In this video, Dr. Mills describes composite addition dentistry; a procedure that improves the appearance of teeth that have been worn and damaged, while protecting the tooth’s enamel. You can also watch our composite addition dentistry video on YouTube and subscribe to our channel.
Dr. Mills: We’re going to be doing what’s called composite addition dentistry today, and what that is it’s a real conservative, noninvasive way to correct people’s either worn teeth or teeth that are not quite in the proper bite without removing any tooth structure. Zero invasiveness. All we’ll be doing today is polishing the teeth, just like when we polish teeth for a cleaning, and then putting some special bonding materials directly on the enamel surfaces and adding the composite a special way, with what we call matrixes. We’ll be discussing that later.
We’ll be treating our patient for about three to four hours. It’s very easy though for them, because we take breaks, there’s no anesthetic involved, so we can stop at any time, and a lot of that time they’re not just with their mouth open the entire time. I’m doing things outside of the mouth and they’re resting, usually they just put some headphones on and some sunglasses and relax and it’s done. It’s not a really hard procedure to go through.
Well there really is no downtime. You’re not numb, so you don’t have to wait for any surprises after the treatment; say, “Oh my goodness, am I going to have pain?” When our patient’s done her bite will feel great, she’ll be just finished and go home and we usually have them back in 24 to 48 hours just to do any final polishing or adjusting that’s needed. We’re going to be doing a treatment, it’s called the functional occlusal rehabilitation, is what it really is called.
That involves addressing all the teeth so they’ll all fit properly together, just like gears all fitting properly together. You can’t have one cog on the wheel out of sync or it disrupts the function of the entire gear or the cogs on the wheel. We usually start with lower teeth, and we’ll be demonstrating that later. What is involved is after we polish and prepare the teeth for bonding, we’ll have some clear matrixes and we’ll demonstrate how we add the composite material very accurately to each of the lower teeth to start balancing the bite. Then we’ll be starting the bonding on the upper teeth, the two central teeth are usually where we start.
After that, in this case the patient also needs what we call a negative coronoplasty. That essentially is there’s some teeth that have been worn slightly unevenly, we’re just round those worn edges so they fit better and then we’ll finish up bonding any areas on the back teeth. This is a good example of a moderate level three case. It’ll be incorporating some significant additions here, where we’re bonding the front area to establish our proper anterior guidance. We have cuspal additions on the posteriors here, here and here. If you look down, we’re going to be having some minor negative coronoplasty on some of the posterior teeth here, here and in these areas.
Here we can see on the maxillary arch we’re going to be doing some additions on the anterior teeth, some moderate coronoplasty on the posterior teeth in these areas, and these darker areas here, that have been marked, are going to be some fascia additions. They were previously waxed and then removed so we could make accurate matrixes. For the anterior areas, where you don’t have adequate vertical stops, you want to be using a very rigid matrix material.
There’s actually two kinds. This material is Durasoft, by Great Lakes. It’s great because it’s very rigid, like night guard material, but has a soft inner lining and it’s very thin, so you can actually see your work while you’re adding the composite. The disadvantage is if you have significant facial contours you’re adding on, you could possibly lock this in. For just incisal edge additions, this is a very nice matrix, but for what we’re doing there’s a good chance we would lock this in when we added our final contours.
This is an example … This patient will be having additions here. This is the untreated models. The matrix basically will go on and the nice thing is, if you see there’re voids in there, when I press there’s no distortion or deflection. This is our patient today, and if you notice, we have added on some heights of contour and some facial contours, so if you were to use that other matrix, the Durasoft, there’s a good chance you’d lock this on or have a very difficult time removing it.
How we overcome that, we’ve designed a two-step matrix. This is our patient’s untreated models. The first matrix is actually RSVP material. It’s a clear polyvinyl, this happens to be SHARP by Parkell. All the materials I’ll be using, there will be a list at the end of the videos. It goes on, it’s a little flexible. You can see I can distort the incisal edges if I over seat it, because there are inadequate vertical stops. How we overcome that is we make a secondary hard outer shell, so when you seat the matrix, you have even distribution and you won’t over seat the anterior areas and distort your incisal edges.
In the posterior areas we have adequate vertical stops and so what we will be able to use is a sectional matrix. The sectional matrix will be going on and now, if you notice, this is SHARP material. There’s adequate vertical stops, so there’s no distortion on the cuspal additions. We’re going to be using, also, a micro-etcher, with fifty micron aluminum oxide, to clean any deeper grooves or any stain that’s embedded in the tooth structure. It’s a great instrument. It comes with little, single use ampoules. Again, this information’s available at the end of the tape. Okay.
It’s going to be a little gritty. We’re going to be adding the next two lower anterior teeth, but the canine here, number twenty-seven, needs a block out, so, once again, you can see we’re going to be adding some Mach-2 material, just very slowly. You can see it fill the chamber where the wax up has been. Hard matrix. Once again, it’s very important to place your hard matrix on and fully seat everything. Now we’re going to be placing the rigid matrix while this is setting, because we don’t have it set in a distorted way.
Here you can see the teeth we are not bonding have been completely blocked out with the Mach-2; here and here. There’s a little bit of flash on the teeth we’re going to be bonding and we’re going to remove that with a number twelve blade. You can see the Mach-2’s blocked out the teeth we will not be bonding, but there’s a little bit of flash. All we’re going to do is just take a number twelve blade and just remove that flash. We’ve removed the excess flash on the adjacent teeth. Now it’s really important to go back in and clean the inside.
This happens to be Ney lubricant. It’s important to also lubricate the inside; it’ll make it much easier to remove the matrix. You do not want to leave pools of material here; it’ll make it difficult for you. We’re going to go ahead and just do our basic etch and bond protocol. I like to use spacers like this to keep things clean. Just use your normal etchant and whatever the enamel bonding material you’re comfortable with. I happen to be using Prelude, by Danville, but all the modern ones are pretty comparable and good.
This is just our enamel bonding agent. Good. You need a little bit of air, Riley, okay? Just like that. Go ahead. Now we’re going to be placing our soft matrix here. We happen to be using ReEnamel, which is a flowable hybrid, by Cosmedent. I have to kind of hold this. We’re in the portal and we’re just going to very lightly start to add material here. Take your time; you don’t want to get any bubbles in it. It’s just filling up quite nicely. Okay. Again, we’re just adding our materials in here.
The nice thing about the thinner RSVP matrix is you can see through them. Again, hard matrix. We’re adding our overlay matrix now to stabilize the softer underlying matrix that’s seated. Go ahead, light. We’re going to be taking off the hard outer matrix and finish our curing now. We’re going to be using a number six round bur to clear the sprue areas here, and we need to do a little bit on this one. Riley, you’re going to feel a little … You’re going to hear a little crack sound when I release this, okay? It’s not you.
We’re going to do a little final polishing of the remaining sprue that’s right there and there. You can … What I want you to notice is how very little flash, if any, is on the adjacent teeth that we’re going to bonding, here and here. We use a ContacEZ, which, again, the information is at the end of the tape, to go in between. What I want you to notice, we haven’t gone in here at all to just check the contacts, and one pass and the contact’s completely opened. Once again, one pass and the contact’s completely open. Two passes and the contact’s completely open, and one final one.
There’s virtually no flash and to do the final polishing on this composite, and once we’ve completed them, is going to take very little time at all. Again, when you’re doing composites you want to control it so you don’t have a lot of access and a lot of cleanup. Here’s our previous Mach-2. Now you can spend a lot of time picking that all out of there or the best thing to do is throw it out and have a second matrix ready to go.
We’re going to go ahead and do our bonding protocol on the adjacent teeth, and notice we’ve put our spacers back in. What we’re going to do is, just before we bond, we’re going to show you putting some lubricant on the existing composites, and you’ll see why. It makes the cleanup just much easier. We had to water spray the area. A little bit more of that stuff, I need it to set. Again, this is Prelude, by Danville.
Speaker 2: Now you need it?
Dr. Mills: Right. Again, we’re going to take our Ney lubricant and on the teeth that we’ve bonded we’re going to put a very thin coat of lubricant on here. Be careful not to touch the tooth surface you’re going to bond to. Okay and then there’ll just be a little bit of air here, Riley. Let me pull the … Okay, once again we’re going to put in our matrix. We’re adding our composite material. Once again, you can see it flow in there and you can just take your time on this. You don’t want to get any air bubbles in it.
It’s all the way down to the gingival area now and we’re just going to turn our tip up and we’re going to just lightly fill in the incisal edge here. Then you want to back it out very slowly. We’re going to do the same to the other tooth. Once again we’re just going to slowly fill it from the gingival area up. Then we’re filling the incisal areas, and keep pressure as you back this out, otherwise you’ll get bubbles when you pull out. We’re going to place our hard matrix, and it’s nice if you’ve marked the mid-line. Okay, light.
We’re going to take our number six round bur, again, do your initial clearing of your sprue hole, there, and there. If you don’t do this step a lot of times you risk locking in the sprue and popping off some composite when you remove it. You might hear a little crack sound again. Once again, you can see there’s very little flash. Here are our sprue areas, we’re just going to dust those off a little bit.
Speaker 3: Left hand down if you can.
Dr. Mills: Be careful you don’t get up on the incisal edge and distort any of your critical anatomy. Let me have the … Once again, here’s our ContacEZ. It’s good. You’re just going to see this … There’s one pass, there’s two passes, okay? Okay. Once again we have our ContacEZ. There’s one pass and we’re through the contact. Okay? ContacEZ again and we’re through the contact. Once again and we’re through the contact, and we’re through the contact. As you can see, there’s very little flash, there’s going to be very little finishing and cleanup on these lower teeth to be done.
The lowers are bonded. Now we’re going to be doing eight and nine. Here’s our matrix, and what I want you to notice, there’s not a lot of facial addition, so right at the gingival area here, we’ve left that open. We’re going to actually be putting some Mach-2 block out in here so you don’t have any interproximal flash to have to clean up later. Here’s our Mach-2, and you can see we’ve actually blocked out the embrasure areas here, here, and here.
Now in Riley’s case, she does have a lot of recession, so the embrasure areas aren’t that large, but in certain cases where there are large embrasures, doing this part of the procedure will really minimize the amount of flash you’ll get interproximally on the teeth and, again, minimize the amount of finishing you will have to do. We’ve completed our etching and bonding protocol and now we’re going to go ahead and place our matrix and add material from the lingual. Now there’s some lingual portals there to inject composite into.
Once again we’re going to go ahead and clear the sprue holes with a number six round. It minimizes the chance of you pulling some composite off when you remove the matrix. What I want you to notice, here we’ve just removed the matrix, you can see our sprues, and if you look at the gingival area there’s no flash in here at all to cleanup. We’ll be polishing off the sprues and then taking our impression to make our mini model.
Once again we’re using our ContacEZ, I’m just placing it here and I just want you to see that one pass and we’re through the contact point. One pass here and, again, we’re through the contact point, and one pass and we’re through the contact points. There will be very low interproximal finishing to be done on these teeth. Our next step we’ll be doing is the negative coronoplasty or you can also call it equilibration, and if you notice these areas through the red paint here, here and here, here and here and up here, we’re going to be contouring those.
Now you’ve already done most of this work in the lab. You’ve already done an equilibration on the models one time, so what we do is we’re actually going to be marking these directly in the mouth and doing about eighty percent of it before we check. We’ve added eight and nine, so we have a nice final vertical dimension jig that we’ll be using. Let me go ahead and get started. I’m just going to dry the teeth gently and then with a Sharpie we’re going to actually transfer our marks from the model onto the tops of the teeth.
We know we’re going to be doing a little equilibration right here and there’s that cusp tip of number four. We’re going to be doing a little equilibration right here, and the distal area, back here. What we’ve done is we’ve taken this area here and, if you look closely, we’ve transferred that exact area onto this tooth, taken that area and transferred it exactly on to this tooth. We’ve taken that area and transferred it exactly onto the other tooth. Okay, so now it’s just a matter of rightly rounding these areas, just like you did on the models one time already.
Now it’s important to, whenever possible, to use a straight bur and not a football diamond or football carbide, because you want to create convexities, not concavities, when you’re doing the equilibration. We have a carbide bur and all we’re going and all we’re going to do is just very gently just take off the Sharpie mark that you put on here. Now you’ve already done this one time on the models, so you should have a pretty good idea of how much shaping you’ve already done. You okay with this, Riley? No problems, right? Okay.
It’s better under equilibrate over equilibrate, so we’re going to stop there and we’re basically going to be doing that to the other four teeth in this area. What we’ve done is completed about eighty percent of the equilibration and now we’re putting shims on the front and we’re going to be using the shims, and eventually when we have good occlusion on eight and nine, to do the final adjustment into position. When she bites down, medium hard squeeze, you can see we have contact here. Open please. Bite down. Squeeze medium hard and no contact in the back. We’re going to be taking one shim off at a time and doing the final equilibration into CR.
We’ve completed all of the anteriors. We’ve checked the occlusion and she has the lights are on eight and nine. We’ve completed all the equilibration and now we’re going to go back and just add the final areas on the lower right, which would be this cusp tip and this canine. What we’ll be doing is a sectional matrix; just fits very easily over the teeth. What you’re going to notice is that there’s no flex in it, there’s plenty of vertical stops. The other thing you notice is by not having it go all the way across it’s much easier to handle, plus it minimizes the chance of you introducing an error.
If you have a slight over bonding here it won’t translate to error over on the right side. You would just follow your normal etch, bond and protocol and then in these portals here and here, you’ll inject your composite material one tooth at a time, and re-verify that you’re still in centric. That will complete Riley’s case. We’ll be doing the same thing on the lower left. There’s a sectional matrix just like this, for a few posterior cusp tip additions also. Then Riley is completed.
We’ve completed all the anteriors and we haven’t done our final polishing yet, but you can see the incisal edges blend completely in. Open just a little bit, please, Riley. A little bit bigger. We’ve completed the lowers, and you can see the little occlusal dots, the markings that we have … That had lights on. Now we’re leaving the canines off for now. We’ll be adding those on later, after we have her back for a final check. Bite down. You can see we have eight micron shim hold on all the teeth, right side, left side, and the anteriors. We’ll have her back for a final check after her muscles get a chance to rest. Open.
Speaker 3: Just smile to the camera. There you are. Nice.
Speaker 4: Perfect.
Speaker 3: Nice.