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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: jon@dentistabilbao.com

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Abstract
When starting a case, having the end
result in mind is the basis in any kind of
treatment, even more so in those where
the anterior teeth morphology, size and
proportion will be changed. Here is
where a good treatment plan based on
a diagnostic wax-up that is tried in with
a mock-up and approved by the patient
becomes crucial.
This case report exemplifies how trans-
ferring the information from the diag-
GURREA/BRUGUERA
nostic wax up to the patient’s mouth is
of help not only to the restorative den-
tist and the laboratory technician, but
also to the surgeon when performing
the crown lengthening. This treatment
plan cannot be seen as a sequence
of isolated procedures but as a single
workflow. The wax-up/mock-up binomi-
al is a guide even for the periodontist
in a novel approach to surgical crown
lengthening.
(Int J Esthet Dent 2014;9:146–162)
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 CASE REPORT
a b
c Figs 1a to 1c
Introduction
Today, esthetics is the keynote in den-
tistry: prosthodontics, periodontics,
implants and orthodontics are all “es-
thetically driven,” just as modern day
patients are much more aware of the at-
tractiveness of a beautiful smile.
Hence, when a patient demands
treatment in the anterior segment, it
is important to begin a treatment plan
“with the esthetics in mind.”1 The es-
thetic goal of treatment will dictate the
decision-making process, making the
planning of the case vital. As archi-
tects and engineers have blueprints,
dentists and laboratory technicians
have wax-ups. The wax-up needs to be
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Extraoral preoperative view.
tried in the patient’s mouth with a res-
in mock-up in order to make sure the
plan is correct.2 The mock-up needs
to be observed by the patient, at which
point, he or she may want to suggest
some correction. Once they have been
done and both parties have come to an
agreement, the mock-up is accepted
and this previsualization leads us to a
true informed consent.3 If there is still
some remaining doubt, a set of diag-
nostic provisional mock-ups could be
fabricated in order to concretize the fi-
nal treatment outcome.4
Once the patient accepts treatment
with an accepted wax-up/mock-up,
these tools can then be used through-
out the different treatment phases: from

a b
Figs 2a to 2c Intraoral preoperative view.
the surgical phase,5,6 if needed, to the
restorative phase.7-9
This case report demonstrates how to
utilize the wax-up/mock-up binomial in
daily practice.
Case presentation
and treatment plan
A 28-year-old woman requested restora-
tive treatment after finishing an ortho-
dontic treatment that never had restora-
tive planning, which left diastemas on
either side of the two maxillary lateral in-
cisors. The patient requested porcelain
veneers on both lateral incisors to close
the spaces (Figs 1a to 3).
GURREA/BRUGUERA
c
At this point there were several differ-
ent treatment options:
„Placing two laminates on the lateral
incisors as the patient requested.
From a professional point of view, this
treatment option would have left the
patient with an undesirable esthetic
outcome, with two lateral incisors the
same size in width as that of the central
incisors and the canines. Therefore, it
was immediately explained to the pa-
tient that closing diastemas with both
central and lateral incisors, instead of
just with the laterals, would result in a
more esthetically proportioned smile.
„Restart the orthodontic treatment to
provide more accurate spaces for the
restorative phase. This treatment op-
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 CASE REPORT
Fig 3 The lateral incisors are longer than the ca-
nines and there is evident asymmetry between both
central incisors.
tion could lead to a less invasive treat-
ment, but the patient rejected it.
„Laminates on the central and the lat-
eral incisors. This could be accept-
able in a patient with a low smile-line
where the canines are not visible. But
the patient had a high smile-line and
the incisors would have been too big
when compared to the canines. It was
also explained that due to the fact that
her lateral incisors were longer than
her canines, simply closing the di-
astema between the lateral and the
canine would result in a smile with
square canines compared to her oth-
er anterior teeth. Hence, the canines
needed to be lengthened.
„Anterior crown lengthening and lami-
nates on the canines and the incisors.
This treatment option could address
all the proportion issues that this case
presented. Lengthening the canines
would make their width/length ratio
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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
their quality. Their color stability and
luster over time has been enhanced
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-
ite resin versus feldspathic ceramic,
depends on many factors and will
continue as the composite resin res-
torations are improving their physical
and optical capabilities.10
All this information then had to be trans-
formed into a wax-up.
Diagnostic wax-up
Irreversible colloid impressions were
taken and the casts were poured with
type IV stone. The casts were mounted
in the articulator according to the face-
bow records.
The wax-up included all the desired
elements in a smile design, from tooth
proportion, axial inclination and gingival
zenith, incisal arrangement and embra-
sures, to gingival architecture, putting
everything in what is called a frame of
reference (Figs 4a to 4c).11,12
 GURREA/BRUGUERA

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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 CASE REPORT
a
b
c tooth16 may not individualize each tooth
Figs 6a to 6c Mock-up. The patient has to ap-
prove the planning before any treatment plan.
The treatment plan included crown
lengthening for a balanced gingival ar-
chitecture, the closing of diastemas and
attaining symmetrical central incisors.
The treatment sequence started with the
“crown lengthening” in the cast.
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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
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
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
to its surroundings, but can be useful as
a reference to start with.
With all these parameters in mind an
additive wax-up was done, slightly over
contouring the facial aspect so that the
gingiva was covered with the wax in the
teeth to be lengthened (Fig 5a). This
then allowed for the resin used for the
mock-up to lay over the gingiva, show-
ing the possible final result (Fig 5b).

Fig 7 Mock-up, intraoral view before
lengthening.
If a mock-up is planned, producing
new gingival levels on the cast by trim-
ming the stone with a bur is a mistake;
since the resin will be distorted either at
the gingival level, the incisal edges or
both, therefore a mock-up that works as
a crown-lengthening guide will not be
precise. And by not being accurate, all
the previous work is useless.
Mock-up-guided crown
lengthening
Once the wax-up was completed, a
silicone key was made with laboratory
condensation silicone (Zetalabor, Zher-
mack, Badia Polesine, Italy) and put un-
der 2 atm of pressure to increase detail
reproduction. This silicone key was par-
tially filled with a bis-acryl resin material
(Protemp 4, 3M Espe) and placed in the
patient’s mouth. Before complete set-
ting, the resin was trimmed with a scal-
pel blade to define the correct gingival
contour, making sure not to touch the
gingiva, as the patient was not yet an-
esthetized since a natural smile was re-
GURREA/BRUGUERA
crown Fig 8 The gingiva is trimmed using the mock-up
as a guide. Then all the resin material is removed
and teeth are measured in order to do the bone
contouring.
quired (Figs 6a to 7). It is recommended
to use an opaque resin material, since
some of them are very translucent and it
will be difficult to define the new gingival
contours in a very thin layer of resin.
It is very important to receive the pa-
tient’s approval of the mock-up. Patients
need to visualize the possible final result
and they may need some time to decide
if they like it or not. Once the patient ac-
cepted the mock-up, the crown length-
ening was performed.
Without removing the resin mock-up,
the gingiva was cut to lengthen teeth
13, 11, and 23 and to attain the exact
gingival architecture desired (Fig 8).
The resin was then removed in order to
have a clean access to the gingiva and
every tooth was measured to calculate
the amount of bone resection that had to
be performed. Using the mock-up was
really useful since it was accurate and
stable due to it being tooth-supported.
Furthermore, it was an accurate guide
since changes were planned at the gin-
gival and the incisal levels; but if there
was not a future incisal edge in mind,
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 CASE REPORT
3 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-
ing would have produced undesired re-
sults.
Some authors5,6 suggest the use of
acrylic or vacuum formed templates but
these templates have problems and are
often imprecise.18 They are usually thick,
vacuum-formed templates are usually
0.5 to 1 mm thick to avoid flexibility and
instability. If the incision is directly done
in a 45-degree angle on a 1 mm thick
template, the final outcome will be 1 mm
longer than desired and that will lead to
undesired results. By marking an inci-
sion line on a thinner resin layer, the ac-
curacy of the procedure is increased.
The other problem is that most of these
templates lack accuracy at the inter-
proximal level; papillae are often found
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4 mm
apical to their actual position and if the
template is followed in the interproximal
area, the papillae will be unnecessarily
damaged and shortened.
Free-hand surgical esthetic crown
lengthening can produce favorable
outcomes, especially when no incisal
changes are planned and it is easy for
the surgeon to visualize the desired
crown size.17,18 But when treating many
teeth, references are often lost, leading
to unfavorable results.
Once the desired tooth length was
achieved, a mucoperiosteal flap was el-
evated, taking care to not surpass the
mucogingival line so that there was more
tissue stability and ease for flap repo-
sitioning. Bone contouring was carried
out with carbide burs (Komet-Brasseler
 GURREA/BRUGUERA

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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 CASE REPORT

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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 GURREA/BRUGUERA

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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 CASE REPORT
a b
Fig 19a Dies after initial trimming.
The next step was to reposition all
dies inside the impression. Once all
the root-shaped dies were in place, the
interface between the die and the im-
pression material was sealed by using
gluing wax (Fig 20). Gypsum or model
resin was then poured over the impres-
sion and the dies, while keeping in mind
that the impression had no wax protect-
ing the thin sulcular and papillae areas.
Epoxy resin (PX Extrarock, PX Dental) is
a material of choice, since using a little
or non-porous material such as this one,
helped in stabilizing the humidity when
Fig 20 Dies are repositioned in the impression.
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Fig 19b The lateral grooves will provide stability.
applying the ceramic, so the cast did not
absorb any water (Fig 21).
With the alveolar model finished, the
dies were removed by steaming them
in order to soften the wax and to allow
for their easy removal. Once all the dies
were removed and cleaned, die spacer
was applied on the preparations. Finally,
the dies were duplicated with high-pre-
cision low-viscosity silicone. A refrac-
tory material (Cosmotech Vest, GC) was
poured in the duplication silicone to pro-
duce the refractory working dies.
Fig 21 The second pour is done with a hydropho-
bic material such as epoxy resin.

a b
Figs 22a to 22c Ceramic layering.
Ceramics
Facing the ceramic stratification for
six laminates is not complicated if the
stump shade of the preparations is fa-
vorable. On the contrary, if the shade
is not favorable, the priority is to block
the unfavorable color to then stratify in a
conventional manner (Figs 22a to 22c).
Once out of the furnace, the morphol-
ogy finishing has to be as light as pos-
sible. If too much ceramic is trimmed to
achieve the desired shape there may
be a risk of finishing with too much of
the dentin shade, since the translucent
layers may be trimmed off. There is no
doubt that in this phase, the information
given by the diagnostic wax-up, a good
GURREA/BRUGUERA
c
reference of length, width and morphol-
ogy, are of crucial importance.
In the final stage of the veneers fab-
rication, the final luster is obtained only
by mechanical procedures with rubber
points (Ceramic polishers, Edenta) to
preserve as much as possible the mac-
ro- and microtopography of the restor-
ations.
Cementation
When the dental office received the ve-
neer restorations, the cementation pro-
cedure following the Magne and Belser
protocol27 was carried out.
Since it happens naturally, people
desire canines with more chroma, and
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 CASE REPORT
lateral and central incisors with a higher
value.28 Therefore, translucent shade
resin cement (Variolink Veneer, Ivoclar)
on the incisors and the -2 value shade
(more chromatic cement) on the canines
are used. Once all the veneers were ce-
mented, the cords were removed and
ceramic polishers for the palatal mar-
gins were used to eliminate any remain-
ing cement, leaving a smooth surface;
very thin polishing strips (Epitex, GC)
were also used for the interproximal ar-
eas. The restorations showed natural
looking proximal contact areas (PCA),
which decrease in size from the central
PCA, to the more distal PCAs.29
Finally, the occlusion was assessed
to make sure the anterior guidance and
the lateral excursions were correct,
while obtaining even occlusal contacts
throughout the restorations.
Discussion
Anterior segment treatments are chal-
lenging and a good patient/dentist/la-
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Fig 23 Final outcome.
boratory technician communication is
crucial. Clinician’s can perform the best
of treatments but if the result does not
meet the patient’s desires, as long as
they are realistic, all the team’s efforts
are worthless. Therefore, the use of a
mock-up to inform the patient of the fi-
nal possible result before touching his/
her teeth, is not only of great help, but
it is a way of obtaining a “true informed
consent.”
In a mock-up, the patient can correct
any of his/her dislikes and this allows
for the information to run bidirectionally
from the wax-up to the mock-up and
vice-versa. Once the mock-up has been
accepted as the simulation of the final
restoration, it can be copied, either by
taking an impression or just correcting
the wax-up.
In this way, the wax-up/mock-up bino-
mial takes a leading role from the diag-
nostic phase all through the surgical and
prosthetic phase as the blueprint. It is a
key element in the surgical crown length-
ening working as a template to provide
us with the adequate framework, the gin-
 GURREA/BRUGUERA

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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 CASE REPORT
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