Easier and Faster Aesthetic Bonding: The Keys to Success

INTRODUCTION
There are unique challenges to running any type of business. I think any business owner will agree that one important key to success is being efficient at as many tasks as possible within the business. By doing so, it can allow any company to be more successful, as it frees up time to improve other aspects of the business. Furthermore, by making any job easier, it creates more opportunities for the business and its employees. In dentistry, the same holds true with aesthetic bonding procedures. If we can do them faster and easier, it allows us more time in the office to be more profitable in other areas of the business.

In cases where a patient presents with a damaged front tooth, there is an urgency due to its cosmetic appearance as well as the desire to alleviate physical discomfort. These composite cases can be quite a challenge to a practice with a busy schedule, as it’s hard to know how long it could take to restore the tooth with composite bonding and create a beautiful appearance. However, there are some simple key steps that can be implemented that have a systematic approach to restoring anterior broken teeth with composite bonding quickly, predictably, and with excellent aesthetics.

CASE REPORT
Diagnosis and Treatment Planning
A 48-year-old man presented with a broken maxillary right central incisor that had previously been restored with a composite resin material (Figures 1 and 2). The material had come out while eating a meal. The tooth was not sensitive, and no decay was present. The patient was presented with all the options available to restore the tooth; however, the only plausible treatment would be to use a minimally invasive treatment that conserves tooth structure. A composite resin restoration was chosen to replace the defect, as no additional tooth structure would need to be removed to create a more favorable, aesthetic appearance.

Figure 1. The patient’s preoperative smile.	Figure 2. The pre-op, retracted photo.

The ability to closely mimic natural tooth color, translucency, and the refractive index is possible with some modern composite resin materials. Technological advancements have allowed for the development and creation of amazing new restorative materials that make our job as dentists easier than with previously available products. Composite resin restorative materials continue to evolve and change in many different aspects. Their physical properties continue to improve, as has their handling, polish, color, and translucency, resulting in consistently high-quality results.

The patient’s maxillary right central incisor did not display any apparent microfractures that needed to be modified by the preparation design. Since the new nano-hybrid composite material (Evanesce [CLINICIAN’S CHOICE Dental Products]) blends extremely well with surrounding tooth structure, no additional tooth modification in the form of reduction and beveling of the enamel would be necessary. Compare this to many earlier composites that required beveling to allow them to blend in with existing tooth structure. The ability of a composite to blend in with the natural tooth structure without the removal of additional tooth structure ensures that a minimally invasive approach can be taken to restoring teeth.

Clinical Protocol
The first key to a fast, accurate, consistent aesthetic outcome is to take a photo and do a shade evaluation. First, take photos to document the process and to see the tooth prior to the dehydration that takes place during the procedure (due to a lack of saliva contacting the tooth’s surface). It is good to include the shade tabs in the photographs. Next, upload the photos to a computer, where they can be manipulated and changed to black and white to evaluate value only. Cross polarization can also be implemented in a photograph to better perceive the incisal edge color characteristics by removing spectral glare.¹

Figure 3. A composite mock-up for color assessment and to create the overall shape used to fabricate a template.	Figure 4. Isolation of the adjacent tooth with a Mylar strip. The total-etch adhesive technique was used.
Figure 5. The application of the bonding agent (MPa MAX [CLINICIAN’S CHOICE Dental Products]).	Figure 6. Enamel composite (Evanesce Composite [CLINICIAN’S CHOICE Dental Products]) was placed in a guide fabricated using Template vinyl polysiloxane impression material (CLINICIAN’S CHOICE Dental Products).
Figure 7. The composite was manipulated into position using a composite placement instrument.	Figure 8. Take a composite instrument (Dr. Ronald Jordan #4 [CLINICIAN’S CHOICE Dental Products]) and adapt the enamel composite to the tooth.

A basic shade of composite for dentin and enamel must be chosen as a starting point. The second key is doing a quick mock-up, which allows the clinician to create the ideal tooth form so that a template for the lingual can be fabricated while simultaneously evaluating color and translucency. Take a composite that best matches the dentin color, and apply it to the tooth in the same area where the dentin will be replaced.² Make sure to taper the material so that the overlaying enamel composite will have different thicknesses mimicking the natural tooth shape and to evaluate final color selections. Then light cure the composite for 3 to 5 seconds. Next, apply an enamel composite shade that best matches the existing enamel and wrap around to the lingual. Typically, I will place the enamel composite on the previously placed dentin composite as well as on the natural enamel, then taper it to make it thinner as it goes across the enamel. (The various thicknesses can offer different levels of translucency and show-through of the dentin composite’s color.) Have the patient bite down and check occlusion on the composite. Mocking up the entire tooth allows you to better understand colors and shape so that you can create a template to work from.³ Then light cure again for 3 to 5 seconds. This whole process of evaluating the composite’s color and creating a mock-up shape of the tooth should take no more than 3 to 5 minutes. Once this is done, a fast-set vinyl polysiloxane (VPS) impression material [Template (CLINICIAN’S CHOICE Dental Products)] can be used to create a lingual-incisal template (Figure 3). In this case, Template was used because of its speed (a 30-second working time and a 30-second set time). The template will allow for quick placement and shaping of the lingual enamel composite while also providing support when compressing the different layers of composite together in the cavity preparation. You now have a template to build with and a composite restoration with various thicknesses of composite resin. The ability to view the composite allows you to verify that the correct colors have been chosen and gives some insight into how to layer the different shades based upon the various levels of thicknesses seen.

At this point, the composite is quickly removed from the tooth, since no preparation or adhesive steps were performed. It is important to avoid the placement of any composite resin into undercuts or embrasures that would make removal of the mock-up difficult and possibly necessitate that it be cut off of the tooth with a handpiece. The next step is to isolate the tooth (ie, with cotton rolls, a rubber dam, etc.,) to provide a dry working environment. The adjacent tooth should be protected with either a Mylar strip or Teflon tape. Air abrasion [MicroEtcher II (Zest Dental Solutions)] is then used to clean the tooth and to create microanatomy, which increases the bondable surface area. After rinsing away the aluminum oxide particles and drying the tooth, phosphoric acid gel is used to etch the dentin and enamel tooth structure (Figure 4).⁴ This was followed by the application of a 7% filled 5th generation bonding agent [MPa MAX (CLINICIAN’S CHOICE Dental Products)] per the manufacturer’s application technique (Figure 5). Be sure to still have the Mylar strip or Teflon tape protecting the adjacent tooth. Next, the adhesive is cured for 20 seconds using an LED curing light [VALO Grand (Ultradent Products)]. The previously fabricated template can be used next.⁵ Remove the Mylar strip or Teflon tape and then rub waxed floss only on the adjacent tooth so that the composite will not stick to it. Then place a thin layer of the enamel composite into the template. Place the composite into the area of the template that will allow for it to be compressed into the defect as well as against the healthy tooth structure. Holding the template firmly against the tooth should cause any excess material on the lingual of the tooth to be very thin, ensuring minimal cleanup (Figure 6). Taking a composite instrument (Dr. Ronald Jordan #4 [CLINICIAN’S CHOICE Dental Products]), compress the material into all areas of the tooth that need to be replaced with an enamel composite. Then take a thin-bladed composite instrument and make sure that the composite is not touching the adjacent tooth (there should be room for a Mylar strip to go back between the teeth). Next, the LED curing light is utilized for 20 seconds to cure the composite. The template is then removed, and the tooth is light cured from the lingual for another 20 seconds.

Figure 16. The postoperative, retracted photo.	Figure 17. The post-op smile.

Next, apply the dentin composite to the tooth using a stratification layering technique while still using the template to support the initial layer of enamel composite (Figure 7).⁶ Once placed, make sure that the dentin composite tapers toward the incisal, and add in some striations, or indentations, in the dentin composite toward the incisal edge using a composite instrument. It appears more natural to have various thicknesses of composite and striations that will mimic the natural tooth. Also, leave room toward the mesial to be able to place enamel composite next. Use an LED curing light (VALO Grand) for 20 seconds to cure the composite. Place the Mylar strip between the teeth one more time. Take the enamel composite and inject it onto the tooth, extending it up to the incisal edge and mesial against the Mylar strip. Take a composite instrument and adapt the enamel composite to the tooth (Dr. Ronald Jordan #4) (Figure 8). Pulling the Mylar strip to the lingual is the third key that will pull the enamel composite into the contact area and out to the lingual. Having now pulled the Mylar strip all the way through the contact, there will still be a thin space between the composite and the adjacent tooth. Tap lightly with a finger or a composite instrument to cause the compressed composite to move laterally against the adjacent tooth, creating an interproximal contact. Take a thin-bladed composite instrument and make sure to put a little roll on the mesial line angle to create the same facial embrasure space profile that the tooth next door creates when sighting down from incisal to gingival. Next, light cure the composite for 20 seconds.

I try to have 90% or more of the shape created before doing the final light-curing step. This is because I want to expend minimal time and effort to do the task of cleaning up any excess composite, and I also want to make the finishing and polishing steps easier and faster. Less cleanup is the fourth key to a faster direct composite restoration outcome. A smooth surface, in my mind, is one of the easiest to accomplish in some ways but also the hardest in others. Starting with a coarse finishing disc to clean off all the gross excess, proceed systematically through the medium, fine, and superfine composite polishing discs (CLINICIAN’S CHOICE Dental Products) to remove any surface scratches (Figures 9 to 13).⁷ Create a nice high luster on the facial, lingual, and interproximal surfaces using polishing wheels (A.S.A.P. Polishers [CLINICIAN’S CHOICE Dental Products]) (Figures 14 and 15). Floss the contacts and remove any interproximal flash with a sharp scalpel or a composite knife (Composite Ninja [CLINICIAN’S CHOICE Dental Products]). The lingual will typically have some flash. Check the occlusion, and use a 12-fluted carbide finishing bur for removing gross excess and a 30-fluted carbide for fine adjustments, followed by the polishing wheels (A.S.A.P. Polishers). Remember to take final photos of your work to document the treatment of the case in the patient’s chart and to use for future marketing efforts (Figures 16 and 17).

CLOSING COMMENTS
There are many challenges we face every day in clinical dentistry, in addition to running a dental business and managing employees. Simplification of the composite bonding procedure allows for better and faster outcomes. These simple key steps to confidently create aesthetic outcomes for faster and easier bonding cases allow the dental practitioner to have more confidence, achieve predictable results, and become more profitable.

References

1. Snyder T. Refine your dental photography. Journal of Cosmetic Dentistry. 2013;29:72-80.
2. Snyder T. Conservative replication of nature with a class IV direct composite. Journal of Cosmetic Dentistry. 2012;28:21-34.
3. Felippe LA, Monteiro S Jr, De Andrada CA, et al. Clinical strategies for success in proximoincisal composite restorations. Part II: Composite application technique. J Esthet Restor Dent. 2005;17:11-21.
4. Kanca J III. Improving bond strength through acid etching of dentin and bonding to wet dentin surfaces. J Am Dent Assoc. 1992;123:35-43.
5. Fahl N Jr. Step-by-step approaches for anterior direct restorative challenges: mastering composite artistry to create anterior masterpieces—part 2. Journal of Cosmetic Dentistry. 2011;26:42-55.
6. Vanini L. Conservative composite restorations that mimic nature. Journal of Cosmetic Dentistry. 2010;26:80-98.
7. Mopper KW. Contouring, finishing, and polishing anterior composites. Inside Dentistry. 2011;7:62-70.

Dr. Snyder received his doctorate in dental surgery at the University of California, Los Angeles (UCLA) School of Dentistry and has trained at the F.A.C.E. institute. He is an Accredited Fellow of the American Academy of Cosmetic Dentistry and is a member of Catapult Education. Dr. Snyder was on the faculty at UCLA, where he created and co-directed the first 2-year graduate program in aesthetic and cosmetic restorative dentistry. In addition to lecturing internationally, he has co-authored 3 books and written numerous articles in publications around the world. He can be reached at the website drtoddsnyder.com.

Disclosure: Dr. Todd Snyder has no financial interest in any of the companies mentioned in this article but did receive compensation from CLINICIAN’S CHOICE Dental Products for writing this article.

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