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Wax-up and mock-up. A guide for anterior

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Article in The international journal of esthetic dentistry · April 2014

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 CASE REPORT

Wax-up and mock-up.

A guide for anterior periodontal
and restorative treatments

Jon Gurrea, DDS

Private practice, Bilbao, Vizcaya, Spain

August Bruguera, CDT

Disseny Dental BCN, Barcelona, Spain

Correspondence to: Jon Gurrea

Rodriguez Arias 32, 1º, Bilbao 48011 Vizcaya, Spain; Phone: +34 944399249; E-mail: [email protected]

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Abstract nostic wax up to the patient’s mouth is

of help not only to the restorative den-
When starting a case, having the end tist and the laboratory technician, but
result in mind is the basis in any kind of also to the surgeon when performing
treatment, even more so in those where the crown lengthening. This treatment
the anterior teeth morphology, size and plan cannot be seen as a sequence
proportion will be changed. Here is of isolated procedures but as a single
where a good treatment plan based on workflow. The wax-up/mock-up binomi-
a diagnostic wax-up that is tried in with al is a guide even for the periodontist
a mock-up and approved by the patient in a novel approach to surgical crown
becomes crucial. lengthening.
This case report exemplifies how trans-
ferring the information from the diag- (Int J Esthet Dent 2014;9:146–162)

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a b

c Figs 1a to 1c Extraoral preoperative view.

Introduction tried in the patient’s mouth with a res-

in mock-up in order to make sure the
Today, esthetics is the keynote in den- plan is correct.2 The mock-up needs
tistry: prosthodontics, periodontics, to be observed by the patient, at which
implants and orthodontics are all “es- point, he or she may want to suggest
thetically driven,” just as modern day some correction. Once they have been
patients are much more aware of the at- done and both parties have come to an
tractiveness of a beautiful smile. agreement, the mock-up is accepted
Hence, when a patient demands and this previsualization leads us to a
treatment in the anterior segment, it true informed consent.3 If there is still
is important to begin a treatment plan some remaining doubt, a set of diag-
“with the esthetics in mind.”1 The es- nostic provisional mock-ups could be
thetic goal of treatment will dictate the fabricated in order to concretize the fi-
decision-making process, making the nal treatment outcome.4
planning of the case vital. As archi- Once the patient accepts treatment
tects and engineers have blueprints, with an accepted wax-up/mock-up,
dentists and laboratory technicians these tools can then be used through-
have wax-ups. The wax-up needs to be out the different treatment phases: from

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a b

Figs 2a to 2c Intraoral preoperative view. c

the surgical phase,5,6 if needed, to the At this point there were several differ-
restorative phase.7-9 ent treatment options:
This case report demonstrates how to „Placing two laminates on the lateral
utilize the wax-up/mock-up binomial in incisors as the patient requested.
daily practice. From a professional point of view, this
treatment option would have left the
patient with an undesirable esthetic
Case presentation outcome, with two lateral incisors the
same size in width as that of the central
and treatment plan
incisors and the canines. Therefore, it
A 28-year-old woman requested restora- was immediately explained to the pa-
tive treatment after finishing an ortho- tient that closing diastemas with both
dontic treatment that never had restora- central and lateral incisors, instead of
tive planning, which left diastemas on just with the laterals, would result in a
either side of the two maxillary lateral in- more esthetically proportioned smile.
cisors. The patient requested porcelain „Restart the orthodontic treatment to
veneers on both lateral incisors to close provide more accurate spaces for the
the spaces (Figs 1a to 3). restorative phase. This treatment op-

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 CASE REPORT

more concordant to the incisors. Plac-

ing veneers on the anterior teeth will
produce a balanced smile with har-
monious proportions. The patient and
the team discussed how the asym-
metry between both central incisors
could also be corrected.
„Finally, instead of using ceramic lami-
nates, composite resin restorations
could be carried out. Composite res-
in restorations have improved largely
Fig 3 The lateral incisors are longer than the ca- their quality. Their color stability and
nines and there is evident asymmetry between both
luster over time has been enhanced
central incisors.
but ceramics are still more reliable.
The patient preferred a more stable
result in terms of color and surface
quality than the more conservative
direct approach. The discussion of
whether to use a direct approach or
an indirect approach, and compos-
tion could lead to a less invasive treat- ite resin versus feldspathic ceramic,
ment, but the patient rejected it. depends on many factors and will
„Laminates on the central and the lat- continue as the composite resin res-
eral incisors. This could be accept- torations are improving their physical
able in a patient with a low smile-line and optical capabilities.10
where the canines are not visible. But
the patient had a high smile-line and All this information then had to be trans-
the incisors would have been too big formed into a wax-up.
when compared to the canines. It was
also explained that due to the fact that Diagnostic wax-up
her lateral incisors were longer than
her canines, simply closing the di- Irreversible colloid impressions were
astema between the lateral and the taken and the casts were poured with
canine would result in a smile with type IV stone. The casts were mounted
square canines compared to her oth- in the articulator according to the face-
er anterior teeth. Hence, the canines bow records.
needed to be lengthened. The wax-up included all the desired
„Anterior crown lengthening and lami- elements in a smile design, from tooth
nates on the canines and the incisors. proportion, axial inclination and gingival
This treatment option could address zenith, incisal arrangement and embra-
all the proportion issues that this case sures, to gingival architecture, putting
presented. Lengthening the canines everything in what is called a frame of
would make their width/length ratio reference (Figs 4a to 4c).11,12

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a b

Figs 4a to 4c Initial wax-up. Some teeth have

been lengthened and all of them have been wid-
ened in order to attain the ideal composition. c

a b

Figs 5a and b The wax is placed over the gingiva to simulate a new gingival level. This way the bis-acryl
resin material can reproduce the new gingival level without distortion.

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In the preoperative picture, if a line was

drawn touching the gingival zeniths of the
canine, lateral and central incisor, there
would be a low-high-low scheme with
the lateral incisors’ zenith higher than the
line that joins the central incisor and the
canine’s zenith, as opposed to a high-
low-high or straight line which is estheti-
cally more desirable.13 Therefore, both
canines were lengthened until a straight
a
line was attained. Ideally, it is desirable
for a lateral incisor’s gingival zenith to be
around 1 mm coronal to the line.14 The
gingival zeniths were displaced distally
as the midline was approached, as has
been shown in the literature.13,14
Symmetrical central incisors were
desired, but in this case the asymme-
try appeared both at the gingival level
as well as at the incisal edge. The right
central incisor (11) was shorter than the
b
left central incisor (21), so this tooth was
lengthened both in the apical and the
occlusal direction.
Finally, all the diastemas were closed,
giving each tooth the adequate shape
and size according to the average
width/length ratio of each tooth: 86% for
central incisors, 79% for lateral incisors
and 81% for canines in women.15 Us-
ing the “proportion tools” that give the
same width/length ratio to every anterior
c tooth16 may not individualize each tooth
Figs 6a to 6c Mock-up. The patient has to ap- to its surroundings, but can be useful as
prove the planning before any treatment plan. a reference to start with.
With all these parameters in mind an
additive wax-up was done, slightly over
The treatment plan included crown contouring the facial aspect so that the
lengthening for a balanced gingival ar- gingiva was covered with the wax in the
chitecture, the closing of diastemas and teeth to be lengthened (Fig 5a). This
attaining symmetrical central incisors. then allowed for the resin used for the
The treatment sequence started with the mock-up to lay over the gingiva, show-
“crown lengthening” in the cast. ing the possible final result (Fig 5b).

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Fig 7 Mock-up, intraoral view before crown Fig 8 The gingiva is trimmed using the mock-up
lengthening. as a guide. Then all the resin material is removed
and teeth are measured in order to do the bone
contouring.

If a mock-up is planned, producing quired (Figs 6a to 7). It is recommended

new gingival levels on the cast by trim- to use an opaque resin material, since
ming the stone with a bur is a mistake; some of them are very translucent and it
since the resin will be distorted either at will be difficult to define the new gingival
the gingival level, the incisal edges or contours in a very thin layer of resin.
both, therefore a mock-up that works as It is very important to receive the pa-
a crown-lengthening guide will not be tient’s approval of the mock-up. Patients
precise. And by not being accurate, all need to visualize the possible final result
the previous work is useless. and they may need some time to decide
if they like it or not. Once the patient ac-
Mock-up-guided crown cepted the mock-up, the crown length-
ening was performed.
lengthening
Without removing the resin mock-up,
Once the wax-up was completed, a the gingiva was cut to lengthen teeth
silicone key was made with laboratory 13, 11, and 23 and to attain the exact
condensation silicone (Zetalabor, Zher- gingival architecture desired (Fig 8).
mack, Badia Polesine, Italy) and put un- The resin was then removed in order to
der 2 atm of pressure to increase detail have a clean access to the gingiva and
reproduction. This silicone key was par- every tooth was measured to calculate
tially filled with a bis-acryl resin material the amount of bone resection that had to
(Protemp 4, 3M Espe) and placed in the be performed. Using the mock-up was
patient’s mouth. Before complete set- really useful since it was accurate and
ting, the resin was trimmed with a scal- stable due to it being tooth-supported.
pel blade to define the correct gingival Furthermore, it was an accurate guide
contour, making sure not to touch the since changes were planned at the gin-
gingiva, as the patient was not yet an- gival and the incisal levels; but if there
esthetized since a natural smile was re- was not a future incisal edge in mind,

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3 mm
4 mm

Fig 9 The Komet-Brasseler H207-316-012 bur is used for the initial bone contouring. It has a 4 mm mark
but we usually leave 3 mm.

or actually visible, the crown lengthen- apical to their actual position and if the
ing would have produced undesired re- template is followed in the interproximal
sults. area, the papillae will be unnecessarily
Some authors5,6 suggest the use of damaged and shortened.
acrylic or vacuum formed templates but Free-hand surgical esthetic crown
these templates have problems and are lengthening can produce favorable
often imprecise.18 They are usually thick, outcomes, especially when no incisal
vacuum-formed templates are usually changes are planned and it is easy for
0.5 to 1 mm thick to avoid flexibility and the surgeon to visualize the desired
instability. If the incision is directly done crown size.17,18 But when treating many
in a 45-degree angle on a 1 mm thick teeth, references are often lost, leading
template, the final outcome will be 1 mm to unfavorable results.
longer than desired and that will lead to Once the desired tooth length was
undesired results. By marking an inci- achieved, a mucoperiosteal flap was el-
sion line on a thinner resin layer, the ac- evated, taking care to not surpass the
curacy of the procedure is increased. mucogingival line so that there was more
The other problem is that most of these tissue stability and ease for flap repo-
templates lack accuracy at the inter- sitioning. Bone contouring was carried
proximal level; papillae are often found out with carbide burs (Komet-Brasseler

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H207-316-012, H390-316-016) leaving

3 mm of space for the biological width
(Fig 9).19-22
Interrupted sutures with 6.0 polipro-
pylene were used to secure the flap pos-
ition, leaving the knot towards the palate
(Fig 10). At the 2-week post-operative
follow-up, the sutures were removed and
an adequate healing was observed. The
patient referred no complications.

Fig 10 Crown lengthening postoperative view.

Second wax-up
and teeth preparation

After an 8-week healing period,23,24 new

impressions were taken and a second
wax-up was made to produce a new
mock-up and set of provisional restor-
ations according to the new and estab-
lished gingival levels and making slight
corrections in the incisal edges (Fig 11).
This new mock-up was made and
used as a preparation guide (Fig 12).
Calibrated three-disc diamond burs
were used over the mock-up as depth
gauges for the preparations so that only
the necessary amount of tooth was pre- Fig 11 Second wax-up.
pared (Fig 13).7-9 The teeth were com-
pletely prepared and a first 000 cord
(Ultrapak, Ultradent) was packed to
refine the margin. The preparation was
refined and a second cord (0 Ultrapak)
was placed for the final impression tak-
ing (Figs 14 and 15).
A VPS impression was taken and sent
to the dental laboratory along with the
wax up and the shade information.
Following the impression, provision-
al restorations were fabricated directly
in the mouth using a silicone key and
bis-acryl resin. Once the resin was com-
pletely polymerized, the occlusal adjust- Fig 12 The mock-up is used as a guide for tooth
ment and polishing could be performed. preparation.

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Alveolar model

The beginning of the laboratory work-

flow starts with the clinician’s job. The la-
boratory technician needs good impres-
sions and a correct mounting. All of this
information is key. The clinician should
never forget that the laboratory techni-
cian does not see the patient, except
through good quality pictures the clin-
ician may send. The technician will then
Fig 13 Calibrated three-disc bur is used over the follow a diagnostic wax-up, but if this
mock-up.
has not been checked in the patient’s
mouth and the photographic work has
not been done properly, this wax-up will
lack all of its initial value. The informa-
tion of the mock-up or the provisional
restorations in contrast to the wax-up in
the model makes a big difference for the
technician.
The guide for the treatment will always
be the wax-up/mock-up binomial since
the gingival contours and incisal edges
can be copied from it, but creating ad-
equate gingival contours in a model with
no gingiva and no emergence referenc-
Fig 14 Prepared teeth with 000 cord. es can be highly difficult.
For restorations with internal copings,
it is our choice to produce a regular re-
movable model to fabricate the coping
and then use a solid cast to finish with
the veneering ceramic. For feldspathic
laminates, our selection of choice is for
an alveolar model and a solid cast, in or-
der to control the interproximal contacts.
The alveolar model is more so indicated
for laminates than it is for crowns since
the chance for precise reposition of the
die in the impression is less for crowns
than it is for veneers. The crown prepar-
ations are 100% non-retentive, therefore
Fig 15 Silicone guides are used to make sure a perfect reposition into the impression
there is space for the laboratory technician’s work. cannot be guaranteed (Fig 16).

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When producing laminates with a re-

fractory technique, the dentogingival
alveolar cast25,26 is very useful since it
is a model were the stone dies and the
refractory dies can be interchanged.
The first laboratory step was to obtain
a solid cast, making sure that it did not
damage the gingival area of the impres-
sion. The impression material is usually
very thin at the intrasulcular level or at the
papillae. In order to avoid the material
trapping in the stone, it is recommended Fig 16 The preparation for a veneer will always
be more stable.
to protect these zones with utility wax on
the external surface of the impression
(Fig 17). In this way, the impression will
be protected until the second stone pour
when the original gingival architecture
is needed. In this first pouring, the most
important element is the preparation.
Once the solid cast was obtained
(Fig 18), the most important step in this
process was performed. The model
was trimmed to individualize each die,
and to give each of them the shape of
a root. It is fundamental not to produce
any concavity that could create retention
of the die. Once all the dies had a coni- Fig 17 The impression material is protected with
cal shape that is entirely expulsive, two utility wax in order to avoid any impression damage.

lateral guidance grooves and a final flat

surface, which will act as a stop, were
created (Figs 19a and 19b).
On the finished dies, a thin layer of
wax was placed on the entire “root” sur-
face except for on the lateral grooves
and the basal area, where a separating
liquid was applied instead. The aim was
to secure an easy insertion, guided and
positioned by the lateral grooves that
have to be wide and in contact with the
walls of the artificial alveolus in order to
attain maximum stability.
Fig 18 Solid cast has to be trimmed with a single
insertion axis of the alveolar model in mind.

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a b

Fig 19a Dies after initial trimming. Fig 19b The lateral grooves will provide stability.

The next step was to reposition all applying the ceramic, so the cast did not
dies inside the impression. Once all absorb any water (Fig 21).
the root-shaped dies were in place, the With the alveolar model finished, the
interface between the die and the im- dies were removed by steaming them
pression material was sealed by using in order to soften the wax and to allow
gluing wax (Fig 20). Gypsum or model for their easy removal. Once all the dies
resin was then poured over the impres- were removed and cleaned, die spacer
sion and the dies, while keeping in mind was applied on the preparations. Finally,
that the impression had no wax protect- the dies were duplicated with high-pre-
ing the thin sulcular and papillae areas. cision low-viscosity silicone. A refrac-
Epoxy resin (PX Extrarock, PX Dental) is tory material (Cosmotech Vest, GC) was
a material of choice, since using a little poured in the duplication silicone to pro-
or non-porous material such as this one, duce the refractory working dies.
helped in stabilizing the humidity when

Fig 20 Dies are repositioned in the impression. Fig 21 The second pour is done with a hydropho-
bic material such as epoxy resin.

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a b

Figs 22a to 22c Ceramic layering. c

Ceramics reference of length, width and morphol-

ogy, are of crucial importance.
Facing the ceramic stratification for In the final stage of the veneers fab-
six laminates is not complicated if the rication, the final luster is obtained only
stump shade of the preparations is fa- by mechanical procedures with rubber
vorable. On the contrary, if the shade points (Ceramic polishers, Edenta) to
is not favorable, the priority is to block preserve as much as possible the mac-
the unfavorable color to then stratify in a ro- and microtopography of the restor-
conventional manner (Figs 22a to 22c). ations.
Once out of the furnace, the morphol-
ogy finishing has to be as light as pos- Cementation
sible. If too much ceramic is trimmed to
achieve the desired shape there may When the dental office received the ve-
be a risk of finishing with too much of neer restorations, the cementation pro-
the dentin shade, since the translucent cedure following the Magne and Belser
layers may be trimmed off. There is no protocol27 was carried out.
doubt that in this phase, the information Since it happens naturally, people
given by the diagnostic wax-up, a good desire canines with more chroma, and

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Fig 23 Final outcome.

lateral and central incisors with a higher boratory technician communication is

value.28 Therefore, translucent shade crucial. Clinician’s can perform the best
resin cement (Variolink Veneer, Ivoclar) of treatments but if the result does not
on the incisors and the -2 value shade meet the patient’s desires, as long as
(more chromatic cement) on the canines they are realistic, all the team’s efforts
are used. Once all the veneers were ce- are worthless. Therefore, the use of a
mented, the cords were removed and mock-up to inform the patient of the fi-
ceramic polishers for the palatal mar- nal possible result before touching his/
gins were used to eliminate any remain- her teeth, is not only of great help, but
ing cement, leaving a smooth surface; it is a way of obtaining a “true informed
very thin polishing strips (Epitex, GC) consent.”
were also used for the interproximal ar- In a mock-up, the patient can correct
eas. The restorations showed natural any of his/her dislikes and this allows
looking proximal contact areas (PCA), for the information to run bidirectionally
which decrease in size from the central from the wax-up to the mock-up and
PCA, to the more distal PCAs.29 vice-versa. Once the mock-up has been
Finally, the occlusion was assessed accepted as the simulation of the final
to make sure the anterior guidance and restoration, it can be copied, either by
the lateral excursions were correct, taking an impression or just correcting
while obtaining even occlusal contacts the wax-up.
throughout the restorations. In this way, the wax-up/mock-up bino-
mial takes a leading role from the diag-
nostic phase all through the surgical and
Discussion prosthetic phase as the blueprint. It is a
key element in the surgical crown length-
Anterior segment treatments are chal- ening working as a template to provide
lenging and a good patient/dentist/la- us with the adequate framework, the gin-

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a a

b b

c c

Figs 24a to 24c Intraoral post-operative close- Figs 25a to 25c Extraoral post-operative view.
ups.

giva, for ceramic restorations. Therefore, Acknowledgements

all of the treatment sequences are ruled
The authors want to thank Dr Galip Gürel and Dr Mya
by the same plan.
Choufani DDS for reviewing this article. The authors
declare no financial interest in any of the products
cited herein.

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