Overview
This lecture covers predictable workflows and key steps for successful anterior direct composite restorations, with emphasis on minimally invasive, aesthetic approaches.
Introduction & Philosophy
- Anterior direct composite restorations are a predictable, minimally invasive alternative to veneers.
- Careful planning, practice, and workflow are essential for high-quality, long-lasting outcomes.
- Focus on biomimetic and minimally invasive dentistry to preserve tooth structure.
Treatment Planning & Design
- Begin with a comprehensive diagnostic workup to assess the patient's needs.
- Use diagnostic wax-ups and mock-ups to visualize and communicate proposed changes.
- Digital smile design (e.g., Photoshop) helps align expectations between patient, dentist, and specialists.
- Assess the environment (teeth, gum, lips) before planning restorations.
Pre-Bonding Preparation
- Complete bleaching (preferably with custom trays, low % carbamide peroxide) before bonding.
- Address white spots with resin infiltration (e.g., Icon system) rather than drilling.
- Perform internal bleaching for discolored, root canal-treated teeth before composite work.
- Evaluate and address needs for aesthetic crown lengthening ("balancing the pink") prior to restoration.
Shade Selection & Mock-Up
- Take shade photos while teeth are hydrated; dehydration affects color accuracy.
- Cross-polarized photography can help determine true tooth shade.
- Use a wet mock-up (trial layering with composite, no etch/bond) to confirm color match before final restoration.
Isolation & Surface Preparation
- Rubber dam isolation with floss ligation is essential for predictable outcomes, patient comfort, and clean working area.
- Clean tooth surfaces using air abrasion (e.g., AquaCare) or pumice before bonding.
Bonding Protocol & Composite Placement
- Etch beyond planned margins to prevent microleakage and brown discoloration.
- Apply primer only on dentin, but bonding agent on all surfaces except etched enamel margins.
- Use layering techniques informed by natural tooth microanatomy (opaque dentin body, characterization, enamel layer).
Composite Material Selection & Handling
- Choose composites with ideal viscosity (e.g., warmed genial Accord system), radiopacity, wear resistance, and polishability.
- Prepare custom shade guides to test combinations of dentin and enamel.
- Use Teflon to protect adjacent teeth during etching and bonding.
Finishing, Polishing & Follow-Up
- Use photography (ring or dual flash) to evaluate and refine line angles and texture.
- Polishing/finishing may span multiple appointments; allow time for patient feedback and rehydration.
Key Terms & Definitions
- Direct composite restoration — tooth-colored filling placed directly onto the tooth.
- Biomimetic dentistry — approach aiming to mimic the natural structure and function of teeth.
- Diagnostic wax-up/mock-up — model to preview and plan the final restoration.
- Digital Smile Design — digital simulation of proposed aesthetic changes.
- Resin infiltration — minimally invasive technique to mask white spots using low-viscosity resin.
- Rubber dam isolation — barrier placed to keep the field dry and clean during procedures.
- Floss ligation — technique to secure the rubber dam tightly around teeth.
- Wet mock-up — temporary, non-bonded composite try-in to check shade and layering.
Action Items / Next Steps
- Review the checklist of pre-bonding, design, and workflow steps before each anterior bonding case.
- Practice shade selection and wet mock-up techniques.
- Read the recommended paper on anterior tooth microanatomy by Panos Bazos and Pascal Magne.
- Consider hands-on courses or further training in biomimetic and minimally invasive techniques.