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centrals at the current length or shorten them? Do we
use direct composite in-office or send the case out to
the lab for porcelain restorations? Does the patient want
teeth whitening? These were all appropriate options, and
the suitable treatment depended on the patient’s desires.
Deciding on these factors would not only impact the
cosmetic outcome, but also influence the clinical treatment.
Figure 5: Simulated photo showing treatment with the diastema left in
place
At this point, I decided visual communication using digital
imaging would simplify the decision-making process.
Using Adobe ® Photoshop ® Elements (Adobe Systems; San
Jose, Calif.), an off-the-shelf photo manipulation software,
I completed several simulations of the various treatment
options. The first simulation showed repairs made to tooth
#8 and #9 using direct bonding, leaving the diastema in
place (Figs. 5, 6). The second simulation showed porcelain
veneers being used to repair tooth #8 and #9 and close the
diastema (Figs. 7, 8). The final simulation showed the patient
what his teeth would look like if he whitened them (Fig. 9).
After seeing all treatment possibilities, the patient decided
to whiten his teeth followed by having porcelain veneers
placed on tooth #8 and #9 that would close the diastema.
The patient whitened his teeth for about two weeks and
then allowed two weeks for rebound (Fig. 10).
Figure 6: Close-up simulated photo of first treatment option
Figure 7: Simulated photo showing second treatment option, closing the
diastema
Clinical Technique
The decision was made to utilize feldspathic porcelain
veneers. Feldspathic veneers require only 0.5 mm of facial
reduction and 1 mm of incisal reduction for adequate
strength and beauty. Feldspathic veneers are layered and
allow the characterizations and color to be built deep within
the restoration. This combination yields a conservative, yet
vital result.
After achieving adequate anesthesia, the teeth were
prepared using the “connect-the-dots” approach. First, a
0.5 mm depth-cutting bur (LVS1 [Brasseler USA; Savannah,
Ga.]) was used to ensure minimum thickness on the facial
surface (Fig. 11), and incisal depth cuts were placed to ensure
minimal incisal reduction (Fig. 12). Incisal depth cuts were
not necessary on tooth #9 because it was being lengthened.
Next, preparations were made for closing the diastema.
When closing a diastema, the preparation margins must
be placed subgingival interproximally and carried to the
lingual to allow for a proper emergence profile. A twogrit
diamond bur (LVS3, Brasseler USA) was used for final
margination (Fig. 13).
Figure 8: Close-up simulated photo of second treatment option
Porcelain restorations require rounded preparations that
are free of sharp angles and unsupported enamel. A coarse
polishing disk (EP2, Brasseler USA) was used to round
all line angles and sharp edges to ensure a smooth final
preparation (Fig. 14).
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