Reality or Resin; Free Hand Artistry with Anterior Bonding Dennis B. Hartlieb, DDS CPR for Complex Dental Treatment; From Concept, to Prototype, to Restoration Wish List: 1. Reversible (no prep/ minimal prep) dentistry 2. Create cosmetic changes 3. Make occlusal changes 4. Test planned occlusal and esthetic changes for function and phonetics 5. Reduce time and financial investment 6. Allow for long term sequencing of treatment Transitional: marked by or during a transition from one state or condition to another Prototype: something having the essential features of a subsequent type, and on which later forms are modeled Cosmetic Considerations with Anterior Treatment: 1. Color (Chroma, Hue, Value) 2. Arrangement of teeth 3. Tooth length/ tooth display 4. Soft tissue / hard tissue interface 5. Material selection Functional Considerations with Anterior Treatment 1) Incisal edge position (esthetics, phonetics, function) 2) Anterior guidance 3) Neutral Space infringement 4) Envelope of function 5) Vertical dimension changes 1
Incisal Edge Position Phonetics Fifty five Incisal edge of maxillary incisors to contact wet/dry line (vermillion border) of lower lip Incisal edge to protrusive Incisal edge at ideal position Incisal Edge Position Anterior guidance Can patient tolerate increased anterior guidance? Ahhhhh! Hmmmm? X!?XV!!! 30 20 o 10 o o 68 lbs 100 lbs 132 lbs Cuspal Angle for every 10 degreee change from 0 40 degrees. Weinberg et al, Int j of prosh, Oct 1995; vol. 8:5 2
Neutral Zone Tongue eutral zone is the area where the forces of the tongue pressing outward re neutralized by the forces of the heeks and lips pressing inward. When teeth and muscle battle, muscle ins. Peter Dawson REVERSIBLE TRANSITIONAL PROTOTYPE BONDING: 1. Smile Design 2. Functional / Occlusal Treatment 1) Smile Design: Determine Incisal Edge Position 1. Porcelain Veneer Cases 2. Direct Resin Bonding Cases Monitor transitional bonding for several months PREOP SMILE PROTOTYPE SMILE Chipping, mobility, or functional/esthetic failure Restorations intact, no problems 4. Re evaluate 5. Re restore 6. Remove 1. Maintain transitional bonding 2. Resurface bonding 3. Porcelain veneers 3
Prototype Bonding Technique 1. Treatment consultation. Review photographs, patient expectations and demands. Discuss treatment objectives and limitations. 2. Study cast impressions, Facebow, Centric bite record, Fmx (Records appointment). 3. Laboratory wax up, Photoshop imaging if necessary. 4. Final consultation, treatment and financial review. 5. From laboratory wax up, create Prototype Guide (Lingual Matrix). Important that Prototype Guide is verified for appropriate length and midline angulation. 6. Prefer not to prepare teeth for transitional bonding. Pumice tooth thoroughly. Smooth share edges. Reduce contours if necessary so that final restorations are esthetic. 7. Rinse and dry teeth thoroughly. 8. Etch (37% phosphoric acid) tooth structure 30 seconds (if all tooth structure is prepped, then 15 seconds is sufficient). If areas of dentin, 15 20 seconds etch only. 9. Rinse, leave moistened. 10. Place multiple layers of 5 th generation of adhesive. Air thin. Light cure 20 seconds. 11. Place small amount of Nanofilled composite in Prototype Guide (lingual matrix) for each tooth. Adapt composite into guide so that there are no voids. 12. Place small amount of Nanofilled composite onto lingual and incisal of teeth to be bonded that correlate to the Prototype Guide. 13. Seat Prototype Guide with light/moderate pressure over teeth. Use IPC and multipurpose instruments to remove excess of composite and blend into facial tooth structure. Use IPC to separate teeth while composite is uncured, to prevent composite from bonding to adjacent teeth. 14. Light cure for only a few seconds. This will freeze the incisal facial composite. Peel back the Prototype guide gently. Smooth the lingual composite to the tooth structure utilizing the wide portion of the Multipurpose instrument. Light cure 10 seconds each tooth (facial and lingual). 15. Free hand facial composite to ideal contours. 16. Adjust occlusion, contour and polish. 4
2) Functional / occlusal treatment 1. Allows for long term stabilization 2. Reversible (if patient cannot/ will not tolerate opening of vertical dimension 3. Provides opportunity for patient to phase treatment without compromising final functional and esthetic results 4. Orthodontic, periodontal and implant treatment can be completed with the use of transitional bonding to optimize final treatment results PREOP OCCLUSION STUDY CASTS, FACEBOW, CR BITE Orthodontics with Transitional Bonding as Needed Wax up to ideal tooth form. Determine if orthodontics necessary Prototype Guide (Lingual Matrix) to duplicate upper incisal edge position and lower incisor edge position and lower buccal cusp heights Monitor for TMJ stability, tooth comfort and stability, patient tolerance and comfort Restore in porcelain as determined by patient financial, time and emotional budget. Because the teeth are not prepared and only occlusals of posteriors are bonded to create proper cusp height, patient is better able to phase treatment without having to worry about leakage and decementation of temporary restorations 5
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Prototype / Transitional Bonding Technique for Occlusal Changes 1. Treatment consultation. Review photographs, patient expectations and demands. Discuss treatment objectives and limitations. 2. Study cast impressions, Facebow, Centric bite record, Fmx (Records appointment). 3. Laboratory wax up, Photoshop imaging if necessary. 4. Final consultation, treatment and financial review. 5. From laboratory wax up, create Prototype Guide (Lingual Matrix). May need Prototype Guide (PG) for upper and lower. Upper PG will xxxx maxillary incisal edge and lingual cotours. Lower PG will replicate lower facial incisal edge position and buccal cusp tips only for lower posteriors. If full occlusal wax up is completed on lower dentition, the PG will not be stable when positioned on teeth. Important that Prototype Guide is verified for appropriate fit, stability and midline angulation. 6. Prefer not to prepare teeth for transitional bonding. Pumice tooth thoroughly. Smooth share edges. Reduce contours if necessary so that final restorations are esthetic. If posterior porcelain, amalgam, gold or resin restorations, microetch with 25 50 micron XXX (Danville Microetcher) to ensure adhesion. If porcelain restorations, utilize 9% Hydrofluoric Acid for 3 4 minutes. Follow with Silane and an unfilled composite resin. For amalgam, resin and gold restorations, microetch, etch with phosphoric acid for 15 seconds, then place unfilled composite resin. Light cure resin. 7. If no restorations, rinse and dry teeth thoroughly. 8. Etch (37% phosphoric acid) tooth structure 30 seconds (if all tooth structure is prepped, then 15 seconds is sufficient). If areas of dentin, 15 20 seconds etch only. 9. Rinse, leave moistened. 10. Place multiple layers of 5 th generation of adhesive. Air thin. Light cure 20 seconds. OPTION TO EITHER BOND LOWER ANTERIORS FIRST, THEN FILL IN POSTERIORS or BOND POSTERIOR CUSP TIPS FIRST FROM GUIDE, THEN LOWER INCISORS. 11. Place small amount of Nanofilled composite in Prototype Guide (lingual matrix) for each tooth. Adapt composite into guide so that there are no voids. 12. Place small amount of Nanofilled composite onto lingual and incisal of teeth to be bonded (if anterior teeth) or buccal cusps of posterior teeth that correlate to the Prototype Guide. 13. Seat Prototype Guide with light/moderate pressure over teeth. Use IPC and multipurpose instruments to remove excess of composite and blend into facial tooth structure. Use IPC to separate teeth while composite is uncured, to prevent composite from bonding to adjacent teeth. 6
14. Light cure for only a few seconds. This will freeze the facial composite. Peel back the Prototype guide gently. Smooth the composite to the tooth structure utilizing the wide portion of the Multipurpose instrument. Light cure 10 seconds each tooth (facial and lingual). 15. Free hand facial composite to ideal contours. 16. If lower anteriors are bonded first, then ok to bond the cusp tips of the posteriors without the use of the PG. The incisors will act as an anterior deprogrammer so that TM joints are seated as posteriors are added. After etching and adhesive placed and cured, free hand place composite on each cusp tip to estimated ideal form. Retract, place curing light in position. Have patient slowly close while guiding to seated joint position, and stay closed while curing the composite on the buccal cusps of the posteriors. Cure for 10 seconds. Have patient open and verify composite contact to the opposing maxillary teeth. If no contact, may need to add more composite to the lower buccal cusp tips, or to the central groove of the maxillary posteriors. Final cure. 17. Adjust occlusion, contour and polish. 18. Monitor restorations for patient comfort, TMJ stability, restoration maintenance for several months / year. 19. Transition to porcelain restorations as determined by patient If restoring posteriors first: Before After 7