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40 | CERECDOCTORS.COM | QUARTER 2 | 2014
a recent patient of mine had what
I would consider very bad luck when
it came to her teeth (Figs. 1-2). She
took great care of her teeth, and never
required a solitary restoration on any of
her permanent teeth. However, she was
left with a laundry list of esthetic and
functional concerns. Paramount of those
concerns were the following:
• Congenitally missing maxillary molars
• Significantly undersized premolars
(maxillary and mandibular)
• Approximately 50 percent anterior
vertical overlap
• Canted and excessive gingival display
• Large diastemas in her upper anterior
(four of five interproximal areas)
We discussed the possibility of compre-
hensive orthodontic treatment. However,
thepatientdecidedagainstitashercurrent
occlusionwas both comfortable and func-
tional, and it was determined that closing
the anterior spaces would lead to a dimin-
ished functional occlusion in the posterior
due to her undersized premolars.
Additionally, the cost of orthodontic
treatmentwas not something towhich she
could commit, knowing that additional
treatmentwould also be needed to achieve
her desired final outcome. Ultimately, the
patient elected to have six ceramic veneers
placed fromcanine to canine.
Clinically,weplannedtoutilizemultiple
tactics to enhance the final outcome.
Namely, the tactics we usedwere:
• Minimal short-term ortho (STO)
• Diagnostic wax-up
• Lingual contact closure
• Post-mill line-angle contouring
To begin the case, a finger-
spring retainer from the
Inman Laboratory was used
to mesially tilt #8 (Fig. 3).
The Dreaded Diastema
Closing Spaces Restoratively
C A S E S T U D Y | | | B Y B A R O N G R U T T E R , D . D . S .
This accomplished three tasks: to slightly
reduce the size of the central diastema, to
better centralize the gingival zenith of #8,
and to make it possible to follow up with
an Essix retainer to help distally rotate #8
and thereby minimize distal-facial tooth
reductionnecessary forceramic thickness.
Next, we took impressions for a diag-
nostic wax-up (AA Dental Design Inc.)
(Fig. 4). Our final goal was communicated
to the lab. We requested all spaces to be
closed, 1mmelevationof the gingival levels
in preparation for slight gingivectomy, and
to have wax primarily added to the facial
surfaces so thatwecouldapproachthecase
fromaminimally invasivemindset.
Then, using a Siltec putty matrix, the
wax-up was transferred to the patient’s
mouth with Bisacryl temporary mate-
rial. This step allowed for pre-treatment
approval and to guide the preparations.
Knowing our final objective in advance
helps to direct our treatment in the most
conservative manner possible. Addition-
ally, it allowed us to identify any occlusal
compromises thatwould be encountered.
KeyPoint: Ifwehadnotusedtheretainer
to pre-rotate #8, we would have had to
slightly re-contour that tooth to allow for
proper seating for the puttymatrix.
The teeth were then prepared with
the following goals in mind: minimize
margin depth to mask the color transi-
tion and establish sufficient reduction to
allow for strength of material (Figs. 5-6).
Figs.: 1-2: Patient’s smile has always
been guarded due to cant, spacing and
“gummy” appearance
Fig. 3: Multiple diastema visible, as well
as mal-positioned #8
Fig. 4: Wax-up by AA Dental Design
Figs. 5-6: All contacts were broken and
minimal facial reduction was performed
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