UNIVERSIDADE ESTADUAL DE CAMPINAS

Faculdade de Odontologia de Piracicaba

MARIANA DIAS FLOR RIBEIRO

Fechamento de diastema com resina composta associado à

cirurgia plástica periodontal: Relato de caso

Diastema closure using composite resin associated with

periodontal plastic surgery: Case Report

PIRACICABA
2019
 MARIANA DIAS FLOR RIBEIRO

Fechamento de diastema com resina composta associado à

cirurgia plástica periodontal: Relato de caso

Diastema closure using composite resin associated with

periodontal plastic surgery: Case Report

Monografia apresentada à Faculdade de

Odontologia de Piracicaba da Universidade
Estadual de Campinas como parte dos requisitos
exigidos para a obtenção do título de Especialista
em Dentística.

Orientadora: Profª Drª Giselle Maria Marchi Baron

PIRACICABA
2019
 Ficha catalográfica
Universidade Estadual de Campinas
Biblioteca da Faculdade de Odontologia de Piracicaba
Marilene Girello - CRB 8/6159

Ribeiro, Mariana Dias Flor, 1991-

R354f Fechamento de diastema com resina composta associado à cirurgia plástica
periodontal : relato de caso / Mariana Dias Flor Ribeiro. – Piracicaba, SP : [s.n.],
2019.

Orientador: Giselle Maria Marchi Baron.

Trabalho de Conclusão de Curso (especialização) – Universidade Estadual de
Campinas, Faculdade de Odontologia de Piracicaba.

1. Diastema (Dentes). 2. Estética dentária. 3. Resinas compostas. I. Marchi,

Giselle Maria,1970-. II. Universidade Estadual de Campinas. Faculdade de
Odontologia de Piracicaba. III. Título.

Informações adicionais, complementares

Título em outro idioma: Diastema closure using composite resin associated with
periodontal plastic surgery: case report
Palavras-chave em inglês:
Diastema (Teeth)
Esthetics, dental
Composite resins
Área de concentração: Dentística
Titulação: Especialista
Data de entrega do trabalho definitivo: 03-09-2019
DEDICATÓRIA

Dedico esse trabalho à minha família que são minha base e referência de amor e
companheirismo.
AGRADECIMENTOS

Agradeço a professora Drª Giselle Maria Marchi Baron pela orientação e pela amizade.
À Faculdade de Odontologia de Piracicaba, na pessoa do seu Diretor Francisco Haiter
Neto e vice-diretor Flávio Henrique Baggio Aguiar.
Ao Prof. Dr. Luis Alexandre Maffei Paulillo, que me auxiliou no planejamento e
execução da parte clínica desse trabalho.
Ao corpo docente da Dentística: Profª Débora Alves Nunes Leite, Prof. Flávio Henrique
Baggio Aguiar, Profª Giselle Maria Marchi Baron, Prof. Luis Roberto Marcondes
Martins, Prof. Marcelo Giannini, Profª Vanessa Cavalli Gobbo.
À Mabelle de Freitas Monteiro, por contribuir com seus conhecimentos e habilidades
na área de periodontia que ilustram esse caso clínico.
À Marília Zeczkowski por compartilhar seus conhecimentos de estratificação e
manuseio de resina composta, que foram fundamentais para uma melhor condução
do caso.
Aos amigos da especialização: Rodrigo Lins, Josué Pierotte, Renata Pereira, Bruna
Guerra, Laura Ferraz, Caroline Mathias e Suelem Chasse.
A todos que direta ou indiretamente contribuíram para a conclusão desse trabalho.
Muito obrigada!
“Sua tarefa é descobrir o seu trabalho e, então, com todo o coração, dedicar-se a ele.”

(Buda)
 RESUMO

O fechamento de espaços interdentais utilizando resina composta é

considerado uma alternativa estética, prática e conservadora. Entretanto, a
combinação de duas ou mais modalidades de tratamento pode ser necessária como
medida de tornar o tratamento mais adequado e completo. Esse relato de caso mostra
o quadro de um paciente com queixa de sua estética dental devido à presença de
diastemas. Objetivo: Objetivou-se a realização de um planejamento e execução de
tratamento restaurador com finalidade estética. Métodos: Foi realizado um plano de
tratamento através de fotografias, modelos de estudo e planejamento digital. Em
seguida, realizou-se o clareamento dental externo, cirurgia plástica periodontal, troca
das coroas provisórias em resina acrílica e ensaio restaurador com a finalidade de
teste de forma e cor dos incisivos centrais superiores e, posteriormente, realizou-se
restaurações diretas em resina composta nesses elementos para o fechamento dos
diastemas e harmonia dental. Resultados e Conclusão: Obteve-se, com esse
procedimento, uma melhora considerável da estética dental, harmonia do sorriso e
satisfação do paciente.

Palavras-chave: Diastema. Estética Dentária. Resinas Compostas.

 ABSTRACT

The closure of interdental spaces using composite resins is considered an esthetic,

practical, and conservative treatment option. However, the combination of two or
more types of treatment may be required in order to handle cases in the most
complete and suitable way. This case report shows the condition of a patient with
complaints about dental esthetics due to the presence of diastema. Aim: The objective
was the planning and implementation of a restorative treatment with esthetic purpose.
Methods: Treatment was planned by means of photographs, study models and digital
planning. Firstly, external tooth whitening was performed, followed by periodontal
plastic surgery, replacement of acrylic resin provisional crowns, and restorative test
with the purpose of evaluating the form and color of the maxillary central incisors prior
to definitive procedures. Then, direct resin composite restorations were carried out for
closing diastema and achieving dental harmony. Results and Conclusion: A
considerable improvement in dental esthetics, smile harmony and patient satisfaction
was obtained by the reported procedures.

Keywords: Diastema. Esthetics, Dental. Composite Resins.

 SUMÁRIO

1 INTRODUÇÃO 10
2 Capítulo único: DIASTEMA CLOSURE USING COMPOSITE RESIN
ASSOCIATED WITH PERIODONTAL PLASTIC SURGERY 12
ANEXOS 24
ANEXO I - Verificação de Originalidade e Prevenção de Plágio 24
ANEXO II - Comprovante de submissão do artigo 25
 10

1. INTRODUÇÃO

Nas últimas décadas, percebemos uma crescente valorização da estética dental

(Kabbach, 2018). Nesse contexto, estudos mostram que diastemas, principalmente
entre os incisivos centrais, diminuem a auto percepção estética (Kaieda, 2019; Chu,
2011). Como definição, diastemas são conhecidos como o espaço entre 2 ou mais
dentes consecutivos (Proffit et al., 2006) e eles estão entre as principais razões para
a insatisfação odontológica dos pacientes e para a exigência de melhorias estéticas
nos consultórios odontológicos (Kapusevska, 2014; Sen, 2019).
Existem várias alternativas para corrigir a presença dos diastemas e para isso é
essencial que haja um correto diagnóstico e um planejamento abrangente para a
obtenção de resultados estéticos e duradouros (Spear, 2007). Dentre as abordagens
de tratamento, podemos citar: o uso de aparelhos ortodônticos, coroa total, facetas,
laminados cerâmicos e resinas compostas (Kabbach, 2018). Além disso, sabe-se que
o diastema é multifatiorial; e, por isso, seu tratamento varia de acordo com a
complexidade do caso e muitas vezes demanda a aplicação de mais de uma área de
conhecimento para a resolução do caso, geralmente envolvendo ortodontia, prótese,
dentística e periodontia (Chu, 2011).
Existem vantagens do uso da resina composta citadas na literatura, como exemplo
temos:
- Mimetização da aparência da estrutura dental normal (Kabbach et al.., 2018);
- Menor custo do que as restaurações indiretas (Wolff et al., 2010; Ergin et al.,
2018);
- Menor tempo de tratamento em comparação com uso de aparelhos ortodônticos
(Kabbach et al., 2018);
- Adição ou remoção de compósitos podem ser feitos para se adequar ao objetivo
desejado do paciente (Prabhu, 2015).
- Permite o uso do adesivo de 2 passos, que é aceitável tanto para o esmalte quanto
para a dentina (Gresnigt et al., 2012)
- Taxa de sucesso que quase 90% das restaurações em até 10 anos de
acompanhamento (Lempel et al., 2017).
Além da estética dental (estética branca), há uma preocupação também com a
estética gengival (estética rosa) para que haja harmonia do resultado final do
procedimento odontológico. Assim, além de se obter bons resultados, esses
 11

procedimentos procuram obter um grau de equilíbrio entre função e estética (Novaes

et al., 2019).
Assim, o objetivo desse estudo é relatar um caso clínico de um paciente com
amplos diastemas anteriores tratado com cirurgia plástica periodontal e reabilitação
estética em resina composta.
 12

2. Capítulo único: DIASTEMA CLOSURE USING COMPOSITE RESIN

ASSOCIATED WITH PERIODONTAL PLASTIC SURGERY
Submitted in Journal of Esthetic and Restorative Dentistry
Authors: Mariana Dias Flor-Ribeiro; Flávio Henrique Baggio Aguiar, Giselle Maria
Marchi
ABSTRACT

Objective: The closure of interdental spaces using composite resins is considered

an esthetic, practical, and conservative treatment option. However, the combination
of two or more types of treatment may be required in order to handle cases in the
most complete and suitable way. This case report shows the condition of a patient
with complaints about dental esthetics due to the presence of diastema. The objective
was the planning and implementation of a restorative treatment with esthetic purpose.
Clinical considerations: Treatment was planned by means of photographs, study
models and digital planning. Firstly, external tooth whitening was performed, followed
by periodontal plastic surgery, replacement of acrylic resin provisional crowns, and
restorative test with the purpose of evaluating the form and color of the maxillary
central incisors prior to definitive procedures. Then, direct resin composite
restorations were carried out for closing diastema and achieving dental harmony.
Conclusions: A considerable improvement in dental esthetics, smile harmony and
patient satisfaction was obtained by the reported procedures.
Clinical Significance: With proper planning, closure of anterior teeth diastema using
composite resin and periodontal recontouring surgery become viable options for the
dentist.

Keywords: Diastema. Esthetics, Dental. Composite Resins.

 13

INTRODUCTION

Midline jaw diastema is reported as a common type of incomplete occlusion 1, 2, and

is often the primary complaint of patients seeking dental care in the field of Esthetic
Dentistry 2, 3, 4.
By definition, diastema is the space greater than 0.5 mm between the proximal
surface of adjacent teeth 5, 6 and the midline diastema is the space greater than or
equal to 1mm between the two permanent central incisors during adulthood 7.
Generally, the presence of diastemas leads the patient to dissatisfaction with oral
health and is associated with unpleasant appearance, which may have psychological
and social effects 7, 8.
In order to obtain satisfactory results in the treatment of diastemas, it is essential to
have a correct diagnosis and planning 9. Only in this way can predictable, esthetic and
lasting results be obtained 10, 11.
There are several methods reported in the literature for treating diastema. Many of
these covers more than one area of dentistry and are performed in conjunction with
areas such as: Orthodontics, Prosthodontics, Dentistry and Periodontics 2, 7, 12.

The esthetic and functional rehabilitation of the diastema is recognized as one of

the most common dental treatments 2, 13. However, one of the clinician's greatest
difficulties is related to obtaining an adequate height x width ratio of the dental elements
to be restored 12.
This often requires digital planning (Digital Smile Desgins - DSD) 14, as well as
diagnostic waxing 9. With these steps together, an adequate proportion and harmony
of the dental elements can be achieved, and excess restorative material in the gingival
contour avoided 12.
Regarding the choice of treatment approaches, it is known that indirect restorations
generally have greater potential for destruction of healthy dental structure. Direct
techniques are in line with minimally invasive dentistry, which is the key principle
guiding dentistry 4, 15. Therefore, dental contouring and closure of composite resin
diastemas are highly advantageous 4.
In recent years, esthetic improvement aimed at preserving healthy teeth has been
increasingly performed non-invasively through cosmetic remodeling with composite
resins 16. This is due to the great advance in knowledge about the technology of
composite resins and adhesive systems that has occurred in recent decades 4.
 14

In addition, advances in resin particle technologies that led to the transition from
microparticulate to nanoparticulate and nanohybrid resins may also justify broadening
indications for the use of composite resins 17.
Advantages of using composite resin over other techniques include:
- Mimicry of the appearance of normal dental structure 12;

- Lower cost than indirect restorations 4, 18;

- Less treatment time compared to use of orthodontic appliances 12;

- Addition or removal of composites can be made to suit the patient's desired goal 6;
- Allows use of 2-step adhesive, which is acceptable for both enamel and dentin 17;
- Success rate almost 90% of restorations within 10 years of follow-up 19.
In addition to dental esthetics (white esthetics), there is also a concern with gingival
esthetics (pink esthetics) so that there is harmony of the final outcome of the dental
procedure. Thus, in addition to obtaining good results, these procedures seek to
achieve a degree of balance between function and esthetics 20.

Plastic periodontal procedures include interdental papilla reconstruction, gingival

smile correction, and increase of clinical crown for esthetic purposes 20.
Thus, the aim of this study is to report a case report of a patient with large anterior
diastemas treated with periodontal plastic surgery and cosmetic resin composite
rehabilitation.

CASE REPORT

Male patient, salesman, 57 years old, attended the Clinic of the Dentistry
Specialization of the Piracicaba School of Dentistry, complaining that “the spaces
between his front teeth” were hindering his sales and would like to improve his dental
esthetics. Initially, anamnesis and complete clinical examination, photographs and
initial radiographs were performed (Fig. 1).
 15

Figure 1. Initial photographs, smile line analysis and initial radiographs.

The prophylaxis was performed with scraping and supra-root smoothing, digital
smile planning, and upper and lower impression for diagnostic waxing (Fig. 2).

Figure 2. Analysis of maxillary central incisor width and interdental space, digital smile planning
and diagnostic waxing.

As the dental elements were in a darkened color (Fig. 3), we performed office dental
bleaching (Whiteness HP Blue - FGM, Joinville, SC, Brazil), 3 sessions of 40 min (35%
concentration), with an interval of 1 week between each session. After bleaching, we
wait 3 weeks (21 days) before starting the restorative procedure. During this period,
we performed periodontal esthetic contouring with repositioning of the dental Zeniths
 16

and reshaping of the teeth shape to promote better harmony between white esthetics
(teeth) and red esthetics (gums) – Fig. 3. At this stage, we pay attention to the
preservation of the biological space and intervention only until the inserted gum height
necessary for the recontouring. We performed the replacement of the provisional
crowns of the upper lateral incisors, based on the diagnostic waxing aiming at
maintaining the new gingival contour and esthetic improvement.

Figure 3. Initial color take followed by tooth whitening. Following, image of periodontal cosmetic
contour with repositioning of the Zeniths and making the previous impression to replace the
provisionals (upper lateral incisors).

In order to predict the results, check the colors of the resins to be used, size of the
elements to be restored and patient satisfaction with the planned treatment, we
performed the restorative clinical trial (Fig 4). At this stage, we performed the color
selection of the composite resin (Filtek Z350, 3M ESPE, St. Paul, USA), making the
 17

palate enamel shell by silicon guide (Express XT, 3M ESPE, St. Paul, USA) and
performing restoration excluding the steps of acid etching and adhesive system
application. Thus, this trial worked as a mock up, but with all the effects of the
overlapping resin layers, layering and texturing, and so it is much closer to the end
result and more likely to meet the patient's real expectations. The purpose of this step
is to analyze the patient's adaptation to the volume of the restored elements, size,
shape, color, etc.

Figure 4. Restorative clinical trial.

Thus, in a subsequent session we performed the modified absolute isolation and

removal of all old restorations that were in both 11 and 21 (Figs. 5 and 6). As we
observed that the restorations were extensive and there was a thin layer of dentin
separating the pulp from the restoration to be fabricated, we performed the protection
of the dentin-pulp complex with Glass Ionomer Cement (Vidrion F, SSWhite, Germany)
only on the deeper dentin (Fig. 6). Soon after, we checked the buccal workspace with
the silicone guide and proceeded with the application of 35% phosphoric acid (Ultra-
Etch, Ultradent Inc., South Jordan, USA) for 30 sec on enamel and 15 sec on dentin,
wash by 60 sec and drying. In this last step, we protected the dentin with a slightly
 18

moistened cotton ball while vigorously drying the enamel to prevent collagen fibrin
collapse in the dentin.

Figure 5. Removal of old restorations. Observe modified absolute isolation and presence of
composite resin veneer - marked on element 11 by the explorer probe.

Figure 6. Image after removal of all resin present in elements 11 and 21. Glass Ionomer
Cement (Vidrion F, SSWhite, Germany) pulp protection, silicone guide check, application of
phosphoric acid (37%, Ultra-Etch, Ultradent Inc., South Jordan, USA) for 30 s enamel and 15
s dentin, abundant washing. Observe slightly moistened cotton balls while drying the enamel.
 19

Sequentially, we applied the adhesive system (Adper Single Bond 2 - 3M ESPE

Adhesive, St. Paul, USA) with double active adhesive application, drying after each
layer and photoactivation for 20 s on both layers. We performed the restoration itself,
following what was planned through the restorative clinical trial and checked the
vestibular adaptation through the silicone guide (Fig. 7). As element 21 (without
restoration on the buccal face) presented expressive smoothness and lack of texturing,
we repeated this anatomy in element 11.

Figure 7. Sequence of the adhesive and restorative protocol. Vestibular dimension check with
silicone guide.

We checked the width of the elements with a compass (Trident, São Paulo, SP,
Brazil) to verify that the elements were of equal width (Fig. 8), removed excess
restorations and removed major irregularities.

Figure 8. Photograph immediately after the restorative procedure and checking the width of
the elements.
 20

After 24 hours, we continued the complete finishing and polishing procedures,

where we were able to explore the areas of light and shade. In this case, we chose to
explore the area of reflection and brilliance in the central part of the tooth and to expand
the shadow area at the mesial and distal edges to create a visual effect of smaller teeth
width and greater harmony between them. Finally, we checked the anatomy with
golden icing sugar and made the final photos (Fig. 9).

Figure 9. Finishing and polishing, exploring technique of light and shadow areas. Final
photography.

DISCUSSION

Despite the growing appreciation of esthetics currently perceived, the success of an

esthetic case in dentistry depends on a number of factors, but above all on good
planning 11.
Correct planning involves thorough history taking, clinical examination, occlusion
analysis and patient habits, intra- and extraoral photographs, modeling to obtain a
study model 12. In addition, the advantages of digital smile planning have now been
discovered 2.
This digital planning assists in all the steps mentioned above, and allows greater
visualization and predictability of the final outcome of the case 14 (Fig. 2). Through DSD
planning, we were able to analyze and plan both the surgical and the restorative
stages.
 21

Prior to the beginning of the restorative stage, we performed gingival plastic surgery.
Plastic periodontal procedures encompass a series of surgical techniques aimed at
achieving improvements in what is today called “pink esthetics” 20.
It is extremely important to determine which predisposing factors are present in the
case to be treated and this is intended to prevent and treat the condition, and to
maintain long-term esthetic results. One of the most important of these factors is the
periodontal biotype, and when the appropriate technique is selected, it is vital to take
the biotype into account 20.
This step was fundamental for obtaining the final result of the study, as the patient
presented the interdental papilla that was too thick and prevented the creation of a
correct emergence profile of the new restorations (Fig. 3). In addition, it helped to
shape the entire gingival contour, returning the red esthetic satisfactory to the case.
Using composite resin, we can achieve highly predictable results regarding
mechanical strength, adhesive strength, durability and esthetics 4. In addition to
traditional particles, most nanohybrid resins - such as the resin of choice - contain small
concentrations of microparticles and / or nanoclusters that increase the amount of
charge, improve mechanical properties, and produce highly polished surfaces 21. The
use of nanocomposites in previous restorations is recommended because of their
superior mechanical and esthetic strength, so this was our approach of choice for this
case.
We opted for the restorative clinical trial (Fig. 4), as it is a quick and simplified
procedure that aims to predict the final outcome of the planned restorative procedure
22. This step aims to replicate the healthy dental structure to achieve desirable dental
mimicry. For this, the stratification of the composite resin is performed using
composites with different degrees of translucency depending on the color of the dentin
and enamel to be achieved. This essay, as its name implies, acts as a test for the final
restoration and the advantage is that it can be performed more than once.
This technique is considered one of the most advantageous for the color selection
of composite resins because it tends to result in a higher success rate of the final
restoration, although there are few studies on it 23. As we performed the periodontal
surgical stage, we were very careful regarding the maintenance of gingival contours
and health of the interdental papilla. Therefore, we opted for modified isolation, which
in this case is indicated, as the conventional conceals the interdental papilla and limits
access to gingival regions 24.
 22

In addition, studies show that properly performed polishing exhibits an improved

periodontal response, which reduces the impact of restoration to adjacent oral tissues
4, 25, as well as increasing durability of composite resin restorations 25.
Overall, composite resin diastema closure associated with periodontal plastic
surgery, when well planned, demonstrates satisfactory esthetic results and improves
the quality of life of patients with this condition.

CONCLUSION

The presence of diastema is characterized as esthetically unsatisfactory. Anterior

teeth diastema closure using composite resin and periodontal recontouring surgery are
viable options for the clinician as they restore the esthetic harmony and well-being of
the patient.

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 24

ANEXO I

Verificação de Originalidade e Prevenção de Plágio

 25

ANEXO II
Comprovante de submissão do artigo