Using the front wing technique to close a midline diastema

Balraj Sohal introduces a midline diastema closure case, using the ‘front wing technique’.

A 53-year-old female attended the clinic concerned about the appearance of her teeth. Improving her smile was her main interest. The patient focused on the aesthetics of her central incisors. She had discussed porcelain veneers with her dentist in the past.

After a thorough assessment and consultation, the patient wanted to focus her efforts on improving the central incisor teeth. Her main concern was the midline diastema and asymmetrical incisal edges.

We informed her that after we close the midline diastema, the central incisors would be more dominant. Therefore we should also consider restoring the lateral incisors to improve the ratios of her centrals and laterals. This would give her a more aesthetically pleasing smile. Due to finances the patient declined this. Instead she asked we focus our efforts on the midline diastema, which we opted to restore with direct composite.

The front wing technique

There are multiple ways to close a midline diastema; using a matrix fabricated from a diagnostic wax up or using the bioclear matrix system to mention a few. In this case we opted to close the diastema using the ‘front wing technique’. This is a method taught by Jordi Manuata. It is shaping the composite free hand to develop the emergence profile. Followed by using sectional matrices to develop a refined profile and tight contact point. This technique will be described in this case discussion.

Figure 1: Pre-operative view of the patient’s smile
Figure 2: Pre-operative retracted view. The periodontal health of the tissues needs to be improved so the patient was referred to the hygienist for oral hygiene instruction and supragingival debridement
Figure 3: Pre-operative close up view – note the cervical restoration and stained mesial surface of the upper right central incisor. Due to patient’s low smile line we opted not to change the cervical restoration
Figure 4: Rubber dam isolation with B4 Brinker clamps to get maximum retraction of the soft tissues. These clamps are incredibly useful for such cases as they enable very easy access to the mesial aspects of the central incisors – hence freehand composite modelling can comfortably be done
Figure 6: Occlusal pre-operative view – there is approximately 2mm of space between both teeth giving us 1mm to add to each tooth to close the diastema symmetrically
Figure 7: A medium coarse sof-flex disc was used to roughen the surface of the central incisors and remove the undermined and unsupported enamel from the upper right central incisor
Figure 8: The upper central incisors were micro-abraded with 27-micron alumina oxide particles
Figure 9: Both central incisors were etched with 37% orthophosphoric acid for 30 seconds, followed by rinsing with water and drying with air for 30 seconds
Figure 10: The surfaces of the incisors post micro-abrasion and etch. Kulzer’s Ibond universal bonding agent was then applied to the etched surfaces. This was air dried for 30 seconds to evaporate the solvent and light cured
Figure 11: Shade A2 Venus Pearl Composite was used to build the front wing of the upper left central incisor first. The wing is built completely freehand using a flat plastic. The aim is to place and shape the composite from the cervical towards the incisal edge, focusing on developing the ideal emergence profile. Note in Figure 12 the front wing does not extend to the palatal surface – the front wing is only to be buccal as we will fill from the palatal once both front wings are restored. By doing this freehand we have complete control over the shape and profile. The composite has been adapted well cervically to ensure there will be no ledge or overhang once the gingivae rebound post rubber dam removal
Figure 12: The occlusal view shows the front wing does not extend onto the palatal surface of the upper left central incisor. The next step is to do the front wing for the upper right central incisor in the exact same way – freehand with a flat plastic. For this step I placed PTFE tape over the upper left central incisor to prevent the composite from sticking the teeth together
Figure 13: Now that both front wings have been built, we only have to fill the teeth from the palatal surface to finish the restorations. We have developed two natural emergence profiles completely freehand. Now with the aid of Tor VM sectional matrices we will finish the restorations. I chose to restore the upper left central incisor first – please note once one of the incisors is restored completely, the sectional matrix should be removed and only one should be left in place – this will ensure a tight contact point is developed
Figure 14: The occlusal view shows there is an unfilled area palatally (ie a space between the tooth and the matrix). Although the buccal has been restored the palatal is the next step

We place a drop of Venus Shade A2 flowable composite uncured between the upper central incisor and the sectional matrix. Then we place an increment of packable shade A2 composite (to restore the buccal surface) palatally and adapted against the palatal surface of the tooth.

We push the composite very hard against the tooth using…

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