86

AESTHETICS

Injection Overmolding for

Aesthetics and Strength, Part 1
Finishing Orthodontic Cases Using Direct Composite

O
rthodontics has seen significant
advances during the past decade. In
spite of these advances, there is no
magic wand or silver bullet when teeth are
undersized. In addition, there are a staggering
number of adult ortho cases that produce the
dreaded black triangle, an aesthetic dilemma
David Clark, that is considered to be more unsightly than
DDS the crowding that led to the ortho in the first
place. Part one of this 2-part article will dis-
cuss the treatment of undersized teeth, and
part 2 will discuss post-ortho black triangles. Figure 1. Patchwork style of bonding, as seen here Figure 2. Identical twins with undersized teeth and
on the central incisors, has served to hurt the peg laterals. When compared with the postoperative
reputation of composite resins. Note the excess photographs, the faces seem a little sad and strain-
BIOCLEAR INJECTION OVERMOLDING translucency, small holes full of brown stain, and ing to smile. Most patients dislike tooth gapping far
VERSUS “BONDING” most importantly, an ignorance of the larger issues more than dark teeth or crowded teeth.
“Bonding” sounds a lot like “Bondo,” which is that could have been addressed had an up-to-date
technique, as described herein, been used.
a cheap way to fix a wrecked car fender.
Bonding and Bondo have given composite
resins a bad name (Figure 1). Go online and
read how some “cosmetic dentistry experts”
tell the public that bonding is inferior to
porcelain veneers. This statement is due in
large part to a flawed delivery system, lack of
training, and a dearth of proper engineering
principles for composite, leaving some cases
to look like poor asphalt patchwork, sooner or
later. The Bioclear approach is not bonding. It
is injection overmolding. Instead of just patch-
Figure 3. Post-orthodontic, preoperative smile Figure 4. Retracted post-orthodontic, pre-restorative
ing the tooth, the Bioclear Matrix and method photograph of one of the twins. view of the maxillary anterior sextant.
allow the entire tooth to be over-molded with
variable thickness composite. Why perform
patchwork when you can routinely pave the
whole street? Properly done, it is superior to
porcelain for both black triangles and young
post-ortho patients. This 2-part article series
will first introduce the Bioclear Matrix and
method, and how it works to completely
injection over-mold cases with undersized
incisors, and then will examine injection
over-mold teeth with black triangles.

DOUBLE TROUBLE
Identical Twins With Peg Laterals
At first glance and at a straight facial view
(Figure 2), these twins might just look like the
need a “little bonding” on their peg laterals
(Figures 3 and 4). However, a closer profile
angled look (Figures 5 and 6) revealed that all
4 incisors were undersized, and simply adding
to the lateral incisors or even just the 4 anteri-
or teeth would produce inappropriately sized
Figures 5 and 6. Lateral views of the peg laterals and general spacing dilemma. This view demonstrates
that a comprehensive approach adding to all 6 anterior teeth, using both anterior and diastema closure
matrices, was indicated.
teeth. With the Bioclear method, “bonding to were then also approved by the 2 patients
hide gaps,” in my practice, has evolved to “360° and their parents.
composite overmolding” for a strong, pre-
dictable, and permanent solution. The Treating Orthodontist’s Thoughts
After a discussion with the treating or- In his own words, Dr. Jerrold S. Johnson
thodontist, the overmolding procedures (to stated: “A tooth size discrepancy caused by nar-
include teeth Nos. 6 to 11 for both patients) row maxillary lateral incisors is a very com-

DENTISTRYTODAY.COM • AUGUST 2014


mon problem faced by orthodontists. Changing
the tip and torque of the maxillary incisors, or
reducing the mesial-distal dimensions of the
lower incisors, can often solve the discrepancy
without the need for future maxillary restora-
tions. However, when the discrepancy is large,
as was the case with these twin sisters, restora-
tions are a necessity. Determining the exact
position to place the maxillary lateral incisors
can be difficult, especially when working with
various restoring dentists, each with different
professional opinions. What impressed me the
most about the Bioclear Matrix method was the
ability to modify the shape more apically on the
mesial and distal aspects of the incisors, thereby
changing the emergence profile and giving more
flexibility for the position of the teeth. When dis-
cussing where to place the lateral incisors ortho-
dontically, Dr. Clark was less concerned about
their exact position than I was, and yet his
results were excellent.”
Rethinking Priorities
in the Veneering of Teeth
Spend enough time at an aesthetic academy
and your head begins to spin when it comes
to cases like this. Sadly, there is so much
focus on diagnostic wax-ups, proportionality
rules, nuances of multiple shading of porce-
lain or composite, etc, that the average gener-
al dentist walks away thinking, “I can’t afford
to spend that much time and energy on these
cases!” In addition, in the author’s opinion,
too much focus is spent on pleasing the other
dentists in the room with not enough atten-
tion given to pleasing the patient and to the
soft-tissue response. Frankly, a good number
of the “fancy porcelain cases” have mediocre
soft-tissue health and are simply inappropri-
ate for a 14-year-old patient. Traditional
direct bonding cases may look alright for a
few months but then begin to stain, often
having horrific overhangs, or residual black
triangles, or all 3 problems.
Many doctors using Bioclear have com-
mented that the ideal and varied shapes of the
matrices (Figure 7) have allowed them to
throw away their diagnostic wax-ups and just
get to work. This is a bottom-line approach.
The spaces must be closed. The matrix dictates
the appropriate shape and emergence profile.
The patient needs to love his or her smile. It
must be smooth, strong, and healthy. The
change in emergence profile must begin sub-
gingivally, which requires the use of a diastema
closure matrix (Figure 8) (Table).
Trimming the Bioclear Matrices
When the patented Bioclear Matrices were
first introduced, clinicians were happy to
finally have a matrix that truly had multiple
anatomic shapes. It is quite puzzling that no
one had invented matrices with these shapes
before. After trial and error, we have discov-
Figure 7. Selection guide for the 3 most popular Bioclear diastema closure matrices.
Table. Let the Matrix Do the Work and Understand the Basic Rules
Simplified Aesthetic Rules
for Eliminating Tooth Gapping and
Undersized Incisors
Rule 1: The central incisors must be
perfectly matched (identical twins) and should
be close to the 70% width to height.
Rule 2: The laterals only need to be
siblings with each other. The 70% rule is
more flexible here.
Rule 3: Let the mesial of the canines finish
the closure as needed. Never discount the
forgiving aesthetics and power of adding to
the canine. The canines can just be cousins.
Figure 8. The DC-203 matrix is shown along with
the complete kit. (Note the dramatic change in
subgingival emergence profile that will stimulate
true papilla regeneration.) The green dotted line
shows the typical notch that should be cut with the
Bioclear microscissors to accomodate the papilla.
ered that for young patients, or for patients
with “young bone,” the gingival apron needs
to be trimmed with special Bioclear micro-
scissors to duplicate the significant rise and
fall of the attachment (Figure 8, green dotted
line). These instructions are now carefully
spelled out in the new users’ guide and in the
video of this case (available at the Web site
bioclearmatrix.com). This quick but crucial
modification allows the matrix to seat up to
3.0 mm deeper with a hand-in-glove-like fit.
The matrix can be surprisingly comfortable
as it slides gently and neatly into the sulcus.
The absence of bleeding and stability are
87
Sequence
Restore Nos. 8 and 9 (central
incisors) first. Measure them. Adjust as
needed.
Next, restore No. 7 (right lateral) and then
No. 6 (right cuspid).
Then restore No. 10 (left lateral) and then
No. 11 (left cuspid).
remarkable. One of the reasons that a flat
Mylar strip causes gingival bleeding is that it
slices the delicate soft tissue. Think of the
soft tissue having the same softness as a ripe
strawberry. It needs tender loving care!
“Just Say No!” to Layering
Layering is “fancy pants” dentistry that is often
the enemy of the good. Dentists, physicians,
and other discriminating patients fly from
both North America and abroad to my office,
seeking microscope-enhanced, minimally
invasive, monolithic Bioclear composite resin
restorations. None of them ask for layered
composites. What do patients want? Color
uniformity (a bright but believable color), no
preparation of the tooth, no porcelain, no tis-
sue inflammation, no black triangles, no stain-
ing, no roughness, no fractures, and an assur-
ance that the restoration will be as strong as
porcelain. My office guarantees Bioclear res-
torations for 10 years against stain and debond-
ing. In contrast, my office warranty on porce-
lain is 5 years. While the offer of a 10-year war-
ranty is strictly a personal business decision
that I have made uniquely for my practice, doc-
tors should be confident that these over-mold-
ed restorations should hold up as well as porce-
lain. Most dentists, myself included, can’t satis-
AUGUST 2014 • DENTISTRYTODAY.COM
 88 AESTHETICS

Figure 9. The pre-polished width of the Figure 10. Two trimmed Bioclear DC203 Figure 11. A 37% phosphoric acid gel was Figure 12. The entire tooth was etched for
central incisors was measured before matrices were placed on the mesial and injected into the matrices. (Note: Make sure 20 seconds, then rinsed thoroughly and
moving on to teeth Nos. 10 and 11. (Note: distal of tooth No. 7, creating a crown-like to start the injection apically to ensure air-dried.
The central incisors must match perfectly.) containment system. etching of the entire tooth.)

fy that list with hand-stacked multi-

shade composite. I ask this every time in
my lectures: “Who is the boss?” The
answer is, “The patient,” and then I add,
“and the soft tissues.” Masters of layer-
ing, such as Drs. Bob Margeas and Jeff
Brucia, have extraordinary long-term
results, but they will freely admit that
layering is more artistic than is usually Figure 13. Adhesive was quickly painted Figure 14. The tip of the flowable composite Figure 15. High-magnification view of the
asked for by their patients. In reality, completely over the tooth, then air-thinned, (Filtek Supreme Ultra Body [3M ESPE]) was initial placement of composite. This “flow-
most dentists who dabble in layering but not light cured. When there is little to no then inserted 360° around the gingival able composite hip” was not individually light
dentin involved, it is better not to cure the margin, facilitated by the wetting action of cured in this case because these
often have problems later and find the adhesive independently of the composite the yet-to-be cured adhesive. post-orthodontic teeth were a little mobile.
procedure to be a labor of love that is resin. The radius of the matrix actually allows the
unprofitable and eventually disappoint- matrix to push the teeth apart slightly so
that no delayed wedging will be necessary.
ing to patients. If you love to layer and
are good at it, then you can certainly
layer using the Bioclear Matrix system.
If not, say goodbye to layering.

“Just Say No!” to Translucency

This case, as most are in my practice,
was restored with Filtek Supreme
Ultra Body flowable and regular com-
posites (3M ESPE). The most popular
shade used in my office is B-1. We Figure 16. Once the regular composite Figure 17. Retracted postoperative view of Figure 18. Occlusal postoperative view. The
(Filtek Supreme Ultra Body) was injected into the composite over-molded dentition, at 3 buccal-lingual thickness (recommended to
have most patients do tray bleaching the pool of uncured flowable composite, the weeks. be between 1.5 to 2.0 mm) of the teeth
before the teeth are restored, allow- tooth was contoured in the loading zones shown here is sufficient to give porcelain-like
ing the routine use of B-1 body com- and then polished with a polishing cup (Jazz strength.
Polishers Supreme [SS White Burs]).
posite. We don’t use Enamel Shade,
Dentin Shade, or Translucent Shade.
The Body shade is a perfect balance of
translucency and opacity, permitting
me to focus on more important issues
like shape and strength. In addition,
the flowable and regular composite
shades match perfectly.

DETAILS OF THE CASE

The brevity of this article does not
allow a complete description of this
case. However, a narrated video is
available at dentistrytoday.com. This
HD video, shot through the lens of an
operating microscope (Global Sur-
gical) has an abundance of tips, fully
explaining the sequencing issues.
Blasting
“Blasting” is not simply air abrasion
that uses very aggressive aluminum
oxide. In order to adequately remove
biofilm, the teeth are painted with dis-
closing solution and then meticulously
blasted with pressurized aluminum triox-
ide/water mix (Bioclear Blaster [Bioclear
Figure 19. A 6-week postoperative view with
breathtaking soft-tissue response, regenerat-
ed papillae, and an undulating surface that
breaks up the specular highlights to create a
bright yet believable aesthetic outcome.
Matrix Systems]). To achieve an ideal
bond to enamel or dentin, clinicians
must be reminded that phosphoric gel
etchant alone cannot be relied upon to
remove dental plaque. The use of rub-
ber dam isolation is often dismissed
when doing anterior aesthetic work as
unnecessary or, worse, counterproduc-
tive. As the inventor of Bioclear Matrix
Systems, I have found that, in most
cases, the amount of interproximal
gingival retraction afforded by the rub-
ber dam is ideal for predicting the
Figure 20. Smile image showing ideal
proportionality of the additive dentistry.
amount of static tension needed to
generate or regenerate a papilla. The
rubber dam also protects the soft tis-
sues when blasting is performed to
remove pesky biofilm.
Once the central incisors were over-
molded using Bioclear A-101 and a-102
matrices (not pictured), they were meas-
ured (Figure 9) and sculpted with a
rough finish. The rest of the left side was
completed one tooth at a time, and then
the same with the right side. Tooth No. 7
shows several steps (Figures 10 to 15).
Figure 21. Postoperative view of the twins.
Note the changed countenances of their
faces in comparison to the preoperative
faces. “Double Trouble” no more!
The Clark Three-Step Polish
The Bioclear method is unique in that
the loading zone (injection zone) is left
with intentional excess, while the diffi-
cult areas (such as interproximal and
subgingival areas) are essentially “porce-
lainesque” by virtue of the composite-to-
Mylar finish effect. The goal is to then
safely and quickly grind back the load-
ing zone, marrying it to the glassy
smooth Bioclear Mylar finish zone.
The 3-step polish technique is as
follows:

DENTISTRYTODAY.COM • AUGUST 2014


1. Shofu Brownie with water
coolant at medium speed,
2. Coarse lab pumice in a dispos-
able cup,
3. The polishing cup (Jazz
Polishers Supreme [SS White Burs])
on the facial surfaces (Figure 16); and
the one-step Jazz polisher cone on the
lingual.
The postoperative photos reveal a
patient-friendly, strong, and incredibly
stain resistant finish (Figures 17 to 21).
Upon subsequent routine visits,
the patients’ mother reported that
random people often stopped the
twins in the street and said, “You 2
have the most beautiful teeth I’ve ever
seen!” The family noted that their
facial posture improved after the
work. Patchwork composite bonding
rarely produces such noticeable and
life-altering dental makeovers.
DISCUSSION
Materials and Treatment Planning
In Figure 18, the reader should care-
fully study the thickness of the teeth.
Our research and follow-up studies
have shown that if the incisal edge of
the composite is at least 1.5 mm thick and
the entire tooth is over-molded, we can
expect no incisal edge fractures. In the
same way that monolithic all-ceram-
ics (such as lithium disilicate and
full-zirconia crowns) do not break,
monolithic (nonlayered) composite
restorations created using the Bio-
clear method of composite overmold-
ing can have surprising durability.
Unlike many of the porcelain veneer
cases presented in dental journals in
the past, most porcelain veneers are
fabricated as a monolithic material
(single material and shade), using
either pressed or milled porcelain.
While very durable, these restorations
are generally more monochromatic
than layered porcelain veneers. And,
any significant multichromatic effects
that were achieved via staining tech-
niques have a limited lifespan.
In short, using the Bioclear over-
molding technique, we have moved
to color uniformity, and patients like
it. Furthermore, dentists appreciate
the strength and durability. (Note: I
use the term color uniformity and not
monochromatic in a purposeful way.
Patients prefer uniformly colored
teeth, so I have changed the lexicon
to reflect the new thinking.)
In the past 24 months, the author
has placed hundreds of Bioclear over-
molded anterior composites and has
seen no incisal edge fractures. Layering
and patchwork with composites creates
compromised strength. Composite
overmolding, in contrast, produces
AESTHETICS 89
extraordinary toughness. Furthermore, lar composite, and the trends away from He developed the Bioclear Matrix System,
not a single patient asked for translu- both layering and incisal translucency. which promises an advancement for placement
of biologically appropriate, aesthetically pleas-
cent incisal edges. Better, faster, prettier, Modern techniques (as illustrated in this ing direct composite restorations for treating
and stronger composites are the new article) and composite resin with the minimally invasive Class II preparations, dias-
catchphrases that we embrace. Bioclear method can have the same face- tema closures, black triangle elimination com-
bined with papilla regeneration, and traditional
“When should I use Bioclear over- changing and life-altering effect as anterior composites. He has been granted sev-
molded composites versus porcelain?” porcelain rehabilitation.! eral US patents. He has helped pioneer the
is the new big question that I am being concept of micro-invasive endodontics and has
authored chapters on modern endodontic ac-
asked by doctors at lectures and hands- Acknowledgement cess in textbooks and is on the editorial board
on courses. Here is a good rule of The author would like to thank con- for several journals. He lectured for and was on
thumb: age matters. We know that a tributing orthodontist Dr. Jerrold S. the board of CRA (now CR) for many years and
helped design the Endoguide burs by SS White.
lifetime of occlusion will selectively Johnson. He can be reached at drjohn- He can be reached at drclark@bioclearmatrix.com
wear down the enamel on lower inci- son@naumannjohnson.com. or at drclark@microscopredentistry.com.
sors if we use porcelain. If the patient is
Disclosure: Disclosure: Dr. Clark is the owner of
less than 40 years old, I suggest compos- Dr. Clark founded the Academy of Microscope Bioclear Matrix Systems.
ite as a first choice. Any time the author Enhanced Dentistry and is an associate mem-
ber of the American Association of Endo-
is only doing a limited case (ie, one to 3 dontists. He is a course director at the Newport Other articles linked in this series can be
anterior teeth), composite is again pre- Coast Oral Facial Institute and the director of found on dentistrytoday.com
ferred; this is because trying to prepare the Bioclear Learning Center in Tacoma, Wash.
and match one or 2
porcelain laminates to
natural teeth can be
very invasive, the
color matching excru-
ciating, with all this
being a potential prof-
it killer. After age 40,
and in cases that I do 6
to 10 teeth, patients
are told that either
porcelain or compos-
ite is great.
The true infinity
edge (featheredge on
nonprepared enam-
el) margin is only
possible with direct
composites. A com-
posite margin can
easily be thinned and
polished to have an
almost microscopi-
cally imperceptible
margin. Composites’
infinity edge benefits
both color matching
and pink aesthetics
and nearly always
has better gingival
health than micro-
scopically fitted por-
celain margins.
CLOSING
COMMENTS
There are 6 new fac-
tors that have
changed the game in
“additive dentistry.”
They are as follows:
modern resin design,
breathtaking compos-
ite polishing, heated
composite, anatomic
and diastema closure
matrices, injection
overmolding combin-
ing flowable and regu-