Revista 1835 FGMNews ENG 5 Baixa

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edition 5 october 2013
EDITORIAL STAFF
Friedrich Georg Mittelstdt
Bianca Mittelstdt
Bruno Lippmann
Constanza Odebrecht
Letcia Dias Ferri
Vanessa Cardoso
SPECIAL THANKS TO
Adilson Yoshio Furuse
Adriana Pigozzo Manso
Alan Rodrigues
Alessandra Reis
Ana Lcia Franco
Andr Briso
Andrea Brito Conceio
Andria Affonso Barreto Montadn
Angelica de Oliveira Urbano
Annalisa Mazzoni
Caio Cezar Ferraz
Carlos Augusto de Oliveira Fernandes
Carlos Francci
Ceclia Veronezzi
Chiara Ottavia Navarra
Cristian Higashi
Daniela Prcida Raggio
Edson Araujo
Edison Willrich Sales
Erika Manuela Asteria Clavijo
Eugenio Jos Garcia
Fabiano Araujo
Fabio Sene
Fernanda Ruiz Gregrio
Fernando Fialho
Gil Montenegro
Gislaine Denise Czlusniak
Ilana Pais Tenrio
Expedient
MANAGING DIRECTOR AND
MARKETING FGM
Bianca Mittelstdt
Ana Claudia Silveira
Douglas Raiser
Fernanda M. Busarello
Lais Mizuno
Marluce Atansio
Rodrigo Vargas
Joo Carlos Gomes
Jorge Eustquio
Jos Carlos Garfalo
Jos Carlos Pettorossi Imparato
Jos Mondelli
Leandro Augusto Hilgert
Lndiel Olmpio
Leonardo Fernandes da Cunha
Lorenzo Breschi
Lus Fernando Medeiros
Luiz Antonio Borelli Barros
Maciel Jr
Mary Aparecida Pereira Heck
Mauricio Clavijo Beltrn
Milena Cadenaro
Oscar Fernando Muoz Chvez
Paula Mathias
Paulo Quagliato
Renata Pascotto
Ricardo Marins de Carvalho
Tarcsio Pinto
Teresa Vale
Victor Grover Rene Clavijo
Vitor Alexandre Marinho
Weber Adad Ricci
Weider Silva
Yasmine Mendes Pupo
EDITORIAL BOARD
Friedrich Georg Mittelstdt
Bianca Mittelstdt
Constanza Odebrecht
Letcia Dias Ferri
ART DIRECTOR
EF Design Grfco
Publishing Editor: FGM Produtos Odontolgicos Ltda.
Edition 5 - October 2013
Address: Av. Edgar Nelson Meister, 474 - Zip Code 89210-501, Joinville / SC / Brazil
+55 47 3441-6100
www.fgm.ind.br
fgm@fgm.ind.br
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Summary
Pursuing a perfect and beautiful smile. Cementation of ceramic veneers
The use of sealants in Dentistry
Concepts and trends for use of pit and fssure sealants
Resin-based sealant for pits and fssures: an effective material for caries lesions
prevention
Treatment of dystrophic calcifcation by external bleaching
Dental bleaching to improve teeth esthetics Case report
Combined at-home and in-offce dental bleaching
In-offce dental bleaching with Whiteness HP Maxx
The effectiveness of the combined dental bleaching
The effectiveness of dental bleaching in non-vital and discolored teeth
Enamel microabrasion with Whiteness RM for removal of enamel hypoplasia stains
Everyday questions about dental bleaching: what do clinicians need to know?
Dental bleaching for vital and non-vital teeth followed by a direct restorative proce-
dure Case report
Section Research & Development Science and Esthetics
Self-ligating brackets in orthodontics
Update in Adhesive Systems
What do the experts say about adhesive systems?
Dental bonding with the adhesive Ambar
Modifying smiles with composite resins
Simplifying the layering technique in posterior teeth Case report
Esthetic re-anatomization: natural results with the composite resin Llis
From restorative esthetics to cooking
Achieving a harmonic smile after cementation of veneers: A 4-year follow-up
Anatomical fber post after endodontic re-treatment
Research with FGM products
Authors guidelines for publication of clinical cases
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volume 15 janeiro 2013 october 2013 edition 5
Cementation of
ceramic veneers
Pursuing a perfect
and beautiful smile.
New esthetic techniques along with materials with improved properties have been employed for the
solution of challenging cases in a highly efcient and safe way. Ceramic materials with high mechanical
strength along with adhesives and resin cements play key roles in several esthetic protocols both in
posterior and anterior teeth. Ceramic veneers, associated with careful planning, can transform a smile
and restore the patients self-esteem in a most conservatively way.
Ceramic veneers are indirect restorations that aim to reproduce the dental enamel. Tey are extremely
thin indirect restorations bonded to the buccal surface of anterior teeth.
1
Te depth of the dental
preparation is based on the patients case. Tere are some indications for ceramic veneers: the patients
desire for changing their teeth color in case of unfavorable bleaching results, the presence of large dental
fractures or enamel/dentin malformation. Tis treatment can also be used for diastema closure, conoid
teeth, mispositioned teeth, cases of enamel loss due to erosion or abrasion or when there is a need to
increase the cervical-incisal length.
2

Photo: Dr Sanzio Marques.
5
1. Stoll L.B., Lopes, F. Harmonizao do sorriso atravs de laminado cermico lente de contato. R Dental Press Estt, Maring, v.6, n. 1, p. 116-124, jan/fev/mar 2009.
2. Conceio E.N. et al. Restauraes Estticas: compsitos, cermicas e implantes. Porto Alegre: Artmed, 2005. 308 p.
3. Farias D.C.S., Lopes G.C. Cimentos resinosos: infuncia do modo de cura sobre a correta indicao. Clnica International Journal of Brazilian Dentistry, Florianpolis, v. 4, n.
4, p. 432-436, out/dez 2008.
Adhesive cementation should be the clinicians choice for ceramic veneers since it strengthens the
remaining tooth structure and improves the marginal sealing.
2
For this purpose, it is necessary to choose
efective adhesive systems and resin cements in order to increase the lifespan of the esthetic treatment.
Te good quality of these materials infuences the treatment success. Light-curing resin cements are
indicated for cementation of thin ceramic veneers due to several advantages. Tey have unlimited
working time, which facilitates the removal of excesses; and air bubbles are not incorporated into the
resin cement as they do not require mixing. Lastly, light-curing resin cements have better color stability
over the years. Tis is a essential esthetic aspect; since color change of the resin cement may be clinically
detected through extremely thin and translucent ceramic veneers.
3

Resins cements specially developed for veneers still have the advantage of the try-in pastes, which
facilitates the selection of the defnitive resin cement shade. Te try-in cements have exactly the same
color of the cured resin cement, which allows clinicians to predict the fnal color outcome afer defnitive
cementation. However, they do not bond to the substrates, and they can be easily removed afer use.
Te adhesive cementation of ceramic veneers is an issue that generates many questions by the dentists.
In face of that, FGM News selected renowned professionals with deep knowledge
in the feld to clarify some frequent asked questions in an aim to assist clinicians
in their daily practice.
Photo: Dr Sanzio Marques.
REFERENCES
6
october 2013 edition 5
1. CERAMIC VENEERS ARE A GOOD TREATMENT OPTION FOR ESTHETIC RESTORATIONS. IN WHICH
SITUATIONS ARE THEY INDICATED?
2. THE CHOICE OF THE RESIN CEMENT FOR CEMENTATION OF VERY THIN CERAMIC VENEERS (ALSO CALLED
CONTACT LENSES) INFLUENCES THE FINAL RESULT OF THE RESTORATIVE PROCEDURE. LIGHT-CURED
RESIN CEMENTS ARE USUALLY INDICATED FOR CEMENTATION OF THESE VENEERS. WHY?
Dr Maciel Jr: The effectiveness of the current adhesive
cementation along with the possibility of testing resin
cement color before defnitive cementation has increased
the indications of ceramic veneers. They are now not only
indicated for restoration of teeth with the loss of dental structure
due to caries, fractures or wear, but also for correcting teeth
malposition and for the achievement of a more harmonic smile.
For the latter aim, the patients should be evaluated as a whole,
especially in the aspects related to their facial features such
as face shape, area of teeth appearance during
smile, lip positioning and lip line.
One must also take into account that
the increased knowledge of dental technicians,
associated with the development of ceramic
materials, has been responsible for the wide
indications of ceramic veneers. Currently, it is
possible to make the so-called contact lenses,
which can be made as thin as 0.3 millimeters,
reducing the need of dental preparation.
Dr Fernando Fialho: Ceramic materials are very hard
and hence they are resistant to wear. On the other hand,
they are brittle and may suffer catastrophic fracture under
stress. The dental porcelain, which is the most popular
ceramic employed in dentistry, reproduce with more precision
the dental optical characteristics. Therefore, they are the
most used material for production of ceramic
laminates since they provide the achievement
of a high esthetic standard. On the other hand,
they have lower inherent strength than other
ceramic materials available in the market.
The cementation of veneers (contact
lenses) with resin cements is essential for the
success of the procedure. This allows the
formation of a structural unit, i.e. a monoblock,
between the tooth and the restoration,
increasing the material resistance and making it
possible its clinical use. For the luting procedure,
This condition is in agreement with the clinicians and
patients preference of reduced tooth wear. Although this type
of treatment requires highly precise indications, its indications
have been expanded recently. The analysis and preparation
of ceramic restorations is a daily procedure in the clinicians
offces. The professional who does not offer the option of
esthetic rehabilitation with ceramic veneers for his patients can
be considered outside the dental market.
Dr Maciel Jr
Specialist in Restorative Dentistry (Bauru
School of Dentistry, University of So Paulo)
and MS in Restorative Dentistry (Araraquara
School of Dentistry, University of the State of
So Paulo).
light-cured resin cements and adhesive systems can be used
since the thin and translucent laminates allow easy passage
of light. Additionally, the use of light-cured resin cements
increases the working time and prevent the maladaptation
of the laminate as the activation of the material (adhesive and
cement) is made after cementation.
Dr Fernando Fialho
Undergraduation in Dentistry (Federal
University of Maranho, UFMA). Specialist
in Restorative Dentistry and MS in Dental
Prothesis (University So Leopodo Mandic).
Coordinator of the Specialization course
of Restorative Dentistry at the Brazilian
Association of Dentistry (ABO-MA).
Coordinator of the Improvement course in
Restorative Dentisry (ABO-MA).
3. THE ADHESIVE CEMENTATION STEP IS OF PARAMOUNT IMPORTANCE FOR THE CLINICAL PERFORMANCE
AND LONGEVITY OF INDIRECT RESTORATIONS, AS WELL AS THE CORRECT DIAGNOSIS AND THE
APPROPRIATE TREATMENT INDICATION. WHAT FACTORS SHOULD BE TAKEN INTO CONSIDERATION WHEN
CHOOSING A LUTING MATERIAL?
7
Dr Mauricio Clavijo Beltrn: The factors that must
be considered when choosing a luting material are adequate
mechanical properties, low flm thickness, radiopacity, ease
of handling, biocompatibility, low solubility, bonding to dental
structure and the restorative material as well as proper
esthetic properties.
The conventional cements, such as glass ionomer or
zinc phosphate cements, have good tensile, compression
and shear strength as long as they are used in appropriate
dental preparations and respecting the cementation line.
Additionally, they are radiopaque, which allows the excess
removal from the cervical area and they are biocompatible
with the dentin-pulp complex. The easy handling of these
materials allows adequate working time. However, glass
ionomer and zinc phosphate cements still leave much to
desire when it comes to the other properties.
The development of the adhesive bonding and the
resin composites led to the production of the resin cements.
These materials have important features that were still lacking
in the other cements employed in the past for indirect ceramic
restorations. The silanization made it possible the chemical
bonding of the ceramic restoration with the resin
cement; the formation of the hybrid layer allowed
the bonding of the resin cement with the dental
structure. The adhesive bonding improved
the mechanical properties of the restorative
procedure and favored the advent of minimally
invasive dentistry with more conservative and non-
retentive dental preparations. The low solubility
of the resin cement and its wear resistance
signifcantly improved the marginal integrity.
The resin cements have been improved. One of the
clinicians complaints in the past was the need of several
steps for the cementation procedure. Nowadays, one fnd
in the market self-adhesive and self-cured cements that can
be used in a single step. More and more, better predictable
esthetic results can be achieved with resin cements as they
are produced in a wide range of colors and they have good
color stability. Besides that, try-in pastes, which are also
available in the market, allow the simulation of the results
before the defnitive cementation procedure.
It is also important to consider the type of resin cement
activation. In posterior teeth or where the light curing is not
satisfactory, for instance when bonding intra-radicular fber
posts, metallic indirect restorations, zirconia restorations or
indirect thick restorations, the use of dual-cure resin cements
is of paramount importance. The incorrect selection of the
resin cement may lead to uncured resin cement layer due to
low degree of conversion. This, in turn, increases the water
sorption and negatively affects the mechanical properties of
the cement layer.
Dr Mauricio Clavijo Beltrn
Undergraduation in Dentistry at Piracicaba
School of Dentistry (University of Campinas -
FOP-UNICAMP). Specialist in Dental Prothesis
at Bauru School of Dentistry (University of So
Paulo FOB-USP). Specialist in Implantotogy
at the Paulista Assocation of surgeon dentists
(APCD SP). Member of the International Team
for Implantology ITI.
4. THE PREDICTABILITY OF INDIRECT RESTORATIONS, ESPECIALLY VENEERS OR CROWNS IS A GREAT
CHALLENGE TO THE DENTIST. THE SELECTION OF APPROPRIATE COLOR IS A VERY DIFFICULT PROCEDURE
IN THE DAILY PRACTICE. IN FACE OF THAT, TRY-IN PASTES WERE PRODUCED TO ALLOW CLINICIANS TO
SIMULATE THE COLOR AND DECIDE THE ONE THAT MATCHES BETTER THE NEIGHBORING STRUCTURES
BEFORE THE DEFINITIVE CEMENTATION. IN YOUR OPINION, DO YOU CONSIDER THE USE TRY-IN PASTES AN
IMPORTANT STEP?
Dr Jorge Eustquio: The use of try-in
pastes is not only important, but essential for the
cementation procedure of veneers and ceramic
crowns. As very thin ceramic veneers have been
prepared they are no longer just translucent, but
almost transparent. The previous use of try-in
pastes is one of the keys to ensure the success
of a procedure which has the esthetic feature as
the most important requirement. Resin cements
that do not have a wide range of colors and do
not allow testing prior to defnitive cementation
procedures are, in my opinion, useless.
Dr Jorge Eustquio
MSc student of Restorative Dentistry at
CPO (University of So Leopoldo Mandic
- Campinas SP). Professor of the
Specialization Course in Restorative Dentistry
and Prothesis Brazilian Association of
Dentistry (ABO) - Macei AL. Coordinator
of the Course of Ceramic Veneers - Brazilian
Association of Dentistry (ABO) - Macei AL.
Scientifc Advisor of the Journal Prothesis
Laboratory in Science - Publisher Plena.
Professor. MSc. Yasmine Mendes Pupo
Doctorate in Dentistry, in the concentration area of Restorative Dentistry, line of research:
physicochemical and biological properties of materials, UEPG - PR - Brazil
Teacher of Graduate and Post Graduate courses in Dentistry in Tuiuti University - PR - Brazil
"... FGMs sealant, Prevent, has desirable physico-chemical properties and
its satisfying viscosity allows creating thin lms with adequate owing. It
really does the work its intended for, consisting of a promising material in
therms of longevity on dental structure ."
Source: Dr. Gislaine Czlusniak et al.
Contains uoride.
Opaque white and mottled versions.
Contains load lling for a greater
mechanical strength.
Lightcuring for greater exibility in
the application.
Low viscosity allowing eective
lling of pits and ssures.
Youre Worth it. www.fgm.ind.br/en
prevent copy.pdf 1 03/10/2013 09:09:29
Professor. MSc. Yasmine Mendes Pupo
Doctorate in Dentistry, in the concentration area of Restorative Dentistry, line of research:
physicochemical and biological properties of materials, UEPG - PR - Brazil
Teacher of Graduate and Post Graduate courses in Dentistry in Tuiuti University - PR - Brazil
"... FGMs sealant, Prevent, has desirable physico-chemical properties and
its satisfying viscosity allows creating thin lms with adequate owing. It
really does the work its intended for, consisting of a promising material in
therms of longevity on dental structure ."
Source: Dr. Gislaine Czlusniak et al.
Contains uoride.
Opaque white and mottled versions.
Contains load lling for a greater
mechanical strength.
Lightcuring for greater exibility in
the application.
Low viscosity allowing eective
lling of pits and ssures.
prevent copy.pdf 1 03/10/2013 09:09:29
10
The use of sealants
in Dentistry
Te sealants were introduced in the sixties from the last century, in order to protect the pits and fssures
from accumulation of bioflm and food debris, and consequently prevent the development of carious
lesions in these areas. Generally, sealants can be resin- or glass ionomer-based products. According to
the Reference Manual for Clinical Procedures in Dentistry, published by the Brazilian Association of
Pediatric Dentistry, sealants are efective in preventing the development of caries lesions in pits and fssures
of teeth from children and adolescents. Sealants were shown to be superior to other preventive measures,
with no risk or side efects to patients. Teir indication is primarily in individuals and populations with
high caries risk, a group of patients who has beneft a lot from the sealant use.
In regard to the use of sealants, the American Association of Pediatric Dentistry (AAPD), follows the
recommendations of the American Dental Association (ADA). Tey were published in the Journal of the
American Dental Association, 139(3):257-263 (2008). According to the Scientifc Afairs report by the
American Dental Association Council, sealants are efective in preventing tooth caries and they can also
prevent progression of non-cavitated incipient carious lesions.
Te most critical step in the application protocol of sealants is the isolation of the operative feld. Tis can
be especially difcult in very young children with behavioral problems. Te professional should provide
an adequate cleaning of the surfaces to be sealed: organic material should be removed from the pits and
fssures to allow a good selective enamel etching, thereby improving the sealant efectiveness and reten-
tion.
Based on scientifc evidence reported in the main journals of the Pediatric Dentistry Association, every
dental professional from public or private service should include the use of sealants as part of their pre-
vention programs.
PUBLIC LEVEL
INDIVIDUAL LEVEL
TOOTH LEVEL
SURFACE LEVEL
Children and adolescents of lower socioeconomic status.
Previous experience of dental caries,
cariogenic diet,
poor oral hygiene.
Teeth with a macromorphology that allows greater accumulation and/or diffculty for bioflm removal,
permanent molars, especially the frst, in the frst years after the eruption,
although there is no defnitive evidence of effectiveness in primary molars, it is suggested that it has a
similar beneft than that demonstrated for permanent molars.
Pits and fssures from occlusal surfaces without or with an incipient enamel caries lesion.
Caries risk*.
*Manual de referencia para Procedimientos Clnicos en Odontologa Peditrica (Asociacin Brasilea de Odontologa Peditrica)
Prof. Lus Fernando Medeiros
Professor of Pediatric Dentistry University of Joinville (Univille) Joinville, SC.
11
Concepts and trends
for use of pit and fssure
sealants
FGM News sought two renowned specialists in Pediatric Dentistry, the professors Jos Imparato and Da-
niela Raggio, to clarify what one needs to consider in regard to sealants application in the daily practice. In
this interview they also mentioned the current concepts that require attention during sealant placement.
Good reading!
1. THERE IS A WIDE VARIATION IN THE CRITERIA FOR SELECTION OF PATIENTS AND TEETH TO
BE SEALED AS WELL AS THE PLACEMENT AND TYPE OF MATERIAL USED FOR SEALING PITS AND
FISSURES. WHAT IS THE CURRENT PROTOCOL, APPLICATION TECHNIQUE AND TYPE OF MATERIAL
YOU SUGGEST FOR A SUCCESSFUL TREATMENT?
Currently we indicate sealants according to the risk
and/or level of caries activity. There are two main types
of sealants: glass ionomer cement and resin sealants.
Glass ionomer cements are indicated mainly for erupting
teeth. In this case high-viscosity glass ionomers should
be applied with digital pressure. The application technique
of glass ionomer sealants begins with the isolation of
the operative feld with cotton rolls and saliva ejectors.
Subsequently, the occlusal surface is cleaned with pumice
and water or professional brushing. The glass ionomer
cement is then manipulated with the correct powder/
liquid ratio and placed on the surface. When applied on
the surface, the glass ionomer cement should be bright
to ensure adequate bonding to the enamel surface. After
material placement, one should press the material with a
gloved hand lubricated with petroleum jelly. The following
step is to remove the material excesses and adjust the
occlusion. Finally, the surface of the material should be
protected against syneresis and imbibition (Rocha et al.
2003).
The resin-based sealants, which were typically
indicated for prevention, have been used therapeutically
for sealing caries lesions extending up to half of the dentin
tissue. The operative feld should be preferably isolated
with rubber dam and the surface cleaned with pumice and
water or professional brushing. Enamel conditioning with
35% phosphoric acid is performed for 15 to 30 seconds,
followed by copious water rinsing. The surface should be
well dried before the resin-based material application. If a
light-cured material is used, it should be photo-activated
for at least 20 seconds. The occlusion contacts should be
adjusted; in case of premature contacts they should be
removed with diamond burs.
The literature does not report how often sealants
should be evaluated after application. However, it is
important to recall patients regularly in order to diagnose
and detect sealant failures. Macroscopically partial or total
loss of glass ionomer sealants is very common. However,
even under low retention rates, prevention of caries
lesion is as effective as the one provided by resin-based
sealants. It is likely that glass ionomer particles, retained at
the bottom of the fssures, can prevent the development of
caries lesions by means of continuous release of fuoride
to the enamel surface.
Professor Dr. Jos Carlos Pettorossi Imparato
Tenure Professor of Pediatric Dentistry.
University of So Paulo. Rector of the
University Camilo Castelo Branco and Professor
of the Graduation Course in the University So
Leopoldo Mandic (Campinas-SP). Research
Fellow in Productivity from National Council
for Scientifc and Technological Development
(CNPq) level 2.
Professor Daniela Prcida Raggio
Tenure Professor of Pediatric Dentistry.
University of So Paulo.
12
2. WHAT ARE THE METHODS USED FOR IMMEDIATE AND LONG-TERM EVALUATION OF SEALANTS?
Usually, the clinical assessment is done by visual
inspection. Clinicians should observe if there is retention
loss (total or partial) of the material. The clinical decision
during evaluation depends on the clinical case: the lack
of retention does not necessarily mean that the material
should be re-applied. For instance, if one detects lack of
retention of a glass ionomer cement that was applied in
an erupting tooth, one should observe if the tooth has
reached the occlusal contact. In positive case, the surface
no longer needs protection, as the material remained in
place during the highest risk period. In another situation
of partial retention loss, the sealant can be reapplied to
avoid the bioflm accumulation in the retentive margins of
the material.
3. WHAT WOULD BE THE SURVIVAL TIME OF A PIT AND FISSURE SEALANT? WHEN SHOULD IT BE RE-
APPLIED?
The survival time of a sealant depends on the
material type. The resin-based materials usually have
higher longevity, or in other terms, higher retention rates
than the glass ionomer sealants (Khnisch et al., 2012).
Many factors can infuence the sealant longevity and,
therefore, one should follow the manufacturers guidelines
and keep up-to-date with new technological evidence.
4. ALTHOUGH THE SEALING OF PITS AND FISSURES IS A WIDELY RECOGNIZED TECHNIQUE FOR PRO-
MOTING A MECHANICAL BARRIER AGAINST THE DEVELOPMENT OF OCCLUSAL CARIES LESIONS, HOW
IS THE PROCEDURE SEEN IN THE PUBLIC SERVICE?
It is diffcult to talk about sealants on public health.
However, regardless of where we work we should follow
an evidence-based practice. The use of sealants for
prevention/r treatment is recommended regardless of
where (public or private service) the clinician work. We are
often surprised by comments like: sealants are no longer
used! In fact, in the past, sealants were placed in all teeth
without criteria. Nowadays, we follow an evidence-based
practice.
For example, today we use more glass ionomer
sealants than in the past! Similarly, we use more resin-
based sealants to seal incipient caries lesions than
we did a few years ago! We have to read the literature,
interpret the new evidence and apply the new concepts.
In particular, one employ a resin-based sealant for
sealing caries lesions in the outer half of dentin with a
resin-based sealant (therapeutic approach) and employ
a glass ionomer sealant for erupting molars. In this way,
our patients will be the most profted ones. We should
have more well-defned protocols supported by evidence-
based dentistry for application in the public and private
services.
Hesse D, Guerriero RVM, Bonifacio CC, Raggio DP, Mendes FM, Imparato JCP . Avaliao clnica e radiogrfca do selamento de leses de crie. Perionews (So Paulo), v. 2, p.
137-143, 2008.
Hesse D, Raggio DP, Bonifacio CC, Imparato JCP. Avaliao do selamento de leses de crie comparado restaurao com resina composta em dentes decduos.. Stomatos
(ULBRA), v. 13, p. 75-85, 2007.
Bakhshandeh A, Qvist V, Ekstrand KR. Sealing occlusal caries lesions in adults referred for restorative treatment: 2-3 years of follow-up. Clin Oral Investig. 2012 Apr;16(2):521-9.
Epub 2011 Apr 9.
Rocha RO, Oliveira LB, Raggio DP, Rodrigues CRMD. Cimento de ionmero de vidro como selante de fossas e fssuras. Revista da Associao Paulista de Cirurgies Dentistas,
So Paulo, v. 57, n.4, p. 287-290, 2003.
Khnisch J, Mansmann U, Heinrich-Weltzien R, Hickel R. Longevity of materials for pit and fssure sealing--results from a meta-analysis. Dent Mater. 2012 Mar;28(3):298-303. Epub
2011 Dec 3.
The clinical situation will defne the best material for
sealing. When the tooth is erupting, with white stains or
small cavities in enamel, glass ionomer sealants should be
preferred. On the other hand, if tooth is completely erupted
and presents demineralization restricted to enamel or on
the outer half of the dentin, the best choice is the resin-
based material.
REFERENCES
13
Resin-based sealant for pits and fssures:
an effective material for caries lesions
prevention
INTRODUCTION
According to the current concepts of Dentistry, growing attention
has been directed to the early diagnosis of dental caries as well as to the
development of improved materials and methods for oral health care. Within
this context, pit and fssure sealants contribute effciently for the minimal
intervention philosophy. In general, caries lesions in occlusal and buccal/lingual
surfaces are responsible for almost 90% of the lesions that occur in the oral
cavity of children and adolescents.
4
The reduction of caries lesions prevalence was possible due to the
fuoride-based treatments, along with greater public awareness regarding the
need of oral hygiene techniques and the use of less cariogenic diets. However,
although these aforementioned factors were effective for smooth surfaces, they
were not for occlusal areas. The occlusal surfaces are highly susceptible for
development of carious lesions due to the morphology of the pits and fssures,
which have a wide variation in shape and depth. However, they are generally
narrow and winding, with irregular invaginations where bioflm accumulates.
Additionally, these regions cannot be protected by the preventive effect of
systemic and topical fuoride.
5
Besides that, saliva does not have access to the
inner areas of the fssures and thus it does not remineralize the incipient caries
lesions in these areas.
2
Thus, numerous and varied procedures were developed, with the aim
to protect the occlusal surface. Nowadays, the importance of using sealants
in private or public health level is unquestionable since there is evidence that
supports its effectiveness. Sealants are the most effective technique for the
prevention of caries lesion development in pits and fssures.
5

Gislaine Denise Czlusniak
PhD in Pediatric Dentistry.
Professor of the Dentistry
Department. State University of
Ponta Grossa (UEPG).
Yasmine Mendes Pupo
PhD student in Restorative
Dentistry. State University of Ponta
Grossa (UEPG).
Professor of the School of
Dentistry. University of Tuiuti of
Paran.
yasminemendes@hotmail.com
Joo Carlos Gomes
PhD in Restorative Dentistry.
Professor of the School of
Dentistry. State University of Ponta
Grossa (UEPG).
14
Dental sealants protect the pits and fssures of
posterior teeth, reducing the growth of bacteria in these
surfaces. Sealants should be applied on the occlusal
surfaces of the teeth from high caries-risk patients.
1
In
general, children who have their posterior teeth sealed
are less prone to the caries lesion development.
1
The
aim of this study was to report a clinical case of sealant
application.
1. Baseline aspect of the tooth 46 after tooth prophylaxis.
2. Rubber dam isolation of the tooth 46 using a dental clamp (ASH A).
3. Enamel conditioning with 37% phosphoric acid for 30 seconds, followed by copious water rinsing for 30 seconds and air drying.
1.
2. 3.
CASE REPORT
After dental diagnosis of a six-year old male patient,
who attended the Pediatric Dentistry Clinic of the State
University of Ponta Grossa, we identifed the need of
resin-based sealants on the frst permanent molars due to
the presence of deep pits and fssures, and the diffculty
hygiene in these regions.
15
After anamnesis and clinical examination, the patient
was instructed about the importance of oral hygiene. The
patient was also instructed on how to perform a proper
tooth brushing. The occlusal contacts were checked, and
no occlusal interference was found in the area of the pits
and fssures. We performed a previous prophylaxis with
pumice and water; the surface was water rinsed and dried
and left in a suitable condition for the sealant application
(Figure 1). The feld was isolated with rubber dam (Figure
2) and a new surface prophylaxis with rubber cups or
rotating brushes was performed to clean the surface. The
37% phosphoric acid conditioner (37 Condac, FGM) was
applied for 30 seconds, rinsed copiously, and the surface
was air dried (Figure 3).
4. Application of the adhesive system Ambar (FGM Dental Products, Joinville, SC, Brazil) followed by light curing for 10 seconds.
5. Application of the resin-based Prevent sealant (FGM Dental Products, Joinville, SC, Brazil) on the pits and fssures. The sealant was light cured for 20 seconds.
6. After clinical inspection and rubber dam removal, the occlusal contacts were checked.
7. Final aspect after fnal adjustments.
4.
6.
5.
7.
We performed a modifed resin-based sealant
application (Prevent, FGM Dental Products, Joinville, SC,
Brazil). Before sealant application, the adhesive system
Ambar (FGM Dental Products, Joinville, SC, Brazil) was
applied to improve the infltration in the enamel (Figure 4).
We employed a flled and light-curing sealant adhesive.
The tip of the Prevent syringe was placed, and the sealant
was applied in the whole area of pits and fssures (Figure
5). Special care was taken to avoid sealant placement in
the areas of occlusal contact. The light curing step was
carried out for 20 seconds, according to the manufacturers
recommendations. After removal of the rubber dam
isolation, the occlusion was adjusted and any interference
removed with an abrasive rubber point (Figures 6-7).
16
DISCUSSION
Signifcant progress has been achieved in terms of
prevention of dental caries in children and adolescents
over the past 30 years.
5
The new paradigm of the
restorative dentistry is no longer based on the quality of
the restorations, but on the use of preventive measures
to keep the dental structure sound.
3
For this purpose, a
suitable preventive treatment plan should be defned for
each clinical case. Thus, a correct diagnosis with adequate
visual accuracy should be performed in a clean surface
with adequate illumination and appropriate instruments
(modifed or not) without exerting excessive pressure.
Aside from that, the individual patients caries risk should
be taken into consideration. We can employ a resin-based
or a glass-ionomer based sealant. This clinical case was
performed with the resin-based sealant from FGM, which
is a flled, light-cured and resin-based sealant with reduced
opacity and a slight yellowing shade.
Generally, resin sealants are composed of Bis-GMA
monomer. They can be light or chemically cured; flled or
unflled, colorless or slightly yellow, with or without fuoride
in their chemical composition. The most signifcant factor,
however, is the correct sealant indication, i.e., they should
be used in children with active caries and occlusal surfaces
with deep fssures. Patients with teeth erupted for less than
two years and within the window of infectivity, with greater
bioflm accumulation, poor psychomotor ability for brushing
have a high risk for caries development and, therefore,
can also beneft from sealant application. In regard to the
application technique, clinicians should strictly follow the
manufacturers instructions to achieve adequate retention,
effectiveness and material longevity.
It is worth to mentioning that the prior application
of an adhesive before the sealant aims to improve the
penetration of the material in the enamel structure.
Although the incorporation of inorganic fller increases
the mechanical strength of the material, it jeopardizes the
material penetration into fssures due to its high viscosity.
Therefore in this clinical case we attempted to use the
contemporary knowledge of restorative dentistry.
The clinical preservation with periodic clinical and
radiographic follow-up is required. If needed, sealant repair
should be performed to ensure the integrity of the resin
sealant and allow a health status for children with caries-
free teeth. The general health and well-being begins in the
patients mouth.
CONCLUSION
The promotion of healthy is the responsibility of all
professionals engaged in the health science, who search
for balance and quality of the human life. So the dentist
should be part of this educational and preventive context
and make use of the tools needed to reach this aim. At
the same time, the dentist should avoid unnecessary
treatments: sealants should be used carefully and
accurately along with other effective measures for
chemical and mechanical bioflm control.
ACKNOWLEDGMENTS
We would like to thank FGM Dental Products for the
donation of the materials used in this clinical case.
REFERENCES
1. Bendinskaite R, Peciuliene V, Brukiene V. A fve years clinical evaluation of sealed
occlusal surfaces of molars. Stomatol Baltic Dental Maxillofac J. 2010; 12: 87-92.
2. Feldens EG, Feldens CA, Arajo FB, Souza MA. Invasive technique of pit and fssu-
re sealants in primary molars: a SEM study. J Clin Pediatr Dent. 1994;18:187-90.
3. Marino AC, Rego MA. Diagnstico de crie oclusal e indicao de selamentos de
cicatrculas e fssuras. Rev Biocienc. 2002; 8(2): 59-67.
4. Ripa LW, Leske GL, Sposato A. The surface specifc caries pattern of participants
in a school-based fuoride mouthrinse program with implications for the use of sea-
lants. J Public Health Dent. 1985; 45(2): 9094.
5. Strassler HE, Grebosky M, Porter J, Arroyo J. Success with pit and fssure sealants.
Dent Today. 2005; 24(2): 124-140.
primeirapagina_perfect copy.pdf 1 03/10/2013 09:08:36
primeirapagina_perfect copy.pdf 1 03/10/2013 09:08:36
Desensitizing agents:
Potassium Nitrate and Sodium Fluoride.
Neutral pH:
avoid sensitivity and demineralization of
enamel.
High water content:
avoid dental dehydration.
Excellent viscosity:
does not runs off of the tray
Ideal wettability:
better penetration into the tooth structure.
More performance:
3g in each syringe, yields 9 applications.
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Desensitizing agents:
Potassium Nitrate and Sodium Fluoride.
Neutral pH:
avoid sensitivity and demineralization of
enamel.
High water content:
avoid dental dehydration.
does not runs off of the tray
Ideal wettability:
better penetration into the tooth structure.
More performance:
3g in each syringe, yields 9 applications.
Dental bleaching gel based
on Carbamide Peroxide,
in concentrations of
10%, 16% and 22%.
Available in Kit,
Mini Kit and refill.
perfect copy.pdf 1 03/10/2013 09:08:01
20
Treatment of dystrophic calcifcation by
external bleaching
ABSTRACT
External bleaching is a fairly conservative alternative and can provide
highly satisfactory results, especially in cases where there is limited access
to the root canal system. This clinical case reports a patient who presented
discolored maxillary central incisors due to trauma, and in one incisor, the
discoloration was due to calcifcation. The treatment consisted of thirty days
of dentist-supervised at-home bleaching with the use of 22% carbamide
peroxide gel.
KEYWORDS
Dental bleaching, pulp calcifcation, peroxide.
INTRODUCTION
Among the causes of dental discoloration, trauma is a major factor,
and the upper central incisors are the most susceptible teeth. In response to
the trauma, the dentin-pulp complex may respond with pulp necrosis, root
resorption or a process of dystrophic calcifcation, resulting in discoloration that
may vary from yellow to brown.
1
Comparing to composite resin restorations, veneers or crowns, tooth
bleaching is the most conservative treatment for dental discoloration.
2
Among
the available techniques, the one introduced by Haywood and Heymann is the
most widely used and it consists in the wearing of custom trays flled with low
concentrated carbamide gels.
3
The degree of whitening is infuenced by several factors, such as gel
concentration, the ability of the oxidizing agent to achieve dental chromophores,
the number and duration of gel applications, among others.
4
This article
reports an at-home bleaching technique with 22% carbamide peroxide for the
treatment of dental discoloration caused by dystrophic calcifcation.
Eugenio Jose Garcia
DDS, MS, PhD
Dentist.
Undergraduation obtained at the
National University of Crdoba,
Argentina.
MS degree in Restorative Dentistry,
State University of Ponta Grossa,
Brazil.
PhD degree in Dental Materials,
University of So Paulo, Brazil.
eugenegarcia11@hotmail.com
21
CASE REPORT
A 26-year-old female sought treatment for being
dissatisfed with the color of its upper central incisors. The
patient reported that she suffered a trauma that caused
the fracture of the left incisor angle when she was 9-years
old. The dental fragment was reattached to the remaining
dental structure. Over time, teeth started to get darker,
but without any pulp symptom.
During clinical examination, we detected that
the upper right incisor was not vital (Figure 1). In the
radiographic evaluation, a complete calcifcation of the
pulp chamber and the root canal was detected in tooth
11. No periapical lesion was observed (Figure 2). An initial
photograph of the patients teeth along with the shade
guide tab corresponding to the patients teeth color was
taken. This was done not only for professional record,
but for treatment monitoring and patient motivation. For
color evaluation we employed the Classical vita shade
guide oriented (Vita Zahnfabrik, Bad Sckingen, Germany)
arranged in descending order of value: from the highest
(B1) to the lowest (D4) value (Figure 3).
1. Initial clinical case
2. Initial radiographic evaluation.
3. Recording the patients teeth color.
3a. 3b. 3c.
1. 2.
22
5a.
4c. 4b.
5b.
4. Fabrication of the custom-bleaching tray with reservoirs (a-b). Bleaching tray in the patients mouth (c).
5. The baseline (a) and fnal color (b) can be compared in these fgures.
4a.
23
The nightguard at-home bleaching with 22%
carbamide peroxide (Whiteness Perfect, FGM Dental
Products, Joinville, SC, Brazil) was performed. An
impression of the upper arch with alginate was done.
On the plaster model, reservoirs were created with the
application of the light-curing gingival barrier (Top Dam,
FGM) on the buccal surfaces of the teeth to be bleached
(right and left upper incisor). A custom-bleaching tray was
prepared with a 1-mm thick ethylene vinyl acetate sheet
(Whiteness, FGM). As the bleaching trays are very fexible,
it was trimmed 2 to 3 mm beyond the gingival margin to
ensure better adaptation and stability (Figure 4).
The patient was instructed to brush her teeth
prior to the use of the bleaching tray at night. After use,
the tray should be removed, washed and stored dry in
plastic boxes. The color evaluation was performed at the
baseline and weekly with the aid of a value-oriented shade
guide. Before treatment, the left and right upper incisors
were color A3 and A3.5, respectively. After 10 days of at-
home bleaching, the left and right upper incisor reached
color A1 (similar to neighboring teeth) (Figure 5); and after
30 days the right upper incisor reached the same color.
The patient also reported mild tooth sensitivity only in
the second day of treatment, which did not require any
intervention.
DISCUSSION
There is no consensus in the literature regarding the
treatment protocol for teeth with dystrophic calcifcation.
There are some authors that advocate the endodontic
treatment while others do not. Aside from the biological
questions, it is important to consider that the simple
access to the pulp chamber can lead to tooth weakening
and can also increase the risk of accidents such as crown
or root perforations.
5
Likewise, the esthetic treatment of teeth with
dystrophic calcifcation by means of crowns or veneers
means unnecessary removal of the dental structures and
also increases the time required for treatment and its
costs.
1
The use of dentist-supervised, at-home bleaching
with low hydrogen peroxide concentration is an effcient,
conservative and low-cost clinical alternative. Regardless
of the treatment longevity, at-home bleaching does not
prevent the use of other invasive procedures in case the
bleaching result is not satisfactory.
6
After 30 days of at-home bleaching, central incisors
reached its saturation point and achieved the same color of
the upper lateral incisors (control teeth). As the saturation
point was reached, the other teeth were not bleached to
not run the risk of getting lighter lateral incisors than the
central incisors.
CONCLUSION
A satisfactory and very conservative esthetic
outcome was obtained with dentist-supervised at-home
bleaching with 22% carbamide peroxide for the treatment
of teeth with dystrophic calcifcation.
REFERENCES
1. Pedorella CA, Meyer RD, Woolard GW. Whitening of endodontically untreated
calcifed anterior teeth. Gen. Dent. 2000; 48(3):252- 5.
2. Cardoso PC, Reis A, Loguercio A, Vieira LC, Baratieri LN. Clinical effectiveness
and tooth sensitivity associated with different bleaching times for a 10 percent
carbamide peroxide gel. J Am Dent Assoc. 2010; 141:1213-20.
3. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int. 1989;
20:173-6.
4. Joiner A. The bleaching of teeth: a review of the literature. J Dent. 2006; 34:412-9.
5. Alhadainv HA. Root perforations: a review of literature. Oral Surg. Oral Med. Oral
Pathol. 1994; 78(3): 368-74.
6. Silva RVD, Muniz L. Clareamento externo para dentes com calcifcao distrfca
da polpa: relato de caso clnico. R. Ci. Md. Biol. 2007; 6(2):247-51.
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Also available in loose syringes
Kits
04 syringes of whitening gel application containing 3g each;
04 tips application;
01 tray case;
01 card for the next visit;
Instructions for the patient and the professional.
Dental bleaching gel based on hydrogen peroxide for home
use. Provides safety and comfort.
Contains calcium, potassium nitrate and sodium fuoride.
*30 minutes a day for the 10% concentration
class copy2.pdf 1 03/10/2013 09:16:47
26
Dental bleaching to improve
teeth esthetics Case report
ABSTRACT
Teeth discoloration is esthetically not acceptable. The study of bleaching
protocols is important to gather more information about the techniques that
are currently used in the clinical practice. The bleaching technique is a conser-
vative alternative for the management of dental discoloration, both in vital and
non-vital teeth. A mild loss of translucency can be reversed by proper sealing
of the pulp chamber. The endodontist should be aware that the endodontic
treatment and the choice of the intracanal medication and flling material are of
great importance to prevent discoloration of the dental crown after endodontic
root canal flling.
After removal of the dental pulp, teeth may lose its translucency, main-
ly because of dehydration of the dental structure. The aim of this study was
to review the literature and report a clinical case about a 22-year-old female
with complaints of inadequate esthetics. The at-home bleaching with 7.5%
hydrogen peroxide (White Class, FGM-Dental Products) was associated with
re-anatomization of esthetic details with a composite resin in a clinically accep-
table time.
KEYWORDS
At-home bleaching, hydrogen peroxide. Esthetics.
INTRODUCTION
The at-home dental bleaching is a conservative alternative to recover
the esthetics of discolored vital and non-vital teeth (Sampaio et. Al, 2010). The
bleaching technique is a conservative alternative for the management of dental
discoloration, both in vital and non-vital teeth. A mild loss of translucency can
be reversed by proper sealing of the pulp chamber. The endodontist should be
aware that the endodontic treatment and the choice of the intracanal medica-
Angelica De Oliveira Urbano
Undergraduated student. School
of Dentistry. University Jos
do Rosrio Vellano Federal
University of Alfenas, Campus
Alfenas, MG.
Vitor Alexandre Marinho
MS and PhD in Restorative
Dentistry. Professor and Chair
of Restorative Dentistry from the
University Jos do Rosrio Vellano
Federal University of Alfenas,
Campus Alfenas, MG.
27
tion and flling material are of great importance to prevent
the discoloration of dental crown after endodontic root ca-
nal flling. After removal of the dental pulp, the tooth may
lose its translucency, mainly because of dehydration of the
dental structure (Erhardt et al., 2003).
The at-home bleaching has been widely used in
dentistry; however, some doubts remain as to its use. For
esthetic reasons, the pre-existing restorations need to be
replaced after bleaching, since they can contrast with the
bleached teeth (Inger, Freire, 2000). According to Baratieri
(1996), esthetic treatments have become very common in
the modern dentistry. Nowadays, in this globalized world,
more and more people are exposed to concepts of beau-
ty and health as being synonymous of white and aligned
teeth.
Junior Rodrigues et al. (2002) reported that since the
introduction of at-home bleaching in 1989 by Haywood
& Heymann, the at-home bleaching technique has been
routinely used. This technique consists in the self-appli-
cation of carbamide peroxide or hydrogen peroxide gel
in a custom-ftted bleaching tray under supervision of a
dentist. It requires more time to reach satisfactory results
than the in-offce bleaching and it also depends on the
patient cooperation. However, the effcacy and safety of
the technique justify the use of at-home bleaching.
In this context, one of the most requested and
effective cosmetic dental treatment is the bleaching of
discolored teeth. At-home bleaching is the most used
technique, which stands out for its low cost, safety (as
low concentrated bleaching agents are used) and effec-
tive results after three to four weeks. Recently, hydrogen
peroxide started being used for at-home bleaching. Diffe-
rent concentrations and application methods have been
employed such as daytime wear of the bleaching tray as
well as whitening adhesive strips (Marson et al., 2008).
The study of bleaching protocols is important to ga-
ther more information about the techniques that are cur-
rently used in the clinical practice. The at-home bleaching
has gained popularity because it is an effective, simple,
conservative and low cost procedure. This article aims to
describe the esthetic planning, the step-by-step protocol
of the at-home bleaching technique until completion. The
materials and the results obtained were also reported in
detail.
LITERATURE REVIEW
Hirata et al. (1997) recalled that the dental bleaching
technique is known since ancient Egypt, where abrasive
powder was mixed to vinegar to whiten peoples teeth.
Other products such as oxalic acid, hydrochloric acid,
alone or associated with ether, were later used. Hydro-
gen peroxide was introduced in Dentistry around 1885,
by Harlan, and it is still the most commonly used active
ingredient for dental bleaching. This agent can be found
28
either alone or produced by chemical reaction of carba-
mide peroxide or sodium perborate (Plotino et al. 2008).
Bleaching agents and mechanism of action.
The dental structure is polychromatic and its color
is determined by the dentin, which has a yellow color in
the permanent teeth. Over the years, the enamel wears
and dentin becomes thicker due to the constant deposi-
tion of reparative dentin. This characterizes the physiolo-
gical yellowing of teeth over time and it responds well to
the at-home bleaching (Baratieri et al. 2001).
Considering the minimally invasive intervention, re-
ported by Rodrigues Junior et al. (2002), bleaching of vital
teeth is preferable for treatment of intrinsic discoloration in
comparison with the placement of veneers that requires
dental preparation and wear of dental structure. Cases of
dentinogenesis imperfecta, fuorosis and even moderate
tetracycline discoloration can be successfully treated with
dental bleaching (Baratieri, 1996).
Many in vitro and in vivo studies have reported the
effectiveness of different concentrations of bleaching
agents, either using hydrogen peroxide or carbamide
peroxide as the active ingredient (Faria et al., 2003). The
choice of hydrogen peroxide or carbamide peroxide de-
pends on the availability of the patient for daytime use.
Hydrogen peroxide should be applied for one hour dai-
ly while carbamide peroxide gel should be applied for
longer periods. This recommendation is based on the
degradation time of each type of bleaching gel (Kose,
Loguercio, 2012).
According to Carneiro Junior et al. (2010), three
dentist-supervised, vital tooth bleaching techniques are
available: at-home bleaching using bleaching trays flled
with low carbamide peroxide (10, 16, 22%) or hydrogen
peroxide (6 or 7.5%) concentrations; in-offce bleaching
using high concentrated hydrogen peroxide gels (20-
1. Baseline photograph.
2. Bleaching agent based on 7.5% hydrogen peroxide (White Class, FGM Dental Products).
3. Acetate bleaching tray positioned in the lower arch.
4. Acetate bleaching tray positioned in the upper arch.
1.
3.
2.
4.
29
35%) and the association of at-home and in-offce ble-
aching in an aim to be reach long-lasting and effcient
results with low cost.
CASE REPORT
A 22-years old female patient attended the dental
clinic with the chief complaint of the yellowish color of
her teeth (Figure 1). An at-home dental bleaching using
7.5% hydrogen peroxide was performed (White class,
FGM Dental Products) (Figure 2). Before the beginning
of the treatment we recorded the baseline color of the
patients teeth (shade A3) with a value-oriented shade
guide. Impression of the upper and lower arches was
performed with alginate. Dental stones were prepared
and the custom-ftted bleaching trays were fabricated
using acetate sheets (Figures 3 and 4). In a second clini-
cal session the bleaching tray was tested in the patient
to check the adaptation to the dental arches. The blea-
ching tray should cover the entire dental crowns as well
as the part of the gingival tissue to increase the stability
of the bleaching tray and its marginal sealing.
The patient was instructed on how to apply the
bleaching gel, period of time the gel should be in contact
with the teeth as well as the frequency of use. The pa-
tient was instructed to apply a small amount of bleaching
material in the bleaching tray and to wear it one hour
daily for 15 days. The bleaching was performed in each
arch separately. The patient was evaluated every seven
days for treatment control and to verify tooth sensitivity
complaints, gum irritation or any discomfort during the
bleaching technique (Figures 5 and 6).
A satisfactory result of whitening was obtained. Tee-
th achieved the color A1, according to the value-oriented
vita shade guide. The patient reported no tooth sensitivity
and gum irritation during and after bleaching. She repor-
ted to be completely satisfed with the outcome and the
5.
5. Seven days after the beginning of at-home dental bleaching in the upper arch.
30
6. Fifteen days after the beginning of at-home dental bleaching in the upper arch and seven days after the beginning of the bleaching in the lower arch.
7. Final photograph (15 days after at-home dental bleaching in both arches).
8 and 9. Final comparison. Baseline (8) and fnal result (9).
6. 7.
8.
9.
31
at-home bleaching protocol (Figure 7). One week after
bleaching a small restoration was performed in the ante-
rior teeth. The distal incisal angle of tooth 12 was re-ana-
tomized; proximal restorations were performed in tooth 22
and the mesial restoration in the tooth 11 was replaced in
an aim to complement the esthetic result.
DISCUSSION
Tooth bleaching is one of the most popular cosmetic
procedures that patients seek to improve the smile appe-
arance. At-home bleaching with 7.5% hydrogen peroxide
is a noninvasive, safe, effective and long-lasting procedure
when well indicated and supervised by a dentist (Junior
Lamb et al., 2010).
Rodrigues et al. (2002) argue that prior to the ble-
aching treatment a throughout clinical and radiographic
examination is required to check for the presence of
caries lesions, exposed dentin, enamel cracks or resto-
rations with inadequate marginal adaptation. These fac-
tors can infuence the tooth sensitivity during and after
the treatment. The tooth sensitivity is the most common
bleaching-induced side effect, but when the treatment is
done with hydrogen peroxide gels (6 to 7.5%), the pa-
tients do not complain or only report mild and transient
tooth sensitivity.
According to some authors (Saldanha et al., 2007;
Almeida et al., 2011 and Kose, Loguercio, 2012) the at-
-home bleaching is the technique that has the better re-
lation between tooth sensitivity and bleaching effcacy.
Additionally, this technique is the one that has the lower
cost than the other bleaching modalities. In this clinical
case, the patient did not complain of tooth sensitivity or
any other discomfort. The technique allowed the achie-
vement of satisfactory color change, as desired by the
patient.
CONCLUSION
At the end of the treatment, one could conclude that
the at-home bleaching technique using 7.5% hydrogen
peroxide (White Class, FGM) is effective to whiten natu-
rally yellowish teeth, producing satisfactory and long-las-
ting results.
REFERENCES
ALMEIDA, L. C. A. G. et al. Clareamento dental caseiro: relato de caso. Revista
FGM News., v. 13, p. 61-66, 2011.
BARATIERI, L.N. Clareamento de dentes. In: Baratieri LN, Monteiro Jnior S, Andra-
da MAC, Vieira LCC, Ritter AV, Cardoso AC. Odontologia restauradora: fundamen-
tos e possibilidades. So Paulo: Santos, 2001.
BARATIERI, L. N. et al. Clareamento Dental. So Paulo: Quintessence, 1996.
CARNEIRO JUNIOR, A. M. et al. Clareamento dental com Whiteness HP: Associa-
o de tcnicas sem o uso de fontes de luz. Revista FGM News, v. 12, p. 23-28,
janeiro, 2010.
HIRATA, R.; SANTOS, P.C.G.; PEREIRA, J.L.N.; MASSAKI, R.Y. Clareamento de
dentes vitalizados: situao clnica atual. JBC, Curitiba, v. 1, n.1, p. 13-21, jan./
fev.,1997.
KOSE, C.; LOGUERCIO, A. D. Clareamento dental com White Class 7,5%. FGM
News, v.14, janeiro, p. 32-37, 2012.
MARSON, F.C., et al. Efeito do clareamento dental sobre a resistncia adesiva do
esmalte. RGO., v.56, n.1, p. 33-37, jan./mar. 2008.
PLOTINO, G. et al. Nonvital Tooth Bleaching: a Review of the Literature and Clinical
Procedures. Journal of Endodontics, v. 34, n. 4, p. 394-407, Apr. 2008.
RODRIGUES JR., S. et al. Clareamento Dental Caseiro na Dentstica de Mnima
Interveno. JBD, Curitiba, v. 1, n. 3, p. 194-200, jul/set. 2002.
SIMES, M.P. Efetividade do clareamento caseiro com perxido de hidrognio e
sua infuncia na dureza e rugosidade do esmalte. 2008. 55f. Dissertao (Mestra-
do em Odontologia) Universidade de Guarulhos, Guarulhos, 2008.
Whiteness HP Blue.
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with three.
Calcium ions for
remineralizing enamel;
Reduced sensitivity.
Calcium uptake and stability of
the pH provides practicality,
comfort and safety.
No need to replace the gel;
Attachable syringes to
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Direct application from the syringe.
Available in Kit and Mini Kit in concentrations of 20% and 35%.
Safety:
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Whiteness HP Blue.
The only product with a trio of attendees:
If working with one
assistant facilitates
the work, imagine
with three.
Calcium ions for
remineralizing enamel;
Reduced sensitivity.
Calcium uptake and stability of
the pH provides practicality,
comfort and safety.
No need to replace the gel;
Attachable syringes to
facilitate mixing;
Direct application from the syringe.
Available in Kit and Mini Kit in concentrations of 20% and 35%.
Safety:
Technology:
Practicality:
N
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34
Combined at-home and in-offce dental
bleaching
CASE REPORT
The challenge of bleaching naturally yellow teeth from young patients
is the bleaching-induced tooth sensitivity during treatment, regardless of the
bleaching therapy employed (at-home or in-offce bleaching). This fnding was
observed in the following clinical case. An 18-year old male patient sought for
dental treatment as he was dissatisfed with his teeth.
In the clinical evaluation (Figures 1 to 4) one could detect that the patients
teeth were unusually dark (shade 3L1,5 in the Vitapan 3D Master shade guide).
After placing the shade guide tab of the desired color (shade OM3; Vitapan
1. Initial patients smile.
Maciel Jr
Specialist in Restorative Dentistry
(Bauru School of Dentistry,
University of So Paulo) and MS in
Restorative Dentistry (Araraquara
School of Dentistry, University of
the State of So Paulo).
macieljuniorpg@yahoo.com.br
1.
35
2. Close view of the patients teeth.
3. Baseline color of the patients teeth (3L1,5).
4. Baseline color of the patients teeth (3L1,5).
5. Comparison of the patients teeth color with the desired color (OM3).
5.
3.
4.
2.
3D Master shade guide) close to the patients teeth, one
could observe a high discrepancy of the desired color in
comparison with the color of the patients teeth (Figure 5).
This situation showed an unfavorable prognosis for dental
bleaching.
The treatment plan consisted of an in-offce dental
bleaching with Whiteness HP Blue 35% combined with at-
home bleaching with Whiteness Perfect 10%. After teeth
prophylaxis (Figure 6), the light-cured gingival barrier Top
Dam (FGM) was applied on the gingival tissue (Figure 7)
and the in-offce bleaching gel immediately applied on the
buccal surfaces of the teeth (Figure 8). After 40 minutes,
one could observe the presence of bubbles in the gel
which is the result of oxygen release (Figure 9).
The fabricated custom-ftted bleaching tray was
tested in the patients mouth (Figure 10). The patient was
36
6. Teeth prophylaxis.
7. Application of the light-cured gingival barrier TopDam on the gingival tissue.
8. Application of the in-offce gel Whiteness HP Blue 35%.
9. The appearance of the gel after the 40-min application.
10. Custom-ftted bleaching tray for at-home bleaching with Whiteness Perfect 10%.
11. Bleaching trays positioned in the patients arches.
12 and 13. Bleaching result in the upper arch after one week of at-home bleaching.
13. 12.
6.
9.
11. 10.
7. 8.
instructed about the bleaching protocol verbally and also
with a written text. The patient recalls were scheduled
weekly. An effective bleaching could be observed in the
upper arch, one week after the use of Whiteness Perfect
10% (Figures 12 and 13). The outcome after the use of
three syringes of at-home bleaching gel can be seen in
Figures 14 and 15 and after the use of six syringes in
fgures 16 and 17.
At the end of at-home bleaching, teeth were polished
with the felt disc (Diamond Flex, FGM) and diamond paste
(Diamond Excel, FGM) (Figures 18 and 19). Then neutral
fuoride was applied for 1 minute (Figure 20). In Figure 21,
the fnal result can be compared with the baseline color
of the patients teeth. In Figure 22, one can observe that
the fnal result matched the planned color OM3. In Figures
23-25, the fnal result of the bleaching treatment can be
seen. The fgures 25 and 26 show the contrast between
the baseline and the fnal result.
37
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14 and 15. Bleaching result after the use of three syringes of the bleaching gel.
16 and 17. Bleaching result after the use of six syringes of the bleaching gel.
17.
14.
15.
16.
38
18. Diamond paste used for polishing.
19. Felt disk (Diamond Flex, FGM) with the diamond paste (Diamond Excel, FGM) used for polishing.
20. Application of neutral fuoride on the bleached enamel surfaces.
21. Comparison of the fnal result with the baseline color of the patients teeth.
22. Final result after combined bleaching.
23 and 24. Intraoral view of the fnal result.
25. Initial patients smile.
26. Patients smile after bleaching.
25.
23.
21.
18.
26.
24.
22.
19. 20.
Drop by drop mixing system avoids wasting.
Can be used in whole arches or individual teeth.
Suitable for vital and non-vital teeth.
Available in Kit and Mini Kit versions
With
Neutralize
solution
Hydrogen
peroxide at 35%
for in ofce use
hpmaxx copy.pdf 1 03/10/2013 09:01:11
40
In-offce dental bleaching with Whiteness
HP Maxx
CASE REPORT
The male patient LG, 28-years old, attended the dental clinic aiming
to have his teeth bleached. During anamnesis, the patient reported that he
had undergone orthodontic treatment and the brackets were removed few
days earlier. He also reported that he had mild tooth sensitivity. Upon clinical
examination, we observed some gingival recession and the presence of
abfraction lesions in some teeth.
The previous tooth sensitivity associated with the need to use removable
orthodontic retainer in the upper arch restricted the use of the dentist-
supervised at-home bleaching. Therefore, we opted for the in-offce bleaching.
This technique allows the application of the gel only on the areas of preserved
enamel. Besides that, the gel remains on the enamel surface for a short period,
not compromising the use of the orthodontic retainer.
Jorge Eustquio
MS student of Restorative
Dentistry - CPO University of So
Leopoldo Mandic - Campinas SP.
Professor of the Specialization
Course in Restorative Dentistry and
Prothesis Brazilian Association of
Dentistry (ABO) - Macei AL.
Coordinator of the Course of
Ceramic Veneers - Brazilian
Association of Dentistry (ABO) -
Macei AL.
Scientifc Advisor of the Journal
Prothesis Laboratory in Science -
Publisher Plena
Ilana Pais Tenrio
Student of the Specialization course
in Restorative Dentistry at CETAO
So Paulo SP.
Assistant of the Improvement
Course in Restorative Dentistry -
NEO Dentistry Macei AL.
1. Initial photograph of the patients smile.
2. Recording the color of the patients teeth with a value-oriented shade guide Vita Classical (shade A1). Observe
that the upper central incisors (reference teeth) are brighter than the neighboring teeth.
3. Placement of the lip rectrator ArcFlex (FGM).
4. Teeth prophylaxis with a rotating brush and a paste of pumice and water.
1.
3.
2.
4.
41
Prevents inltration of saliva or blood
Easy to apply, easy to remove
Also recommended to enhance
rubber dam isolation
Light curing
gingival barrier.
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5. Application of the light-cured gingival barrier Top Dam (FGM). Observe the complete
coverage of the areas with dentin exposure.
6. Gingival and root protection obtained with the application of the gingival barrier Top Dam
(FGM).
5.
6.
42
7 and 8. Adequate mixing of the bleaching gel Whiteness HP Maxx (FGM). Twenty-one drops of hydrogen peroxide were mixed with seven drops of the thickener (3:1 ratio).
9-11. Material mixing.
12. Application of the material on the surface of the teeth with the plastic spatula presented in the Whiteness HP Maxx kit.
13. Placement of a thin layer of Whiteness HP Maxx (FGM) on the buccal surface of the teeth.
14. Product removal with a disposable surgical ejector. Three clinical sessions of in-offce bleaching were performed. Three 15-min applications were done in each clinical session
with the Whiteness HP Maxx (FGM).
15. Removal of the gingival barrier after aspiration of the bleaching gel. Teeth were then rinsed copiously with water, and the desensitizing product Desensibilize KF 2% (FGM) was
applied on the areas of root exposure.
16. Final aspect of the patients smile three days after three clinical sessions of in-offce bleaching.
17-19. Intraoral view with a black contrast and lateral view of the bleached teeth.
14. 13. 15.
17. 16. 18.
11. 10. 12.
8. 7. 9.
43
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CONCLUSION
In-offce dental bleaching was shown to be an effective alternative
after orthodontic treatment, especially when the patient cannot wear
bleaching trays due to removable orthodontic retainer. Additionally, the
application of gel is restricted to enamel surfaces avoiding areas of
exposed dentin.
20. Baseline color of the patients teeth evaluated with a value-oriented shade guide (A1).
21. Final color of the patients teeth evaluated with a value-oriented shade guide (B1). Observe that the
patients teeth are brighter than the B1 tab of the shade guide. One can also detect that the difference in
color between the central incisors and the neighboring teeth is no longer detected.
20.
21.
19.
44
The effectiveness of the combined
dental bleaching
CASE REPORT
The good results of the bleaching techniques led this female patient to
seek for dental whitening. During initial clinical assessment of the patients smile
(Figure 1) one could observe that patients teeth were dark and the presence of
wear of the incisal edge of the central incisors (Figure 2).
Based on the clinical assessment we opted to perform the combined
in-offce and at-home bleaching. The frst step was the fabrication of a
custom-ftted bleaching tray. In the following clinical session, the in-offce
bleaching was performed after teeth prophylaxis (Figure 3). The light-cured
gingival barrier was applied only in the upper arch (Figure 4) as this arch
would be bleached frstly. Three 15-min applications of the Whiteness HP
were performed (Figure 5).
A color change was noticeable one week after at-home bleaching with
Whiteness Perfect 10% (Figures 6 and 7). In a new clinical session, the in-offce
bleaching was performed with the Whiteness HP in both arches (Figures 8 and
1. Initial patients smile before combined in-offce bleaching with 35% hydrogen peroxide (Whiteness HP) and
at-home bleaching with 10% carbamide peroxide (Whiteness Perfect) for one week. After this procedure, in-offce
bleaching was performed in both arches, and the patient continued the at-home bleaching
2. Close view of the teeth to be bleached.
3. Teeth prophylaxis of the upper arch before in-offce bleaching. The in-offce bleaching was performed initially only
in this arch.
4. Application of the light-cured gingival barrier.
Maciel Jr
1. 2.
3. 4.
45
5. Three 15-min application of the Whiteness HP. After each application, the gel was removed with a disposable surgical aspirator.
6. Immediate aspect after at-home bleaching with Whiteness Perfect for one week. One can notice the some level of whitening in the upper arch.
7. One week after at-home bleaching with Whiteness Perfect.
8. Second in-offce bleaching with Whiteness HP in both arches.
9. Application of the bleaching gel in both arches.
10. Custom-ftted bleaching tray positioned in the patients mouth.
9. 10.
6. 7.
8.
5.
9). The patient continued the at-home bleaching until the
end of four bleaching gel syringes (Figure 10). After the
end of the at-home bleaching, the surfaces were polished
with diamond paste (Diamond Excel, FGM) and felt disks
(Diamond Flex, FGM), and fuoride was applied on the
buccal enamel surfaces. The bleaching outcome can be
seen in fgures 11 and 12.
Twenty one days after the end of the bleaching
treatment, the incisal edge of the central incisor was
re-anatomized with the composite resin Opallis. The
embrasure areas of the central incisors were inverted due
to the incisal wear (Figure 13). Condac 37 (FGM) was
applied beyond the enamel area to be restored (Figure
14). After moisture control, the adhesive Ambar (FGM)
was applied. The incremental flling of the restoration
started with the insertion of the composite resin T Blue
(Figures 15 and 16). The next step was the application of
the OP resin (Figure 17) following by the use a thin layer of
enamel resin EB1 in the areas between the T-Blue and OP
resins (Figure 18). The fnal resin increment was the resin
VH for value correction. A composite resin with high value
was selected as the restoration was done in bleached
teeth (Figure 19). The fnal restorative result, after fnishing
and polishing with the abrasive disk Diamond Pro (FGM)
can be seen in the fgures 20, 22 and 23. Figure 21 shows
the baseline condition of the patient before bleaching and
restorative treatment.
46
11. Final aspect of the bleaching after polishing with Diamond paste and fuoride application.
12. Patients smile after bleaching
13. Twenty one days after the end of the bleaching treatment. Observe the situation of the central incisors before restoration of the incisal edges.
14. Application of the Condac 37 (FGM).
15. After application of the adhesive system, a thin layer of T-Blue resin was applied in the incisal edge of both central incisors.
16. Composite Resin T-Blue being applied in the central incisors.
17. Application of the composite resin OP in the incisal edge of both central incisors.
18. Application of the composite resin EB1 over the resin increments previously inserted.
19. Application of the composite resin with a high value (VH) as fnal enamel layer.
11.
13.
16.
18.
12.
14. 15.
17.
19.
47
Manipulation
in the right
portions
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Indicated for whole archs or individual teeth.
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20. Final result after fnishing and polishing.
21. Initial aspect of the patients teeth before bleaching and restorative procedures
22. Final aspect of the patients teeth after bleaching and placement of the restorations.
23. Final patients smile.
20.
21.
22.
23.
48
24-25. Comparative photograph: Baseline appearance (24) and the fnal result (25).
26. Final result.
25.
24.
Fotografa: Eloisa Silveira.
Two presentations
for the same purpose.
The choice is yours.
Source: Dr. Carlos Augusto Fernandes et al.
Conservative Alternative way to bleach

Walking Bleach Technique.
Two formulations: Gel and Liquid + Powder.
non vital darkened theet.
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50
The effectiveness of dental bleaching in
non-vital and discolored teeth
CASE REPORT
Despite the great advances in the endodontic therapy, we still have
discolored teeth due to endodontic treatment, which are not an easy task to
manage in the daily practice. Even being sound, a visible dark tooth visible
during smile can affect the patients well-being. The present clinical case is
from a female patient who presented mild discoloration of the tooth 11. The
treatment of choice was the internal tooth bleaching with sodium perborate,
with the aim to reach a satisfactory esthetic result without damage to the
periodontal tissues.
An anamnesis and radiographic examination for evaluation of the quality
of the endodontic treatment was performed. After rubber dam isolation of
tooth 11, approximately 3 mm of the root canal flling was removed. On the
top of the endodontic flling material, a plug of zinc phosphate cement was
placed followed by sealing with glass ionomer cement to prevent external root
Fabiano Araujo
Specialist, MS and PhD in
Restorative Dentistry at the Federal
University of Santa Catarina
(UFSC).
Coordinator of the Integrated
Specialization in Prothesis and
Restorative Dentistry at the
University Tuiuti of Paran (UTP).
Coordinator of the Esthetic
Dentistry Courses in the Brazilian
Association of Dentistry (ABO - So
Jos dos Pinhais).
Full Professor of Restorative
Dentistry and Integrated Clinics
at the University Tuiuti of Paran
(UTP).
Professor of the Improvement
Course in Dentistry and Esthetic
Prothesis in the Brazilian
Association of Dentistry (ABO
So Jos dos Pinhais).
fabianoaraujo_@hotmail.com
Mary Aparecida Pereira Heck
PhD in Dentistry at the Federal
University of Santa Catarina.
Associate Professor at the
1. Initial clinical aspect.
1.
51
2. Removal of approximately 3 mm of the root canal flling.
3. Placement of zinc phosphate cement in the cervical third of the root canal.
4. Sealing of the root canal with a glass ionomer cement to avoid external root resorption.
5. The sealing was performed 2 mm below the cervical margin of the crown.
5.
3. 2.
4.
resorption. Two scoops of Whiteness Perborate (FGM)
were mixed with 1 drop of 20% hydrogen peroxide to
produce a paste. The pulp chamber was flled with this
paste, and a thin cotton pellet was placed over the paste
before cavity sealing with a provisional restorative material.
To achieve satisfactory results, the material was changed
three times with one week interval between sessions. After
the end of the bleaching treatment, the pulp chamber was
restored with a composite resin.
52
6. The pulp chamber was flled with a paste of Whiteness Perborato (FGM).
7. Then, a cotton pellet was placed over the paste and the cavity was provisionally.
8. After the bleaching procedure, the pulp chamber was conditioned with 37% phosphoric acid.
9. The pulp chamber was copiously water rinsed.
10. Application of the adhesive system.
11. Light-curing the adhesive for 20 seconds.
12. Palatal view of the fnal aspect of the restoration. The patients occlusion was adjusted.
13. Final result after changing the bleaching agent three times with one week interval between sessions.
13. 12.
9. 8.
11. 10.
7. 6.
Whiteness RM. Permanent enamel
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Can be associated with dental bleaching
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54
Enamel microabrasion with Whiteness RM
for removal of enamel hypoplasia stains
ABSTRACT
The enamel hypoplasia has different etiologies and different treatments
have been described in the literature. Recently, enamel microabrasion has
been suggested as a safe, effective and conservative technique with allows the
achievement of satisfactory esthetic results. Aside from that, this technique is
defnitive and can be performed in a single clinical session. Different materials
can be used in this technique; it is the professionals responsibility to select the
appropriate material. This clinical case presents a step-by-step procedure of
enamel microabrasion with a paste of hydrochloric acid and silicon carbide for
removal of enamel hypoplasia.
KEYWORDS
Enamel hypoplasia, enamel microabrasion, dental esthetic.
INTRODUCTION
The alterations of the dental structures may have several causes,
1
and
these alterations may have different colorations, depth and extension. Most
often, these enamel alterations are opaque white stains. When these stains are
superfcial, the enamel microabrasion is the treatment of choice.
2,5
The enamel microabrasion technique was frstly described by Croll
and Cavanaugh (1986). This technique indicates the removal of the modifed
superfcial enamel layer by application of an erosive agent (acid) mixed with
an abrasive agent (pumice stone or silicon carbide). This procedure aims to
expose a deeper enamel layer with normal features.
3,4
Over the years, this
Leonardo Fernandes da Cunha
Dentistry, Bauru School of
Dentistry, University of So Paulo.
cunha_leo@yahoo.com.br
Jos Mondelli
Full Professor of the Department of
Restorative Dentistry, Endodontics
and Dental Materials. Bauru School
of Dentistry, University of So
Paulo.
Adilson Yoshio Furuse
Dentistry, Bauru School of
Dentistry, University of So Paulo.
Professor of the Professional Master
of Science Program in Clinic
Dentistry. University Positivo.
55
technique were improved, and nowadays it can be
performed with different materials. Slurries of hydrochloric
acid/silicon carbide or phosphoric acid gel/pumice in
equal volumetric portions have been recommended for
the enamel microabrasion procedure.
3,7
The advantage of this technique is that it is an
easy protocol and allows fast results, which is essential
for the professionals acceptance. Additionally, esthetic
results can be obtained using a conservative approach.
12
Therefore, the aim of this article is to report a clinical case
of enamel microabrasion for removal of white stains due
to enamel hypoplasia.
CASE REPORT
A 27-years old female patient, presenting small
hypoplastic enamel stains in the central and lateral
incisors, sought for dental treatment. The patient was
dissatisfed with the appearance of her smile (Figures
1 and 2). After anamnesis and clinical examination, the
enamel microabrasion technique was proposed as the
treatment plan.
Dental prophylaxis was performed before rubber dam
isolation (Figure 3). A product composed of hydrochloric
acid and 6% silicon carbide was used (Whiteness RM,
FGM Dental Products) according to the manufacturers
instructions (Figures 4 to 6). The hydrochloric acid
presented in the paste demineralizes the surface, while
an abrasive rubber, mounted in a low-speed hand-piece,
wears some micrometers of the altered enamel surface.
The abrasive rubber should be applied intermittently only
for few seconds. After this procedure, one of the stains
was still visible, and a second application was conducted
in the same manner as already described. Between
applications, the teeth were washed thoroughly to remove
the paste. The result after the second application of the
microabrasion paste can be seen in Figure 7.
Before removal of the rubber dam, neutral fuoride
(Fluoride Care, FGM Dental Products) was applied for 1
minute. Then, the enamel was polished using a felt disk
(Diamond Flex, FGM) and a diamond polishing paste
(Diamond Excel, FGM). The fnal result of the treatment
can be seen in Figures 9 and 10. The post-operative
control, eight weeks after the procedure, is seen in Figure
11.
56
1. Lateral view of the patients smile with hypoplasia stains in the central and lateral incisors.
2. Close view of the right central incisors. Observe the hypoplasia stains in the incisal third of the upper incisors.
3. Rubber dam isolation to avoid ingestion of the acid-containing paste.
4. Application of the paste containing hydrochloric acid and 6% silicon carbide (Whiteness RM, FGM) on the white stains.
5. The product was scrubbed on the enamel surface with the plastic spatula (manufacturers recommendation).
6. An abrasive rubber, mounted in low speed hand-piece, is intermittently applied on the affected enamel surface.
7. Final result after two applications of the paste in a single clinical appointment.
8. We applied fuoride for one minute, immediately after removal of the rubber dam isolation.
7.
5.
8.
6.
4. 3.
1. 2.
57
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9. Close view of the enamel surface after microabrasion.
10. Final aspect of the patients smile
11. Post-operative control 8 weeks after the treatment.
12. Initial aspect of the patients smile.
11.
9.
12.
10.
58
DISCUSSION
The choice of the procedure for treatment of
enamel hypoplastic changes depends on the depth of
the stain; however, this diagnosis is diffcult. The enamel
microabrasion is usually indicated for the great majority
of enamel intrinsic stains. For deep and very deep
stains, the microabrasion technique can be associated
with restorative procedures.
5,12
When the professional
is in doubt whether to adopt the enamel microabrasion
or to choose a direct or indirect restorative procedure
(in the cases of deep enamel stains) one should try
enamel microabrasion frstly as it is a more conservative
approach.
5,6,12
Different materials can be used for enamel
microabrasion. The association of pumice and phosphoric
acid has the advantage of being easily available in private,
and public dental offces.
5,8
The microabrasion product
employed in this article is already in proper consistency,
so there is no need to manipulate the material as in
phosphoric acid/pumice technique. Thus, clinicians
save time and avoid errors and accidents during the
manipulation of the paste.
The enamel microabarasion technique is described
in the literature as a safe and fast procedure. The results
can be achieved in a single clinical session, presenting
immediate results,
10,12,13
as shown in this clinical case.
Aside from that, no tooth sensitivity and color rebound
is reported and the roughened enamel surface develops
greater resistance to demineralization by S. Mutans.
11
The periodic control of the patient is recommended for
assessment of the patients oral health.
9
In each patients
recall clinicians should not only evaluate the esthetic issue
but also the general patients health. Thus, the follow-up
recalls should be done whenever possible.
CONCLUSIONS
The enamel microabrasion with a paste of
hydrochloric acid and silicon carbide is an effcient,
conservative, fast and low-cost procedure for removal of
superfcial hypoplasia stains.
REFERENCES
1. Black GV. A work on operative dentistry. The pathology of the hard tissues of the
teeth. 6 ed. Chicago: Medico-Dental Publishing Company; 1908.
2. Croll TP, Bullock GA. Enamel microabrasion for removal of smooth surface
decalcifcation lesions. J Clin Orthod 1994;28:365-370.
3. Croll TP, Cavanaugh RR. Enamel color modifcation by controlled hydrochloric
acid-pumice abrasion. I. technique and examples. Quintessence Int 1986;17:81-
87.
4. Croll TP, Cavanaugh RR. Enamel color modifcation by controlled hydrochloric
acid-pumice abrasion. II. Further examples. Quintessence Int 1986;17:157-164.
5. Furuse AY, Cunha LFd, Valeretto TM, Mondelli RFL, Mondelli J. Tratamentos
conservadores por meio de microabraso do esmalte. Revista Dental Press de
Esttica 2007;4:54-63.
6. Mendes RF. Avaliao da quantidade de desgaste, da textura e da morfologia
do esmalte dentrio submetido tcnica de microabraso. Bauru: Faculdade de
Odontologia de Bauru, Universidade de So Paulo; 1999.
7. Mondelli J, Mondelli RFL, Atta MT, Franco EB. Microabraso com cido fosfrico.
Rev Bras Odontol 1995;52:20-22.
8. Mondelli J, Mondelli RFL, Bastos MTAA, Franco EB. Microabraso com cido
fosfrico. Rev. bras. Odontol 1995;52:20-22.
9. Navarro MFL, Cortes DF. Avaliao e tratamento do paciente com relao ao risco
de carie. Maxi-Odonto: Dentistica 1995;1:1-38.
10. Segura A, Donly KJ, Wefel JS. The effects of microabrasion on demineralization
inhibition of enamel surfaces. Quintessence Int 1997;28:463-466.
11. Segura A, Donly KJ, Wefel JS, Drake D. Effect of enamel microabrasion on
bacterial colonization. Am J Dent 1997;10:272-274.
12. Sundfeld RH, Croll TP, Briso AL, de Alexandre RS, Sundfeld Neto D. Considerations
about enamel microabrasion after 18 years. Am J Dent 2007;20:67-72.
13. Sundfeld RH, Rahal V, Croll TP, De Aalexandre RS, Briso AL. Enamel microabrasion
followed by dental bleaching for patients after orthodontic treatment--case reports.
J Esthet Restor Dent 2007;19:71-77.
59
FGM NEWS: DIFFERENT BLEACHING TECHNIQUES ARE CURRENTLY AVAILABLE AND EACH ONE
HAS BENEFITS AND INDICATIONS. WHAT FACTORS SHOULD WE TAKE INTO CONSIDERATION FOR
SELECTION OF THE MOST APPROPRIATE BLEACHING PROCEDURE?
FGM NEWS: SHOULD AT-HOME DENTAL BLEACHING BE PERFORMED AT NIGHT OR DURING THE DAY?
Everyday questions about
dental bleaching:
what do clinicians need to know?
Doctor, I would like to whiten my teeth. As dentists, we ofen hear from our patients that desire.
Fortunately, dentistry allows us to ofer many esthetic techniques, and among them, we can provide
dental bleaching. However, when it comes to ofering dental bleaching to patients, clinicians still
experience some doubts. Having this in mind, we invited internationally renowned professors to explore
usual questions in light of the evidence-based dentistry. Te answers to frequently asked questions of
clinicians and patients about selection of the technique, longevity, safety and others can be seen below.
SELECTION OF THE BLEACHING TECHNIQUE
Dr Carlos Francci: This is a question every dentist
makes himself when dealing with a patient who seeks
dental bleaching. Unfortunately, most of the
clinicians choose the bleaching technique
that they like the most. The best starting
point, upon any clinical decision, is the
constant reading of the literature. In Brazil,
colleagues usually report that they opt for
in-offce bleaching as they claim this is a
procedure that brings the patient into the
dental offce. Nowadays, the literature
Dr Jorge Eustquio: In my opinion, there are
indications for both types of dentist-supervised at-home
dental bleaching. The use of bleaching trays can be
uncomfortable for the patient. When carbamide peroxide
gel is chosen, the patient should wear the bleaching tray
for a minimum of three hours; therefore, this procedure is
better accomplished at night for the own patients comfort.
Hydrogen peroxide requires the patient to wear the
indicates that the ideal is to combine in-offce and at-
home techniques. The new trend is the use of hydrogen-
peroxide bleaching gels so that patients can
wear the bleaching trays for reduced time.
Dr Carlos Francci
MS, PhD and Associate Professor of Dental
Materials. School of Dentistry. University of
So Paulo.
bleaching tray for a shorter period, i.e., 20 to 30 minutes,
up to twice daily.
However, when comparing both products, the
literature reports that carbamide peroxide has a slower
reaction, with continuous and effective release. The
presence of urea breaks down during product reaction and
increases the pH of the reaction. This, in turn, increases
the amount of perydroxil radicals, responsible for the
60
breakdown of high and darker molecular
chains into smaller and lighter compounds.
Additionally, urea reduces the demineralization
potential of the dental enamel. This fact along
with safety issues explains why the hydrogen
peroxide is used for a shorter period. In the
protocol we usually employ, the patient began
the bleaching treatment with night-guard at-
home beaching with carbamide peroxide.
In case the patient reports discomfort by the use of the
bleaching tray or diffculties to sleep, the product can be
changed and the bleaching protocol performed during the
day with hydrogen peroxide.
Dr Jorge Eustquio
MS student of Restorative Dentistry
- CPO University of So Leopoldo
Mandic - Campinas SP. Professor of
the Specialization Course in Restorative
Dentistry and Prothesis Brazilian
Association of Dentistry (ABO) - Macei
AL.
Coordinator of the Course of Ceramic
Veneers - Brazilian Association of Dentistry (ABO) -
Macei AL. Scientifc Advisor of the Journal Prosthesis
Laboratory in Science - Publisher Plena
FGM NEWS: IS CLINICIANS FREQUENT MONITORING ESSENTIAL FOR SAFETY AND BETTER
ESTHETIC RESULTS? WHAT ABOUT THE MOMENT TO STOP THE BLEACHING PROCEDURE, IS IT ALSO
IMPORTANT?
Dra Paula Mathias: The right moment to conclude
the bleaching procedure to maximize the esthetic results
using a safe protocol requires professional supervision
of the color changes during treatment. During weekly
professional monitoring, the dentist uses tools such
as standardized photographs and shade guides to
record and evaluate the color changes. In this way, the
professional can determine the level of whitening that has
occurred in each clinical appointment.
The absence of color change in
bleached teeth in two consecutive clinical
visits indicates that the teeth are no longer
responding to treatment, and at this time, it
is probably that structural losses can occur
without any esthetic improvements (i.e.,
teeth will not get brighter and whiter). We
emphasize that this limit is individual as it
is the result of many variables, such as the
cause of discoloration, degree of dental mineralization,
structural features of teeth as well as the chosen
bleaching technique and the selected bleaching products.
Therefore, the clinical analysis is essential to determine
the right moment to stop the treatment. This highlights
the importance of dentist supervision and monitoring
during bleaching techniques as well as the danger of self-
treatment.
Dra Paula Mathias
MS and PhD in Restorative Dentistry.
Piracicaba School of Dentistry. University of
Campinas. Adjunctive Professor. School of
Dentistry. Federal University of Bahia (UFBA).
Professor of the Update Course of Esthetics
and Specialization in Restorative Dentistry.
School of Dentistry at the Federal University
of Bahia (FOUFBA) and Brazil and Brazilian
Association of Dentistry (EAP-ABO Bahia).

[...] the clinical analysis is crucial to determine the right moment to stop
the treatment. Tis highlights the importance of dentist supervision and
monitoring during bleaching techniques, as well as the danger of self-
treatment.
61
FGM NEWS: OVER TIME, COLOR REBOUND MAY OCCUR IN BLEACHED TEETH BECAUSE THE TOOTH
STRUCTURE IS PERMEABLE TO PIGMENTS FROM FOODS AND DRINKS. THIS FACT VARIES SUBSTANTIALLY
FROM INDIVIDUAL TO INDIVIDUAL DUE TO THEIR HABITS. HOWEVER CAN WE ESTIMATE WHEN TEETH CAN
RECEIVE A NEW BLEACHING PROCEDURE AFTER THE COMPLETION OF THE DENTAL BLEACHING? HOW
SHOULD THIS BE CONDUCTED?
Dr Edson Araujo: In terms of longevity of at-
home dental bleaching, two decisive factors should be
considered. Firstly, the treatment should be performed, on
average, for 3 weeks. Secondly, at-home bleaching was
shown to provide more effective and lasting results when
the bleaching trays are worn continuously overnight and
not for few hours during the day (Matis et al. 2009).
At the end of the at-home bleaching with 10%
carbamide peroxide, an immediate color rebound always
occurs. According to Prof. Matis, a color rebound of
approximately 0.5 unit in the value-oriented Vita shade
guide is observed. As this initial color rebound is minimal
immediately after the procedure, the at-home bleaching
with carbamide peroxide is then considered stable as
shown by some clinical studies (Swift et al. 1999; Leonard
et al. 2003).
With respect to the in-offce bleaching, which
employs high concentrations of hydrogen peroxide, the
color change of the bleached tooth color is not as stable
as that obtained with at-home bleaching with carbamide
peroxide. According to Matis et al. (2009), the in-offce
bleaching with hydrogen peroxide produces an immediate
whitening of the teeth, but two weeks after treatment, the
color rebound is observed.
For this reason, many of the in-offce bleaching
systems recommend association with at-home bleaching
with carbamide peroxide after an in-offce
bleaching session in order to ensure the
durability of the whitening effect. This
combined treatment may be considered
useless. Bernardon et al. (2010) showed
that at-home bleaching with 10% carbamide
peroxide results in a similar effect to that
obtained with in-offce bleaching followed by
at-home bleaching with carbamide peroxide.
With respect to bleaching retouch for
maintenance of the whitening effect, there is
no specifcation of when this procedure should be done.
After a follow-up of 7.5 years (Leonard et al. 2003), the
authors from a clinical study reported that the effect of
at-home bleaching with carbamide peroxide bleaching
is durable and safe even when the patient wears the
bleaching tray for periods up to 6 months without reporting
any side effects. We lead to the patients decision whether
they want or not a bleaching retouch and where they
want it. In some countries, there are disposable bleaching
trays already impregnated with hydrogen peroxide
for this procedure. Some professionals in the U.S.A.
recommend adhesive strips impregnated with hydrogen
peroxide. However, if the bleaching tray employed in the
frst bleaching procedure still adapts well in the patients
arch, we recommend the use of the same tray flled with
10% carbamide peroxide for 2-3 nights. The results are
immediate and esthetically pleasing.
REFERENCES
1. Matis BA, Cochran MA, Eckert G. Review of the effectiveness
of various tooth whitening systems. Oper Dent. 2009; 34:230-
235.
2. Swift Jr. EJ, May KJN, Wilder Jr. AD, Heymann HO, Bayne SC.
Two-year clinical evaluation of tooth whitening using an at-home
bleaching system. J Dent Esthet. 1999; 11:36-42.
3. Leonard RH, Haywood VB, Caplan DJ, ND Tart. Nightguard
vital bleaching of tetracycline-stained teeth: 90 months post
treatment. J Esthet Rest Dent. 2003; 15:142-153.
4. Bernardon JK, Sartori N, Ballarin A, Perdigo J, Lopes GC,
Baratieri LN. Clinical performance of vital bleaching techniques.
Oper Dent. 2010; 35:3-10.
Dr Edson Araujo
Specialist in Restorative Dentistry at the
Federal University of Santa Catarina.
MS and PhD in Restorative Dentistry at
the Federal University of Santa Catarina.
Adjunctive Adjunct Professor of Integrated
Clinics at the Federal University of Santa
Catarina. Professor of the Specialization
course in Restorative Dentistry at the
University of Moniz in Lisbon (Portugal).
Professor of the Specialization course in Restorative
Dentistry at the University of Rey Juan Carlos in Madri
(Spain). Assistant Editor of the Clnica - International
Brazilian Journal of Dentistry.
62
volume 15 janeiro 2013
62
FGM NEWS: ON AVERAGE, HOW DURABLE ARE THE RESULTS OBTAINED WITH THE AT-HOME AND IN-
-OFFICE BLEACHING?
FGM NEWS: WHICH TECHNIQUE DO YOU EMPLOY FOR NON-VITAL DISCOLORED TEETH?
Dr Andr Briso: Regardless of the bleaching
technique, the durability of the bleaching treatment
is unpredictable and depends on dietary habits, oral
hygiene and other patient-related factors such as salivary
fow, number of demineralization-remineralization cycles,
among others. However, some clinical observations
are useful and should be evaluated during
patient anamnesis before the beginning of
the bleaching technique.
In this context, patients with large
chromatic changes require greater exposure
to the bleaching agents to get the desired
whitening degree, and in these cases, color
rebound is more frequent. We also observed
that patients undergoing dental bleaching
pays more attention to the color of their teeth
and becomes more demanding in terms esthetics. Thus, as
the in-offce dental bleaching promotes teeth dehydration
and other transient superfcial changes in the enamel
surface, a color rebound that follows the procedure is
Dr Carlos Augusto de Oliveira Fernandes: For
non-vital discolored teeth with endodontic treatment we
recommend the following protocol:
1. Clinical and radiographic evaluation taking into account
the remaining coronal tooth structure (absence of large
restorations) and favorable endodontic treatment;
2. The pulp chamber should be accessed, and
approximately 3 mm of the root canal flling
should be removed in an apical direction,
beyond the clinical inciso-gingival height of
the crown. Then, a mechanical plug of glass
ionomer cement should be placed;
3. An immediate bleaching with 35%
hydrogen peroxide (e.g. Whiteness HP,
FGM) can be done (optional) followed by the
walking-bleach technique with Whiteness
Super-Endo. The material used in the
noticeable. This color rebound may reduce the patients
satisfaction, who usually requires complementation of the
technique for better results.
Although the literature lacks information about the
comparison of the longitudinal chromatic changes that
occur to bleached teeth and the physiologically changes
that occur to non-bleached teeth, the patients
that undergo bleaching treatment becomes
extremely attentive to any change in the
esthetics of their smile and seek for esthetic
standards currently valued by society.
Dr Andr Briso
DDS, MS, PhD Adjunctive Professor. Head
of the Department of Restorative Dentistry at
the Araatuba School of Dentistry. University of the State
of So Paulo, Brazil.
walking bleaching technique should be left inside the
pulp chamber for a period of 4 5 days and replaced on
average three times;
4. The pH of the pulp chamber should be neutralized with
a slurry of calcium hydroxide for a period of 7 to 15 days;
5. Finally, the cavity should be restored.
Dr Carlos Augusto de Oliveira Fernandes
PhD in Restorative Dentistry at the Bauru
School of Dentistry; Pos-doctoral stage
in the Department of Biomaterials &
Biomimetics at the College of Dentistry from
the New York University (NY, USA). Professor
of the Department of Restorative Dentistry
at the Federal University of Cear (UFC) and
Professor of the Graduation Course (FFOE/
UFC)
LONGEVITY
63 63
FGM NEWS: WHY SHOULD THE DENTAL BLEACHING BE SUPERVISED BY THE DENTIST?
Dra Andra Brito Conceio: Tooth bleaching is a
very good cost-effective technique both for the patient and
professional, mainly when it is well performed with safety,
and within clinical and biological standards. Diagnosis of
color change and the physical and emotional needs of
each patient are critical for the success of the treatment.
This is because there are some dental discolorations that
are harder to be removed such as those
produced by tetracycline, which requires a
very long treatment time.
On the other hand, there are patients
with a high tooth sensitivity degree who
require the use of bleaching gels with low
concentrations or reduced daily time use.
Aside from that, there are others that do not
adapt to the use of bleaching trays for longer periods of
time and this requires adjustments in the concentration to
compensate for the reduced bleaching tray wearing time.
Due to the above and many other reasons, dental
bleaching should always be supervised by a dentist, as
well as any other procedure involving the patients health.
Therefore, patients can beneft from a cosmetic treatment
that has completed over 20 years of clinical
follow-up with biological safety.
Dra Andra Brito Conceio
Adjunctive Professor of Restorative Dentistry.
School of Dentistry. Federal University of Rio
Grande de Sul.
DENTIST-SUPERVISED TREATMENT
[...] dental bleaching should always be supervised by a dentist, as

well as any other procedure involving the patients health. Terefore,
patients can beneft from a cosmetic treatment that has completed over
20 years of clinical follow-up with biological safety.
FGM NEWS: DENTAL BLEACHING HAS BEEN PERFORMED FOR OVER 20 YEARS AND TODAY WE KNOW
THAT IT IS AN EFFECTIVE AND CONSERVATIVE PROCEDURE. WHAT ARE THE STUDIES THAT PROVE THE
DENTAL BLEACHING SAFETY?
Dra Teresa Vale: In Portugal, the association
of dentists (OMD) considers that tooth whitening is a
medical procedure and, therefore, should be dentist
prescribed. Dental bleaching, when performed under
dentist supervision, is a safe procedure. The dentist
should perform a careful clinical examination and previous
treatments should be advocated depending on the quality
of the existing restorations.
Dental bleaching can be considered a safe procedure
as long as we follow the manufacturers instructions and
select the appropriate bleaching technique for each case
(at-home, in-offce and combined techniques).
SAFETY
64
dental bleaching can be considered a safe procedure as long as we follow

the manufacturers instructions and select the appropriate bleaching
technique for each case (at-home, in-ofce and combined techniques).
FGM NEWS: IT IS ESSENTIAL THAT THE PATIENT WHO UNDERGO DENTAL BLEACHING KNOW THE
TECHNIQUE DETAILS, WHICH AIDS IN A SAFE AND EFFECTIVE PROCEDURE. WHAT INFORMATION
SHOULD PATIENTS KNOW BEFORE STARTING THE DENTAL BLEACHING?
Dr Paulo Quagliato: The patient should be
instructed about the details of the dental bleaching
technique mainly because this is a non-predictable
procedure and many factors can affect the fnal results
and the experience of tooth sensitivity. Recommendations
should be followed by the patient either when treated with
the at-home and in-offce procedure. Thus, the patient
should:
brush their teeth before wearing the bleaching tray with
the bleaching agent.
remove the excess of the gel that fows out of the tray
with a with a cotton swab or gauze and do not ingest
the bleaching gel.
not drink or eat with the bleaching tray in position.
wear the bleaching tray by the time recommended by
the professional.
not brush their teeth immediately after the removal of
the bleaching tray and should not drink water or any
other liquid.
rinse a solution of 0.05% neutral sodium fuoride
mouthrinse.
avoid the ingestion of acid liquids and foods like vinegar,
citrus juice, soft drinks in general, isotonic and energy
drinks, wine and others.
discontinue treatment and seek for dentist assistance
in case of gingival irritation caused by lack of adequate
adaptation of the bleaching tray.
not smoke.
PATIENTS INSTRUCTIONS
The patients evaluation and monitoring
are essential to minimize tooth sensitivity.
The supervision of this clinical procedure is,
therefore, of utmost importance. The studies
that show that the dental bleaching is safe
evaluate the periodontal integrity and health
after bleaching, assess the experience and
intensity of tooth sensitivity as well the pulp
vitality after treatment.
Dra Teresa Vale
Dentist, graduated in the Higher Institute of
Health Sciences - North (ISCSN), Portugal.
PhD degree in Dentistry at the School of
Dentistry, University of Barcelona, Spain.
Assistant Professor in the ISCSN. Member
of the Coordination Committee of the Master
of sciences course in Orthodontics (ISCSN).
Coordinator of the Discipline of Pediatric
Dentistry III - Medical School of Dentistry in ISCSN -
Portugal. -Coordinator of the Postgraduate Course in
Pediatric Dentistry in ISCSN - Portugal.
65
IMPORTANT REMARKS
Dental bleaching does not cause
weakening of the tooth structure, but it
increases the enamel permeability and
roughness. During bleaching, white stains
can be seen in enamel. They represent
areas of enamel hypoplasia which were
imperceptible before bleaching. In some
cases, these white stains disappear upon
completion of treatment due to enamel rehydration and
remineralization. For clinical success, the dental bleaching
should follow a pre-determined planning and a strict
protocol, with clinical and radiographic examination.
These procedures are necessary for the correct diagnosis
and proper case documentation. The patients habits, diet,
age, degree of discoloration and lifestyle are factors that
should be identifed before the selection and beginning of
the bleaching technique.
REFERENCES
1. Ludmila C. Mendona, Lucas Zago Naves1,2, Lucas da
Fonseca R. Garcia, Loureno Correr-Sobrinho, Carlos J. Soares,
Paulo S. Quagliatto, Permeability, roughness and topography of
enamel after bleaching: tracking channels of penetration with silver
nitrate. Braz J Oral Sci. January | March 2011 - Volume 10, Number
2. Paulo S.Quagliatto, Jssica Idelmino Duarte, Marlia
Cherulli Dutra, Ludmila Cavalcanti de Mendona. Anlise do pH
de gis clareadores durante o perodo de aplicao- In Pint-
(Prelo)-2012.
3. S. Wongkhantee, V. Patanapiradej, C. Maneenut, D.
Tantbirojn. Effect of acidic food and drinks on surface hardness of
enamel, dentine, and tooth-coloured flling materials. Journal of
Dentistry (2006) 34, 214220.
4. Yan-Fang Ren *, Azadeh Amin, Hans Malmstrom. Effects of tooth whitening and
orange juice on surface properties of dental enamel. Journal of Dentistry (2009)
37, 4 2 4 4 3 1.
5. Richard B.T. Price, Mary Sedarous, Gregory S. Hiltz. The pH of Tooth-Whitening
Products . J Can Dent Assoc 2000; 66:421-
Dr Paulo Quagliato
Associate Professor of Restorative Dentistry and Dental
Materials at the School of Dentistry from the Federal
University of Uberlndia (UFU).
During bleaching, white stains can be seen in enamel. Tey represent

areas of enamel hypoplasia, which were undetectable before bleaching.
In some cases, these white stains disappear upon completion of
treatment due to enamel rehydration and remineralization.
For clinical success, the dental bleaching should follow a pre-determined
planning and a strict protocol, with clinical and radiographic
examination. Tese procedures are essential for the correct diagnosis
and proper case documentation. Te patients habits, diet, age, degree
of discoloration and lifestyle are factors that should be identifed before
the selection and beginning of the bleaching technique.
66
Dental bleaching for vital and non-vital
teeth followed by a direct restorative
procedure Case report
INTRODUCTION
The dental discoloration can be caused by a number of factors, and among
them dental trauma and flling materials used in endodontic treatment. Dental
trauma, even the ones that do not result in crown fracture can affect the dental
pulp, causing, for example, internal bleeding and pulp necrosis. This can result in
need of endodontic treatment immediately after the trauma.
Endodontic materials may result in dental discoloration and pigmentation.
1,2

Internal dental bleaching can be used to stop and solve discoloration in non-
vital teeth. This technique consists in sealing the root canal 2 mm beyond the
enamel-cementum junction in an apical direction with a plug of resin modifed
glass ionomer. Two different protocol can be used for internal dental bleaching. In
the walking bleaching, a paste of sodium perborate or 37% carbamide peroxide
gel is placed in the pulp chamber. In the immediate bleaching, a 35% hydrogen
peroxide gel is applied inside the pulp chamber and used similarly to what is done
in the in-offce bleaching technique.
1
Endodontically treated teeth with little structural loss that have suffered
trauma for over one year have good clinical prognosis with low risks. The criteria
for indication of the technique should be properly followed.
2
The current concepts
of restorative dentistry recommend the use of conservative techniques i.e.,
techniques that allow preservation of the dental structure. The professional is
the one responsible for the correct indication of the procedure for each clinical
situation based on scientifc knowledge.
The advantage of direct restorations is that it depends exclusively on the
professional. The costs are also lower as it does not involve any laboratory step.
For direct restorations, composite resins are excellent materials as they can
reproduce the teeths shape and natural color and mimic the optical properties
of the anterior teeth. However, to reach satisfactory results, the limitations of the
composite resin should be respected. Adequate case selection and management
of the technique sensitivity is essential.
The material translucency is of greater importance for anterior restorations,
especially in young patients who have a relatively intact enamel structure. In these
cases, the incisal and interproximal edges are thicker and clearly visible as they
Jorge Eustquio
MS student of Restorative
Dentistry - CPO University of So
Leopoldo Mandic - Campinas SP.
Course in Restorative Dentistry
and Prosthodontics Brazilian
Macei AL.
Coordinator of the Course of
Ceramic Veneers - Brazilian
Macei AL.
Scientifc Advisor of the Journal
Prosthesis Laboratory in Science -
Publisher Plena.
Ilana Pais Tenrio
Student of the Specialization course
in Restorative Dentistry at CETAO
So Paulo SP.
Assistant of the Improvement
Course in Restorative Dentistry -
NEO Dentistry Macei AL.
67
did not wear out due to aging. According to Villarroel et al.
the translucency is one of the optical features diffcult to
quantify in the natural dentition since it varies from individual
to individual and often varies in the same person. The
modern composite resins have hues and different opacities
that mimic the chromaticity and translucency of enamel and
dentin in a very convenient way.
3
In this article, we reported a clinical case of discolored
non-vital tooth where the conservative walking bleaching
technique was employed. For this aim, the pulp chamber of
tooth 21 was flled with a paste of sodium perborate mixed
with distilled water. The other vital teeth were bleached with
the in-offce bleaching protocol and the fracture of the tooth
11 was restored with a composite resin.
CASE REPORT
The patient KC, 22-years old sought for dental
treatment with the chief complaint of the discoloration in
the tooth 21. The patient was also not satisfed with the
incisal shape of the tooth 11 (Figures 1a 1b). During
anamnesis, the patient reported that both the discoloration
and the class IV restoration of tooth 11 were the result of
a domestic accident with a trauma impact in the anterior
teeth. The trauma had occurred 1 year and 2 months
earlier. The incisal edge of the tooth 11 fractured, and the
blood vessels from the pulp chamber of tooth 21 might
have disrupted causing blood extravasation through the
dentin tubules.
According to the patient, endodontic treatment of
tooth 21 was initiated on the same day of the accident,
and the restoration of tooth 11 was performed a few days
later. During the frst clinical session and after examination,
we considered the restoration of tooth 11 as inadequate
as the format of the incisal edge was not appropriately
reproduced. We also observed a restoration in the palatal
surface of tooth 21, which was done to fll in the pulp
chamber opened for endodontic treatment. Periapical
radiographs were obtained from both teeth which allowed
the diagnosis of a satisfactory endodontic treatment with
the absence of periapical changes in both teeth.
1a. Initial patients smile.
1b. Close magnifcation of the patients teeth with a black contrast.
1a. 1b.
68
During the same clinical session, the patients teeth
were photographed, and stone models were obtained for
the study of the case. This allowed us to make appropriate
treatment plans between two clinical appointments and in
the absence of the patient. In the second clinical session,
two different treatment plans were proposed for the
patient:
Treatment plan A:
Placement of a ceramic veneer in tooth 11.
Placement of a metal-free ceramic crown in tooth
21 after a fber post cementation in the root canal.
Treatment plan B:
Dental bleaching of the discolored and non-vital
tooth (# 21). The patient was aware that color
rebound could occur, and the procedure could not
be totally effective.
Composite restoration in tooth 11.
The patient opted for the treatment plan B, and in
the same clinical session, the procedure was initiated. As
a frst step, the pulp chamber of tooth 21 was opened
and approximately 3 mm of the endodontic gutta-percha
was removed. On the top of the gutta-percha, a plug of
resin-modifed glass ionomer was placed and light-cured
in a way to cover the gutta-percha and the proximal and
palatal walls of the root canal. At the buccal root wall,
the glass ionomer plug was placed 2 mm high to allow
the bleaching product to contact the cervical area of the
dental crown 1 mm sub-gingivally (Figures 2a-2c).
2a. Opening of the pulp chamber.
2b. Measurement of the amount of gutta-percha to be removed.
2c. Placement of the cervical plug.
3a. Gingival protection with the light-cured gingival barrier Top Dam and internal bleaching with Whiteness HP Blue 35%.
3b. Aspect of the tooth after two clinical sessions of immediate in-offce bleaching.
2a.
2c.
2b.
3a.
3b.
69
Firstly, we performed the immediate bleaching with
35% hydrogen peroxide (Whiteness HP Blue - FGM). Two
clinical sessions of 40-min applications were performed.
For the protection of the soft tissues, the light-cured
gingival barrier Top Dam (FGM) was applied. After the
end of the second clinical session, we observed that the
whitening degree was yet not satisfactory (Figures 3a-3b).
Thus, we opted to start the walking bleaching technique,
where a paste composed of sodium perborate (Whiteness
Perborate) and distilled water was placed inside the pulp
chamber and left in place for 7 days (Figure 4). The pulp
chamber was provisionally restored.
After this period, the patient returned to the clinic,
and we could detect signifcant whitening. The tooth was
even lighter than the neighboring teeth as can be seen in
Figure 5. Thus, in-offce dental bleaching was performed
in the other teeth with Whiteness HP Blue 35%. Three
sessions with a single 40-min application were done. Prior
to in-offce bleaching, the lip retractor ArcFlex (FGM) was
placed to retract the lips and tongue and the light-cured
gingival barrier Top Dam (FGM) applied on the gingival
tissue (Figures 6a-6c).
At the end of the treatment, all teeth were lighter,
but a small color difference between tooth 21 and the
neighboring teeth was still noticeable. We decided to
restore the tooth 11 reproducing adequately the format of
the incisal edge as well as the tooth 21. For this purpose,
the tooth 11 of the upper arch stone model was worn to
4. Whiteness Perborato.
5. Whitening result of tooth 21 after one week of the walking bleaching technique.
6a. In-offce bleaching with Whiteness HP Blue 35% after placement of Arcfex and protection of the gingival tissues with Top Dam. Tooth 21 was protected and not bleached.
6b-6c. Application of the Whiteness HP Blue 35%.
7a. After three in-offce bleaching sessions, one can observe the level of whitening achieved with the protocol.
7b. Close view with black contrast of the level of whitening obtained after three in-offce bleaching sessions.
6a. 5.
6c. 6b.
4.
7b. 7a.
70
mimic the anatomy of the tooth 21. This allowed us to
prepare a palatal guide to facilitate the reproduction of the
palatal surface of the tooth 11. We opted to apply a thin
layer of an ochre dye in the cervical and medium thirds of
the crown, followed by a thin layer of a high translucent
resin.
The restorative technique of the tooth 11 followed
the next steps:
1. The existing restoration of tooth 11 was removed
(Figure 8);
2. The palatal guide obtained in the stone model was
tested in position (Figure 9);
3. The operative feld was isolated with a lip retractor
and cotton rolls. The neighboring teeth were
protected with the use of a Tefon tape.
4. The surface was conditioned with a 37% phosphoric
acid (Condac 37, FGM) for 30 and 15 seconds
respectively in the enamel and dentin. The etchant
was copiously rinsed with an air-water spray. The
excess moisture was removed with a slight air
stream and small cotton pellets (Figures 10a-10b).
5. Two consecutive coats of the adhesive Ambar
(FGM) were applied followed by light curing for 20
seconds (Figures 11a-11b).
6. The composite resin Opallis T-Neutral (FGM) was
placed in the palatal guide with the aim to simulate
8. Removal of the class IV restoration in tooth 11.
9. Trying the adaptation of the palatal guide.
10a. Acid etching with Condac 37% for 30 and 15 seconds respectively in enamel and dentin.
10b. Etchant removal with water rinsing for 30 seconds.
11a. Application of the adhesive system Ambar (FGM).
11b. Light-curing of the adhesive for 20 seconds.
11a.
10a.
8.
11b.
10b.
9.
71
the palatal enamel. The palatal guide was, then,
placed in position, and the composite resin was
light-cured for 20 seconds (Figures 12a-12b).
7. The composite resin Opallis, shade DA1 (FGM) was
applied on palatal resin with the aim to simulate the
dentin and the dentin mamelons of the fractured
area. The composite resin was light-cured for 40
seconds (Figures 13a-13b).
8. The composite resin Opallis shade OW (FGM) was
applied on the incisal edge of the restorations with
the aim to reproduce the opaque halo of this area.
The composite resin increment was light-cured for
40 seconds (Figures 14a-14b).
9. The composite resin Opallis shade T Neutral (FGM)
was applied in the area of the dentin mamelons
for reproduction of the dental opalescence. The
composite resin was light-cured for 20 seconds
(Figure 15).
10. The composite resin Opallis shade E-bleach M
(FGM) was applied over the entire surface of the
restoration for reproduction of the buccal enamel.
The composite resin was light-cured for 40 seconds
(Figure 16).
11. An initial fnishing was performed with the abrasive
disks Diamond Pro (FGM) (Figure 17).
The protocol used to solve the color mismatch
12a. The composite resin Opallis, shade T-Neutral was used to reproduce the palatal enamel. The increment was light-cured for 20 seconds.
12b. Aspect of the palatal enamel after light-curing.
13a. Application of the Opallis shade DA1 for reproduction of the dentin and dentin mamelons of the incisal edge. This layer was light-cured for 40 seconds.
13b. Aspect of the composite resin that reproduced the dentin of tooth 21.
14a. Application of the composite resin Opallis, shade OW for reproduction of the incisal opaque halo. This resin increment was light-cured for 20 seconds.
14b. Aspect of the resin applied on the incisal edge.
14b.
13b.
12b.
14a.
13a.
12a.
72
between tooth 21, and the neighboring teeth was the
following:
1. The operative feld was isolated with a lip retractor
and cotton rolls. The neighboring teeth were
protected with the use of a Tefon tape.
2. The enamel was conditioned with a 37% phosphoric
acid (Condac 37, FGM) for 30 seconds. The etchant
was copiously rinsed with a spray of air-water for 30
seconds. The water moisture was removed with an
air stream and small cotton pellets (Figure 18).
3. Two consecutive coats of the adhesive Ambar
(FGM) were applied, followed by light curing for 20
seconds (Figure 19).
4. The ochre dye was applied on the medium and
cervical thirds of tooth 21, followed by light-curing
for 20 seconds (Figure 20).
5. A thin layer of the composite resin Opallis, shade T
Neutral (FGM) was applied on the buccal surface
15. Application of the composite resin Opallis, shade T-Neutral for reproduction of the opalescent areas, followed by light-curing for 20 seconds.
16. Application of the composite resin Opallis, shade E-Bleach M for reproduction of the buccal enamel, followed by light-curing for 40 seconds.
17. Preliminary fnishing with abrasive disks Diamond Pro.
18. Acid etching with Condac 37 (FGM) of the tooth 21 for 30 seconds, followed by water rinsing for 30 seconds. The surface was air dried with an air stream and cotton pellets.
19. Application of the adhesive Ambar (FGM) followed by light-curing for 20 seconds.
20. Application of the ochre dye to increase the color saturation of the cervical and medium thirds of the tooth 21, followed by light-curing for 20 seconds.
19.
17.
15.
20.
18.
16.
73
of the tooth to cover the dye and keep the enamel
transparency. The composite resin was light-cured
for 20 seconds (Figure 21).
6. A preliminary fnishing of the restoration was
performed with abrasive disks Diamond Pro (FGM).
In the next clinical session, the features of the dental
anatomy as well as the teeth color were evaluated. The
minor corrections in shape were performed with the use
of fne- and extra-fne diamond burs and abrasive disks
Diamond Pro (FGM). The fnal fnishing was accomplished
by using the entire sequence of the abrasive disks (Figures
22a-22d). Final polishing of the restoration was achieved
through the use of felt disks (Diamond Flex, FGM) with
a diamond polishing paste (Diamond Excel, FGM) (Figure
23). The fnal result can be seen in Figures 24a to 24d.
21. Application of a thin layer of composite resin Opallis, shade T-Neutral to cover the dye. The composite resin was light-cured for 20 seconds.
22a. Finishing of the restorations with a coarse abrasive disk (Diamond Pro, FGM).
22b. Finishing of the restorations with a medium-coarse abrasive disk (Diamond Pro, FGM).
22c. Finishing of the restorations with a fne abrasive disk Diamond Pro (Diamong Pro, FGM).
22d. Finishing of the restorations with an extra-fne abrasive disk (Diamond Pro, FGM).
23. Polishing of the restorations with a felt disk Diamond Flex (FGM) with a diamond paste (Diamond Excel, FGM).
23.
22c.
22a.
22d.
22b.
21.
74
24a. Final aspect of the restorations with the lips in a relaxed position.
24b. Final aspect of the restorations in the patients smile.
24c. Intraoral view of the fnal aspect of the restorations with a black contrast.
24d. Final view of the restorations. Observe the translucency of the incisal edge.
25. Baseline condition of the patients teeth.
24d.
24c.
24a.
25.
24b.
75
DISCUSSION
The treatment plan chosen by the patient allowed
the implementation of a more conservative but less
predictable technique when compared to an indirect
procedure. This uncertain prognosis results from different
response of discolored teeth submitted to internal
bleaching. In this clinical case, the tooth 21 whitened
more than expected, and the in-offce vital bleaching did
not bleach the other teeth to the same extent.
The quality of the restorative material associated
with a layering technique allowed the perfect reproduction
of the incisal and cervical features of the tooth 11. The use
of the entire sequence of the abrasive disks associated
with felt disks and diamond paste were fundamental for
the suitable fnal polish.
CONCLUSION
In spite of the complications, the performance of a
well-defned treatment and the use of a proper sequence
of techniques enabled the achievement of a predictable
successful treatment. The products from FGM (bleaching
systems, adhesive system and the fnishing and polishing
systems) were highly effective to solve this diffcult clinical
case.
REFERENCES
1. MacIsaac AM, Hoen CM. Intracoronal bleaching: concerns and considerations. J
Can Dent Assoc. 1994 Jan;60(1):57-64. Review.
2. Attin T, Paqu F, Ajam F, Lennon A M. Review of the current status of tooth
whitening with the walking bleach technique. International Endodontic Journal, 36,
313-329, 2003.
3. Villarroel M et al. Direct Esthetic Restorations Based on Translucency and Opacity
of Composite Resins. J Esthet Restor Dent 23:7388, 2011
76
CHEMISTRY IN ESTHETICS
One of the landmarks of cosmetic dentistry has
been the development of minimally invasive adhesive
techniques. This was possible due to the use of acidic
agents for conditioning the dental substrates (enamel
and dentin), to the chemistry of functional methacrylate
monomers, surface treatments (such as silanization),
chemical initiators, photo-initiators, peroxides and amines.
Altogether these components allow a chemical and
micromechanical adhesion of composite resins to dental
substrates. We also have the chemistry of ceramics,
peroxides for bleaching agents, surface treatments for
dental implants, the chemistry of calcium phosphate for
bone grafting, among others.
The chemical basis for most of these processes
rely on solubility and ion exchange reactions, oxidation-
Esthetics is one of the requirements of any dental treatment, which signifcantly afects the patients
self-esteem as well as the patients quality of life in personal and professional relations. For the success of
the esthetic dental treatment, it is essential that the dentist understands the patients expectations and be
able to combine restorative abilities, accurate techniques and excellent products. In this sense, how dental
manufacturers can direct their skills for developing esthetic materials? How can science (chemistry, phy-
sics, materials engineering, biology, pharmacology, microbiology, process engineering) be translated in
esthetics?
Section
Science and Esthetics
R&D
reduction reaction mediated by free-radicals, processes
of surface chemical modifcation by covalent molecular
binding used in the synthesis of nanostructured
compounds, etc. The individual look at each one of these
processes may be easy, but combining them into a single
product is challenging because one cannot always rely on
molecular synergism.
It is surprising to think that a one-bottle adhesive
system requires hydrophilic monomers to infltrate into
the collagen fbrils of dentin and hydrophobic monomers
to bind to the restorative material and prevent water
sorption. It is a very complex chemistry, which involves
years of investigation for the production of the content of
an amber bottle of adhesive solution.
77
PHYSICS IN ESTHETICS
The dentistry seeks for a product capable to
reproduce the natural esthetics of the teeth not only
in shape but also in color. For the latter purpose, the
principles of optical diffraction and light refraction,
opalescence, translucency and fuorescence are applied
for the development of products with different range
of colors. In dentistry, the physics is still applied in the
study of thermodynamics and the effects of temperature,
pressure and volumetric changes on the rheological
and viscoelastic behavior of gels and composite resin
systems. Physics is also involved in the selection of the
fller size (macro, micro and nano), fller shape (crushed,
spherical, spheroidal, perforated cylindrical rods and rods
mixed with machined particles) and fller type (dielectric) of
the composite resins.
Physics is also found in the study of the optical
phenomena and its application in the processes of particle
acceleration for light curing. It is also used in the study of
chemical kinetics, the speed of curing reactions as well
as for the study of micro-and nanostructure of surfaces
etc. The development of product packaging, with the
defnition of its characteristics for greater stability of the
formulations, low risk of leakage and better packaging in
the dentists table is also the role of physics.
It is surprising to think how glass fbers shall be
organized in intra-radicular posts to reach maximum
strength. Additionally the shape, the translucency and
luminosity (L *, CIELab scale) of the fber post should
be adequate to optimize the passage of light and light
refection inside the root canal. Altogether these features
enable an effective curing of adhesive systems and resin
cements in this clinical situation.
ENGINEERING MATERIAL SCIENCE IN ESTHETICS
Although esthetics is a dynamic process (people
get older, the concepts and standards of beauty changes
over time), dental products must ensure the longevity and
quality of clinical restorations. It is within this context that
the engineering material science is indispensable: throu-
gh the selection of differentiated raw materials and crea-
tion and analysis of parameters capable to quantify and
qualify the beauty.
For the accurate reproduction of the cervical end of
a prosthetic preparation or the placement of a sub-gingi-
val direct restoration, it is essential the use of retraction
cords as it maximizes the adhesive esthetic and perio-
dontal health. It is amazing to think about how the selec-
tion of fbers with high performance in terms of fexibility,
strength, low weight, absorption capacity, among others,
are essential to develop a retraction cord of excellence.
Usually, the marketing of dental materials contains
a set of charts and/or tables, containing information on
bond strength, tensile (pull-out) strength, water sorption
and compressive and fexural strength, among others. But
what is the clinical relevance of these results?
High compressive and fexural strength, high mi-
crohardness and reduced water sorption and solubility
indicate that the product withstand masticatory forces
while keeping the esthetics. A high resin-dentin and resin-
-enamel bond strength indicates that the material has an
effective micromechanical and/or chemical bonding to the
dental substrates, which contributes to the material lon-
gevity. Products with elastic modulus close to that of the
dental structure allow a better distribution of forces and
minimize the risk of fractures.
Low values of polymerization shrinkage stress indi-
cate that a material will not stress the remaining dental
structure during polymerization, allowing more conserva-
tive adhesive restorations. A high degree of conversion re-
veals that an adequate monomer-to-polymer conversion
occurred, or in other words it indicates adequate material
set (material hardening). This reduces the material perme-
ability, which can be clinically translated into stability and
longevity of the treatment (e.g. adhesive restorations). A
high curing depth indicates that the material has an effec-
tive polymerization system and a good ability to transmit
light, which in some cases makes possible to place it in
bulk-fll, i.e., in a single increment.
78
BIOLOGY IN ESTHETICS
The esthetic is only relevant when accompanied by
health. Can a beautiful restoration be seen in a patients
smile with periodontal disease? Can the beauty of a smile
prevail with considerable tooth sensitivity? Can a bleaching
product that dehydrates and produces excessive demine-
ralization be considered a minimally invasive technique?
Can a prosthetic component that does not meet the bio-
logic requirements be used to guarantee a beautiful smile?
The polishability of a restorative material is essen-
tial to obtain a smooth surface, which, in turn, will reduce
bioflm accumulation. This will prevent the development
of gingivitis or periodontitis. These parameters, along
with the color stability, are essential to maximize the cli-
nical longevity of the restorations and minimize the needs
for restoration replacement. Consequently this results in
more preservation of the remaining dental structure.
A hydroxyapatite nanoparticle product, capable to
remineralize the dental structure and eliminate the dental
hypersensitivity, restores the biological composition of the
teeth and contributes to greater treatment effciency and
longevity. This allows the achievement of a natural smile
without tooth sensitive to changes in temperature (hot or
cold), pH and osmolarity (such as high sugar concentra-
tion) of liquids and solid foods.
Bleached teeth can only be achieved i) with pro-
ducts that have a biologically safe pH in terms of dental
demineralization, and ii) with aqueous-based gels capa-
ble to prevent dental dehydration. Additional benefts can
be achieved with calcium-containing products. They offer
additional protection against demineralization by creating
a calcium barrier in the interface between enamel and
the bleaching gel. This barrier prevents the calcium relea-
se to the surroundings.
The tapering of the intra-radicular root space is the
biological reason for the design of the fber posts. The
fber post design contributes to a better distribution of
masticatory forces along the periodontal fbers and bone
tissue, respecting the dental biology and preserving func-
tional esthetics of the smile.
PHARMACOLOGY IN ESTHETICS
In some situations, it is necessary to employ the
knowledge of the pharmacology feld in dentistry so that
an esthetic success can be achieved. The accurate per-
formance of some procedures (impressions, cementation
of crowns, prosthetic preparations or preparation of sub-
-gingival cavity etc.) requires temporary gingival retraction
and control of the fuids and/or bleeding. This provides
clinicians with a good visualization of the operative feld.
In this regard, aluminum chloride-based products can be
an excellent adjuvant. Aluminium chloride swells the colla-
gen fbers within the broken blood vessels and obliterates
them. This hemostasis is free of blood clots and debris
that can adhere to and affect the quality of the dental pre-
parations. This compound is also astringent and therefo-
re, reduces the lumen of blood vessels.
One of the side effects of dental bleaching is the
tooth sensitivity. A chemical strategy to prevent it is throu-
gh the addition of wetting agents, anti-infammatory and
desensitizing agents in the bleaching gel composition.
Potassium nitrate has been used in bleaching systems as
a desensitizing agent with nerve action. The presence of
potassium nitrate increases the concentration of potas-
sium in the extracellular medium, depolarizing the nerve
fbers and, thus, preventing the propagation of the pain
signal transmission.
79
MICROBIOLOGY IN ESTHETICS
Cosmetic dentistry seeks to reproduce not only the
beauty but also the biological safety of the oral cavity, pre-
venting the negative impact on the overall patients heal-
th. It is known that the systemic spread of oral infection
can complicate heart diseases, lead to premature and low
weight birth, diabetes, lung disease, stroke, arterial dise-
ase, sepsis etc.
From the industrial point of view, the biological sa-
fety of the oral cavity can be achieved with the use of
materials that can alter the bacterial metabolism, with the
development of products with high polishability, low solu-
bility, anatomical design and accurate connectivity.
Chlorhexidine is a cationic chemical agent with bac-
tericidal and bacteriostatic action. It binds to the phos-
pholipids of the bacterial cell membrane and causes
changes in ion permeability. A consequence of this bin-
ding is bacterial membrane rupture and inhibition of bac-
terial proliferation.
Apart from the remineralizing action, fuoride is an
effective antimicrobial agent that acts by inhibiting the
enzyme enolase, which is involved in the metabolic de-
gradation pathway of glucose (glycolysis). This process
results in the inhibition of i) the transport of sugars into the
bacterial cell, ii) ATP synthesis and iii) the trans-membrane
proton pump (H+/ATPase).
As the bacteria from the dental bioflm depend on
aforementioned processes for survival and for production
of acids that demineralizes the tooth structure during the
cariogenic process, the reduction of carbohydrate meta-
bolism has signifcant clinical benefts. It reduces bacterial
enzymatic activity, exerts an antibacterial action and even-
tually prevents caries lesion development.
Functional monomers based on quaternary ammo-
nium have also been used in dentistry due to its antibacte-
rial action. The positive charge of the ammonium grouping
binds to the negatively charged bacterial cell wall. This
alters the bacterial wall by bactericidal immobilization.
Restorative systems with a stable polymeric and ce-
ramic matrix refect in products with low porosity and high
polishability. This allows the achievement of satisfactory
esthetic works with high surface smoothness. This con-
tributes to a lower bioflm accumulation on the dental and
reduces the risk of infections.
Intra-radicular fber posts that reproduce the ana-
tomy of the root canal reduce the free area available for
bacteria invasion. This design associated with the use of
luting materials with an effective polymerization system
and low solubility contributes to the production of a mi-
crobiologically-controlled endodontic environment.
PROCESS ENGINEERING IN ESTHETICS
How does FGM direct its expertise for the develo-
pment of esthetic materials? To overcome these challen-
ges, FGM has a multidisciplinary group, distributed in the
specialties of chemistry, physics, materials engineering,
biology, pharmacology, microbiology, dentistry etc. Addi-
tionally, FGM develops process engineering in esthetics,
which enables the creation and management of multidis-
ciplinary interfaces in industrial scale, providing technolo-
gy, concepts and products with guarantee.
AFTER ALL, YOU ARE WORTH IT!
DEPARTMENT OF RESEARCH AND DEVELOPMENT,
FGM DENTAL PRODUCTS.
If you want to share your opinion on this matter or on the
subjects that would like to see in future issues, please
write to fgm@fgm.ind.br
Orthocem, the evolution of Orthodontics.
Brackets xed in less time.
Orthocem is an adhesive/cement
with nanoparticulated load lling for
bonding of orthodontic brackets.
Excellent retention rate of brackets
after 6 months of clinical evaluation*
Practical: Primer
incorporated to the resin
(one less clinical step)

Perfect
Bond
Strength
Excellent
Viscosity
Contains
Fluoride
Just 20 seconds of curing time
92,7%
Package with 1 syringe of 4g + 1 acid etchant.
*Siqueira MR, Stanislawczuk R, Kossatz S, Reis A, Loguercio AD.
Clinical Evaluation of self adhesive resin for bonding brackets orthodontic.
Orthodontics SPO, v.44, n. 5, p. 435-441, 2011.
orthocem.pdf 1 03/10/2013 09:06:36
Orthocem, the evolution of Orthodontics.
Brackets xed in less time.
Orthocem is an adhesive/cement
with nanoparticulated load lling for
bonding of orthodontic brackets.
Excellent retention rate of brackets
after 6 months of clinical evaluation*
Practical: Primer
incorporated to the resin
(one less clinical step)

Perfect
Bond
Strength
Excellent
Viscosity
Contains
Fluoride
Just 20 seconds of curing time
92,7%
Package with 1 syringe of 4g + 1 acid etchant.
*Siqueira MR, Stanislawczuk R, Kossatz S, Reis A, Loguercio AD.
Clinical Evaluation of self adhesive resin for bonding brackets orthodontic.
Orthodontics SPO, v.44, n. 5, p. 435-441, 2011.
orthocem.pdf 1 03/10/2013 09:06:36
82
Self-ligating brackets in orthodontics
The philosophy of transverse bio-adaptation of the jaws is based on
four main factors: the self-ligating brackets system, thermoset wires of high
technology, Win System and less invasive clinical procedures. Using the
philosophy base of transversal bio-adaptation of the jaws, we reduce by 98%
the need for extractions (authors clinical experience), and allow biologically
safer treatments which avoids many irreversible procedures practiced in
conventional orthodontic planning.
In the book O Sistema Autoligvel segredos clnicos, from the
Publisher Napoleo Alan Rodrigues et al. demonstrated the step-by-step
procedures for the transverse bio-adaptation of the jaws. For this purpose,
several comparative clinical cases with different types of malocclusions were
presented, using all types of self-ligating brackets currently available in the
market.
For this reported clinical case, we used the self-ligating brackets
CRYSTAL 3D Vtria (www.crystal3d.com.br) and the Orthocem resin from
FGM. We chose Orthocem as it is a resin that has excellent viscosity
and allows the correct positioning of the self-ligating brackets on
all teeth. It also provides the ideal resistance to forces applied to the
brackets, including the tubes of the molars. This material has a simplifed
application protocol, thus, reducing the application time required for the
clinical procedure. This procedure starts with the enamel etching and
the immediate application of the resin on the bracket and the teeth.
Orthocem offers a safe, fast and accurate bonding procedure, which is in
line with our clinical needs in the application of self-ligating orthodontics.
We used the center of the clinical crown to place the self-ligating
brackets, including the second molars. We immediately initiated the procedure
with the use of the soft and esthetic thermo-activated wire 0.014. This wire has
ideal properties to trigger transverse bio-adaptation of the jaws: the win was
initially positioned in the midline. With the evolution of the cases, we employed
distal wins for the maxillary central incisors and maintained the win in the lower
midline.
A disocclusion with composite build up should be done in the second
molars as the frst molars are part of Spee curve. This procedure allows a
Alan Rodrigues
Author of the book Sistema
Autoligvel segredos clnicos.
International Coordinator of the
Courses of Self-Ligating University.
Developer of the self-ligating
bracket CRYSTAL 3D Vtria.
President of the Euro Orto Consult.
Edison Willrich Sales
Co-author of the book Sistema
Auxiliary Professor of the Self-
Ligating Orthodontic Course at Self
Ligating University.
Clinical director of the Euro Orto
Consult.
Fernando Ruiz Gregrio
Co-author of the book Sistema
Auxiliary Professor of the Self-
Ligating Orthodontic Course at Self
Ligating University.
Executive MBA in Health in the
Faculty of Getulio Vargas (FGV).
83
1.
4.
1-5. Initial pictures of an adult patient with malocclusion.
5.
3. 2.
faster leveling. After two months, we bonded the brackets
in the lower jaw and started using the soft, esthetic
thermo-activated wired 0014. The use of intermaxillary
light elastics was introduced at night.
After 6 months of leveling, we introduced the soft
and esthetic thermo-activated wire 0014 x 0025 for
fnalization of the case. The cusps and incisal edges
were reconstructed to restore the mutual protection
guides. After 12 months of treatment, we started the
intercuspidation with light elastics at night. After 14
months of treatment, we removed the orthodontic device
and proceeded to fxed retaining with esthetic upper and
lower elastics.
84
6.
10.
8.
7.
11.
9.
Clinical sequence 1: Self-ligating esthetic brackets CRYSTAL 3D Vtria, bonding with Orthocem FGM, esthetic
thermo-activated wire 0.014 for 4 months, esthetic and thermo-activated wire 0.014 x 0.025 to fnalize the clinical case.
Clinical sequence 2: The use of the light elastic at night in the self-ligating system is fundamental since the
beginning of treatment in order to improve the crossed bite and for fnal interscupidation.
6. Bonding with Orthocem.
7. 4 months.
8. 10 months.
9. 14 months of treatment.
10-11. Initial case.
CLINICAL SEQUENCE 1
CLINICAL SEQUENCE 2
85
14.
16.
12.
15.
17.
13.
12-13. 2 months.
14-15. 12 months.
16-17. 14 months of treatment.
86
The transverse bio-adaptation of the jaws is evident in the occlusal sequence of the orthodontic treatment with the
self-ligating system.
18. Initial case.
19. 2 months.
20. 10 months.
22. Initial case.
23. 6 months.
24. 12 months.
26. Initial case photograph.
27. End of the treatment after 14 months.
20.
18.
21.
19.
87
REFERENCE
1. Rodrigues A. et AL. O Sistema Autoligvel: segredos clnicos. So Paulo: Napoleo, 2012.
26.
24.
22.
27.
25.
23.
More practicality and
comfort on orthodontic
treatment.
Light curing resin material that prevents oral
tissues to be injured by brackets.
Pack with 1 syringe of 2g + 5 pointers.
Simple removal:
with the help of pliers.
Easy to apply:
ready for use.
Aesthetic:
with translucency.
topcomfort copy.pdf 1 03/10/2013 09:14:59
More practicality and
comfort on orthodontic
treatment.
Light curing resin material that prevents oral
tissues to be injured by brackets.
Pack with 1 syringe of 2g + 5 pointers.
Simple removal:
with the help of pliers.
Easy to apply:
ready for use.
Aesthetic:
with translucency.
topcomfort copy.pdf 1 03/10/2013 09:14:59
90
Each year various adhesive systems are placed on the market so that more effective
products can be used in daily practice of hundreds of thousands of professionals around
the world. The bonding technology to tooth tissue has developed gradually since it was
introduced ffty years ago. Since then, countless technological developments have been
achieved, and perhaps we, dentists, failed to understand the real extent of progress in
this feld. Thanks to numerous laboratory and clinical research, adhesives are continually
under development in terms of chemical composition so that the reported problems
identifed in scientifc studies can be reduced or, ideally, eliminated.
The challenge for these materials, however, is the fact that they should produce
and effective and simultaneous bonding to two remarkably different substrates: dentin
and enamel. In dentistry, one expects to produce a hybrid polymeric compound which
last for decades in the challenging conditions of the moist environment with bacteria
contamination. Contrary to the polymer industry, the polymeric compound in dentistry
protocols should be produced in few minutes and adverse conditions of temperature,
pressure and moisture.
Due to all these factors, the clinician should understand the features of the materials
so that the best of them can be achieved in the end of an adhesive restorative procedure.
Given the large number of products currently available in the market, the choice of the
best material for different clinical situations has become a challenge for the clinician.
Thus, in this brief update on adhesive systems, we sought to bring scientifc support to
lead to professionals critical thinking in the selection of the most suitable material for the
daily practice.
At present it is known that bonding to the dental hard tissues can be obtained from
three different approaches: the use of etch-and-rinse adhesive systems, the use of self-
etch systems or through the use of glass ionomer cements.
1
Etch-and-rinse systems are
those which employ a separate etching step with 32 37% phosphoric acid and requires
rinsing after application. In the self-etch systems, the etching step is incorporated in
the acidic primer (2-step self-etch system) or the self-priming adhesive (1-step self-etch
system). In both cases, the acidic primer is not removed from the dental surface but
incorporated in the hybrid layer complex.
Laboratory and clinical studies compared the performance of the different adhesive
systems to the dental substrates. By means of immediate and long-term bond strength
tests, they could identify the advantages and limitations of each system in any particular
clinical situation.
2-7
Although it is not possible to provide a direct correlation between the
laboratory data and the clinical results, we can clearly observe that laboratory studies
can somehow predict the clinical effectiveness of an adhesive material.
1,8

Adriana Pigozzo Manso
DDS, MSc, PhD The University
of British Columbia, Faculty
of Dentistry, Division of
Biomaterials.
Ricardo Marins de Carvalho
DDS, PhD The University
of British Columbia, Faculty
of Dentistry, Division of
Biomaterials.
Update in
ADHESIVE
SYSTEMS
91
ETCH-AND-RINSE ADHESIVE SYSTEMS
They are considered as traditional adhesives, and
there are many representative products available in the
market. It can be presented in a 3-step version, where
etchant, primer and adhesive are separate steps, or in a
2-step version, where the steps of priming and adhesive
were joined in a single application step.
Both versions (2-or 3-steps) have shown to be
effective in enamel.
9,10
The conditioning pattern and the
essential mineral composition of enamel confer to this
group of adhesive excellent results with bonding stability
over time as demonstrated by several clinical studies of
sealants, direct and indirect restorations.
11-13
On the other hand, when dentin is concerned,
several factors should be taken into consideration as this
is a moist and collagen-rich substrate. Etch-and-rinse
adhesives are more technique-sensitive and require more
attention during application. They require the maintenance
of ideal moisture on the dentin substrate before adhesive
application. They also require adequate water and residual
solvent evaporation before light-curing. The failure in this
step results in adhesive interfaces with reduced mechanical
properties.
14-16

Among the anhydrous solvents presented in
dental adhesive, ethanol and acetone are the most
commonly used. Although
acetone-based systems
have excellent clinical
performance, they have
a greater sensitivity to
the moisture condition
of dentin.
14
They also
have a narrower window
of opportunity than
the ethanol-based
systems which requires
greater operative care in
maintaining optimal dentin
moisture during the adhesive procedure.
17
Ethanol, by
contrast, allows the bonding to a slightly drier dentin.
This result in a larger moisture spectrum, making them
less sensitive to variations in surface moisture during the
adhesive procedure.
17
For this reason, virtually all etch-
and-rinse adhesive systems available in the market employ
ethanol as solvent.
Among the etch-and-rinse systems, the 3-step
version is considered the gold standard in resin-dentin
bonding studies. These materials have been extensively
evaluated, and they demonstrated to be signifcant stable
over time.
9,10,12
On the other hand, 2-step adhesive systems
combined the primer and adhesive in a single bottle, which
reduces the application time by eliminating a clinical step.
Although these systems, also called simplifed materials
exhibit good clinical performance, especially when there
is enamel at the cavity margins, a signifcant reduction
of the resin-dentin bond strength is observed over time.
Thus, the selection of the appropriate adhesive for class
V or class II cavities with margins in dentin should receive
particular attention.
Sclerotic dentin and deep caries-affected dentin
are usually available substrates encountered in the
daily practice. Such substrates, combined or isolated,
jeopardize the bonding quality to dentin. Therefore, this
should be taken into consideration when choosing an
adhesive system.
2,18

Morphologically, the hybrid layer resulting from the
application of 2-step and 3-step etch-and-rinse adhesive
is quite similar. As they employ a separate etching step,
usually the phosphoric acid for 15 seconds, the depth
of dentin demineralization and the subsequent hybrid
layer is approximately 3-5 m deep.
19
The smear layer
produced during cavity preparation is invariably removed
during phosphoric acid etching. The adhesive material that
subsequently infltrates into dentin is essentially monomers
and solvents. Ideally, the
hybrid layer could be
characterized as a three-
dimensional network of
polymer and collagen
which would act as a
continuous connection
between the adhesive resin
and the dentin. However,
there is suffcient evidence
to support that this goal
is not achieved
20,21
and
as such, the hybrid layer
is currently nominated as the weakest link in the resin-
dentin bonded interface.
22,23

In the case of 3-step systems, the primer is
essentially composed of hydrophilic monomers and
solvents. In turn, the adhesive is essentially composed of
hydrophobic monomers, which bonds to the hydrophilic
monomers presented in the primer. Thus, a hydrophobic
surface layer is created on the adhesive interface making
the interface more resistant to hydrolytic degradation and
acting as a sealing agent.
22,24
In the 2-step etch-and-rinse adhesives, primer and
adhesive are combined into a single step. Thus, solvents,
On the other hand, 2-step
adhesive systems combined
the primer and adhesive in a
single bottle, which reduces
the application time by
eliminating a clinical step.
92
hydrophilic and hydrophobic monomers are joined in a
single bottle to simplify the bonding procedure. A mixture
of such monomers and solvents with water from dentin
substrate result in a non-homogeneous mixture as more
volatile solvent evaporates and the water remains. This
event, known as phase separation,
20,24,25
results in the
production of an incompletely infltrated hybrid layer
which is more susceptible to hydrolytic and proteolytic
degradation after some time of clinical service.
Thus, it is clear that the hybrid layer produced
by etch-and-rinse systems is imperfect, in most of the
cases. Incomplete infltration in the whole extension of
the demineralized zone, the presence of residual water
in the polymerized mixture, phase separation due to the
heterogeneity of the compound; incomplete evaporation
of the solvent before polymerization, contamination of
the adhesive surface during the procedure, and sub-
polymerization of the material are events that may happen,
whether combined or not, and result in partially infltrated
hybrid layers.
22
Thus, the clinical care and understanding of the
bonding procedures dynamics for the chosen material is
crucial to ensure the best results in any clinical situation.
For 2-step self-etching systems, the operators experience
is critical to achieving improved bond strength. Signifcant
differences in bond strength were found when 2-step etch-
and-rinse adhesive systems were applied by students or
skilled professionals.
26
It is known that there are differences among many
etch-and-rinse systems available on the market. However,
we note that such variations are more dependent on the
technique, the quality of dentin and operative care during
application than the brand/manufacturer of the material
itself.
18,26,27
It is essential to mention that the application,
handling and storage should follow the manufacturers
instructions for achievement of better clinical outcomes
and low post-operative sensitivity and premature failures
of adhesive restorations. The latter can be due to recurrent
caries, marginal discoloration at the interface or retention
loss.
SELF-ETCH SYSTEMS
The benefts of these materials have led to
their increased acceptance and popularity among
professionals. The ease of use, reduced operative time,
substantial reduction in the technique sensitivity and the
reduced prevalence of post-operative sensitivity are key
factors in the selection of these adhesives for bonding
procedures.
5,28,29
In contrast, the poor ability to bond
to the enamel substrate is still considered a signifcant
limitation of this group of adhesives, which restricts its
use in some clinical situations where retention to enamel
is fundamental.
3
In this case, the selective enamel etching
with phosphoric acid can be considered an alternative to
circumvent this limitation.
29
The advantage of self-etch adhesive systems is
that they demineralize and infltrate the dental surface
simultaneously, and theoretically, at the same depth,
ensuring complete resin penetration in the demineralized
area.
29
The interaction of self-etch systems with the dental
substrate depends largely on the material chemistry. Self-
etch systems are commercially presented as 2-step or
1-step systems. In both situations, etching and subsequent
rinsing steps are eliminated. Self-etching materials have
low pH and this factor play a very important role on the
demineralization depth and subsequent interaction of the
material with dental substrates.
29
Although all self-etch systems have an acidic pH,
this can vary from product to product, and it usually ranges
from 0.3 to 2.5. The most acidic ones produce thicker
hybrid layer while the mild self-etch produce thinner hybrid
layer (Table 1).
29
Additionally, the acidity of the primer is
responsible for the good quality of the enamel bonding.
Aggressive self-etch systems produce an etching pattern
similar to that produced by etch-an-rinse adhesives;
however, differs in the fact that the calcium phosphate
ions are not washed away from the surface. These ions
appear to be quite unstable in aqueous media and may
weaken the adhesive interface. Therefore, etch-and-rinse
systems are still the best choice when it comes to bonding
to enamel.
4,30,31

Adhesive pH
< 1
1 2
= 2
> 2.5
Degree of
aggressiveness
Aggressive
Moderate
aggressive
Mild
Extra mild
Demineralization
depth
Approximately 4m
Between 1 and 2 m
Between 0.5 and 1 m
Approximately 300
nm (0.3 m)
Table 1. Classifcation of the acidity of the self-etch systems.

The performance of these materials is also variable.
It depends on the class to which the self-etch adhesive
belongs to (1-step or 2-step) as well as its monomeric
composition. The self-etch systems contain the so-called
functional monomers responsible for dental surface
conditioning. 4-META (methacryloyloxyethyl trimellitic acid),
93
10-MDP (10-metacriloiloxidecil dihydrogen phosphate)
and phenyl-P (2-(methacryloxy-ethylphenyl phosphate)
are the most commonly used functional monomers and
they are capable to interact with hydroxyapatite in different
ways.
Micromechanical interlocking is an essential
requirement for adequate bonding between the adhesive
and the dental structure. However, recently, the beneft of
the chemical interaction between the functional monomers
and the dental structure has been investigated.
29
The way
the molecules of monomers interact with hydroxyapatite
has been described in the Concept of Adhesion-
Decalcifcation.
29
This model shows that functional acidic monomers
chemically bond to calcium of hydroxyapatite with the
release of phosphate and hydroxyl
ions into the own solution, such that
the surface remains electro-neutral.
Whether the molecule will remain
bonded or will de-bond, depends on
the stability of the formed bond to
calcium of the dental structure.
Molecules like 10-MDP (as
functional monomer in self-etch
adhesives), but also polyalkenoic
acids (as functional polymer in
glass-ionomer cements), will
chemically bond to calcium
of hydroxyapatite, and have
limited surface-decalcifcation effect. In this case, the
hydroxyapatite crystals are not dissolved by rather keep
in place. On the contrary, molecules like phenyl-P and
4-META (in self-etch systems) will initially bond to calcium
of hydroxyapatite, but will readily de-bond. This will
result in calcium removal from the surface and a severe
decalcifcation or etching effect in the surface. Thus,
functional monomers should not only bond chemically to
the surface; the formed ionic bonds should also be stable
in an aqueous environment.
In this sense, the chemical bonding promoted by
10-MDP is not only more effective but also more stable in
water than that provided by 4-MET and phenyl-P, in this
order. Thus, differently from etch-and-rinse systems, the
performance of self-etch systems is directly correlated with
the chemical interactions with the dental surface.
It is considered that adhesives based on 10-MDP
have the best performance in the laboratory and clinical
trials. This is due to superior chemical interaction produced
with the hydroxyapatite of the dentin substrate. Two-step
self-etch systems are composed of a self-etching primer
(frst step) and an adhesive resin (second step). These
systems are considered the gold standard for comparative
purposes with other adhesive systems, due to the long
records of scientifc research and the consistency of their
bond strength. Similarly, to 3-step etch-and-rinse systems,
2-step self-etch systems have an adhesive resin coating
as a separate step. This resin is essentially composed of
hydrophobic monomers, ensuring higher bond strength
stability in bond strength tests.
Single-step self-etch systems combine the self-
etching primer and adhesive resin in a single step procedure.
However, one-step systems can be commercially
presented in two ways according to the manufacturer. The
components can be separated into vials (2-component) or
in a single vial (one-component). The former has greater
chemical stability as components
that may react one another are
kept separated until the moment of
the adhesive application. However,
they need effective mixing of both
components immediately before
the clinical application, and some
professionals consider it as an extra
and undesirable clinical step.
The one-step self-etch
systems available in a single vial
are the true all-in-one systems
because they combine the acidic
primer and the adhesive resin in
a single bottle and do not require preliminary mixture.
In contrast, they presented limited shelf-life especially
when stored at room temperature. Some chemicals
can potentially react with each other, impairing their
action or stability over time. This factor must be taken
into account when choosing these materials for clinical
use. The intricate mixture of hydrophilic and hydrophobic
monomers and other components such as acids,
solvents, and water (required for the ionization of self-
etching agent) make these simplifed materials limited in
many issues.
It is also reported that one-step self-etch systems
have lower immediate and long-term bond strength than
the multi-step adhesives (2-step self-etch or etch-and-
rinse systems). An increased marginal discoloration is
observed even after short-term clinical service. Additionally,
the retention rates of composite restoration in Class V
restorations (the clinical model employed to evaluate the
adhesive performance) is lower compared to the other
adhesive strategies.
[...] it is known
that the MDP
has the best
performance in
terms of chemical
bonding to
hydroxyapatite.
94
THE FUNCTIONAL MDP MONOMER
(10-METACRILOILOXIDECIL DIHYDROGEN
PHOSPHATE)
The functional monomer MDP appeared on the
market approximately 18 years ago, patented by the
company Kuraray. Only after the expiration of the patent
protection, other companies could use such a monomer
in the composition of their adhesive systems, primers and
resin cements. More recently, research groups began to
investigate the actual role of this monomer in the formation
and durability of the adhesive interface. It is known that this
monomer can bond permanently to dentin.
32, 33
Besides the micromechanical interaction of this
monomer with the dental substrate, a primary chemical
interaction between the functional MDP monomer and
hydroxyapatite, which remains around the exposed
collagen fbrils, is observed. This allows that the
hydroxyapatite remains around the exposed collagen
protecting them
34
and creating an acid resistant-zone
interface against degradation.
35,36
Among the various functional monomers used in
dental adhesive systems (phenyl-P, 4-MET and other
phosphate-based monomers), it is known that the MDP
has the best performance in terms of chemical bonding to
hydroxyapatite. Although this chemical interaction does not
result in increased bond strength, it is known that makes
the interface more resistant to the biodegradation process,
which improves the stability of the adhesive interface.
34
Recent chemical and ultra-structural analyses have
demonstrated that MDP reacts with the hydroxyapatite
producing a self-assembled nano-layered structure. In
this process, the calcium released by the dissolution
of the hydroxyapatite diffuses into the hybrid layer and
ionically bond to the MDP forming nano-layers of MPD-
Ca salt. Each layer measures approximately 3.5 nm. This
nano-layering can occur within the hybrid layer in different
degrees, depending on the adhesive system used. The
concentration of MDP, the fller loading, and the mode of
the adhesive presentation (number of steps) are factors
that can change the nano-layering characteristics of the
material.
34,37
Although no one knows the real importance of such
nano-layering, it is believed that it may be responsible for
the documented stability of 2-step self-etch systems.
32
The
Ca-MDP salts are hydrolytically stable,
38,39
which certainly
contributes to the increased longevity of the hybrid layer
and the adhesive interface. Thus, it is clear that many new
future perspectives will arise with the recent discoveries
about the functional MDP monomer.
CONCLUSION
Currently, it is suggested that the stability of the
adhesive interface components may have a secondary role
in the survival of adhesive clinical restorations.
40
Recent
clinical studies show that composite restorations may
remain clinically viable even after many years of clinical
service.
41,42
Thus, the degradation of the constituents
of the hybrid layer, widely demonstrated by laboratory
studies,
9,12
may not necessarily represent the clinical failure
of the adhesive restorations.
Thus, it is clear that all the knowledge generated by
laboratory and clinical research directs the development
of new products, as well as guides professionals on the
advantages and limitations of each adhesive system. This
allows the selection of materials with better performance.
However, it is up to each professional to select those that
best apply to each particular clinical situation. It is also
the professionals responsibility the understanding of the
bonding mechanisms, so that particular care is given to the
accomplishment of this important operative step. Finally,
we must not forget that excellence in dental treatment is
to treat patients and their unfavorable oral conditions and
not spend time only in the treatment of the dental caries
sequelae.
Te Ca-MDP salts, produced between the calcium
and MDP, are hydrolytically stable,
38,39
which certainly
contributes to the increased longevity of the hybrid layer
and the adhesive interface. Tus, it is clear that many new
future perspectives will arise with the recent discoveries
about the functional MDP monomer.
95
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Adhesive to
enamel and dentin.
Primer + bond
in one product.
Contains Nanoparticles.
Chemical and
micromechanical
bonding potential.
Ability to maintain
a stable adhesion
in aqueous
medium.
of the restorations with Ambar,
after 6 months, remained stable
without need for repair.
97,1%
Clinical study conducted by Dr. Alessandro Loguercio, Dr. Alessandra Reis, Dr. Letcia
Ferri and Dr. Thays Costa (Ponta Grossa State University - PR) in non-carious cervical
lesions. The full study is published in Ambars Technical Prole, available at
www.fgm.ind.br/en
Dr. Jorge Perdigo:
University of
Minnesota - USA
"Ambars hybrid layer was
completely filled by the
adhesive."
Dr. Alessandro Loguercio:
Ponta Grossa State
University - Brazil
"The clinical and laboratory results obtained
show that Ambar is a material of
excellent quality."
In 4 to 6 mL.
ambar copy.pdf 1 03/10/2013 08:49:28
97
What do the experts say about
Nowadays one of the most referenced materials in the literature is the adhesive systems. Te adhesive
dentistry has developed signifcantly searching for adequate bonding of the restorative materials to the
dental substrates. Lets see what internationally renowned researchers say about the adhesive systems,
which is a material of paramount importance for daily practice:
FGM: WHAT SHOULD CLINICIANS TAKE INTO ACCOUNT FOR THE SELECTION OF AN ADHESIVE SYSTEM?
FGM: DOES THE DENTAL SUBSTRATE INFLUENCE THE QUALITY OF THE BONDING?
Dra Ceclia Veronezi: The adhesive should have a
simplifed technique and should provide good immediate
and stable bonding. The material should not suffer
hydrolytic degradation.

Dra Renata Pascotto: As the enamel and dentin
substrates are different in composition one should expect
that they respond differently to the same treatment.
The enamel has a crystalline and prismatic structure,
and approximately 96% of its structure is inorganic
(hydroxyapatite crystals). Additionally, this substrate has
selective permeability. The exposure of enamel to the oral
environment infuences its composition and structure:
the enamel maturation changes its structure and this
could exert some infuence during bonding with the
restorative materials. Mature enamel is acellular and more
mineralized in the outer surface layer (Darling layer). The
enamel conditioning with 37% phosphoric acid results in
the release of soluble by-products that are easily removed
during rinsing. This step leaves micropores in the enamel
surface to be flled with the adhesive system. After adhesive
Dra Ceclia Veronezi
Professor of Dental Materials,
Restorative Dentistry and
Supervised Stage in Integrated
Restorative Dentistry. University
Sagrado Corao (USC), Bauru,
SP.
polymerization, the so-called resin tags, responsible for
the micromechanical interlocking, are produced.
On the other hand, dentin is constituted by 35% of
organic substance and water. The organic material consists
of collagen fbrils, which is coated with hydroxyapatite
crystals. The inorganic composition of dentin corresponds
to 65% of its composition. The presence of odontoblasts
within the dentin tubules is responsible for the higher
permeability and moisture of dentin compared to enamel.
The bonding mechanism to dentin is determined by
different processes: micromechanical retention (surface
adhesion and formation of intra-tubular resin tags) and
formation of precipitates that adhere for chemical and
mechanical retention to the dentin (hybridization). The
amount (bond strength) and quality (microleakage) of the
bonding depends on the homogeneity of the hybrid layer
ADHESIVE SYSTEMS?
98
FGM: THE DENTIN HYPERSENSITIVITY IS MORE RELATED TO THE QUALITY OF THE BONDING PRODU-
CED BY THE ADHESIVES THAN OTHER RESTORATIVE RELATED FACTORS. WHAT FACTORS DO YOU CON-
SIDER RELEVANT TO AVOID THIS INCONVENIENCE?
Professor Dr Fabio Sene: It is a enormous pleasure
to have the opportunity to clarify factors associated with
the post-operative sensitivity after bonding procedures.
This is an extremely serious and challenging issue,
especially for the clinician. Most often, the solution to this
problem is easier than what we initially think, as long as
we respect some aspects related to the techniques and
materials employed.
We have to bear in mind that adhesive restorations,
whether direct or indirect, are polymeric materials
that will suffer dimensional deformation in the cavity.
Therefore, we should avoid errors during the restorative
technique considering that the materials have chemical
limitations. We should be as accurate as possible during
the application protocol. The post-operative sensitivity
is related to the bonding quality provided by the current
adhesive systems as well as to factors related to the
operative steps during restoration placement.
We will briefy discuss the most infuential factors
related to the post-operative sensitivity of adhesive
restorations, mentioning some alternatives to solve and
control this problem.
1. DENTIN TREATMENT AFTER CAVITY PREPARATION
One of the most infuential causes of tooth
sensitivity in adhesive restorations is undoubtedly the
incorrect dentin treatment after cavity preparation.
Certainly, the adhesive technique brought fantastic
benefts for dentistry, however, the abuse and misuse
of these materials, often without the use of rubber dam
isolation and the application of the materials in a suitable
and the amount of resin monomers that can penetrate the
demineralized dentin zone.
The hybridization process depends on several
factors: the characteristics of the substrate, the moisture
dentin conditions, the adhesive application method and,
fnally, the type of adhesive agent. Upon a chemical and
mechanical aggression, dentin changes in its structure
and composition, resulting in hyper-mineralization (dentin
sclerosis). Sclerotic dentin presents twisted tubules
partially or totally obliterated. Additionally, the number of
dentin tubules is lower than in sound dentin. The bonding
of the restorative material to modifed dentin is less
effective because the etching and the formation of resin
tags are reduced.
The formation of resin tags is more
essential in deep than in superfcial dentin
because the latter has a larger area of
intertubular dentin for hybridization. On
the other hand, the greater depth of the
cavity, the greater the number and diameter of dentinal
tubules and the higher the dentin moisture, a fact that
directly affects the quality of the resin-dentin bonding.
Furthermore, the dentin that underlies a caries lesion or a
restoration is different to the freshly cut and sound dentin.
It is worth noting that most of the clinically
dentin surfaces are modifed, either by physiological or
pathological processes, and they may respond differently
to the bonding procedure.

Dra Renata Pascotto
Associate Professor of the School of Dentistry.
State University of Maring (UEM). MS and PhD in
Restorative Dentistry (Bauru School of
Dentistry. University of So Paulo). Adjunct
Coordinator of the Master of Science
Course in Integrated Dentistry at the State
University of Maring.
99
dentin substrate can result in the painful symptom of
post-operative sensitivity.
Unfortunately, even with all the evolution and
development of adhesive systems, they are still defcient in
certain types of substrates such as deep dentin, sclerotic
dentin and caries-affected dentin. In these substrates, the
performance of the adhesives is poor due to inadequate
resin infltration and bonding. Therefore, a careful and
safe way to avoid post-operative sensitivity when dealing
with these substrates is by means of cavity sealing
with calcium-hydroxide cements and/or glass ionomer
cements. These materials can improve the cavity sealing
without jeopardizing the bonding and retention.
2. ADHESIVE SYSTEMS
Undoubtedly, the selection of an inadequate
adhesive or its incorrect use and application technique
may imply in tooth sensitivity and pain. One of the biggest
mistakes in the bonding procedure is to ignore that the
adhesive systems differ one another. Therefore, a single
application technique will not be effective to all of them.
It is extremely valuable to know some factors such as the
ones described below:
A. Factors related to the material:
Type of adhesive system employed (simplifed
or 2-step etch-and-rinse adhesives or self-etch
systems);
Solvent type;
Monomer composition.
B. Factors not related to the material:
Rubber dam isolation of the operative feld;
Ideal dentin moisture for each adhesive system;
Application technique (active or passive);
Solvent type and evaporation time;
We should keep the adhesive systems in a
closed and fresh place;
# acetone-based adhesives should be applied in a
slightly moist substrate and using a passive application
technique. On the other hand, water-based and ethanol-
based systems should be applied in a slightly drier
substrate following an active application mode.
# etch-and-rinse adhesives should be applied in
a moist dentin. On the other hand, self-etch adhesives
should be applied in a dry dentin.
We should employ small micro-brushes to avoid
application of an excess of adhesive.
We should not employ the adhesive liquid that
fows outside the bottle.
The adhesive procedure should be performed
with proper care and criteria so that we can produce a
high quality adhesive interface without errors that may
compromise its integrity. It is important to understand that
adhesive systems are technique-sensitive, and we should
respect the features and limitations of each product during
application.
3. COMPOSITE RESINS
Composite resins are composed of monomers that
shrink during polymerization. Therefore, they should be
placed in small increments so that light can penetrate in
a suffcient depth for the achievement of a high degree of
conversion. Additionally, the smaller the resin increment,
the lower the volume of the resin that is applied. This may
reduce the generation of polymerization shrinkage stress.
Therefore, the professional should know that as the
material shrinks, stresses are developed at the adhesive
interface. These problems and the resulting post-operative
sensitivity can be minimized by appropriate composite
placement and polymerization techniques.
4. PLACEMENT TECHNIQUE
The composite resin should be applied in small
increments with a thickness lower than 2 mm so that
light can penetrate and allow high monomer to polymer
conversion. In addition, during the placement of the resin
increments, we should bond it to the smallest number of
cavity walls at each time so that there will be suffcient free
surface area for stress dissipation.
Another extremely essential factor that accounts
for much of the post-sensitivity of adhesive restorations
is that we should not bond opposing cusps with the same
resin increment (for instance, buccal and lingual walls) to
avoid cusp defection. If this care is not taken, these cusps
may move under stress during patient biting resulting in
tooth pain.
100
5. LIGHT-CURING UNITS, TECHNIQUES AND
EXPOSURE TIMES
Another factor responsible for post-operative
sensitive is the use of inadequate light curing devices and
incorrect polymerization techniques. Devices with low
or very high power density are deleterious for adhesive
restorations. Low light intensity devices will not provide
enough energy for proper degree of conversion of the
monomers into polymers, compromising the mechanical
properties of the resin and its sealing ability. In the other
extreme, the use of light curing devices with high light
intensity will not increase the physical properties of the
resin as it is commonly believed, but it will generate a high
polymerization stress. Consequently bending of the cusps
and/or de-bonding of the adhesive interface may occur,
resulting in post-operative sensitivity.
The ideal is to use LED-based devices with power
density around 600-800 mw/cm2. The energy delivered
for these devices is suffcient to activate and polymerize
the composite resin without causing
considerable polymerization stresses.
Besides that, the use of an appropriate light
curing technique is of extreme importance.
Although many techniques have been
created and reported, one should initiate this
procedure with moderate power. This will
increase the pre-gel phase and provide time
for the slow arrangement of the monomers.
Thus, during the resin hardening, the polymer
will be produced without the generation of the deleterious
effects of polymerization stress due to the slow release
of stress during the polymerization process. After light
curing, each increment, we should use a high light power
(gradual polymerization).
Although the literature is contradictory in regard
to the exposure time of each resin increment, the most
conclusive studies still consider safer use of 40 seconds
for each increment. Thus, attempts to reduce this
exposure time, certainly will compromise the physical
properties of this composite resin, thereby undermining
the interface and sealing properties of the material, often
resulting in microleakage and tooth sensitivity.
6. OCCLUSAL ADJUSTMENT OF THE RESTORATION
Another factor often overlooked or neglected by
the professional, which is signifcantly responsible for the
post-operative sensitivity of adhesive restorations, is the
lack of adequate occlusal adjustment after the end of
the restorative procedure. Even the simplest restoration
requires occlusal check in maximal intercuspidation, left
and right laterality in a way to avoid deleterious premature
contacts, mainly on balance side or on protrusive
movements. Undoubtedly, this is a extremely serious step
for the success of the procedure.
Regardless of the adhesive system, composite resin
and the type of adhesive restoration (direct or indirect)
selected, the adhesive procedure is extremely complex,
technique-sensitive and cannot be neglected at any time.
The professional must have particular care and diligence
not to compromise the restorative work and cause
discomfort to the patient and himself.
Professor Dr Fabio Sene
Specialist, MS and PhD in Restorative
Dentistry (Bauru School of Dentistry,
University of So Paulo). Resident in
Periodontics in IEO Bauru-SP. Specialist in
Oral Rehabilitation at Integrale/UNICSUL.
PhD stage in the Univerisity of Missouri
School of Dentistry Department of
Oral Biology. Associate Research of the
Department of Bioengineering at Kansas University
(BERC). Adjunct Professor of Restorative Dentistry. State
University of Londrina
101
FGM: INDEED, THE MONOMERIC COMPOSITION OF THE ADHESIVE SYSTEMS IS ONE OF THE MOST
IMPORTANT FACTORS FOR THE BONDING QUALITY. WHAT STUDIES HAVE BEEN PERFORMED IN
RELATION TO THE ADHESIVE COMPOSITION?
Dra Alessandra Reis: Yes, the appropriate
combination of monomers is essential for the formation
of an adhesive interface with good bonding to the dental
substrates. The choice of monomers, photo-initiators
and solvents are a diffcult challenge for any company of
dental products. In the uncured condition, the adhesive
solutions must be hydrophilic to be compatible with the
moist demineralized dentin and after curing they should
produce a polymer with hydrophobic characteristics to
resist degradation by hydrolysis over time.
A favorable feature of the adhesive Ambar (FGM) is
that the main hydrophobic monomer is not the bisphenol
glycidyl methacrylate (Bis-GMA), but the urethane
dimethacrylate (UDMA). This allows the material to reach
a high degree of conversion
1,2
due to low viscosity of the
UDMA, and also provide a strong resistance to hydrolytic
degradation. This increased resistance to hydrolysis was
demonstrated by our research group, which showed that
the water sorption and solubility of the adhesive Ambar
(FGM) was approximately half of that observed by other
simplifed adhesives such as Prime & Bond NT (Dentsply),
XP Bond (Dentsply) and Adper Single Bond 2 (3M ESPE).
3
It is known that the main bonding mechanism of
etch-and-rinse adhesive systems is micromechanical.
However, some studies have shown that the addition of
functional monomers that can also chemically bond to the
dental structure plays a decisive role on the immediate
performance of the adhesives
4,5
and their hydrolytic
stability over time.
6
Among functional monomers, the
10-metacriloxydecil dihydrogen phosphate
(MDP), initially employed in the self-etch
adhesives from Kuraray, adheres easily
to hydroxyapatite in a fairly stable way.
4,7
Only recently, after the patent expiry of the
monomer MDP, the monomer becomes available for
use by other companies. It is likely that FGM has been
the frst company to incorporate this monomer in a
simplifed etch-and-rinse adhesive. The excellent result of
Ambar in laboratory studies (internal and by independent
researchers)
8
and in a recent clinical evaluation
9
attest the
effectiveness of the chemical composition of this product,
which was similar to that of Adper Single Bond 2 (3M
ESPE), marketed and available in the dental market for
over ten years.
REFERENCES
1. Floyd CJE, Dickens SH. Network structure of Bis-GMA- and UDMA-based resin
systems. Dent Mater 2006; 22:1143-1149.
2. Perdigo J, Gomes G, Sezinando A. Bonding ability of three ethanol-base d
adhesives after thermal fatigue. Am J Dent 2011;24:159-164.
3. Reis A, Wambier L, Malaquias T, Wambier DS, Loguercio AD. Effects of warm air
drying on water sorption, solubility and adhesive strength of simplifed etch-and-
rinse adhesives. J Adhes Dent 2012, in press.
4. Yoshida Y, Nagakane K, Fukuda R, Nakayama Y, Okazaki M, Shintani H, Inoue S,
Tagawa Y, Suzuki K, De Munck J, Van Meerbeek B. Comparative study on adhesive
performance of functional monomers. J Dent Res 2004;83:454-458.
5. Van Landuyt KL, Yoshida Y, Hirata I, Snauwaert J, De Munck J, Okazaki M, Suzuki
K, Lambrechts P, Van Meerbeek B. Infuence of the chemical structure of functional
monomers on their adhesive performance. J Dent Res 2008;87:757-761.
6. Inoue S, Koshiro K, Yoshida Y, De Munck J, Nagakane K, Suzuki K, Sano H, Van
Meerbeek B. Hydrolytic stability of self-etch adhesives bonded to dentin. J Dent
Res 2005;84:1160-1164.
7. Dabsie F, Grgoire G, Sharrock P. Critical surface energy of composite cement
containing MDP (10-methacryloyloxydecyl dihydrogen phosphate) and chemical
bonding to hydroxyapatite. J Biomater Sci Polym Ed 2012;23:543-554.
8. Perdigo J, Gomes G, Sezinando A. Bonding ability of three ethanol-based
adhesives after thermal fatigue. Am J Dent 2011;24:159-164.
9. Ferri LD. Avaliao clnica de dois adesivos simplifcados em leses cervicais no
cariosas: ensaio clnico randomizado. Dissertao (Mestrado) Universidade
Estadual de Ponta Grossa, 2012, 63f.
Dra Alessandra Reis
PhD in Dental Materials (University of So
Paulo) and Adjunct Professor of Restorative
Dentistry at the State University of Ponta
Grossa, Paran.
Te excellent result of Ambar in laboratory studies (internal and by
independent researchers)
8
and in a recent clinical evaluation
9
attest the
efectiveness of the chemical composition of this product [...].
102
FGM: WHAT IS THE IMPORTANCE OF LONGITUDINAL CLINICAL STUDIES FOR THE EVALUATION OF
ADHESIVE SYSTEMS?
Professor Dr Leandro Augusto Hilgert: I believe
that the longitudinal clinical studies, especially those with
long-term follow-up periods, are the ones that provide
the most valuable contributions for the evaluation of an
adhesive system. After all, the ultimate goal of the product
is to promote reliable and durable restorations in our
patients in the everyday clinical practice.
Obviously, that laboratory studies are an important
source of information. They allow rigorous control of
variables, provide faster results and are less costly. Some
criteria analyzed in laboratory research can
be correlated with the clinical success.
1

This means that the laboratory fndings can
estimate whether or not the material will
work in the clinical condition. However, no
laboratory study can perfectly simulate the
challenging conditions of the oral environment. Although
clinical trials are time-consuming and expensive, long-
term studies with a well-defned methodology (and of
course, systematic reviews of these studies) are certainly
the ones that provide the highest level of evidence for
success (or failure) of an adhesive system.
REFERENCE
1. Van Meerbeek B, et al. Relationship between bond-strength tests and clinical ou-
tcomes. Dent Mater. 2010 Feb;26(2):e100-21.
Professor Dr Leandro Augusto Hilgert
Adjunct Professor of the University of Braslia
(UnB). MS and PhD in Restorative Dentistry
at the Federal University of Santa Catarina.
[...] long-term studies with a well-defned methodology (and
of course, systematic reviews of these studies) are certainly the
ones that provide the highest level of evidence for success (or
failure) of an adhesive system.
FGM: WHAT ARE THE FACTORS THAT CAN LEAD TO INADEQUATE POLYMERIZATION OF THE
ADHESIVES?
Dr Cristian Higashi: There are several factors
that may contribute to inadequate curing of polymeric
materials. Among them, we can cite the use of light curing
devices with low power density and the use of reduced
exposure times. The light intensity can also
be reduced by keeping the light curing tip
of the device far from the polymeric material
(Aravamudhan et al., 2006; Nomoto et al.,
2006; Rueggeberg, 2011).
When it comes to adhesive systems,
other factors may also play a role on the
inadequate polymerization, such as the
dentin moisture and the excessive amount of solvent
entrapped in the adhesive before light curing. It is
known that an ideal surface moisture should be left on
the dentin surface prior to the application of a single
bottle etch-and-rinse adhesives (Reis et al.,
2003). Additionally, soon after the adhesive
application, a correct solvent evaporation
should be performed. An excessive amount
of water on the dentin surface may cause
adhesive dilution, interfering with the proper
adhesive polymerization (Tay et al. 1996,
Paul et al. 1,999). Similarly, the incorrect
103
evaporation of the solvent by an air stream can lead to
areas of incomplete curing in the adhesive interface
(Soderholm and Jacobsen, 1995; Cadenaro et al. 2,009;
Bail et al. 2,012; Navarra et al. 2012).
REFERENCES
1. Aravamudhan K, Rakowski D, Fan PL. Variation of depth of cure and intensity with
distance using LED curing lights. Dent Mater. 2006 Nov;22(11):988-94.
2. Nomoto R, Asada M, McCabe JF, Hirano S. Light exposure required for optimum
conversion of light activated resin systems. Dent Mater. 2006 Dec;22(12):1135-42.
3. Rueggeberg FA. State-of-the-art: dental photocuring--a review. Dent Mater. 2011
Jan;27(1):39-52.
4. Reis A, Loguercio AD, Azevedo CL, de Carvalho RM, da Julio Singer M, Grande
RH. Moisture spectrum of demineralized dentin for adhesive systems with different
solvent bases. J Adhes Dent. 2003 Fall;5(3):183-92.
5. Tay FR, Gwinnett JA, Wei SH. Micromorphological spectrum from overdrying to
overwetting acid-conditioned dentin in water-free acetone-based, single-bottle
primer/adhesives. Dent Mater. 1996 Jul;12(4):236-44.
6. Paul SJ, Leach M, Rueggeberg FA, Pashley DH. Effect of water content on the
physical properties of model dentine primer and bonding resins. J Dent. 1999
Mar;27(3):209-14.
7. Jacobsen T, Sderholm KJ. Some effects of water on dentin bonding. Dent Mater.
1995 Mar;11(2):132-6.
8. Cadenaro M, Breschi L, Rueggeberg FA, Suchko M, Grodin E, Agee K, Di Lenarda
R, Tay FR, Pashley DH. Effects of residual ethanol on the rate and degree of con-
version of fve experimental resins. Dent Mater. 2009 May;25(5):621-8.
9. Bail M, Malacarne-Zanon J, Silva SM, Anauate-Netto A, Nascimento FD, Amore R,
Lewgoy H, Pashley DH, Carrilho MR. Effect of air-drying on the solvent evapora-
tion, degree of conversion and water sorption/solubility of dental adhesive models.
J Mater Sci Mater Med. 2012 Mar;23(3):629-38.
10. Navarra CO, Breschi L, Turco G, Diolos M, Fontanive L, Manzoli L, Di Lenarda R,
Cadenaro M. Degree of conversion of two-step etch-and-rinse adhesives: In situ
micro-Raman analysis. J Dent. 2012 Sep;40(9):711-7.
Dr Cristian Higashi
MS and PhD in Restorative Dentistry at the State
University of Ponta Grossa. Paran. PhD stage in
the University of Porto (Portugal). Professor of the
Specialization course in Restorative Dentistry at ILAPEO
Paran.
FGM: WHAT ARE THE FACTORS THAT CONTRIBUTE FOR THE GOOD PERFORMANCE OF THE ADHESIVE
SYSTEMS?
Dr Fabiano Araujo: Regardless of the dental
substrate, different methods of adhesive application are
reported in the literature. They are currently highlighted,
in the manufacturers recommendations, to improve the
adhesive performance. To achieve a satisfactory bonding, a
fundamental factor is the use of rubber dam isolation so that
we can avoid contamination by blood, saliva and moisture.
It is noteworthy that, for the correct conditioning
of the resin-dentin interface, we should follow the
recommended etching time for enamel (30 seconds) and
dentin (15 seconds). This etching should be extended
approximately 2 mm beyond the margins of the cavity.
This will enhance the wetting ability of the adhesive
system as this has been considered fundamental in
establishing an intimate contact between the bonding
resin and the dental structure for the establishment of the
micromechanical interlocking.
1
The bonding technique should be
performed on a moist dentin
2-4
to allow
the resin infltration in dentin. The adhesive
system needs to be applied vigorously on the
dentin surface
4-6
to fll in the irregularities and
microporosity created by conditioning step.
This will allow the formation of a homogenous
hybrid layer (adhesive system + collagen
matrix). An incomplete removal of the solvent, from the
adhesive layer prior to light curing, can make this interface
more prone to polymeric degradation. Therefore, a gentle
air stream, distant from the adhesive layer, should be
applied to evaporate the solvents from the adhesive layer
(the solvents, at this stage have already fulflled their role).
The prolonged application time
7-9
along with the
increase in the number of adhesive coats on dentin
10-13
are also mechanisms that increase the bonding
performance. In this regard, attempts to eliminate
or reduce the demineralized dentin area reduce the
number of unprotected collagen fbrils and accelerate the
evaporation of residual water/solvents from the dentin
surface. These approaches lead to high longevity of the
resin-dentin bonds.
9
Current studies have identifed the presence and
activity of dentin enzymes (metalloproteinases and
cysteine cathepsins) in the mineralized dentin
and dentinal fuid. The role of these enzymes
on the degradation of the hybrid layer were
recently demonstrated.
14
Chlorhexedine has
been shown to act as an inhibitor of the host-
derived enzymes and can be used to enhance
the durability of resin-dentin interface.
15-17
Within this context, the current stage
104
of adhesive systems allows the performance of a high
number of clinical restorative procedures with high
success rates and predictable results. However, to take
full advantage of the benefts of the adhesive systems, it is
of paramount importance not only selecting the best and
the most modern adhesive systems, but to apply them
following a very careful clinical protocol. The knowledge of
the bonding mechanisms is the key for the establishment
of satisfactory results.

REFERENCES
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2. Higashi C, Michel MD, Reis A, Loguercio AD, Gomes OM, Gomes JC. Impact of
adhesive application and moisture on the mechanical properties of the adhesive in-
terface determined by the nano-indentation technique. Oper Dent 2009;34(1):51-7.
3. Loguercio AD, Loeblein F, Cherobin T, Ogliari F, Piva E, Reis A. Effect of solvent
removal on adhesive properties of simplifed etch-and-rinse systems and on bond
strengths to dry and wet dentin. J Adhes Dent. 2009;11(3):213-9.
4. Zander-Grande C, Ferreira SQ, da Costa TR, Loguercio AD, Reis A. Application
of etch-and-rinse adhesives on dry and rewet dentin under rubbing action: a
24-month clinical evaluation. J Am Dent Assoc. 2011;142(7):828-35.
5. Dal-Bianco K, Pellizzaro A, Patzlaft R, Bauer JRO, Loguercio AD, Reis A. Effects
of moisture degree and adhesive agitation on the immediate resin-dentin bond
strength. Dent Mater. 2006;22(12):1150-6.
6. Amaral RC, Stanislawczuk R, Zander-Grande C, Michel MD, Reis A, Loguercio
AD. Active application improves the bonding performance of self-etch adhesives
to dentin. J Dent. 2009;37(1):82-90.
7. Miyazaki M, Tsubota K, Onose H, Hinoura K. Infuence of adhesive application du-
ration on dentin bond strength of single-application bonding systems. Oper Dent.
2002; 27:278-83.
8. Cardoso PC, Loguercio AD, Vieira LCC, Baratieri LN, Reis A. Effect of prolonged
application times on resin-dentin bond strengths. J Adhes Dent. 2005; 7:1-7.
9. Reis A, de Carvalho Cardoso P, Vieira LC, Baratieri LN, Grande RH, Loguercio AD.
Effect of prolonged application times on the durability of resin-dentin bonds. Dent
Mater. 2008 May;24(5):639-44.
10. Pashley EL, Agee KA, Pashley DH, Tay FR. Effects of one versus two applications
of an unflled, all-in-one adhesive on dentine bonding. J Dent. 2002; 30:83-90.
11. Hashimoto M, Sano H, Yoshida E, Hori M, Kaga M, Oguchi H, Pashley DH. Effects
of multiple adhesive coatings on dentin bonding. Oper Dent. 2004; 29:416-23.
12. Ito S, Tay FR, Hashimoto M, Yoshiyama M, Saito T, Brackett WW, Wallerg JL,
Pashley DH. Effects of multiple coatings of two all-in-one adhesives on dentin
bonding. J Adhes Dent. 2005; 7:133-41.
13. Nakaoki, Y, Sasakawa, W, Horiuchi, S, Nagano F, Ikeda T, Tanaka T, Inoue S, Uno
S, Sano H, Sidhu SK. Effect of double-application of all-in-one adhesives on dentin
bonding. J Dent. 2005; 33:765-72.
14. Tjderhane L, Nascimento FD, Breschi L, Mazzoni A, Tersariol IL, Geraldeli S,
Tezvergil-Mutluay A, Carrilho MR, Carvalho RM, Tay FR, Pashley DH. Optimizing
dentin bond durability: Control of collagen degradation by matrix metalloproteina-
ses and cysteine cathepsins. Dent Mater. 2012; 16.
15. Carrilho MR, Carvalho RM, de Goes MF, di Hiplito V, Geraldeli S, Tay FR, Pash-
ley DH, Tjderhane L. Chlorhexidine preserves dentin bond in vitro J Dent Res.
2007;86(1):90-94.
16. Soares CJ, Pereira CA, Pereira JC, Santana FR, do Prado CJ. Effect of chlorhexidi-
ne application on microtensile bond strength to dentin Oper Dent. 2008;33(2):183-
188.
17. Stanislawczuk R, Amaral RC, Zander-Grande C, Gagler D, Reis A, Loguercio AD.
Chlorhexidine-containing acid conditioner preserves the longevity of resin-dentin
bonds. Oper Dent. 2009;34(4):481-90.
Dr Fabiano Araujo
Specialist, MS and PhD in Restorative Dentistry at the
Federal University of Santa Catarina (UFSC). Coordinator
of the Integrated Specialization in Prothesis and
Restorative Dentistry at the University Tuiuti of Paran
(UTP). Coordinator of the Esthetic Dentistry Courses in
the Brazilian Association of Dentistry (ABO - So Jos
dos Pinhais). Full Professor of Restorative Dentistry and
Integrated Clinics at the University Tuiuti of Paran (UTP).
Professor of the Improvement Course in Dentistry and
Esthetic Prothesis in the Brazilian Association of Dentistry
(ABO So Jos dos Pinhais).
FGM: WHAT ARE THE NEW TRENDS IN THE DEVELOPMENT OF ADHESIVE SYSTEMS?
Professor Yasmine Mendes Pupo: The innovation
in the dental materials, technologies and changes in the
biologic safety mechanisms have enhanced the current
restorative dentistry and improved the clinical longevity of
restorations.
Given this context, the trend of researches both in
the industries of dental products as well as in universities
is to develop resin monomers with chemical stability, to
synthesize and incorporate components with antimicrobial
activity at the adhesive interface, as well as to incorporate
materials with nanometric bioactive properties, capable to
induce biological repair and remineralization of dental tissues.
Current trends in the production of new adhesives
relate primarily to the procedures performed in dentin,
which remains the major challenge in bonding. The
degradation of resin-dentin interface occurs mainly due
to water sorption, hydrolysis of methacrylate esters and
activation of host-derived matrix metalloproteinases.
1
The dynamic characteristics of the dentin substrate
with regional differences and changes due to aging and
various intrinsic or extrinsic stimuli, should be considered
to increase the predictability of resin-dentin bonding.
2
To
minimize the effect of these substrate-related factors
increased importance has been given to the chemical
105
adhesion of resin components, apart from the micro-
mechanical bonding. The 10-MDP (10-metacriloxydecil-
dihydrogen phosphate) has a high chemical affnity
to the dental structure with the formation of stable
Ca-MDP salts. Altogether these features promote
stable bonding.
3,4
Studies have also indicated that the
use of enzymatic inhibitors such as chlorhexidine and
benzalkonium chloride, and the use of the ethanol-wet
bonding technique can also improve the durability of
the resin-dentin bonds. The ethanol-wet bonding allows
infltration of relatively hydrophobic resins to the dentin
substrate.
2

The evaluation of these different and established
bonding protocols requires the use of long-term bond
strength tests so that the performance of new
strategies in the development of products
can be monitored. The clinical effcacy
of modifed adhesive systems must be
evaluated by the survival rate of restorations
placed in non-cervical caries lesions.
5-7

Furthermore, the evaluation of the marginal
discoloration and marginal integrity is also
essential since the failure of the restoration
margins is a common reason for replacement
and repair of adhesive restorations.
6

Within this context of the Restorative Dentistry, it is
necessary to monitor the development and applicability of
the new trends of the adhesive systems, to determine the
success or failure of these procedures. Great emphasis
should be given to the slow kinetics release of active
ingredients with antimicrobial and bioactive properties
over a prolonged period and clinically relevant time.
REFERENCES
1. Manuja N, Nagpal R, Pandit IK. Dental adhesion: mechanism, techniques and
durability. J Clin Pediatr Dent. 2012; 36(3):223-34.
2. Carvalho RM, Tjderhane L, Manso AP, Carrilho MR, Carvalho CA. Dentin as a
bonding substrate. Endodontic Topics. 2012; 21:6288.
3. Van Landuyt KL, Snauwaert J, Munck JD, Peumans M, Yoshida Y, Poitevin A,
Coutinho E, Suzuki K, Lambrechts P, Van Meerbeek B. Systematic review of
the chemical composition of contemporary dental adhesives. Biomater. 2007;
28:37573785.
4. Yoshida Y, Nagakane K, Fukuda R, Nakayama Y, Okazaki M, Shintani H, et al.
Comparative study on adhesive performance of functional monomers. J Dent Res.
2004; 83(6):4548.
clinical success of adhesive restorations. Dent Mater. 2012; 28(1):72-86.
6. Chee B, Rickman LJ, Satterthwaite JD. Adhesives for the restoration of non-ca-
rious cervical lesions: a systematic review. J Dent. 2012; 40(6):443-52.
7. Miyazaki M, Tsubota K, Takamizawa T, Kurokawa H, Rikuta A, Ando S. Factors
affecting the in vitro performance of dentin-bonding systems. Jpn Dent Sci Rev.
2012; 48:53-60.
Professor Yasmine Mendes Pupo
MS in Restorative Dentistry. State University
of Ponta Grossa (UEPG), Paran. PhD
student in Restorative Dentistry. State
University of Ponta Grossa. Adjunct
Professor of Restorative Dentistry, Dental
Materials and Integrated Clinics. University of
Tuiuti of Paran. Professor of the Integrated
Specialization Course in Prosthodontics and
Restorative Dentistry at the University Tuiuti of Paran.
[...] apart from the micro-mechanical bonding, increased
importance has been given to the chemical adhesion of resin
components. Te 10-MDP (10-metacriloxydecil-dihydrogen
phosphate) has a high chemical afnity to the dental structure,
allows the formation of stable Ca-MDP salts. Altogether these
features promote stable bonding.
3,4
106
Dental bonding with the adhesive Ambar
INTRODUCTION
The longevity of the adhesive systems has increased signifcantly,
allowing clinicians to make predictable bonding restorations with a high level of
success. Bond strength studies have shown excellent performance of current
adhesive formulations. Two-step etch-and-rinse adhesives are used worldwide
to bond composite resins to dental surfaces; however, the stability of the resin-
dentin interface produced with these systems is of interest, especially when
exposed to the oral cavity.
A signifcant concern related to the instability of these adhesives is their
degree of polymerization. In fact, the degree of conversion of monomer to
polymer1 of adhesive systems determines their physico-chemical properties.2
Improperly cured adhesives can result in the release of un-polymerized
monomers in the oral environment,2-5 and this may signifcantly infuence
the stability of bonded interface.1,2 Additionally, a low degree of conversion
is correlated to high permeability of the adhesive interfaces produced with
these systems, which, in turn, accelerates the degradation of the resin-dentin
bonding and facilitates the development of nanoleakage (diffusion of small ions
or molecules within the hybrid layer in the absence of interfacial gaps)7.
Few studies investigated the in situ degree of conversion of etch-and-
rinse adhesives using the polymerization kinetics reaction. This procedure
allows the evaluation of the interaction between the material and the dental
substrate. The objective of this study was to evaluate the microtensile bond
strength, the nanoleakage and the in situ degree of conversion of the resin-
dentin interface produced by two 2-step etch-and-rinse adhesives: Ambar
(FGM) and Scotchbond 1 XT (3M ESPE, available in Brazil as Adper Single
Bond 2).
Lorenzo Breschi
Associate Professor. Department of
Biomedicine. Division of Dental Sciences
and Biomaterials. University of Trieste. Italy.
Chiara Ottavia Navarra
Pos-doctoral Researcher. Department of
Annalisa Mazzoni
Pos-doctoral Researcher. Department of
Human Anatomy and Pathophysiology
of Musculoskeletal System, University of
Bologna Italy.
Milena Cadenaro
Associate Professor. Department of
107
MATERIAL AND METHODS
Ambar (FGM) and Scotchbond 1XT (3M ESPE) were
applied in human dentin according to the manufacturers
instructions and bonded with a 4-mm thick resin
increment.
Then:
1. Some teeth were sectioned for microtensile bond
strength testing. The specimens were tested under
tensile forces until fracture both in the immediate
period and after 6 months of storage in artifcial sa-
liva at 37C.
2. Other teeth were transversely sectioned resulting
in two 2-mm resin-dentin slices. The specimens
were then polished to expose the bonding interface
for characterization under micro-Raman spectros-
copic.2 For this purpose, several scans along the
resin-dentin interface were done to evaluate the in
situ degree of conversion of the adhesive system.
3. Each slice was evaluated, under scanning electron
microscopy (SEM), to investigate the nanoleakage
at the bonding interface.
RESULTS
1. Analysis of the microtensile bond strength. The
bond strength values of both adhesives are described in
the next table.
Scotchbond 1XT and Ambar showed high and
statistically similar degree of conversion (79 7% and 77
7%, respectively; Figures 1-3).
ADHESIVE SYSTEM
Ambar
Scotchbond 1XT
IMMEDIATE PERIOD
32,1 9,8
b
MPa
40,6 8,7
a
MPa
6-MONTH PERIOD
27,5 7,4
b
MPa
34,5 6,5
a,b
MPa
Las diferentes letras sobrescritas indican diferencia estadstica (p <0,05).
1.
Intensidad (a.u.)/Desplazamiento Raman (cm
-1
)
2.
Intensidad (a.u.)/Desplazamiento (cm
-1
)
Figure 1 and 2. Micro-Raman spectrum of the adhesives Ambar and Scotchbond 1XT in the uncured condition, respectively. The arrows show the reference band (1610 cm
-1
) and
the C=C band (1640 cm
-1
). The signal of the C=C band decreases as the monomer is converted to polymer, and this signal is used to calculate the degree of conversion of the
adhesives.
108
Figure 4. Correlated analysis of the adhesive interface in SEM produced by Ambar (4a) and Scotchbond 1XT (4b). The adhesive interface produced by both adhesives showed
absence of nanoleakage.
Figure 3. Representative mapping of the micro-Raman spectra of the bonded interface produced with Ambar (a) and Scotchbond 1XT (b) in etched dentin. Figures 3a and 3b
show the frst spectrum acquired in mineralized sound dentin. The following spectra were taken in 1 m intervals, and they show the reduction in the intensity of the mineral P-O
band (960 cm
-1
) due to the presence of the hybrid layer. The transition of the dentin to the adhesive is visible following the inferior spectra to the superior spectra. The arrows
indicate the adhesive bands; pointers show the mineral band.
4b.
3a. 3b.
4a.
The morphological evaluation under SEM showed reduced nanoleakage expression in both adhesives tested
(Figures 4a and 4b).

Te micro-Raman spectroscopy of the hybrid layer applied on the resin-
dentin interface showed that both adhesives presented similar degree of
conversion, supporting the hypothesis of a suitable polymerization in
both materials. Te SEM images showed that the dentin substrate was well
impregnated by both tested adhesives.
Contagem/Deslocamento Raman (cm
-1
) Contagem/Deslocamento Raman (cm
-1
)
109
DISCUSSION AND CONCLUSION
This study investigated the microtensile bond
strength, the nanoleakage expression and the degree
of conversion of two 2-step etch-and-rinse adhesives.
The results indicate although the Ambar produced lower
immediate bond strength values than the Adper Single
Bond 2, both adhesives tested showed similar bond
strength means after aging.
The micro-Raman spectroscopy of the hybrid
layer applied on the resin-dentin interface showed that
both adhesives presented similar degree of conversion,
supporting the hypothesis of a suitable polymerization in
both materials. The SEM images showed that the dentin
substrate was well impregnated by both tested adhesives.
Although the literature reports that simplifed
adhesives (e.g. 2-step etch-and-rinse and one-step self-
etch adhesives) demonstrate lower degree of conversion
and higher permeability than un-simplifed adhesives (e.g.
3-step etch-and-rinse and 2-step etch-and-rinse),6-10
this in situ study suggests that the 2-step etch-and-
rinse adhesives tested have different behavior than the
simplifed adhesives previously mentioned when applied
in human dentin. The results of this study demonstrated
that the 2-step etch-and-rinse adhesives tested showed
good bond strength, polymerization and infltration into
dentin.

REFERENCES
1. Ferracane JL, Greener EH. The effect of resin formulation on the degree of conver-
sion and mechanical properties of dental restorative resins. Journal of Biomedical
Materials Research 1986; 20:12131.
2. Ferracane JL. Elution of leachable components from composites. Journal of Oral
Rehabilitation 1994; 21:44152.
3. Munksgaard EC, Peutzfeldt A, Asmussen E. Elution of TEGDMA and BisGMA from
a resin and a resin composite cured with halogen or plasma light. European Jour-
nal of Oral Sciences 2000; 108:34145.
4. Miletic V, Santini A, Trkulja I. Quantifcation of monomer elution and carbon-carbon
double bonds in dental adhesive systems using HPLC and micro-Raman spec-
troscopy. Journal of Dentistry 2009; 37:177-84.
5. Perdigo J, Gomes G, Sezinando A. Bonding ability of three ethanol-based adhe-
sives after thermal fatigue. American Journal of Dentistry 2011; 24:159-64.
6. Breschi L, Cadenaro M, Antoniolli F, Sauro S, Biasotto M, Prati C, et al. Polymeri-
zation kinetics of dental adhesives cured with LED: correlation between extent of
conversion and permeability. Dental Materials 2007; 23:106672.
7. Cadenaro M, Antoniolli F, Sauro S, Tay FR, Di Lenarda R, Prati C, et al. Degree of
conversion and permeability of dental adhesives. European Journal of Oral Scien-
ces 2005; 113:52530.
8. Sauro S, Mannocci F, Toledano M, Osorio R, Thompson I, Watson TF. Infuence of
the hydrostatic pulpal pressure on droplets formation in current etch-and-rinse and
self-etch adhesives: a video rate/TSM microscopy and fuid fltration study. Dental
Materials 2009; 25: 1392402.
9. Pashley DH, Tay FR, Breschi L, Tjderhane L, Carvalho RM, Carrilho M, et al. State
of the art etch-and-rinse adhesives. Dental Materials 2011; 27:116.
10. Sauro S, Pashley DH, Mannocci F, Tay FR, Pilecki P, Sherriff M, et al. Micropermea-
bility of current self-etching and etch-and-rinse adhesives bonded to deep dentine:
a comparison study using a double-staining/confocal microscopy technique. Eu-
ropean Journal Of Oral Sciences 2008; 116:18493.
Opallis. Makes from restoration an art work.
The application of basic dentin and enamel colors combined
with efect colors, recreates the natural appearance of the tooth,
allowing dental surgeons to make restorations more aesthetic
and functional.
Rell
syringes with
4g or 2g.
Shade guide
Available in colors of enamel, dentin, efect and value.
Clinical Kit
15 syringes (EA1, EA2, EA3, EB2,
DA1,DA2, DA3, DB2, D-Bleach,
T-Blue, T-Neutral, T-Yellow,
E-Bleach H, Opaque Pearl, VH)
Basic Kit
6 syringes
(EA2, EA3, EA.5,
DA2, DA3, T-Neutral)
opallis copy.pdf 1 03/10/2013 09:05:36
Opallis. Makes from restoration an art work.
The application of basic dentin and enamel colors combined
with efect colors, recreates the natural appearance of the tooth,
allowing dental surgeons to make restorations more aesthetic
and functional.
Rell
syringes with
4g or 2g.
Shade guide
Available in colors of enamel, dentin, efect and value.
Clinical Kit
15 syringes (EA1, EA2, EA3, EB2,
DA1,DA2, DA3, DB2, D-Bleach,
T-Blue, T-Neutral, T-Yellow,
E-Bleach H, Opaque Pearl, VH)
Basic Kit
6 syringes
(EA2, EA3, EA.5,
DA2, DA3, T-Neutral)
opallis copy.pdf 1 03/10/2013 09:05:36
112
Modifying smiles with composite resins
Weider Silva
Specialist in Implantology.
Courses in Implantology,
Restorative Dentistry and
Prosthodontics (Brazilian
Association of Dentistry DF and
Brazilian Association of Dentistry
TAG-DF).
Lndiel Olmpio
Specialist in Implantology,
Prosthodontics and Restorative
Dentistry.
Course in Prosthodontics and
Restorative Dentistry (Brazilian
Association of Dentistry -TAG/DF).
Tarcsio Pinto
Mster en Odontologa
Profesor del curso de
Especializacin de Prtesis y
Odontologa de ABOTAG/DF,
Brasil
Gil Montenegro
MS in Restorative Dentistry.
Course of Prosthodontics and
Restorative Dentistry (Brazilian
Association of Dentistry -TAG/DF).
2. 1.
CASE REPORT
Mal-positioned discolored anterior teeth with diastema can harm the
beauty of a smile. Regardless of the technique chosen to restore the shape,
position and color of the teeth, knowledge about the dental anatomy and
dental proportion is essential for planning. Furthermore, it is essential to
conduct a previous planning with computerized images, waxed models and
silicone guides.
With the development of adhesive systems and composite resins,
different clinical situations that required esthetic and resistance were resolved
with invasive prosthetic treatments. Nowadays, these situations can be entirely
solved with the use of composites with minimal or no teeth wear.
1. Diagnostic wax-up.
2. Fabrication of a silicone guide.
113
3.
6.
4.
7.
5.
8.
3. Virtual planning showing the small cervical-incisal length of the central incisors.
4. Virtual planning showing the small cervical-incisal length of the lateral incisors.
5. Final virtual planning.
6. Right lateral aspect of the initial condition.
7. Front view of the initial condition.
8. Left lateral view.
Besides the excellent physical and optical properties
of the latest generation of composite resins, the reduction
in the number of clinical sessions and the costs are other
advantages of composite resins over ceramics. This
article reports the planning and predictability of a clinical
case aimed to restore the esthetics of a patients smile
in a natural and harmonious way with the use of the
adhesive system Ambar (FGM) and the composite resin
Opallis (FGM). In this clinical case, no tooth preparation
was performed. The bleaching was performed in the low
arch using a single 1-hour in-offce bleaching session with
the Whiteness HP Blue 35% (FGM).
114
9. Enamel roughening with an abrasive disk FGM.
10. 37% Phosphoric acid.
11. Enamel etching for 1 minute.
12. Light-cured adhesive system.
13. Application of the adhesive system.
14. Prepared silicone guide in position.
15. Composite resin Opallis were employed in the following shades VL; DA1; T-YELLOW; E-BLEACH H; EA1.
16. VL; DA1; T-YELLOW; E-BLEACH H; EA1.
16.
14.
12.
10.
15.
13.
11.
9.
115
Available in 4 sizes:
extra ne, ne, regular and long.
Unique in the market
with two bending points.
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Exclusive design.
Easy application in
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Cavibrush.
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17. Composite resin VL palatal region.
18. Composite resin VL palatal region.
19. Composite resin DA1 dentin mamelons.
20. Composite resin T-YELLOW pigmentation.
20.
19.
18.
17.
116
21. Composite resin E-BLEACH H - pigmentation.
22. Composite resin EA1 enamel layer.
23. Immediate fnal result.
24. Abrasive disks for fnishing and polishing + polishing paste.
25. Coarse abrasive disk for fnishing procedures.
26. Medium-coarse abrasive disk.
27. Fine abrasive disk.
28. Polishing disk + paste.
28.
26.
24.
22.
27.
25.
23.
21.
117
29. Final frontal view.
31. Final frontal view.
31. Final lateral and right view.
32. Final lateral and left view.
33. Light-cured gingival barrier.
34. Application of the light-cured gingival barrier.
35. Light curing the gingival barrier.
32. 31.
29. 30.
34. 35.
33.
118
36-39. Bleaching agent Whiteness HP Blue Calcium 35%.
40. Application of the bleaching product.
41-42. Lip retractor.
40.
38.
42. 41.
39.
37. 36.
119
43. Color change of the bleaching agent.
44. End of the bleaching procedure.
45. Desensibilize.
46.-47 Application of the Desensibilize for 10 minutes.
48. Final bleaching result.
49. Initial view.
50. Final view.
48.
50.
46.
44.
47.
49.
45.
43.
120
Simplifying the layering technique in
posterior teeth Case report
Oscar Fernando Muoz Chvez
Dentistry at the University of the
State of So Paulo. Araraquara
(UNESP).
Assistant Professor of the Integrated
Clinics. University of the State of
So Paulo. Araraquara (UNESP).
Ana Lcia Franco
PhD student of the Oral
Rehabilitation Course at the
University of the State of So
Paulo. Araraquara (UNESP).
Andria Affonso Barreto
Montandon
MS and PhD in Periodontics at
the University of the State of So
Weber Adad Ricci
MS and PhD of the Oral
Rehabilitation Course at the
University of the State of So
Luiz Antonio Borelli Barros
MS and PhD in Periodontics at
the University of the State of So
Assistant Professor of the
Integrated Clinics. University of
the State of So Paulo. Araraquara
(UNESP).
ABSTRACT
Based on the clinical case herein described, the authors demonstrate a
simplifed layering strategy for restoration of posterior teeth using the composite
resin Opallis (FGM). Existing class I amalgam and provisional glass ionomer
restorations in teeth 36 and 37, respectively, were replaced by composite resin
restorations. A simplifed layering sequence was used: 1) a composite resin
with dentin shade was used to simulate the dentin from the class I cavity, 2)
this dentin resin was covered with an enamel resin and 3) the restoration was
fnally coated with an effect resin that modulates the value. Both restorations
showed satisfactory results in terms of esthetic, which validates the simplifed
technique for routine use in clinical practice.

INTRODUCTION
The modern restorative dentistry is focused on minimally invasive
concepts. This is reached with preservation of the dental structure and the
choice of materials and restorative techniques that produce restorations like
the natural teeth. The composite resin has mechanical properties close to the
dentin, such as the modulus of elasticity and resilience. These properties make
these materials similar to dentin in terms of deformation and absorption of
masticatory forces.
1,2
Furthermore, composite resins can be effectively bonded to the dental
tissues with the use of adhesive systems. This occurs with the formation of the
hybrid layer, in a similar manner to what naturally occurs in the dentin-enamel
junction. Thus, it is possible to restore the biomechanical integrity of the tooth
in a condition similar to one presented in sound teeth.
3
The aforementioned factors along with the changes in the esthetic
properties of the direct restorative materials in recent years, has made
the composite resins the election material to restore conservative cavities
of anterior and posterior teeth.
4
The composite resin presents a wide
range of colors with different saturation and translucency. This allows the
dentist to stratify the restoration similarly to what is done by the laboratory
121
technician when using dental ceramics. This layering
process is required to create esthetic results in anterior
restorations. In anterior dentition, the incidence of light
and the different color variations of the dental substrate
require reproduction.
However, the limited visual access of posterior teeth
associated with the technical diffculty of working in this
feld requires the use of a simplifed stratifed strategy to
optimize the esthetic results. Therefore, based on a clinical
case the authors reported a simplifed layering technique
for composite resin restoration in posterior teeth.
CASE REPORT
The patient CG, 23-years old sought for the
Integrated Clinics from the Araraquara School of Dentistry
(Univeristy of the State of So Paulo - FOAr) complaining
of tooth sensitivity to sweets in the fourth quadrant. After
clinical and radiographic examination, we found the
presence of a defective amalgam restoration in tooth
36 with signs of infltration and we noted a temporary
restoration of glass ionomer cement in tooth 37 due to
an indirect pulp capping. Both teeth were symptomless
to stimuli. Therefore, it was proposed to replace the
amalgam with composite resin, and to restore the occlusal
area of the tooth 37 with composite resin. A layer of glass
ionomer was kept in the bottom of the class I cavity of
tooth 37 (Figure 1).
After anesthetic procedure and rubber dam isolation
of the operative feld with dental clamps, both restorations
were removed with a diamond bur #1014, mounted in a
high speed hand-piece, under abundant water cooling.
In the tooth 37, the bottom layer of the glass ionomer
cement was not removed and kept in the cavity. By means
of carbide round bur,4 mounted at low speed hand-piece,
the carious lesion was removed, and the cavity cleaned
with 2% chlorhexidine (FGM) for antibacterial action
(Figure 2).
As the cavity of tooth 36 was shallow, the dentin-
pulp complex was protected with the hybridization
produced by the adhesive. For this purpose, both cavities
were conditioned with 37% phosphoric acid for 30 and
15 seconds in enamel and dentin respectively (Figure
3). After this period, the cavities were copiously rinsed
with water and slightly dried with an air stream. Again,
a solution of 2% chlorhexidine (FGM) was applied for 60
seconds followed by gentle drying, in order to re-wet the
dried demineralized dentin and also to inactivate host-
derived matrix-metalloproteinases that could compromise
the longevity of the restoration by deterioration of the
hybrid layer.
5
In the sequence, four coats of the adhesive system
Ambar (FGM) were applied actively with a microbrush in
the conditioned enamel and dentin. We applied a slight
air stream between coats and only the last coat was light-
cured for 20 seconds (Figure 4). For both teeth, the dentin
resin DA2 (Opallis, FGM) was employed. This shade was
selected as it was the most compatible color with the
occlusal foor of the dental cavities. Additionally, the DA2
resin had enough opacity to cover the sclerotic dentin
and amalgam pigmentation in the sound remaining dentin
structure. Increments of resin were applied in the occlusal
foor so that all exposed dentin and/or glass ionomer
122
1. Initial aspect of the amalgam and glass ionomer restorations in teeth 36 and 37.
2. After rubber dam isolation, the restorations were removed keeping a thin layer of glass ionomer cement as a liner in the deepest occlusal regions of tooth 37.
3. Acid etching of the dental cavities with 37% phosphoric acid.
4. After water rinsing and drying, a solution of 2% chlorexedine (FGM) was used, and the simplifed adhesive Ambar (FGM) applied on enamel and dentin with a microbrush.
5. The dentin resin Opallis DA2 (FGM) was adapted in the cavity so that a higher volume of material was placed in the cusp inclines than close to the main occlusal fssure.
6. The enamel resin (Opallis EA2, FGM) coated the dentin resin and delimited the boundary of the cusps inclines. A space of approximately 1 mm was left for the last effect resin
increment.
5.
3.
2.
6.
4.
1.
123
7. Final sculpture of the composite resin restoration with an effect resin VM (Opallis, FGM). Occlusal view.
8. Buccal view of the fnal sculpture.
9. Final polishing with a felt disk impregnated with a Diamond paste (FGM).
cement was covered. A higher volume of resin was placed
below the cusps than close to the fssures.
Each resin increment was light-cured for 60
seconds. Care was taken to not bond several cavity
walls with a single resin increment to avoid generation of
polymerization stress at the adhesive interface (Figure 5).
On the top of the resin dentin increment, a layer of enamel
resin (EA2 Opallis, FGM) was applied. With this increment,
the cusps were defned, and the resin was used to cover
the occlusal surface of the restoration, but still leaving
a space of approximately 1 mm for the last effect resin
increment (Figure 6).
During placement of this second enamel layer,
it is essential to delineate the boundary of the cusps
inclines that will serve as reference for the last composite
resin increment. This should be done considering the
characteristics of the main occlusal fssure, which is
individual for each tooth.
3
After that, dyes can be used to
highlight the fssures. For the fnal resin increment, we used
an effect resin to modulate the value of the restoration
(VM Opallis, FGM). The anatomical sculpture of the cusp
inclines and fssures were performed one at a time, thus
avoiding unnecessary polymerization stress during curing.
In the end, we coated the complete restoration with a
glycerin gel and the restoration was light-cured again
aiming to inhibit the surface layer that was exposed to
oxygen, and thus contributing for the maintenance of the
esthetic for longer periods (Figures 7-8).
In the same clinical session, we performed the
occlusal adjustments and the restoration fnishing with
multi-blade burs at low speed. In the next appointment,
we employed felt disks impregnated with diamond paste
(FGM) mixed with natural oil. After this step, a silicon
carbide-impregnated rubber brush was used for fnal
polishing and shine (Figures 9-10).
9.
8.
7.
124
DISCUSSION
The incidence of light in posterior teeth is different
than in anterior teeth. This makes the reproduction of the
restoration individual. In the posterior teeth factors related
to value, opacity and translucency are more infuential
than hue and chroma.
6,7
The dentin of posterior teeth is characterized by a
10. Occlusal view, one week after the restorative procedure.
11. Initial view.
10. 11.
high degree of saturation and opacity. Therefore, to mimic
the natural dentin lost, it is necessary to employ composite
resins with reduced translucency (A2 Dentin). As posterior
teeth have large enamel thickness, it is reasonable to
use high translucent resins to reproduce this area. In this
clinical case, we decided to recreate this lost area with
125
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flow copy.pdf 1 03/10/2013 08:58:47
resin enamel (enamel A2) in suffcient thickness and a
last effect resin increment to modulate the value of the
occlusal surface (VM, medium value).
During the placement of this last effect resin
increment, it should be considered that certain areas of
the posterior teeth (such as cusp edges, marginal edges
and cusp inclines) have superior translucency and may
appear white or grayish. The attention to these factors
will allow the clinician to decide for the most adequate
effect resin (high, medium or low value) to reproduce
the optical features of the natural posterior teeth with a
higher accuracy.
CONCLUSION
The sequential use of an opaque resin (dentin
resin), enamel resin and a last layer of an effect resin
to modulate the value of the occlusal surface can lead
to a satisfactory restoration in posterior teeth from an
esthetic point of view.
REFERENCES
1. Anusavice KJ. Phillips Science of Dental Material. 11th ed. St. Louis:Saunders
Company;2009.
2. Stanford JW, Weigel KV, Paffenbarger GC, Sweeney WT. Compressive properties
of hard tooth tissues and some restorative materials. J Am Dent Assoc. 1960;
60:746-56.
3. Hirata,R. Tips: dicas em Odontologia Esttica,So Paulo: Artes Mdicas, 2011,
576p.
4. Ferracane, J.L. Resin composite- State of the art. Dental Materials 27; 2011: 29-
38.
5. Boushell L. ,Swift E. Dentin Bonding: Matrix Metalloproteinases and clorexidine. J.
Est. Rest. Dent.2011;3(5): 347-352
6. Dietschi,D.Free hand bonding in the esthetic treatment of anterior teeth: creating
the illusion. J Esthet Dent. 1997;9(4):156-64.
7. Vanini L. Light and color in anterior composite restorations. Pract Periodomtics
Aesthet dent. 1996 Sep;8 (7): 673-82;quiz 684.
The simplicity
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Indicated for anterior and posterior teeth
- 5 shades kit: EA2, EA3, EA3.5, EB2 and DA3 (Universal);
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- Dentin rel: DA1, DA2, DA3 (Universal), DA3.5, DB2.
llis copy.pdf 1 03/10/2013 09:03:07
127
Esthetic re-anatomization: natural results
with the composite resin Llis
Fabiano Araujo
Restorative Dentistry at the Federal
University of Santa Catarina
(UFSC).
Coordinator of the Integrated
Specialization in Prosthodontics
and Restorative Dentistry at the
Coordinator of the Esthetic
Dentistry Courses in the Brazilian
Association of Dentistry (ABO - So
Jos dos Pinhais).
Full Professor of Restorative
Dentistry and Integrated Clinics
at the University Tuiuti of Paran
(UTP).
Professor of the Improvement
Course in Dentistry and Esthetic
Prosthodontics in the Brazilian
Association of Dentistry (ABO
So Jos dos Pinhais).
CASE REPORT
The case of a 20-years old patient, with a fractured and discolored central
incisor due to trauma and an inadequate restoration that did not match the
esthetic demands of the patient, illustrates this procedure (Figure 1a). Although
the tooth was vital, there was a color mismatch between the tooth and the
remaining teeth from the upper arch and the restoration not acceptable with
lack of material. The patient had undergone two previous restorative treatments
without success (Figures 1b 1f). The remaining teeth were satisfactory, but
they have a yellowish color.
The tooth discoloration was treated with at-home bleaching with 10%
carbamide peroxide (Whiteness Perfect, FGM) for 20 days. After the bleaching
procedure, the color matched the remaining teeth color of the upper arch. After
that, the anatomy of the palatal and incisal area of tooth 21 was temporarily
restored with a composite resin so that a silicone guide could be fabricated
(Figure 2).
1a. Aspecto inicial de la sonrisa.
1a.
128
1b to 1f. Details of the unsatisfactory esthetics of the tooth under several angles.
2. Silicone guide for placement of the palatal resin.
3. Light-curing of the frst resin layer.
1f.
1b. 1c. 1d.
3.
1e.
2.
The restoration was carried out following a pre-
determined clinical procedure: 1) application of 37%
phosphoric acid gel for 30 and 15 seconds in enamel and
dentin respectively; 2) water rinsing by the same period
of etching; 3) gentle drying with compressed air and
absorbent paper; 4) adhesive system application (Ambar,
FGM) according to the manufacturers recommendations
and 5) light curing for 20 seconds.
Using a spatula, a translucent incisal resin (Llis,
FGM) was placed in the silicone guide for reproduction of
the lost palatal enamel. The silicone guide was positioned
into the patients teeth, and the resin increment was light-
cured on the buccal surface (Figure 3). After removing the
matrix, one can see the palatal enamel reconstructed in
resin. Then, an increment of opaque resin Llis DA2 was
used to reproduce the dentin. This increment was used
to mask the region of the fracture slightly. Shades with
lower saturation were applied successively (opaque resin
Llis DA1), from the fracture line up to the incisal edge,
reproducing the dentin and its mamelons. A white dye and
129
4. Placement of a white dye and enamel resin EA1 to characterize the dentin mamelons.
5. Incisal third flled with a translucent resin.
6a-6c. Defnition of the mirror area, texturing and fnal polishing.
7a-7c. Details of the excellent esthetics achieved with the composite resin system employed.
8. Initial aspect of the patients smile.
8.
6c.
4. 5. 6a.
7a.
6b.
the resin Llis EA1 were applied to mimic small hypoplastic
stains presented in the neighboring teeth (Figure 4).
In the incisal edge, the opaque resin Llis DA2 was
placed to reproduce the opaque halo of the tooth. The
incisal third was flled with a translucent incisal resin (Figure
5), followed by the application of the translucent resin Llis
EB1 to reproduce the natural look of the enamel surface,
which had a high value. Initial fnishing was performed,
and the patient dismissed. In the next clinical session, we
proceeded to surface texturing and fnal polishing (Figures
6a - 6c). The characterization was performed with extra-
fne diamond burs, and the polishing was performed with
abrasive disks (Diamond PRO, FGM) and diamond paste
(Diamond Excel, FGM) with felt disks (Diamond Flex,
FGM).
At the end of this step, it was possible to observe
the excellent esthetics achieved with the composite resin
system (Figures7a - 7c). We instructed the patient about
dietary habits and oral hygiene and we fabricated a mouth
protector for anterior teeth.
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thicknesses and colors to
match diferent cases and
techniques.
The easiest and safety way to obtain
temporary gingival retraction.
Non-impregnated retraction cord
Easy insertion into the
gingival sulcus without
damaging the tissue.
High absorption capacity and expansion
enabling the entire procedure to be
carried out in a dry environment
with temporarily retracted gum.
Composed of
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132
From restorative
esthetics
to
cooking
In our daily life, we observe that many dental professionals have other activities - hobbies - to escape from
the daily routine of work. Gradually, we discovered some surprising individual particularities. In this
edition, we spoke with Dr. Jos Carlos Garofalo*, a Specialist in Esthetic and Restorative Dentistry. He tells
us in a very relaxed manner his career as a dentist/professor until the discover of his culinary skills.
TELL US A LITTLE ABOUT YOUR HISTORY BEFORE STAR-
TING THE DENTISTRY COURSE.
In fact, my whole life was connected to Dentistry. My
father had a small dental laboratory and at the age of 11 I
started attending this laboratory, working as an offce boy.
I also learned basic services of the laboratory, which in the
seventies from the last century were the inclusion of wax
patterns for casting, assembling prosthetic teeth in den-
tures and waxing of crowns and cast metal restorations.
I worked part-time in my fathers laboratory and the other
period I studied in the high school. This went on until I
completed 16 years old. At this age, I started the full-time
College, which prevented me from continuing working at
my fathers lab.
WHY DID YOU CHOOSE TO BE A DENTIST?
I had the opportunity to meet, socialize and attend
the dental offces of renowned names in Dentistry at the
time I was working at my fathers lab, who later on beca-
me my teachers. Among them, Gilberto Marcucci, Walter
Genovese, Antonio Rodrigues, Antonio Fernando Toma-
zzi. I also met a teenager, the Professor Jos Luiz Mar-
ques Lages. The work in the laboratory and the example
of these professionals certainly motivated me to choose
dentistry as my career.
WHAT WERE THE STUMBLINGS IN THE BEGINNING?
I do not know if I stumbled in the beginning of my
career. I did experience some diffculties, many diffculties
indeed. I had to overcome some obstacles to be the pro-
fessional I am today. It is a profession that I have been
building up step-by-step. It has been a long way since
the beginning. Although my father was a prosthetic tech-
nician, the beginning was diffcult. As soon as I fnished
the undergraduation in dentistry, I leased a small popular
dental offce in So Paulo downtown. I also got a job to
work as a dentist on duty twice a week, from nine in the
evening at 8 am. When I fnished my duty I used to go
straight to my leased offce. This routine went on for four
years until the eve of my daughters birth, when I decided
to drop the job on duty to stay longer and closer to my
newly assembled family. It has been 25 years since under-
graduation, and over the years Ive been fying higher and
higher which always brought me immense pleasure and
no regrets for choosing dentistry as a profession.
WHICH WERE THE GREATEST ACHIEVEMENTS IN THE
DENTISTRY CAREER?
Arguably, the greatest achievement is the recog-
nition of being an ethical and reliable professional who
works not only thinking about economic success but who
works in the name of our profession. Undoubtedly, to be
a reference name in the Brazilian dentistry is an achieve-
ment that goes far beyond my expectations and intentions
during my academic education. To receive the recognition
of my patients, students, my fellow teachers and people
from the business market is a great prize of my career and
this has been a factor of great professional motivation.
WE KNOW THAT YOUR GREATEST HOBBY IS COOKING.
HOW DID IT START?
I would say that my great hobby (actually it is al-
most an addiction) is the sports, whether as a practitioner,
whether as a lover. I have always done physical activity
for competition, and I have already practiced basketball,
volleyball, handball, football, athletics, especially until the
end of the undergraduation course. Today, now older and
with several commitments imposed by the profession, I
use to play tennis and practice running.
As for the cuisine, this is in my blood and familys
history. My family is of Italian origin. I grew up watching my
mother, grandmother and great grandmother creating and
reproducing fantastic dishes. And the food was always
excuse to join the family at parties and on weekends. It
was around the pastas and polenta that we showed our
affection and our passions.
To complete the picture, my wife is a Greeks dau-
ghter. A culture with equal passion for tasty food. The sce-
nario of parties and weekends was the same. Only with
an increased menu options. My mother-in-law also cooks
divinely, which allowed the children and grandchildren to
received from both sides of the family, the culture of inci-
tement to delicious food.
Italians and Greeks together: when we are not ea-
ting, were thinking about what we are going to eat. Only
more recently, the culinary and cooking came into my life
as a hobby. A few years ago, I went with a close childhood
friend, which is now a professional colleague, Arnaldo
Gondo, to take a course in Japanese cuisine. Pure revelry
and fun. However, I liked the joke and took a chance on
this exquisite and meticulous cooking.
134
From sushi and sashimi to western cuisine was a
leap. I started risking the basics of pastas and risotto just
for my wife and children, then for a larger part of the family
Sunday lunches. As the dishes were getting right, I incre-
ased my interest in learning new techniques and dishes.
I became a regular viewer of cooking shows on TV and a
collector of recipes from books, websites and programs
on the subject. It is a immensely rich universe and allows
endless combinations and variations, especially for those
who take pleasure in discovering new favors and try new
possibilities.
WHAT ARE THE PLEASURES OF THIS HOBBY?
The cuisine is a extremely eclectic and democratic
hobby. The pleasure of eating can be found both in a so-
phisticated French bistro recipe as well as in freshly baked
rice topped with a fried egg with the yolk delightfully soft.
It is so pleasant to recall a particular dish tasted in a re-
markable journey, as remembering the taste of the warm
mothers or grandmothers seasoning, experienced in the
childhood. It has much to do with the mood, the moments
of our lives and the presence of remarkable people in our
existence. And I do not give up this eclecticism.
Sometimes, I allow myself to choose exquisite ingre-
dients such as to cook a lobster recipe for my daughters
birthday. Other times, I open the fridge and take what is
inside to transform them into last minute risottos. There
are many pleasures: the novelty, the experiment, the com-
bination of spices the pleasure to challenge ourselves,
and try doing the same of this or that famous chef. Howe-
ver, the great pleasure of cooking is sharing the fnal pro-
duct with the ones we love. Nothing like gathering loved
ones and give them a sample of our work, our passion.
These are particular moments at home that we try to re-
peat ever. Being with the ones we love around tasty food
and good wine, is tremendously invigorating.
CAN YOU ASSOCIATE SOME EMOTIONS OF YOUR PRO-
FESSION WITH THAT OF YOUR HOBBY?
Yes, many. My area of expertise is the Esthetic Res-
torative Dentistry. Likewise, cuisine, this dentistry specialty
requires attention, careful observation of details, whimsy,
harmony, accurate technique. In both, the satisfaction of
the customer is the ultimate goal. I think my career and
my hobby require the same qualities from me.
WHAT IS YOUR BIGGEST DREAM?
Well, related to food, my biggest dream is to travel
and enjoy the favors of famous cuisines. If possible, to
invest a proper time in courses to increase my knowled-
ge and to experience professionally what I now do in an
amateurish and intuitive way. Italy and France are logically
part of the script, but there are other notable places for a
gastronomic tourism like Asia, especially China and Thai-
land. My life aim is to live many and many years with the
lit fame of the stove, and having my family and my friends
around the table with the dishes I cook. Many stories and
lots of laughs, indeed.
AFTER LEAVING US SALIVATING, DR. GAROFALO GAVE
US ONE OF HIS FAVORITE RECIPES. WRITE DOWN AND
ENJOY!
It is so pleasant to recall a certain dish tasted in a remarkable
journey, as remembering the taste of the warm mothers or
grandmothers seasoning, experienced in the childhood. It has
much to do with the mood, the moments of our lives and the
presence of remarkable people in our existence.
Squid with Shimeji Mushroom Stuffing
Recipe for 4 Portions
4 medium clean squids. Chose squids without holes in the skin to prevent losing the stuffing.
Squid heads
600 g Shimejo mushrooms
Small chopped red chillies
1 sprig of chopped parsley and chives/spring onions
Olive Oil
1 glass of saki
1 teaspoon of sesame seed oil
3 teaspoon of soy sauce
1 teaspoon grated fresh ginger
2 cloves of garlic
1 medium onion cut up into thin strips
1/2 tablet of butter
Salt
Pepper
Method
For Filling: In a deep frying pan or large saucepan, melt butter with a little olive oil, so that the butter
does not burn. Fry the onion, garlic, chillies (to taste) and ginger, until the onions are transparent. Add
the chopped mushrooms and allow to soften for around 5 minutes. Season with freshly ground pepper.
Add the saki, shoyo and sesame seed oil, and mix well, allowing the mixture to simmer for around 15
minutes. Add the parsley and spring onions/chives. Adjust the salt. Remember Shoy sauce is salty, so
do not add salt before adding the shoy, so that you do not over-salt. Switch off the heat and leave the
pan with a lid on while the stuffing cools
Filling the squid with stuffing: As soon as the mushrooms have cooled a bit, use a spoon to fill the
squid with stuffing, taking care not to compact the layers of stuffing too much. Fill the squid leaving
an edge of 2 cm, to enable closing the piece with a tooth pick. Pour a little olive oil into a pre-heated pan,
and brown the filled squid until they are slightly golden brown. Remove from the frying pan, place in
an oven-proof dish, and leave in an oven preheated to about 180 degrees, for another 10 minutes. Pour
a little more olive oil into the same frying pan, and lightly fry the squid heads, seasoned to taste with
salt and pepper. Keep these to decorate the dish. Remove the squid from the oven, and cut the pieces into
rings about 1.5 2 cm wide, using a sharp knife. To decorate the dish, use the squid heads and any left
over stuffing. Serve with white rice or salad.
* Professor Dr Jos Carlos Garfalo
MS and PhD in Restorative Dentistry at the
School of Dentistry. University of So Paulo.
Specialist in Restorative Dentistry. School of
Dentistry. University of So Paulo.
Coordinator of the Specialization Course in
Restorative Dentistry at CETAO.
Coordinator of the Update Course in Esthetic
and Adhesive Dentistry at CETAO.
Effective Professor of the Specialization Course
in Restorative Dentistry at EAP-APCD.
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Only a powerful cement manages to unite efciency and practicality.
Self-mixing system:
practical application, without
waste and bubbles.
easy handling.
DUAL cure:
light and chemical activation.
Available in:
1 dual body syringe with 5g
or individual syringes
of 2.5g each.
Colors: A1, A2, A3 and Trans.

anuncio_allcem copy.pdf 1 03/10/2013 08:44:59
138
Achieving a harmonic smile after
cementation of veneers: A 4-year follow-up
CASE REPORT
Ceramic veneers are an extremely satisfactory solution for large esthetic
problems. Successful treatment begins with proper planning and with the
patients perception of the treatment plan. The dental preparation is of utmost
importance as well as the choice of the material and the laboratory responsible
for the fabrication of the veneers.
1. Initial clinical situation showing anterior restorations with inadequate anatomy, texture and marginal sealing.
2. Intraoral clinical situation.
3. Previous dental prophylaxis before the bleaching treatment.
4. The bleaching was performed with Whiteness HP (FGM). We have performed three consecutive applications
followed by three syringes of at-home bleaching with Whiteness Perfect a 10%.
Maciel Jr
1.
3.
2.
4.
139
5. After the end of the bleaching procedure, a re-anatomization and polishing of the anterior teeth was performed mainly in the embrasure areas.
6. Clinically, it can be observed that there is no room for the gingival papilla. This could jeopardize the achievement of an esthetic smile. With an abrasive strip, the embrasure area
was carefully opened with care to keep the contact point.
7. The abrasive strip was employed in all incisors.
8. The embrasure area was improved.
9. Clinical situation immediately after the cosmetic re-anatomization and polishing.
8.
5.
9.
6.
7.
In this reported clinical, a female patient, 54-years
old requested an improvement in her smile. After a
clinical and radiographic examination we suggested
the cementation of veneers in tooth 14 to 24, except in
tooth 23 where we indicated a metal-free ceramic crown.
Prior to the beginning of the clinical case we prepared
a diagnostic wax-up to facilitate the dental preparation,
to provide the patients preliminary view of the defnitive
treatment and the preparation of provisional restorations
very close to the defnitive work. We have also planned to
bleach the upper and lower arches.
140
10. After 30 days, the procedure for the placement of veneers was initiated.
11. In an intraoral view, we can observe a signifcant improvement in the papilla area.
12. This view under improved contrast shows the poor anterior restorations.
13. A diagnostic wax-up was done to facilitate the dental preparation, to provide the patients preliminary view of the defnitive treatment and the preparation of provisional
restorations very close to the defnitive work.
14. A frst impression of the diagnostic wax-up was done to facilitate the dental preparation of the teeth to be veneered.
15. The dental preparation was performed with a diamond bur # 2135.
16. An orientation marginal chamfer was prepared labially and interproximally to facilitate tooth reduction.
17. The buccal inclines were respected during tooth reduction.
16.
14.
12.
10.
17.
15.
13.
11.
141
18. The chamfer was prepared with a bur # 2135.
19. The tooth reduction was guided by the impression mold of the diagnostic wax-up.
20. To improve the stability of the veneer and the anterior esthetics, the incisal edge was reduced. For comparison purposes, tooth 21 was not reduced yet.
21. The reduction of the incisal edge was also performed with a bur # 2135 in a 45 degree with the longitudinal tooth axis.
22. The amount of the teeth reduction was checked with the diagnostic wax-up impression.
23. The fnal preparation required only fnishing and polishing.
24. The preparation margins were rounded, and the unsupported enamel prisms were removed.
25. The area of the contact point was worn with a metallic abrasive strip.
24.
22.
20. 18.
25.
23. 21.
19.
142
26. The polishing was performed with a fne diamond bur and the abrasive disks Diamond Pro (FGM).
27. The dental preparations are ready for impression.
28. A second impression of the diagnostic wax-up was done to facilitate the fabrication of the temporary veneers.
29. A temporary material was inserted inside the second diagnostic wax-up.
30. The impression mold, flled with the temporary material, was taken into the patients mouth for fabrication of the temporary veneers.
31. Patients smile with the temporary veneers in position.
32. Intraoral view immediately after removal of the impression mold. The temporary veneers were not fnished at this point yet.
33. Stone model with the prepared E-max veneers and crown.
32.
30.
28.
26.
33.
31.
29.
27.
143
34. Incisal view of the ceramic veneers and crown.
35-37. Close view of the porcelain E-max pieces.
38-41. E-max pieces outside the stone model.
40.
38.
36.
34.
41.
39.
37.
35.
144
42. Patients smile with the temporary restorations before cementation.
43. Intraoral view of the temporary restorations in place before the cementation procedure.
44. E-max veneers being tested before cementation.
45. Condac Porcelain (FGM) was used for the internal surface conditioning of the ceramic pieces.
46. Condac Porcelain (FGM) was applied in the internal surface of the veneer.
47. Internal aspect of the ceramic veneer after conditioning.
48. Comparison of the internal surface of a conditioned and a non-conditioned veneer.
49. Modifed rubber dam isolation for cementation of the ceramic pieces.
48.
46.
44.
42.
49.
47.
45.
43.
145
50. Dental prophylaxis of the dental preparations.
51. Condac 37 (FGM) was applied in the right side of the upper arch.
52. Moisture control after conditioning with Condac 37.
53. Application of the primer with a Cavibrush (FGM).
54. Adhesive was applied with a Cavibrush.
55. Light-curing of the adhesive system.
56. After light curing of the adhesive on the dental preparation, the silane Prosil (FGM) was applied in the internal surface of the veneers.
55.
54.
52.
50.
56.
53.
51.
146
57-59. Sequence of silane Prosil application in the veneer.
60. The resin cement AllCem, shade A2, was selected for cementation of the veneers.
61. The resin cement AllCem was applied in the internal surface of the veneer.
62-63. The veneer was taken into position.
64. The resin cement excess was cleaned away from the teeth.
65. All veneers from the right side were cemented.
64.
62.
60.
57. 58.
65.
63.
61.
59.
147
66. Placement of the veneer of tooth 21.
67. Placement of the veneer of tooth 22, immediately after placement of the veneer in tooth 21.
68. Veneers of teeth 21 and 22 in position.
69. Removal of the resin cement excess from teeth 21 and 22.
70. Application of the resin cement Allcem in the internal surface of the ceramic crown of tooth 23.
71. Ceramic crown of tooth 23 placed in the dental preparation.
72. Ceramic crown of tooth 23 under pressure in the dental preparation.
73. Light-curing of the left side.
72.
70.
68.
66.
73.
71.
69.
67.
148
74-75. Veneers after cementation.
76-77. Final aspect, one week after cementation.
78. Close view of the incisors after cementation.
79. Final smile after veneer cementation.
80-83. Final patients smile after veneer cementation.
80.
78.
76.
74.
82.
81.
79.
77.
75.
83.
149
84-85. Final photographs of the patients face.
86-88. 4-year follow-up control.
88.
84.
89.
87.
85.
Design and Efciency allied
to a perfect t.
Whitepost.
White Post is a berglass post with High Mechanical Strength
acting as intraradicular reinforcement and promotes retention for
the nal restoration material or core llings for indirect restorations.
White Post presents Double Conicity and two versions:
DC and DCE Special.
Radiopacity
High translucency
Excellent light conductivity
Similar to dentin elasticity
Highly aesthetic
Silanized
Doble Conicity
Special - DCE
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Design and Efciency allied
to a perfect t.
Whitepost.
White Post is a berglass post with High Mechanical Strength
acting as intraradicular reinforcement and promotes retention for
the nal restoration material or core llings for indirect restorations.
White Post presents Double Conicity and two versions:
DC and DCE Special.
Radiopacity
High translucency
Excellent light conductivity
Similar to dentin elasticity
Highly aesthetic
Silanized
Doble Conicity
Special - DCE
M
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post copy.pdf 1 03/10/2013 09:15:53
152
Anatomical fber post after endodontic
re-treatment
ABSTRACT
Intra-radicular retainers are often used in endodontically treated teeth
with excessive loss of coronal dental structure. The objective of this article is
to report a clinical case where endodontic re-treatment was performed in a
discolored tooth (# 11) followed by immediate crown sealing with anatomical
shaping of a pre-fabricated fber post with a composite resin. The restorative
techniques used in this clinical case were reported in details.
INTRODUCTION
The non-surgical endodontic re-treatment aims to access the pulp
chamber and to remove the endodontic flling material of the root canal space.
This treatment also aims to repair and treat pathological or iatrogenic lesions,
when presented. With a three-dimensional hermetic flling, this technique
consists in promoting an effective disinfection of the root canals through a new
treatment to prevent re-infection through the crown restoration.
1
The correct sealing of the dental structure after endodontic treatment
is ideal for the repair of the periradicular tissues. This procedure consists of
making a functional and esthetic restoration capable to protect the remaining
dental structure so that a possible coronal leakage and subsequent bacterial
contamination can be prevented.
2,3
Intra-radicular retainers are often used in endodontically treated teeth
with excessive loss of coronal dental structure. The choice of materials used for
the restoration of endodontically treated teeth has changed. Nowadays hard
materials (stainless steel, gold and zirconia dioxide) were replaced by materials
that demonstrate mechanical properties that resemble the dentin structure
(composite resins and fber posts).
4

The selection of the material to be used as intra-radicular retainer is
essential for the success of the restoration of endodontically treated teeth.
For weakened roots, the material selection should be more careful as the
weakest link is the root walls so that the protection of the remaining root
tissue is desired.
Erika Manuela Asteria Clavijo
Specialist and MS in Endodontics.
Piracicaba School of Dentistry.
University of Campinas
(UNICAMP).
erikaclavijo@hotmail.com
Victor Grover Rene Clavijo
Restorative Dentistry. Araraquara
School of Dentistry. University of
the State of So Paulo (Unesp).
Caio Cezar Randi Ferraz
Associate Professor of the
Department of Restorative Dentistry
and Endodontics. Piracicaba
School of Dentistry. University of
Campinas (UNICAMP).
153
The ideal material should be suffciently elastic to
deform and even fracture before damaging the remaining
dental structure. It is desirable that the fber post bonded to
the root canal walls forms a monoblock. For such aim, the
restorative materials should have mechanical properties
similar to that of dentin. Additionally, the fber post should
adapt and bond well to the root canal walls.
5,6
Within this
context, fber post has advantages over cast metal cores
as they have an elastic modulus (45 GPa)
7
closer to the
dentine (18.6 GPa)
5
while the metallic fber posts (nickel
chromium) has an elastic modulus of approximately 210
GPa. The objective of this clinical case is to report an
endodontic re-treatment, followed by immediate crown
sealing with anatomical shaping of the pre-fabricated fber
posts with a composite resin.
LITERATURE REVIEW
Most of the factors associated with endodontic
treatment failures are related with the failure in preventing
or eliminating the primary infection of the intra-radicular
area. Technical problems for endodontic disinfection
arises from non-adherence of the professional to widely
accepted protocols, such as adequate aseptic control
of the operative feld, adequate access of the root canal,
cleaning and shaping of the root canals and appropriate
restoration of the dental crown. The failure to one of
these steps results in re-contamination through marginal
infltration.
8
The failure causes of endodontically treated teeth
can be classifed into three main categories. They can
be caused by prosthetic, periodontal and endodontic
reasons. Vire
9
in a study with 116 extracted teeth with
endodontic treatment concluded that 59.4% of the failures
were caused by prosthetic factors and 32% and 8.6%
were caused by periodontal and endodontic reasons,
respectively.
Imura et al.10 (2007) evaluated the results of initial
endodontic treatment and non-surgical endodontic re-
treatment performed by a specialist in his private offce.
A total of 2000 teeth were examined clinically and
radiographically. The results were statistically analyzed
by Pearson or Fishers exact text and multivariate logistic
regression. Multivariate analysis evaluated associations
between various factors and revealed that teeth without
fnal restoration can negatively affect the success rate of
the endodontic treatment.
Another study investigated the association between
the success or failure and the presence of a coronal
restoration after endodontic treatment. A study with
200 endodontically treated teeth was performed. The
cases were evaluated 3.5 and 4.5 years after the initial
endodontic treatment. The results showed teeth with
defnitive restorations showed a success rate of 80%,
which was higher than the success rate of teeth without
restorations (60%).
11
Grandini et al.
12
(2003) reported a clinical case where
a fberglass post was associated with a dual cure resin
cement. Anatomical shaping of the pre-fabricated fber
post with a composite resin was prepared to improve the
adaptation of the fber post to the root canal walls. This
procedure aims also to reduce the thickness of the cement
layer. Clavijo et al.
13
(2008) reported a clinical case using
an indirect anatomical fber post as this material possess a
biomechanical behavior similar to that of dentin. This was
an alternative to rehabilitate endodontically-treated teeth
with considerable loss of dental structure. According to
Clavijo
14
(2006), the restoration with this material reduces
the risk of irreversible root fractures.
154
CASE REPORT
A 32-year old male patient sought for dental
treatment, with the complain that tooth 11 became
very dark after endodontic treatment (Figure 1). After
anamnesis, clinical and radiographic evaluation, we
diagnosed that the discolored tooth 11 had undergone
endodontic treatment and presented a darkened crown
with a composite resin restoration. The patient reported
that the initial endodontic treatment (Figure 2) was
performed 15 years ago because of a dental abscess.
The initial clinical examination revealed that the
patient had good oral hygiene and had no signs of gingivitis
and/or periodontal disease. We opted for endodontic re-
treatment of tooth 11 with the immediate preparation
of an anatomical post after endodontic-retreatment. A
provisional restoration was also prepared for tooth 11.
Before starting the endodontic procedure, a provisional
restoration for tooth 11 was prepared (Figure 3). For the
endodontic treatment, the provisional restoration was
removed (Figures 4 and 5), and a distant rubber dam isolation
performed not to harm the gingival tissue of tooth 11 (Figures
6 and 7). The removal of the flling material was performed
using a Largo drill #2 and gate drills #4, #3 and #2 (Figure 8)
1. Initial aspect.
2. Initial periapical radiograph.
3. Temporary restoration fabricated before the treatment.
4. Removal of the temporary restoration.
5. Tooth 11 after removal of the temporary restoration.
1.
3.
4.
2.
5.
155
along with endodontic fles (Figure 9). A saline solution was
used as an irrigating solution, and the 2% chlorhexidine gel
was used as an auxiliary chemical substance for endodontic
re-treatment. After the removal of the endodontic flling, the
root canal was prepared with the technique proposed by the
Piracicaba School of Dentistry (University of Campinas) with
foraminal patency and expansion.
The smear layer was removed with 17% EDTA and
the fnal irrigation was performed with saline solution. The
main gutta-percha cone was tested in position (Figures
10 and 11). The fllling of the endodontic space was
performed with calcium hydroxide-based cement using a
single gutta-percha cone, followed by continuous thermo-
activated condensation (Figure 12). After endodontic re-
treatment (Figure 13), we initiated the shaping of the pre-
fabricated fber post with a composite resin as reported
by some authors (Grandini et al. 2003, Clavijo et al. 2006,
2008, 2009).
Post space preparation
The internal walls of the root canal were regularized
with the corresponding bur of the fber post # 3 (White Post
6. Distant rubber dam isolation.
7. Occlusal view of the distant rubber dam isolation.
8. Gutta-percha removal.
9. Endodontic re-treatment.
8.
7.
6.
9.
156
10. Testing the main gutta-percha cone.
11. Periapical radiograph of the main gutta-percha cone in position.
12. Thermo-activated condensation.
13. Endodontic obturation of tooth 11.
14. Corresponding bur of the fber post # 3 from the kit White Post DC (FGM, Brazil).
15. The root canal walls were regularized with the corresponding bur of the fber post # 3 (White Post DC, FGM, Brazil).
DC, FGM, Brazil) (Figures 14 and 15). This procedure was
performed to remove retentive areas that could jeopardize
the root canal modeling. The fberglass post #3 (White
Post DC, FGM) (Figure 16) was inserted into the root canal
(Figure 17), and a periapical radiograph was performed
to confrm its adaptation at the bottom of the root canal
preparation (Figure 18).
Fabrication of the anatomical fber post
The glass fber post was conditioned with 37%
10. 11.
14. 15.
12. 13.
157
16. Fiber post # 3 (White Post DC, FGM).
17. Testing the fber post in position.
18. Periapical radiograph with the fber post in position.
19. Conditioning of the external surface of the fber post with 37% phosphoric acid.
20. Water rinsing of the fber post with running water.
21. Application of the silane on the external surface of the fber post.
22. Adhesive application on the surface of the fber post.
23. Gentle air stream after adhesive application.
24. Light-curing of the adhesive placed on the fber post.
phosphoric acid gel (Condac 37- FGM, Brasil) (Figure 19)
for 60 seconds, followed by water rinsing (Figure 20) for
30 seconds and drying. Then, the fber post was coated
with a layer of the silane coupling agent (Prosil, FGM) for
1 minute (Figure 21). The adhesive was applied (Figure
22), the adhesive excess removed with gently air drying
(Figure 23) and the material eventually light-cured for 40
seconds (Figure 24). The fber posts were covered with a
microhybrid composite resin (Opallis, FGM), and the set
(fber post + uncured composite resin) was inserted into
20.
19. 16. 17. 18.
21. 22.
23. 24.
158
25. Lubrication of the root canal walls with a natrosol-based gel.
26. The set composite resin + fber post was inserted in the canal space.
27. The excess of resin was removed with the aid of a spatula.
28. After removal of the resin composite excess.
29. Light curing for 10 seconds.
30. Removal of the anatomical fber post.
31. Removal of the anatomical fber post.
the canal (Figure 26), previously lubricate with a natrosol
based gel (Figure 25). The resin excess was cleaned away
with the aid of a spatula (Figures 27 and 28).
The set was light-cured for 10 s with the post
inside the conduit (Figure 29). The anatomical fber post
was then carefully removed (Figures 30 and 31), and
the relining composite resin was also light-cured for 60
seconds (Figure 32). With a diamond bur mounted in
a high speed hand-piece, the composite resin surface
was roughened to avoid possible distortions after light-
curing. To assess the adaptation of the anatomical post,
the set was inserted again in the root canal space (Figure
33).
The surface treatment of the anatomical post (Figure
34) was performed with a 37% phosphoric acid (Condac
37- FGM, Brazil) for 60 seconds (Figure 35), followed by
water rinsing (Figure 36) for 30 seconds and air-drying.
Then, a coat of silane was applied on the surface of the
anatomical post for 1 minute (Figure 37) and light-cured
for 40 seconds. In the sequence, the post space was
25.
27.
26.
28.
31. 29. 30.
159
32. Outside the root canal space, the anatomical post was light-cured for 60 seconds.
33. The anatomical post is ready.
34. Anatomical post.
35. Surface treatment of the anatomical post with 37% phosphoric acid.
36. The fber post was rinsed with running water.
37. The adhesive was applied on the surface of the anatomical fber post.
irrigated with a 2% chlorhexidine solution for 1 minute,
followed by rinsing and drying.
Post luting procedures
The root canal walls of all roots were etched with
37% phosphoric acid gel (Condac 37, FGM, Brazil) for
15 seconds, followed by water rinsing and drying using
paper points. The primer was applied with a microbrush
followed by an air stream for solvent evaporation. After
a delay of 20 seconds, the adhesive was applied with a
microbrush; the excess removed with paper points and
also an air stream was applied for solvent evaporation.
The adhesive was light-cured for 40 seconds.
The dual-cured resin cement AllCem (FGM, Brazil)
was placed inside the root canals. A thin layer of the resin
cement was also applied on the surface of the anatomical
post before its placement in the root space (Figure 38).
The excess was cleaned away with a brush (Figure 39)
and an explorer. The buccal and the palatal surfaces was
light-cured for 60 second each.
33. 32. 34.
36. 37.
35.
160
Restoration of the remaining dental crown
The restoration of the coronal portion of the crown
followed the next protocol: 37% phosphoric acid 37% (37
Condac, FGM, Brazil) for 60 seconds (Figure 40), rinsing
with a water spray (Figure 41), drying of the adhesive (Figure
42) and light curing for 40 seconds (Figure 43).
Then, the composite resin Opallis (FGM, Brazil) was
used to reproduce the lost coronal structure of the tooth
(Figure 44). The composite resin was light-cured for 40
seconds (Figure 45). The anatomical post was sectioned
38. The anatomical fber post was cemented on the root canal space of tooth 11.
39. The excess of resin cement was cleaned away with a brush.
40. The remaining dental crown was conditioned with 37% phosphoric acid.
41. Rinsing with water/air spray.
42. Adhesive application.
43. Light-curing for 40 seconds.
44. Restoration of the remaining dental crown with a composite resin.
45. Light curing the composite resin core.
38.
40.
39.
41.
45. 44.
42. 43.
161
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46. Sectioning of the anatomical fber post.
47. Appearance of fber post after sectioning.
48. Dental preparation of the tooth 11.
49. Gingival retraction.
46.
48.
47.
49.
(Figures 46 and 47), and the preparation was performed
with a diamond bur # 3098 MF. A rounded shoulder was
prepared in the marginal area of the preparation for the
cementation of a metal-free indirect ceramic restoration.
After dental preparation (Figure 48), an impression of the
162
area was performed with an addition silicone. For this
purpose, the gingival tissue was retracted using the double
retraction cord technique (Figure 49).
The indirect provisional restoration was fabricated
using a silicone guide prepared on the diagnostic wax-up
50. 51. 52.
53.
54.
50. A temporary restoration was prepared with bis-acryl resin.
51. The temporary restoration was polished with exacerapol (DHPRO - Paran - Brazil).
52. Final radiograph.
53. Initial aspect.
54. Final temporary restoration (Murilo Calgaro). After this step, the esthetic treatment was completed with a periodontal gingival coverage of tooth 23, dental bleaching and
fabrication of a ceramic crown in tooth 11.
model with the Zetalabor material (Figures 50 and 51). In a
single session, the endodontic re-treatment was performed
followed by complete restoration of the remaining crown
with an anatomical fber post (Figure 52).
163
DISCUSSION
In this clinical case, an endodontic re-intervention
was recommended due to the time elapsed since the
initial endodontic treatment (15 years) and also due to
the esthetic dissatisfaction of the patient and the need
to change the restoration with coronal microleakage.
We performed the anatomical shaping of the fberglass
posts with a composite resin. Immediately after, we
sealed the crown under under rubber dam isolation in an
aim to reduce then number of sessions and the risk of
contamination. This procedure was performed because
endodontically teeth are more prone to contamination
when they are provisionally restored
10
or submitted to
restorative procedures without rubber dam isolation. In this
clinical case, after endodontic flling, the composite resin
core was immediately prepared as this also contributes
for the fnal retention of the restoration and for the root
canal space.
An intra-radicular fberglass post was selected to
create a monoblock system and biomimetism between
the properties of dentin and the post/cement set as
dentin (18 GPa) and the restorative system present
similar properties. Besides that, it allows the cementation
procedure to be done in a single session soon after the
endodontic re-treatment under rubber dam isolation
(Chugal et al., 2007, Clavijo at el., 2008).
12
As there was a mismatch between the root canal
space and the diameter of the fber post, an anatomical
shaping of the post with a composite resin was performed
in order to reduce the thickness of the resin cement.
By doing so, the anatomical post exert high hydraulic
pressure on the resin cement against the dentin walls,
resulting in better contact between the cement/post set
and dentin.
14
This pressure reduces the volume of resin
cement employed, reduces the blister formation in the
cement layer eliminating sources of faw-initiating sites;
increases the number of tubules flled with the resin
cement and the consequent reduces the retention loss of
the fber post, which is the main factor responsible for the
clinical failure of this procedure.
In this clinical case, the immediate sealing was
performed protecting the remaining dental structure and
reproducing the esthetic and masticatory function in
accordance with scientifc and clinical evidence.
12,13,14
CONCLUSIONS
According to the case report and the literature
review, one can conclude:
The crown sealing is particularly relevant for
success and predictability of the endodontic treatment/re-
treatment. The use of an anatomical fber post cemented
immediately after the endodontic treatment allows better
sealing than that provided by a provisional restoration. The
cooperation between the endodontist and prosthodontist
enables the development of a treatment plan and
integrated diagnostics with an appropriate selection of
materials and techniques.
REFERENCES
1. Fristad I, Molven O, Halse A. Nonsurgically retreated root flled teeth: Radiographic
fndings after 20-27 years. Int Endod J. 2004; 37: 12-8.
2. Hommez GM, Coppens CR, De Moor RJ.Periapical health related to the quality of
coronal restorations and root fllings. Int Endod J. 2002 Aug;35(8):680-9.
3. Mindiola MJ, Mickel AK, Sami C, Jones JJ, Lalumandier JA, Nelson SS. J Endod.
Endodontic treatment in an American Indian population: a 10-year retrospective
study. J Endod. 2006 Sep;32(9):828-32. Epub 2006 Jul 3.
4. Boschian Pest L, Cavalli G, Bertani P, & Gagliani M (2002) Adhesive post-endo-
dontic restorations with fber posts: push-out tests and SEM observations Dental
Materials 18(8) 596-602.
5. Ferrari M, Vichi A, Garca-Godoy F. Clinical evaluation of fber-reinforced epoxy re-
sin posts and cast post and cores. Am J Dent. 2000 May; 13(Spec No):15B-18B.
6. Fonseca RG, Santos JG, Adabo GL. Infuence of activation modes on diame-
tral tensile strength of dual-curing resin cements. Braz Oral Res. 2005 Oct-
-Dec;19(4):267-71. Epub 2006 Feb 14.
7. Akkayan B, Glmez T. . Resistance to fracture of endodontically treated teeth res-
tored with different post systems. J Prosthet Dent. 2002 Apr; 87(4):431-7
8. Nair PNR. On the causes of persistent apical periodontitis: a review. Int End J.
2006; 39:249-81.
9. Vire DE. Failure of endodontically treated teeth: classifcation and evaluation. J
Endod. 1991 Jul;17(7):338-42.
10. Imura N, Pinheiro ET, Gomes BPFA, Zaia AA, Ferraz CCR, Souza-Filho FJ. The
outcome of endodontic treatment: a retrospective study of 2000 cases performed
by a specialist. J Endod. 2007; 33: 1278-1282.
11. Chugal NM, Clive JM, Spangberg LS.Endodontic treatment outcome: Effect of the
permanent restoration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007
Oct;104(4):576-82.
12. Grandini S, Sapio S, Simonetti M. Use of anatomic post and core for reconstruc-
ting an endodontically treated tooth: a case report. J Adhes Dent. 2003; 5:243-7.
13. Clavijo VGR, Monsano R, Calisto LR, Kabach W, Clavijo EMA, Andrade MF. Reabi-
litao de dentes tratados endodonticamente com pinos anatmicos indiretos de
fbra de vidro. Rev Dental Press Estet. 2008 Abr- Jun; 5 (2): 31 49
14. Clavijo VGR, Anlise da resistncia fratura de razes fragilizadas utilizando dife-
rentes tcnicas de pinos intra-radiculares [tese]. Araraquara: faculdade de odon-
tologia, UNESP 2006.
Double remineralizing action:
Fluoride + Hydroxyapatite
Some food and drink may
increase pressure on dentin
tubules
Nano P occludes dentin
tubules reducing painful
stimuli
Contains 1 syringe with 3g of product and 5 applications tips
PROVEN REMINERALIZATION AND
DESENSITIZATION IN ONE PRODUCT*.
* Calazans FS et al. Efect of bioactive principles in bovine enamel subjected to erosion. J Dent Res#91(Spec Iss B):504, 2012(www.dentalresearch.org).
** See products technical prole (www.fgm.ind.br/en) Youre Worth It. www.fgm.ind.br/en
Hydroxyapatite
Nanoparticles
Sodium uoride
Potassium nitrate
Anuncio_nanoP_2013 copy.pdf 1 03/10/2013 09:04:47
Double remineralizing action:
Fluoride + Hydroxyapatite
Some food and drink may
increase pressure on dentin
tubules
Nano P occludes dentin
tubules reducing painful
stimuli
Contains 1 syringe with 3g of product and 5 applications tips
PROVEN REMINERALIZATION AND
DESENSITIZATION IN ONE PRODUCT*.
* Calazans FS et al. Efect of bioactive principles in bovine enamel subjected to erosion. J Dent Res#91(Spec Iss B):504, 2012(www.dentalresearch.org).
** See products technical prole (www.fgm.ind.br/en) Youre Worth It. www.fgm.ind.br/en
Hydroxyapatite
Nanoparticles
Sodium uoride
Potassium nitrate
Anuncio_nanoP_2013 copy.pdf 1 03/10/2013 09:04:47
166
Research with
products
The constant improvement of our products is achieved, in large part, by the scientifc knowledge we get from
research centers that perform various tests on our materials. Sometimes the studies evaluate the characteristics of the
products and other times the effcacy of different techniques. One way or another, everyone wins with this cycle: ma-
nufacturers, professionals and patients. Therefore, we are immensely grateful to all researchers interested in producing
evidence-based knowledge. It is our role to spread it to our readers so that they can be up-to-date with the results of
relevant studies.
FGM PRESENTS EVIDENCE-BASED STUDIES
CarvalhO lD, lOpes G. Shear bond strength of adhesive systems with diferent Application Protocols.
J Dent Res 91 (spec Iss B): 1667, 2012 (www.dentalresearch.org).
Objective: To evaluate the effectiveness of two total etching adhesive systems applied to dentin with different
application manners.
Method: Twenty four extracted bovine teeth had their buccal coronal surfaces coarsely grounded until dentin
and were sectioned in two equal parts to be used with the same adhesive. each part of the tooth received a different
application manner. The tooth surfaces were grounded until 600-grit silicon carbide paper under running water and the
teeth were randomly divided into 2 adhesive groups with two application modes (n=12): G1: ambar(FGM) immediately
photo-cured (a0); G2 ambar photo-cured 30 seconds after application (a30); G3: Tetric N-Bond (Ivoclar/vivadent) imme-
diately photo-cured (T0) and G4: Tetric N-Bond photo-cured 30 seconds after application (T30). Cylinders of a fowable
composite resin Opallis fow, shade a1 (FGM), with 1.4 mm diameter size were bonded to the photo-cured adhesives.
The specimens were stored at 24C for 24 h and then subjected to the shear bond strength test in a INsTrON Univer-
sal Testing Machine (model 4444), at a cross-head speed rate of 0.5 mm/min. One-way aNOva showed no signifcant
differences between the group.
Result: The mean shear bond strength (sBs) for the tested groups was: 9.32 Mpa (a0), 9.51 Mpa (a30), 8.42
Mpa (T0), and 10.07 Mpa (T30).
Conclusion: The adhesives systems tested showed similar bond strength to bovine dentin and the application
mode did not infuence in bond strength results.
1
FGM
Da rOCha KBF, aNDraDa MaC, BerNarDON JK, vIeIra lCC e BaraTIerI lN. Clinical evaluation
of a microhybrid composite in non-carious cervical lesions. J Dent Res 91 (spec Iss B): 2019, 2012 (www.
dentalresearch.org).
Objective: The purpose of this study was to evaluate the clinical performance of the universal microhybrid compo-
site Opallis (FGM, Joinville, sC, Brazil) in restorations of non-carious cervical lesions (NCCls) during 18 moths.
Method: Twenty-fve patients affected with forty NCCls (n=40) located either in upper and lower premolars were
selected according to inclusion/exclusion criteria previously established. The NCCls were restored by a single trained
operator, with no beveling, incremental technique and photo-curing according to manufacturers instructions. The res-
torations were evaluated at baseline, 6 months and 18 months, by two calibrated examiners, according to the modifed
Usphs criteria for color stability, surface brightness, and maintenance of anatomical form, retention, marginal integrity,
marginal discoloration, caries incidence, periodontal health and postoperative sensitivity.
Result: all the restorations received alFa(a) ratings in all of the clinical criteria from baseline to the 18-mon-
th evaluation visit (40a/40a/40a), except for surface brightness (40a/40a/35a) and maintenance of anatomical form
(40a/40a/35a) at 18 months. statistical analysis conducted through Walds test (p<0.05) revealed no statistically signif-
cant differences for the evaluated criteria.
Conclusion: The 18-month clinical performance of the universal microhybrid composite Opallis in restorations of
NCCls was considered satisfactory.
2
pereIra pNr, araUJO Ks, COrrea pe, saMpaIO pC, MaCeDO Jl, GarCIa FC e hIlGerT la. Degree
of conversion of composite resins under diferent post-polymerization protocols. J Dent Res 91 (spec Iss B):
1409, 2012 (www.dentalresearch.org).
Objectives: The purpose of this study was to evaluate the effect of different post-polymerization protocols on the
degree of conversion (DC) of three commercially available composite resins.
Methods: Fifteen 0.5 mm composite resin disks (shade a2) were fabricated using Z350XT (3M espe, eUa),
Opallis (FGM, Brazil) or empress Direct (Ivoclar vivadent, liechtenstein), and light-cured for 20 s with an leD curing unit
(Bluephase G2, Ivoclar vivadent, liechtenstein). Ten disks were divided into 2 post-polymerization groups (125C for 10
min or 130C in an autoclave cycle). The other 5 disks were used as the control group (light-curing only). The DC was
determined by means of a Fourier Transform Infrared spectroscopy with an attenuated total refectance (aTr) device after
48 h. The data were analyzed by one-way aNOva and Tukey tests (p<0.05).
Results:
Conclusions: Increased DC upon both post-polymerization strategies was shown to be composite dependent.
although statistically signifcant differences were shown for empress Direct and Opallis, these differences were not high
enough to suggest routine use of these post-polymerization strategies. supported by pIBIC (CNpq) 2010/2011.
3
Z350 XT
DC (%)
64.19
65.79
64.31
empress Direct
DC (%)
67.68
71.41
68.98
Opallis
DC (%)
70.78
69.96
71.55
sD
1.07
2.54
1.48
sD
0.90
0.45
0.83
sD
1.02
0.65
0.33
p=0,33
A
A
A
p<0,01
A
C
B
p<0.02
aB
A
B
light-Curing Unit
Oven (125C)
autoclave (130C)
same uppercase letters in the same row indicate p>0.05.
167
168
sOUZa JB, sIlva CO, lOpes lG, esTrela C e esTrela Cra. Antimicrobial efcacy of glass ionomer
cement. J Dent Res 91 (spec Iss B): 1731, 2012 (www.dentalresearch.org).
Objective: To assess the antimicrobial activity of three commercially available glass ionomer cements (Vitremer,
Maxxion r, and vidrion r).
Method: The antimicrobial effectiveness was assessed by means of agar diffusion method in petri plates with 20
ml of BhIa previously inoculated with 0.1 ml of biological indicator (streptococcus mutans - aTCC 25175) and then
maintained in adequate atmosphere for 48 hours. Microbial inhibition zones, indicative of effectiveness of the tested
materials, were measured using a digital caliper with a resolution of 0.01 mm, after 24 and 48 hours.
Result: The Maxxion r cement was effective on the analyzed bacteria, in 24 as in 48 hours, establishing different
growth inhibition areas. The vitremer cement showed antimicrobial activity only after 48 hours while the vidrion r did not
promote inhibition zone. among the products tested, the largest inhibition halo was observed for the vitremer cement.
Conclusion: The vitremer and Maxxion r cements showed antimicrobial activity against streptococcus mutans.
4
5BONIFaCIO C, hesse D, raGGIO Dp, BNeCKer M, vaN lOvereN C, vaN aMerONGeN e. Glass ionomer
cement brand infuence in the survival rate of approximal ART-restorations. J Dent Res 91 (spec Iss B): 110,
2012 (www.dentalresearch.org).
Objective: laboratory studies show diverse behavior of different brands of glass-ionomer cements (GIC) while
clinical studies are generally performed with the strongest and most expensive materials. as the failure of approximal arT
restorations is mainly related to mechanical properties of the GIC, the aim of this study was to evaluate the survival rate
of approximal arT restorations using three different GIC-brands.
Method: a total of 262 primary molars with approximal caries lesions were restored in 5-8 years old children in
Itatiba city, Brazil. The patients were randomly allocated in three groups: G1 Fuji IX (GC, Be); G2 hI Dense (shofu,
Ge) and G3 Maxxion r (FGM, Br). after caries removal with hand instruments, the cavities were restored with one of
the GICs by two trained operators. restorations were evaluated after 1, 6, 12, 18, 24, 30 and 36 months according arT
criteria. Failed restorations were if possible, repaired or replaced by another arT restoration using the same GIC. Chi
square test (5% signifcance) was used to evaluate the infuence of GIC-brand, tooth-surface and operators in the survival
rate in each evaluation. The repaired restorations were also evaluated in relation to the tooth survival and the GIC brand.
Result: There was no difference in success rate among the different brands of GIC. signifcant operator and tooth-
-surface infuence were found at all evaluations, with the distal surface presenting the higher number of failures. a drop-
-out of 18% was observed, and overall survival of the restorations was 12% after 36 months. Of the repaired restoration,
the tooth survival rate was 74%, and there was no difference among the different GIC-brands.
Conclusion: There is no infuence of the brand of the GIC in the survival rate of approximal arT restorations. re-
pairing and replacing failed ART restorations is indicated to increase the survival of the tooth.
169
MarTINs Mv, lOpes G, GONDO r. Clinical evaluation efectiveness hydrogen peroxide gel 20% in-ofce
bleaching technique. J Dent Res 91 (spec Iss B): 2715, 2012 (www.dentalresearch.org).
Objective: The objective of this study was to evaluate the use of hydrogen peroxide 20% for offce bleaching
technique for color change, number of sessions required and tooth sensitivity.
Method: Fifteen selected patients were submitted to different bleaching techniques performed by quadrants,
Group I: right quadrants received 35% hydrogen peroxide gel (Whiteness hp Blue, FGM, Brazil) and Group II: left qua-
drants received 20% hydrogen peroxide gel (Whiteness hp Blue, FGM, Brazil). It was applied a gingival barrier (Top Dam,
FGM, Brazil) followed by application of the whitening gel from the right second premolar to the left second premolar. a
mylar strip was placed between the maxillary central incisors to isolate gels. The application time was in accordance with
the manufacturers recommendations, 50 min. for G 1 and 40 min. for G II, repeated weekly, until reaching the patient
satisfaction, with a maximum of 6 sessions. shade evaluation was made from maxillary canine to canine, using a shade
guide (bleached vITa 3D-MasTer) and a spectrophotometer (vITa easyshade) in moments initial and before each ses-
sion of bleaching. sensitivity was assessed using a 0-10 vas scale.
Result: The results showed that, there was no statistically signifcant difference between the bleaching agents for
color change. G II required the same number of sessions that G I. For tooth sensitivity, there was no statistically signifcant
difference between the bleaching agents.
Conclusion: It is concluded that the hydrogen peroxide gel is as effective as gel 35% hydrogen peroxide.
CarvalhO FG, BrasIl vlM, FIlhO TJs, CarlO hl, saNTOs el, BarrOs sr e vIeIra aap. In vitro efects
of remineralizing products on enamel erosion. J Dent Res 91 (spec Iss B): 2454, 2012 (www.dentalresearch.org).
Objective: To assess the effect of a fuoride varnish, a Cpp-aCp paste and a calcium nano-phosphate paste on
preventing enamel erosion produced by soft drink using Knoop microhardness (KNh).
Method: sixty human permanent enamel specimens (4 x 4 mm) were randomly assigned to four groups (n=12)
according remineralizing products application: 1- control (without application), 2- Cpp-aCp paste (MI paste plus- GC
america), 3- fuoride varnish (Duraphat-Colgate) and 4- calcium nano-phosphate paste (Desensibilize Nanop -FGM). The
baseline KNh measurements were made in each specimen and four daily demineralizationremineralization cycles of 5
minutes of immersion in a cola drink and 2h in artifcial saliva were conducted during 7 days. Immediately following each
erosive challenge, the specimens were exposed to the products, according each group, except to varnish fuoride that
was applied only one time, after the frst erosive challenge. all specimens were stored in artifcial saliva between and after
cycles. The fnal KNh measurements were made after erosive challenge. The data were analyzed using T test and Two-way
aNOva and Tukeys tests.
Result: The mean baseline standard deviation was approximately 358.3 7.0 KNh values for all groups. enamel
hardness signifcantly decreased after immersion in cola drink for all groups (T test, p<0.05). after erosive challenge, there
was no statistically signifcant difference between groups 1 (96.8 11.4) and 3 (91.7 14.1) in KhN values. Group 4
showed signifcantly higher KNh values (187.2 27.9) in comparison with group 2 (141.8 16.5) (Tukey test, p<0.05).
The % enamel hardness change was lower to group 4 (49.0 7.9) in comparison with groups 1 (72.4 3.0), 2 (60.6
4.0) and 3 (73.4 5.5).
Conclusion: The use of calcium nano-phosphate and CppaCp pastes had a protective effect on enamel erosion
in an in vitro model.
6
7
170
for publication of clinical cases
Dear doctor,
FGM is investing in a new way to promote their products, techniques and also disseminate the work
performed by its partners through the edition and impression of this journal. Tis journal is currently
distributed throughout Brazil and will soon be extended to Latin America and Europe.
To facilitate the selection of clinical cases to be published in the journal and increase our database
for dissemination in other company media, we are now presenting an authors guideline for submission of
clinical cases. We ask your attention to the guidelines described below:
Te clinical cases should be sent for:
FGM Dental Products Department of Scientifc Advisory.
Av. Edgar Nelson Meister, 474 Dist. Industrial Joinville/SC CEP 89219 501
or fgm@fgm.ind.br
ARTICLE
Title in portuguese, name of the author (s) with
the respective academic titles, abstract, introduction,
literature review, objectives, material and methods,
results, discussion, conclusions, references and the
authors pictures.
CLINICAL CASE REPORT
Title in portuguese, name of the authors with the
respective academic titles, abstract, introduction and/
or objectives, literature review, discussion, conclusions,
references and the authors pictures.
PRESENTATION OF CLINICAL TECHNIQUES
respective academic titles, abstract, introduction and/or
objectives, presentation of the techniques, discussion,
conclusions, references and the authors pictures.
AUTHORS GUIDELINES
ILLUSTRATIVE SEQUENCE OF CLINICAL CASE
respective academic titles, description of the clinical case
reporting relevant information.
TEXT
The text should be provided in a printed copy and
digital fle prepared in the software Word for Windows
using arial 12. The subtitles of fgures in the step-by-step
protocol should follow the above description. The pictures
should be numbered in sequence and according to the
pictures sent.
PROFESSIONAL
send a printed copy and a digital fle prepared in
the software Word for Windows arial 12, with mini short
curriculum vitae. please send the authors signature on a
white paper for the purpose of scanning.
171
PICTURES
photographs should be sent in high resolution,
numbered according to their sequence and all with the
same size, so that the issue under description is in the
center of the image.
photographs in power point or Word will not be
accepted.
Images out of focus, with excessive brightness,
dark, or other problem that prevents the
visualization of the issue of interest will not be
accepted.
a color and new authors photograph should
contain the main author alone or with his team.
The minimum size for the photo is 5 cm x 7 cm,
preferably in high digital resolution.
The authors photograph out of focus or having
any other problem that prevents the impression
will not be accepted.
ETHICAL ISSUES
During the presentation of images and text,
one should avoid the use of initials name and
registration number of patients. The patient cannot
be identifed or be recognizable in photographs
unless they give written and informed consent for
publication, which must accompany the original.
The work should be accompanied by a statement
of responsibility and copyright transfer, signed by
all authors.
EVALUATION STEPS
The work will be evaluated by the FGM scientifc
advisory which shall decide whether the submitted article
is compatible with the editorial line, the divulgation method
and the publication date. The compatibility of the article
shall be applied pertaining the intended indication for the
product. The evaluation Committee shall deliver an opinion
on the original, containing one of three possible ratings:
unfavorable accepted with revisions or favorable.
The article which received the rating accepted
with revisions will be sent to the author(s) for appropriate
amendments within 20 days. The revised article will be
then reviewed by the assessor and, if considered suffcient
and appropriate, they will be rated as favorable.
PRESENTATION OF CLINICAL CASES
The clinical cases sent for publication will be part
of the FGM Dental products fles and may be used at
any time at the journal, brochures, newspaper, courses,
website and any other media giving the appropriate
credits to the author(s).
It is highly desirable that the clinical cases should
be performed only with FGM products. When products
of other brands (which are not of major importance) are
used, the technique protocol can be reported without
mentioning the product name and picture.
Important products for the technique that are not
available in FGM may be mentioned. all clinical cases
should include an initial intra-oral photograph and/or the
patients smile, especially showing the initial condition of
the case. The following photos should illustrate the step-
by-step protocol of the technique, quoting the products
used (e.g. acid conditioner, opaque resin, dentin resins,
enamel resins, effect or value resin, disks and polishing
pastes, bleaching gels, desensitizing agents etc.). The fnal
photograph should be attached showing the outcome in
an intra-oral view or the patients smile.
EXAMPLES
In cases of composite resin restorations, the
authors should value the detailed step-by-step protocol
used. When performing a polychromatic restoration, the
colors used, and its sequence should be reported. In the
case of fberglass post cementation, we request the initial
case photograph, the radiographs of the initial condition,
after endodontic flling removal, with the fber post in
position before cementation and the complete sequence
of cementation with the fnal photograph and radiographic
examination.
FGM Scientifc Advisory.
FGM Dental Products.
Finishing and polishing
in the smallest details.
Complete nishing and
polishing line, allowing
clinical and laboratory
restorations to reach the
maximum aesthetic level.
Youre Worth It.
www.fgm.ind.br/en
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pdf 1 03/10/2013 09:01:53

[...] dental bleaching should always be supervised by a dentist, as

dental bleaching can be considered a safe procedure as long as we follow

During bleaching, white stains can be seen in enamel. Tey represent

Table 1. Classifcation of the acidity of the self-etch systems.

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