Mention direct composite bonding to the great majority of dentists and expect a shudder. Perhaps no other process elicits the anxiety associated with having to “create” from “scratch,” if you will, a pleasing smile rehabilitation. The dentist’s artistic ability is ultimately tested without a lab to blame for less-than-ideal results. Case difficulty multiplies with the number of teeth involved in the rehab. This author, a longtime fan of the control and conservatism that direct bonding offers, has found it helpful to enlist laboratory assistance when designing new smiles destined for composite reconstruction. It is particularly helpful to have the new smile “mocked up” in a laboratory setting so as to predetermine incisal edge position and morphology. Most of us will agree that if we can position and shape the maxillary central incisors quickly and effectively, the remainder of the case will quickly fall into place. As they say, “The centrals are the stars…”
We also know that the application of direct composite to natural tooth structure comes in several flavors, from monochromatic, single-color applications to complex, multiple-layer concoctions. While this author is more apt to engage a multiple-layer approach when attempting to restore a single tooth, and in doing so match its counterpart, time-consuming 8-tooth and 10-tooth direct cases beg for a simpler approach to acceptable cosmetics.
In that vein, the following case incorporates a dual-layered approach, utilizing a preformed template to assist in direct composite placement.
BEGIN WITH A SIMULATION…
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Figure 1. Preoperative portrait. |
Figure 2. Idealized simulation. |
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Figure 3. Smile closeup. |
After some encouragement by me, Denise, a longtime patient, decided it was time to upgrade her smile. The process was initiated in a fashion similar to all of my anterior cases…with a simulation from Smile-Vision. I know of no better way to involve the patient emotionally and at the same time receive important cues on case design. The simulation serves two purposes. On the one hand, it truly tests the patient’s desire to go forward with treatment. It does so in a nonconfrontational manner; the hard sell isn’t needed. The patient is either excited and consequently desirous of treatment, or is indifferent. When, after viewing the simulation, the latter prevails, further conversation on the topic can be dispensed with, saving both patient and doctor wasted time and words. If, on the other hand, the patient is motivated to proceed, the simulation becomes the road map for case design; thus the twofold purpose for a digital preview.
As can be seen in Denise’s simulation (Figures 1 and 2), an effort to convert a flat to reverse anterior architecture to a more pleasing curve was accomplished in the simulation. Teeth Nos. 5 to 12 are involved in the preview. No attempt was made to alter gingival architecture, as patient and doctor agreed, although tissue height changes can be simulated easily when requested. Considerable anterior wear due to an anterior/posterior bruxism habit was noted, as were several large composite restorations that displayed stain around the margins. Overall, structural integrity was good, lending the case to an “additive approach,” making use of composite resin to implement the change.
In this instance the material chosen was DENTSPLY Caulk’s Esthet-X, a popular microhybrid resin. Compositionally, Esthet-X’s resin matrix (a urethane-modified bis-GMA) is based on the matrix used in an old standby, TPH Spectrum (DENTSPLY Caulk). The resin is filled to 60% by volume (77% by weight) with bariumalumino fluoroborosilicate glass (BAFG) and nanosized silicon dioxide particles. The product is provided with TruMatch (DENTSPLY Caulk), an innovative, 3-dimensional shade guide with tabs that have been formed from various combinations of the different opacious, body, and translucent shades; 31 shades in all. It handles well for this purpose in that it possesses low stickiness and offers nonslumping sculptability. While microhybrids are not known for their high luster at polishing, Esthet-X is capable of an attractive finish, and having used this material for similar cases over a 6-year period, I had confidence that it could hold up to considerable abuse. Given Denise’s history of bruxism, this was a prime concern (Figure 3).
FROM PHOTO TO RESIN REPLICA
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Figure 4. Smile-Vision composite mock-up. |
Upon receiving simulation approval, upper and lower study model impressions were taken along with a face- bow record using Panadent’s Kois Dento-Facial Analyzer system. This simplified face-bow system maximizes the likelihood that the maxillary cast will be mounted in level fashion relative to the patient’s face. Used in conjunction with a Panadent Articulator, consistent cast mountings become second nature.
As this article’s title implies, the case discussed herein involves template fabrication to facilitate comfortable and accurate placement of the incisal edges in relation to what was viewed in the simulation. This process, involving careful laboratory measurements necessary to transfer the simulated smile to wax, takes place at Smile-Vision. The usual result is a wax-up, available for online preview, that “simulates the simulation” (Figure 4). Once the doctor approves it (after online previewing), the wax is converted first to composite and then to stone to facilitate the “suck-down” template fabrication process. The end result is an exquisitely detailed template ready to transfer in-cisal edge position, shape, and width to the mouth.
SHOW TIME
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Figure 5. Midline creation to set cant. |
Figure 6. Smile-Vision template tried in. |
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Figure 7. Cut away template leaving incisal edge. |
Figure 8. Esthet-X incisal placed in template. |
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Figure 9. Template seated, and excess removed. |
Figure 10. Incisal composite in place. |
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Figure 11. Dominant central incisor completed. |
Figure 12. Excess composite trimmed with fine diamond. |
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Figure 13. Distal of No. 9 polished to avoid adhesion. |
Figure 14. Central incisors roughed out. |
Following local anesthesia of the anterior maxilla with 4% Septocaine (Septodont), the 8 teeth to be bonded were conservatively prepared. The chief goals were to keep the preparations in enamel where possible, remove unsightly or leaking composite, and create a gentle gingival chamfer so as to demarcate the boundaries for composite placement. Of particular importance is the midline cut (Figure 5). It is made with the clinician sitting directly behind the patient from the 12 o’clock position. Its purpose is to remedy a pre-existing midline cant. Nothing is more discouraging than completing the initial placement of the central incisors and discovering that the midline is canted. By carefully making this initial cut in perpendicular fashion, and using it as a guide for interproximal composite placement, this type of misfire soon becomes a rarity.
When the preparations were completed, the Smile-Vision template was tried in to verify that tooth preparation allowed adequate space for composite placement (Figure 6). Once satisfied that the preparations met these requirements, the labial portion was removed to allow for a “reverse layering technique” (Figure 7). This approach, similar to one used to make custom provisionals, calls for initial placement of incisal shaded resin into the remaining incisal portion of the template (Figure 8). After the tooth in question had been briefly cleansed with 37% phosphoric acid (5 seconds) and coated with DENTSPLY Caulk’s self-etching bonding agent, Xeno IV, the filled template was seated (Figure 9) and readied for curing. Prior to curing, a favorite plastic instrument can be used to tuck in and shape excess composite. Using this approach, the open template facilitates access, and the Esthet-X is agreeable to rapid sculpting. A 20-second light-cure locked in the incisal anatomy of tooth No. 8 (Figure 10).
Layer 2 (the dentin layer, A1 shade) was then bulk placed over the body of the tooth and hand-sculpted, following the interproximal boundaries that had been preset by the mock-up and template. After curing, the anatomy of tooth No. 8 was roughed out with a Brasseler 9-mm ET carbide finishing bur (red stripe or 8 fluted, Figure 11).
Esthet-X’s non-opacious dentin shade A1, attractive in its own right, remained as the outer layer of the bonded veneer. By blending the dentin layer into the previously placed incisal composite, a reasonably convincing, natural appearance was achieved. Practitioners wishing to create more “visual depth” might certainly place a thin layer of clear incisal composite over the dentin layer after having removed 0.5 mm of the dentin layer. In the interest of time conservation, this approach was not taken in Denise’s case.
The case proceeded with similar placement of the incisal edge of tooth No. 9, with excess material easily removed with a fine diamond point (Figure 12). Note that prior to placement of each successive bonded veneer, the interproximal surface of the adjacent veneer was “final polished” with Brasseler composite finishing discs (medium, fine, and super fine). This approach prevents unwanted interproximal bonding of the new veneer to the one already placed (Figure 13). Figure 14 demonstrates “the stars” (the central incisors) initially placed via use of the matrix.
THE BONDING EXPRESS
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Figure 15. Hand placement of incisal No. 10. |
Figure 16. A1 Esthet-X Body shade applied. |
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Figure 17. Polishing with Enhance cup. |
Figure 18. Retracted view of completed case. |
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Figure 19. Final portrait. |
Following placement of the central incisors, the remaining teeth were bonded via direct placement, aided by the use of a “gloved digit” (Figure 15). Dentin shade was then bulk placed over the previously placed incisal, and shaped, sculpted, and cured (Figure 16). It must be emphasized that this process is made possible by knife-edged composite placement instruments, such as those marketed by Hu-Friedy (the TNCIGFT2 composite instrument) and Almore International (Almore’s Gold Microfil composite instrument 96041), and DeTak from George Taub Dental Products, a silicone based, nonstick instrument dip that allows for easier sculpting both interproximally and labially. In addition, use of AdDent’s Calset chairside composite heater will facilitate a smoother bulk placement of the composite resin, enabling an easier egress of the material from the compule to the tooth surface.
Final shaping and polishing was accomplished with a series of carbide finishing burs (8 and 16 bladed), Enhance Cups (DENTSPLY Caulk, Figure 17), composite finishing discs, and finally, Cosmedent’s FlexiBuff polishing discs. Alternatively, excellent results can be obtained with DENTSPLY Caulk’s PoGo polishing instruments, sold in a variety of shapes.
As can be seen in Figures 18 and 19, a pleasing result was obtained over the course of a single morning.
DISCUSSION AND CONCLUSIONS
Times have certainly changed. The baby-boomer generation is knocking on dentistry’s door seeking ways to recapture their youthful personas. We as a profession need little convincing to know that a healthy, youthful smile goes a long way in that direction. While porcelain remains king, it also remains beyond the budget of many would-be rehabilitation cases. This dictates that we find ways to satisfy those desires that fall within those budgetary constraints. Dental manufacturers have placed the tools and materials in our hands, and when needed, dental labs can pitch in to facilitate the pro-cess, as was the case for Denise’s smile revitalization. To be sure, when enlisting the help of a laboratory, these costs must be factored into the case fee quote as well as the time needed to deliver the case. Still, as such cases can be delivered in a single, extended session, free from an impression and temporization process and high laboratory costs, they can be delivered at close to half the cost of an equivalent ceramic case.
I typically add the anticipated lab fees to my normal direct composite bonding fee, and make it a habit to inform patients of this when taking preliminary impressions and face-bow. They are also asked to cover the cost of their simulation. This never presents a problem, as patients are thrilled to have an alternative to a more expensive ceramic case.
As we have seen in this article and in many like it (see “Additional Reading”), there are a myriad of ways to deliver attractive, direct composite veneer cases using putty matrices, suck-down templates, and mock-ups of the desired end result. In any such case, a preoperative smile simulation can lay the groundwork for case acceptance, design, and ultimately, case delivery. The key is to find an approach that suits your style and needs, and master it. This will not only delight your patients, but will also bolster your professional self-esteem, not to mention your bottom line. Get going!
Additional Reading
Dietschi D. Layering concepts in anterior composite restorations. J Adhes Dent. 2001;3:71-80.
Fahl N Jr. Achieving ultimate anterior esthetics with a new microhybrid composite. Compend Contin Educ Dent Suppl. 2000;(26):4-13.
Behle C. Placement of direct composite veneers utilizing a silicone buildup guide and intraoral mock-up. Pract Periodontics Aesthet Dent. 2000;12: 259-266.
Goldstein MB. Direct bonded composite veneers for the artistically challenged dentist. Contemp Esthet Restorative Pract. 2002;6:52-59.
Goldstein MB. The 3-hour cosmetic rehabilitation. Dent Today. Apr 2000;19:
62-71.Goldstein MB. A multiphase approach to direct composite veneering. Dent Today. Feb 2003;22:92-95.
Dr. Goldstein practices general dentistry in Wolcott, Conn. He lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. A regular contributing editor for Dentistry Today, he has also authored numerous articles for multiple dental periodicals both in the United States and abroad. He can be contacted at (203) 879-4649 or martyg924@cox.net. His current speaking schedule can be found at drgoldsteinspeaks.com or dentistry today.com (click on Leaders).
Disclosure: Dr. Goldstein is a consultant for and receives material support from DENTSPLY Caulk. He is also a consultant for Smile-Vision.
