waxup When I am restoring excessively worn teeth for a patient, I like to start with direct provisional bonding. While this can be a tremendously beneficial service for the patient, it can also be extremely time-consuming and technically challenging.

One of my favorite things to do when it comes to bonding is direct additive bonding. In this article I would like to share a workflow that I have I have found that makes additive direct bonding easier, faster and more predictable.

Step 1: Do a diagnostic wax-up that represents your desired end-result. If incorporating orthodontics to correct alignment is part of your treatment plan, then it's critical that you wax or have the teeth waxed to the ideal final size and shape independent of alignment. This means the teeth will likely look worse after your bond them until the orthodontist gets things into better position. As you can see in the main photo, the incisal edge position is longer than ideal; this was done on-purpose since we were planning to intrude these teeth.

Step 2: Make a transfer matrix of the wax-up to allow you to quickly and easily replicate the wax-up in the mouth. While there are many ways to do this, my favorite way is to use a PVS putty to make a lingual matrix of the wax-up. To do this I simply take a material, such as Platinum 85, and form it to the model leaving the facial of the areas I plan to add to open. It's also important to cover enough areas that were not changed in the wax-up so you have plenty of good positive stops to accurately place the matrix in the mouth.

Step 3: Go to the mouth and add your composite. While you could add to all the areas at once, I typically like to add to every other tooth first. Once the first teeth are done, I cover them with teflon tape and do the remaining teeth. The teflon tape is great because it is thin enough to not affect the contour of the adjacent additions but it still keeps you from sticking the teeth together. If you captured the incisal and lingual contours of the wax-up well with your matrix, the only thing you are left to freehand are the facial contours.

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Once these three steps are done you're almost finished. All that's left should be some minor finishing and polishing!

John R. Carson, DDS, PC, Spear Visiting Faculty and Contributing Author [ www.johncarsondds.com ]

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Comments

Commenter's Profile Image Uwe Mohr MDT
May 28th, 2014
I recommend the steps as described, but would use a clear matrix material, so that you can lightcure the composite through the matrix. This is much more predictable and accurate, less time consuming and a more esthetic result, since you can actually visually control what you are doing. For improved esthetics and a much more natural looking result, bond dentin first, do an esthetic cutback and bond incisal material. Since you will be able to see through the clear matrix material, you can control the level of cutback and incisal layering.
Commenter's Profile Image John Carson
May 29th, 2014
Uwe, thanks for the comments, I have had a couple photos added above that may help visualize what I was trying to describe. As you can see the matrix I am referring to allows you to add layers from the lingual as you go to the facial and cure from the facial with the matrix in place as you build your layers. This also lets you visualize what you are doing very well. After I do the first teeth I place Teflon tape over the completed teeth to keep things from sticking together when I do the remaining teeth. I am glad you brought up using a clear matrix as I know this works really well for some people however for me the method you described is more time consuming and difficult, to be clear I am NOT saying this is case for everyone, just me, so it's good you brought up another way that works better for you as it's great for folks to have different ways to try so they can find what works best for the.
Commenter's Profile Image Maria
May 29th, 2014
Frank discussed this technique in one of his seminars and I just completed a case where I did not use the matrix and two hours later I was kicking myself for not doing it this way. Do you have a Teflon Tape brand that you prefer? Also do you have a video on this technique? Thank you!
Commenter's Profile Image John Carson
May 29th, 2014
Maria, I do not have a preference on Teflon tape brand, they are pretty much all the same. As far as videos I am sorry I do not have one personally although there may be one in the digital suite online but I have not had a chance to look yet.