July Clinician's Choice Onsert - 4

FEATURE
CLINICAL EXCELLENCE
Patient Management and Treatment
of the Midline Diastema
A
Dimple Desai
DDS, AAACD
Dr. Dimple Desai is the
founder of Luminous
Smiles of Newport Beach,
a boutique dental practice
focusing on rejuvenating
patients' lives through their
smiles. She is one of the
350 Accredited Members
of the American Academy
of Cosmetic Dentistry in
the world. Dr. Desai has
been recognized locally
as Orange County's Top
Dentist for the past four
years and was selected as
one of the Top 40 Dentists
under the age of 40 in the
country. Dr. Desai has been
featured in various dental
publications and continues
to dedicate her passion
to advancing her career
in Dentistry. Dr. Desai is
also a graduate of the Kois
Institute and obtained both
her Bachelor's degree
in Dental Hygiene and
a Doctorate of Dental
Surgery from the University
of Southern California. She
later returned to her Alma
Mater as a Clinical Adjunct
Professor to educate
dental students on the
clinic floor.
FIG. 1
A young woman presented for treatment options
to " fix her flat front teeth " . The accepted treatment
plan involved short-term aligner therapy followed by
a midline diastema closure and lengthening of the
maxillary central incisors.
A comprehensive clinical examination revealed advanced
incisal wear on teeth #6-11, a constricted bite, fixed wire
retention on teeth #7-10 and #22-27 along with failing
and unaesthetic composite restorations in the posterior
and anterior dentition. The treatment plan presented,
and accepted, involved the correction of the restricted
bite and establishing a more harmonious occlusion
through Invisalign (Align Technology) orthodontics,
along with the replacement of the posterior composites.
Lengthening of the central incisors to address the incisal
wear would be undertaken only after this was achieved.
This
treatment plan was
complicated through the
necessity of removing the fixed lingual retentive wires
prior to the aligner therapy as it was anticipated that the
4 SUMMER 2023 | CLINICAL LIFE | clinicianschoice.com
treatment plan is likely to be accepted by a
patient if there is, at a minimum, a faith in the
dentist that the restorative result will reflect
the patient's desired outcome at the agreed
upon cost and timeline. This is especially true with a
new patient with whom there is little or no shared dental
experience. Any treatment plan requires a thorough
investigation and assessment of clinical findings and is
necessary to present treatment options and promote the
patient's understanding and ownership of their existing
dental condition and its impact on the restorative result.
There is a burden of responsibility to collect as much
information from the patient as it relates to all aspects
of treatment. However, this responsibility does not end
with the clinical examination of hard and soft tissues,
radiographs, photos, models, and medical history. Taking
time to establish a rapport, delving into past dental
experiences, and attempting to assess their potential
as partners in the restorative process is essential to
mitigate any challenges once treatment begins. Trust in
the clinician can build as the case progresses, allowing
the patient to " keep the faith " , as the patient's ongoing
engagement and cooperation can be critical to obtaining
the desired clinical result.
Such was the case when a young woman presented as a
new patient seeking options to improve the appearance of
her " flat front teeth " . (FIG. 1)
removal of this fixed retention and orthodontic movement
would result in the re-appearance of the patient's natural
midline diastema. This added the necessity of closing the
diastema in addition to lengthening the central incisors.
While this was foreseen and the patient was informed of
the possibility of the diastema reforming, she nonetheless
presented for an orthodontic recall appointment visibly
frustrated and agitated. Her heightened level of anxiety
was due to the amount of time involved for Invisalign
therapy and questioning the ultimate esthetic outcome
of her treatment. Her fear stemmed from the presence
of the diastema and that longer, wider central incisors
may take on a " Bugs Bunny " appearance. The patient
was subsequently calmed and faith was restored that
treatment was progressing as anticipated, agreeing to
continue with the aligner therapy.
Once the orthodontic goal of the treatment plan was
achieved, the restorative phase entailed the closure of
the midline diastema and lengthening and recontouring
of teeth #8 and 9. Itero (Align technology) scans of the
maxillary and mandibular arches (FIG. 2A, 2B) were
obtained from which diagnostic models were fabricated.
FIG. 2A
FIG. 2B
Scans of the mandibular and maxillary arches
were obtained. Models were made from these and
mounted. Wax-ups of the ideal restorative result
were then fabricated on these mounted models.
A wax-up of the ideal incisal length of the maxillary
central incisors was fabricated on the mounted models.
The wax-up provided the ideal incisal length and
thickness, facial and lingual contours, and occlusal
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July Clinician's Choice Onsert

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