10

Final result at 6-month clinical follow-up.

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Case 2
A 23-year-old Caucasian male patient
presented for esthetic enhancement of
his smile. Clinical examination revealed
the presence of a diastema between
the maxillary central incisors. During
examination and case analysis, it was
observed that inadequate proximal contours existed in the restoration, resulting
in a black triangle with the absence of
an adequate interdental papilla (Fig 11).
After color mapping of the teeth had
been performed, the proximal restor-

Fig

11

Preoperative smile view. Observe the

inadequate proximal contours in the restoration,


which resulted in a black triangle with the absence
of an adequate interdental papilla.

ations were removed (Fig 12). Total isolation of the maxillary anterior teeth was
achieved using rubber dam (Fig 13),
which also allowed for effective gingival
retraction. This facilitated the completion of a new restoration with ideal contour and contacts.
To enhance isolation, the rubber dam
was ligated at the cervix of each tooth
using dental floss.
For this case, the restorative procedure also made use of the freehand
technique and continued according to

Fig 12

the exact same steps as described for

removed.

After the proximal restorations had been

the previous case: acid etching, the application of the Single Bond 2 adhesive
system according to the manufacturers
instructions, and the placement of composite resin (Opallis).
The newly completed restoration not
only reproduced the ideal contours and
contact of the teeth, 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.

anterior teeth.

Total rubber dam isolation of the maxillary

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Fig 14

The newly completed restorations repro-

Fig 15

Postoperative frontal view. Interdental pa-

ducing the ideal contours and contact of the teeth,

pilla fills the embrasure for a natural and esthetic

and resulting in improved esthetics.

result.

Discussion

The technique used in the cases presented here uses rubber dam isolation

Given the numerous treatment options,

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, in-

composite resin. One of the questions

cluding etiology, economics, time avail-

regarding rubber dam isolation for clos-

ability, and the patients

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.

composite resin requires a moisture-free

The literature supports a direct ap-

environment.12 Therefore, rubber dam

proach to diastema closure, 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, compared to the use of

choice due to its good clinical longevity.

retraction cord.

Further, 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.18-21

tissue. 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.

remaining sound tooth structure, as well

The proper location of the contact ar-

spaces.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, 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.

as the size of the interdental

sive

movement.12

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Achieving anatomically correct contact

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, which is the removal of the compos-

nique. Thus, rubber dam isolation offers

ite that had been cemented. The spacing

an advantage in adhesive restorative

is then closed with a new direct compos-

techniques, where a dry and clean sur-

ite resin, without using absolute isolation

gical field provides the foundation for a

and cord retraction.1 Although good re-

long-lasting esthetic

restoration.23

sults are obtained using this technique,

Another factor to be considered is the

it demands more clinical hours. Moreo-

distance from the proximal contact point

ver, sometimes oral hygiene is difficult

and the height of the alveolar bone crest

for patients who have these temporary

interdentally. The proper location of the

restorations, and plaque accumulation

contact point in relation to the bone crest

causes local inflammation, which makes

avoids the appearance of a black triangle

it difficult to obtain an appropriate field.26

between the teeth and gingival tissue.14,23


The apex of the interdental papilla is
used as a reference to determine the
optimum height for the contact point.

Conclusions

Measurement is made with a probe or

In this article, the use of rubber dam iso-

digital caliper, measuring from the in-

lation for direct diastema closure with

cisal edge of the tooth to the tip of the

composite resin is presented. The ad-

papilla. These measurements are made

vantages of this technique include:

to ensure that after the accomplishment

Needing fewer clinical sessions com-

of absolute isolation, reference to the

pared to the technique that uses pro-

DPOUBDUQPJOUMPDBUJPOJTOPUMPTU8JUIPVU

visional restorations for gingival re-

these procedures, there is the possibil-

traction.

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, which is very com-

ing the cord retraction technique.

mon in cases where the cord retraction

Preparing the restoration with appro-

technique is used.3,12,24,25

priate proximal contours and contacts

Another technique requires four ses-

at the tooth restorative interface.

sions to close diastemas. In the first ses-

Greater patient comfort, with invasive

sion, the impression is made and the pa-

techniques such as periodontal sur-

tient model is obtained. The second step

gery being avoided.

takes place in the laboratory, where a

Obtaining excellent field and moisture

scalpel blade is used to carve the region

control.

of the papilla, and the space is closed

Obtaining better access to create

with composite resin, which serves as a

proper contact.

provisional restoration to perform a grad-

Contours and an emergence profile

ual compression of the gingival area. The

that mimics the natural tooth and al-

third step is to anesthetize the patient and

low accommodation of the natural

cement the restorations, to ensure the

gingival papilla, thus preventing the

conditioning of the papilla. The patient

appearance of black triangles.

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