Composite Build Up Notes Template: Complete Guide (2024)

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Composite Build Up Of ....

Medical History: Checked, no changes, see attached sheet
Consent to start tx: Verbal
Risks Discussed:
Noted risks associated with composite restoration: Discolouration, marginal staining, chipping and fracture, post-op sensitivity. Average lifespan around 5-7 years. May need polishing every few years for stain removal.
Benefits: More conservative than a crown or veneer as this procedure conserves tooth tissue.

Procedure:
Local Anaesthetic:
.....
Static and dynamic occlusion checked before starting.
Cotton wool isolation and salivary ejector used/rubber dam placed
Tooth surface prepared for build up.
Stent used to guide/Free-hand build up.
……. used to separate adjacent teeth.
Etch 20 secs, wash 20 secs, bond and air thinned LC 20 secs
Restored with composite …….. and LC 20 seconds each increment.
Checked contact points and adjusted to ensure smooth finish when flossing through.
Occlusion rechecked and adjustments made.
Checked for overhangs. Flush against tooth surface.
Advised the patient that some restorations might feel 'high' and it could take 3-6 months for the teeth to adjust to an even bite.
Post-op instructions given regarding restoration and local anaesthetic.
Patient shown result and given opportunity for refinements.
Patient happy.

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Composite build ups are frequently used in restorative dentistry to contour and reshape teeth. Documenting these procedures with comprehensive notes is essential for tracking the intervention, communicating treatment rationale, and ensuring continuity of care. This guide aims to equip dental professionals with the best practices for dental documentation, complete with a template for 2024.

Key Points in Documenting Composite Build Ups

The dental notes for a composite build up should accurately detail the procedure, addressing the medical history, informed consent, risks, benefits, and step-by-step process, while also exceeding in patient communication and post-operative care instructions.