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DENTAL SCIENCE - ORIGINAL ARTICLE
Year : 2015  |  Volume : 7  |  Issue : 6  |  Page : 559-562  

Clinical evaluation of direct composite restoration done for midline diastema closure - long-term study


1 Department of Prosthodontics, Thai Mogambigai Dental College and Hospital, Chennai, Tamil Nadu, India
2 Karpaga Vinayaga Institute of Dental Sciences, Chennai, Tamil Nadu, India
3 Department of Prosthodontics, Thai Mogambigai Dental college and Hospital, Chennai, Tamil Nadu, India
4 Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
5 Consultant Prosthodontist, Dent Plus Dental Clinic, Guntur, Andhra Pradesh, India

Date of Submission28-Apr-2015
Date of Decision28-Apr-2015
Date of Acceptance22-May-2015
Date of Web Publication1-Sep-2015

Correspondence Address:
Dr. R Prabhu
Department of Prosthodontics, Thai Mogambigai Dental College and Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.163539

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   Abstract 

Purpose of the Study: The aim of this study was to evaluate clinically the performance of composite resin used to restore midline diastema between the maxillary and mandibular central incisors. Methodology: Direct composite restorations were done for 45 patients with midline diastema between the maxillary and mandibular central incisors. Standard protocols were followed for the placement of composite resin for the diastema closure, and recall visits were made for every 6 months for a period of 60 months for evaluation of the success of these restorations made. Qualified dental personnel examined the restorations made. Results: Clinical evaluations were done after the restorations had been in place for an average of 6 months. Results indicate that none of the restorations were totally lost, and resulting in a 91% overall retention rate for the period of 60 months. About 62% of the restorations made had no noticeable color difference with that of the adjacent tooth, and gingival health indicated 73% of the sample was without any signs of inflammation. Conclusions: Composites restored for diastemas exhibit satisfactory survival rates placed with recommended placement protocols and without occlusal loading.

Keywords: Composite restorations, diastema, direct composites, midline diastema


How to cite this article:
Prabhu R, Bhaskaran S, Geetha Prabhu K R, Eswaran M A, Phanikrishna G, Deepthi B. Clinical evaluation of direct composite restoration done for midline diastema closure - long-term study. J Pharm Bioall Sci 2015;7, Suppl S2:559-62

How to cite this URL:
Prabhu R, Bhaskaran S, Geetha Prabhu K R, Eswaran M A, Phanikrishna G, Deepthi B. Clinical evaluation of direct composite restoration done for midline diastema closure - long-term study. J Pharm Bioall Sci [serial online] 2015 [cited 2019 Aug 19];7, Suppl S2:559-62. Available from: http://www.jpbsonline.org/text.asp?2015/7/6/559/163539

Diastema is defined that spaces more than 0.5 mm between the proximal surfaces of adjacent teeth. [1] The continuing presence of a diastema between the maxillary central incisors in adults often is considered an esthetic or malocclusion problem. [2] Diastemas can be closed orthodontically or restoratively. Orthodontics can align teeth within an arch to close space using removable appliances or clear matrixes and brackets to move teeth. Restoration increases tooth dimension to close space while the root position remains the same, and can be accomplished with composite or porcelain placed interproximally to close spaces. The restorative material is placed on the facial surface, as well as interproximally, if the tooth color or shape also requires improvement. [3],[4] The appropriate technique and material for a patient is based on time, physical, psychological, and economic limitations. [5] For orthodontic treatment, the limitations include patients who may not be able to deal with brackets and arch wire on their teeth. They may be concerned with their esthetics, restrictions to eating or the feeling of having braces on their teeth and the effects on their lips, tongue, and cheeks. Porcelain is stronger and stains less than composite; however, it costs more. Porcelain is not easy to customize to a demanding patient. Porcelain restoration requires two or more appointments and a transition time with provisional restorations. [3],[4],[5] Composite bonding between teeth fills spaces and improves the appearance of diastemas. Composite bonding is completed in one appointment and patients like the instant results. Composite can be added or reduced to fit a patient's desired goal. Addition or removal of composites can be done to suit patient's desired goal. It can be completely removed if the patient desire was not satisfied. Composite also can be placed without light curing to confirm patient acceptance. Patients also like that little to no tooth reduction is done, and the restorative procedure can be completed without any anesthetic needed. [6],[7],[8] However, the studies conducted to evaluate the clinical success of composite restorations placed for midline diastema is still lacking. Hence, this study was undertaken to evaluate the clinical success of composite resin used for the treatment midline diastema defect present between the maxillary and mandibular incisors.


   Methodology Top


The study group consisted of patients selected based on the presence of midline diastema between maxillary central incisors or mandibular central incisors from the outpatients of our Dental Clinic. The treatment for midline diastema between maxillary or mandibular incisors using direct composites was explained to the patient, and the need to evaluate the completed restorations by recall visit to be done mandatorily was also explained to them. Forty-five patients with midline diastema who accepted to this procedure formed the study group for our study. For all the patients who formed the study group, oral prophylaxis was done prior to the procedure, and healthy gingival status was ensured as it was included in the evaluation criteria after the completion of the restorations. Complete isolation was done to ensure longevity of the restorations made using rubber dam and high vacuum suction. The procedure consists of etching the tooth with 37% phosphoric acid etchant gel (total Etch, Ivoclar vivadent) to tooth both facially and lingually for a period of 30 s. The etchant gel was removed by thorough rinsing and air dried till the frosty etched surface was achieved. Bonding agent (Tetric N Bond, Ivoclar vivadent) was applied and light-cured for 20 s completely. The applied bonding agent on the tooth was checked for complete wetting of the tooth surface composite shade matching was done during the procedure to select the correct shade of the composite used for the particular patient. The nano filled composite (Tetric N ceram, Ivoclar vivadent) was applied on the facial surface to create a labial wall and cured for 60 s. This process creates a lingual shelf, which helps to completing the lingual aspect of the tooth. Contouring was done using finishing bur from composite to the tooth in both the labial and the lingual surface, and polishing was done using the thin disc and strips. After completion of one tooth, mylar strip was placed in between the tooth and the completed restorations of one tooth and the same procedure was repeated for the next tooth to achieve good esthetic results [Figure 1], [Figure 2], [Figure 3] and [Figure 4]. Occlusion was checked with articulating papers to relieve any occlusal high point in centric and eccentric contact position with the opposing occlusion. The restorations were examined during a routine recall examination which was done for every 6 months for the entire period of 60 months of the study. During the study period, the midline restorations were evaluated for their clinical features which include color matching of the restorations with that of the adjacent tooth, shape, and contour of the restorations, presence of restoration failures and gingival health surrounding the restored teeth. An evaluation rating system was devised similar to the US Public Health Service (USPHS) Alpha criteria rating system. [9] The USPHS system is for posterior teeth, so a new system was developed. The criteria for the rating system are detailed in [Table 1]. Briefly, the examination included an evaluation of the color, shape, and integrity of the restorations made. The health of the gingival tissue was evaluated as an indication for the integrity of the cervical margins of the restoration. The restorations were evaluated for every six months for a period of sixty months, and the results were tabulated and subjected to statistical analysis.
Figure 1: Before closure of upper midline diastema

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Figure 2: After closure of upper midline diastema

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Figure 3: Before closure of lower midline diastema

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Figure 4: After closure of lower midline diastema

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Table 1: Clinical evaluation criteria

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   Results Top


The descriptions of the study group with their characteristics were mentioned in [Table 2]. The mean age group in the study group was 27 years with patient's age ranging from 20 to 43 years were included for the closure of midline diastema between maxillary or mandibular incisors. The study indicated 47% males and 53% females formed the study group. About 73% of midline diastemas restored were in the maxillary arch when compared to 27% restored in the mandibular arch. The etiology distribution for the occurrence of diastema was shown in [Table 3] which indicates occlusal and periodontal reasons predominating by 51% followed by presence of thick labial frenum in 14%, arch length discrepancy in 11% cases, and midline pathology cases with 3%. The inclusion criteria for clinical evaluation obtained for the study for color, contour, and retention of the restorations and gingival health were presented in [Table 1] and [Table 4], respectively which had grades under which the restorations were rated in the study. About 62% of the restorations made had no noticeable color difference with that of the adjacent tooth, and 38% had either slight or obvious shade mismatch made for the 45 restorations made. None of the restorations were totally lost during the follow-up period of 60 months, and only 9% were rated as having lost some resin material, resulting in 91% overall retention rate over the entire period of the study. The contour of the restorations exhibited very good satisfactory results for about 49% of the group and with acceptable contour and need to improve on contour of the restoration for 42% of the sample and 9% with unsatisfactory contour of the study group. Gingival health indicated 73% of the sample was without any signs of inflammation and 23% had mild gingivitis, and 4% of the total sample had moderate gingivitis.
Table 2: Description of the sample

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Table 3: Etiology of diastema restored

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Table 4: Clinical evaluation of restorations and gingiva

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   Discussion Top


Al-Rubayee reported the occurrence of midline diastema was 28% (maxillary 22.5%, mandibular 2.3%, and both arches 3.2%). It occurred more frequently in males (40%) than females (16%), and also better appreciated in females (50.6%) than in males (4.1%). A female is more likely to have a maxillary midline diastema (81.2% females: 65% males), while a male is more likely to have a mandibular midline diastema (22.5% males: 12.5% females). The majority of females (87.5%) found with median diastema were dissatisfied with their esthetic and seeked treatment. [10] Social and cultural and influence was one of the reasons why some people considered diastema as a disfiguring dental feature requiring treatment, while some others saw it as an advantage to their personality, an enhancement of beauty giving them an admirable look and smile. [11],[12] Midline diastema is often complicated by the insertion of the labial frenum into the notch in the alveolar bone so that a band of thick heavy fibrous tissue lies between the central incisors. Tooth material arch length discrepancy with a condition such as missing teeth, microdontia, macrognathia, peg-shaped laterals, causes midline diastema. Habits such as thumb sucking or tongue thrusting can cause proclination of teeth, which causes midline spacing along with generalized spacing. Midline pathology soft tissue and hard tissue pathologies such as cysts, tumors, and odontomes may cause midline diastema. [13] Forces on the anterior teeth are more pronounced if the posterior teeth are missing, which causes flaring to occur. Periodontal and occlusal factor also causes them. [14] Diastemas can be closed orthodontically or restoratively. Restoration includes porcelain laminate veneers, composites, metal free ceramic crowns, and by metal ceramic crowns. Porcelain laminates have their own limitations too. They should not be used when remaining enamel is inadequate to provide adequate retention. Large Class IV defects should probably not be restored with veneers because of the large amount of unsupported porcelain and the lack of tooth-colored backing. The amount of unsupported porcelain should be carefully evaluated in cases with a large diastema. Darkly stained teeth were not optimally restored with veneers. The prognosis for porcelain veneers in bruxing is doubtful. Certainly, such patients should be instructed to use a night guard after final restoration. Even, if the pocelain laminates fail, in the long run, composite bonding between teeth fills spaces and improves the appearance of diastemas. [5] Long-term studies indicating the success of composites is lacking till date. In this study, the results indicate a higher rate of 91% for the restorations made during the study period of sixty months with 9% had mild chipped restorations rather than complete loss of any restorations done. Contouring the restorations to achieve satisfactory results need good clinical expertise but it is less demanding than placing veneers or an orthodontic procedure. Nearly, half of the group of about 49% exhibited very good satisfactory results and with acceptable contour and need to improve on contour of the restoration for 42% of the sample and 9% with unsatisfactory contour of the study group which indicates the need for preoperative planning with wax up and silicone putty index which helps in better contouring of these restorations. Gingival health also showed a satisfactory level of acceptance to composite restorations. In this study, mild and moderate gingivitis which occurred due to overhanging margins created plaque accumulation, which caused changes in the marginal area of the gingiva. The margins showed signs of improvement after removal of the overhanging margins and oral prophylaxis. The limitations of this study, includes the operator variations involved in the meticulous follow of the isolation, shade matching, and placement protocol, which plays a crucial role in the success of these restorations and need for further long-term evaluation of the restorations.


   Conclusions Top


In this study, composite resin restorations done for midline diastemas between maxillary or mandibular incisors exhibited good clinical acceptance and retention when all the protocols be followed for the proper clinical technique used for the clinical condition and the esthetic outcome depends on the clinical expertise of the operator and the material used for the same.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflict of interest.

 
   References Top

1.
Keene HJ. Distribution of diastemas in the dentition of man. Am J Phys Anthropol 1963;21:437-41.  Back to cited text no. 1
    
2.
Baum AT. The midline diastema. J Oral Med 1966;21:30-9.  Back to cited text no. 2
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Tuncay OC. Orthodontics: Current Principles and Techniques. 4 th ed. St. Louis, MO: Mosby; 2005.  Back to cited text no. 3
    
4.
Proffit W. Contemporary Orthodontics. 4 th ed. St. Louis, MO: Mosby; 2000.  Back to cited text no. 4
    
5.
Chalifoux PR. Perception esthetics: Factors that affect smile design. J Esthet Restor Dent 2007;8:189-92.  Back to cited text no. 5
    
6.
Estafan D, Klodnitskaya L, Wolff MS. Treatment planning in esthetic dentistry requires careful listening to the patient. Gen Dent 2008;56:290-2.  Back to cited text no. 6
    
7.
Chalifoux PR. Comprehensive composite restoration. Inside Dent 2006;2:56-9.  Back to cited text no. 7
    
8.
Chalifoux PR. Perception esthetics: Setting treatment goals. Esthet Dent Update 1993;4:132-7.  Back to cited text no. 8
    
9.
Ryge G. Clinical criteria. Int Dent J 1980;30:347-58.  Back to cited text no. 9
[PUBMED]    
10.
Al-Rubayee MA. Median Diastema in a college students sample in the Baghdad city. Med J Babylon 2013;10:400-6.  Back to cited text no. 10
    
11.
Kaimenyi JT. Occurrence of midline diastema and frenum attachments amongst school children in Nairobi, Kenya. Indian J Dent Res 1998;9:67-71.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.
Onyeaso CO. Prevalence of malocclusion among adolescents in Ibadan, Nigeria. Am J Orthod Dentofacial Orthop 2004;126:604-7.  Back to cited text no. 12
    
13.
Nainar SM, Gnanasundaram N. Incidence and etiology of midline diastema in a population in south India (Madras). Angle Orthod 1989;59:277-82.  Back to cited text no. 13
    
14.
Yaffe A, Hochman N, Ehrlich J. A functional aspect of anterior attrition or flaring and mode of treatment. Int J Prosthodont 1992;5:284-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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