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This pa ge inte ntiona lly le ft bla nk

Es s e n t i a l s o f

Es t h e t i c
D en t ist r y
M i n i m a l l y I n v a s i v e Es t h e t i c s
Vo l u m e Th r e e
This pa ge inte ntiona lly le ft bla nk
Es s e n t i a l s o f

Es t h e t i c
D en t ist r y M i n i m a l l y I n v a s i v e Es t h e t i c s
Vo l u m e Th r e e

Edited by
Avijit Banerjee BDS MSc PhD (Lond) LDS FDS (Rest Dent) FDS RCS (Eng) FHEA
Professor of Cariology and Operative Dentistry
Honorary Consultant/Clinical Lead, Restorative Dentistry
Head, Conservative and MI Dentistry
Kings College London Dental Institute at Guys Hospital
Kings Health Partners
London, UK

Series Editor
Brian J. Millar BDS FDSRCS PhD FHEA
Professor of Blended Learning in Dentistry;
Consultant in Restorative Dentistry; Specialist Practitioner, Kings College London Dental Institute
London, UK

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2015
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ISBN: 978-0-7234-5556-1
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Co n t en t s
Contributors vii
Preface from the Series Editor viii
Preface x
Chapter 1 Common clinical conditions requiring minimally
invasive esthetic intervention 1
M. Thomas
Chapter 2 Dental bleaching: materials 31
M. Kelleher
Chapter 3 Dental bleaching: methods 51
M. Kelleher
Chapter 4 Direct anterior esthetic dentistry with resin
composites 101
A. Dozic, H. de Kloet
Chapter 5 Direct esthetics: clinical cases 121
H. de Kloet, A. Dozic
Chapter 6 Direct posterior esthetics: a management
protocol for the treatment of severe tooth
wear with resin composite 147
J. Hamburger, N. Opdam, B. Loomans
Chapter 7 Direct posterior esthetics: clinical case 161
J. Hamburger, N. Opdam, B. Loomans
Chapter 8 Minimally invasive replacement of missing
teeth: Part 1 193
L. Mackenzie
Chapter 9 Minimally invasive replacement of missing
teeth: Part 2 tooth-coloured materials 257
L. Mackenzie
Index 323
v
This pa ge inte ntiona lly le ft bla nk
C O N T R I BU T O R S
Alma Dozic PhD DDS MSD Lo uis Macke nzie BDS
Specialist in Esthetic Composite Dentistry and Sleep General Dental Practitioner
Apnoea Treatment Selly Park Dental Centre;
Department of Dental Material Sciences Clinical Lecturer
Academic Centre for Dentistry Amsterdam (ACTA) University of Birmingham
Amsterdam Birmingham, UK
The Netherlands
Niek J M Opdam DDS PhD
Jo rie n Hamburg e r DDS Associate Professor
Department of Dentistry Department of Dentistry
Radboud University Medical Center Radboud University Medical Center
Radboud Institute for Health Sciences Radboud Institute for Health Sciences
Nijmegen Nijmegen
The Netherlands The Netherlands

Martin G D Kelle he r BDS (Ho ns) MSc FDSRCPS Michael Thomas BDS MSc MRD RCSEng
FDSRCS DGDP(UK) LDS RCSEng
Consultant in Restorative Dentistry Senior Teaching Fellow; Registered Specialist in
Kings College Dental Hospital Prosthodontics
London, UK Kings College London Dental Institute at Guys
Hospital
He in de Kloe t DDS MSD London, UK
Specialist in Esthetic Composite Dentistry
Private Practice: Arnhem;
Department of Cariology, Academic Centre for
Dentistry Amsterdam (ACTA)
Amsterdam
The Netherlands

Bas A C Loomans DDS PhD


Assistant Professor
Department of Dentistry
Radboud University Medical Center
Radboud Institute for Health Sciences
Nijmegen
The Netherlands
P R EFAC E F R O M
T H E SER I ES ED I T O R
Esthetic dentistry is a complex subject. In many ways it requ ires differen t skills
from those requ ired for disease-focussed clin ical care. Yet in other ways esth etic
den tistry is part of everyday den tistry. Th e team wh ich h as created th is series
sh ares th e view th at su ccess in esth etic den tistry requ ires a broad ran ge of
additional skills. Den tistry can n ow offer improved sh ade match in g throu gh to
smile design to reorgan isin g th e smile zon e.
Th e first volu me provided u sefu l, readily applicable in formation for th ose wish in g
to develop fu rth er th eir practice of esth etic den tistry. Th e provision of esth etic
den tistry requires a differen t ph ilosophy in th e dental clin ic an d th e in min ds of
th e clin ical team, a greater awaren ess of th e aspiration s of patien ts an d a solid
eth ical footin g. It also requ ires an ability to car ry ou t a detailed assessmen t of
den tal an d psych ological factors, offer meth ods to sh ow the patient th e available
option s an d, in some cases, be able to offer a ran ge of treatmen ts.
Th e secon d book in th e series focu ssed on smile design tech n iqu es an d some of
th e smile ch an gin g tech n iqu es par ticu larly wh ere tooth preparation is accept-
able. However th ere is an in creasin g con cern amon gst clin ician s an d patien ts
abou t th e amou n t of tooth redu ction some wou ld say destru ction , car ried ou t
to en h an ce esth etics, wh ile h ealth care in gen eral moves towards min imal in ter-
ven tion (MI). I believe patien ts sh ou ld receive th e best possible care, with the
option s n ot bein g limited by th e clin icians skill (or lack of skills). Hen ce, th e
vision for th is Essentials series an d th is th ird volume.
Th e sin gle biggest task th e team faced in pu ttin g th is series togeth er was to
create in formation for den tists across th e world: recogn isin g th at th ere are dif-
fering views on esthetics, MI, essen tial un derstan din g and skills an d patien ts
with differen t attitu des an d budgets. The specific ch allenge was creatin g a series
of books which addresses th ese diverse opin ion s, ran ging from the view that
tooth reduction is acceptable an d in evitable in produ cin g beau tifu l smiles
th in kin g reflected in Volu me 2 to th e view th at su ch tooth redu ction is abh or-
ren t an d u n acceptable an d th at th e MI approach is preferable, as covered in th is
viii
volume. I h ope th e series of books will satisfy both camps an d enable practition-
ers at all levels to develop skills to practise esth etics, wh ile respectin g tooth
tissu e.
We in ten d th is series to ch allen ge you r th in kin g an d approach to th e growin g
subject area of esth etic den tistry, particu larly by sh owin g differen t man agement
of common clin ical situ ation s. We do n ot n eed to rely on a sin gle formu la to
provide a smile make-over, promotin g on ly one treatmen t modality wh ere both
th e den tist an d th eir patien ts are losin g ou t; th e patien t losing valu able ir re-
placeable en amel as well as th eir fu tu re option s.
For those seeking an MI approach th e book will provide a su itable ran ge of effec-
tive procedures in esthetic den tistry.

Professor Brian Millar BDS FDSRCS Ph D FHEA

ix
P R EFAC E
It h as been a great pleasu re an d h on ou r to edit an d write Volu me 3 of th e n ew
Elsevier series en titled Essentials of Esthetic Dentistry, wh ich focu ses on den tal
esth etics an d caters for both den tal u n dergradu ates an d qu alified practition ers
alike.
Wh en I was asked origin ally to compile an d edit the con ten t for a n ew tome with
th e strap lin e Minimally Invasive Esthetics, I did feel a pan g of concern abou t the
direction an d motive of th e textbook an d the series in relation to th e apprecia-
tion of minimally invasive (MI) approach es by th e den tal profession as a wh ole.
Su rely, I th ou ght, all operative dentistry sh ould be esth etic an d th e preservation
of natu ral, biological tissu es must be all clin ical operators primary aim and
objective? Or, in my naivety, is the more invasive one (or multiple) visit and smile
make-over th e positive direction forward?
It was at th at momen t I appreciated th e real valu e of th is n ew volu me an d its
importan t position in dental literature. There is a vital, an d perh aps u nmet, n eed
to h igh ligh t th e con siderable an d sign ifican t differen ces between den tal cos-
mesis, wh ich aims to deliver operative care solely for th e improvemen t of th e
appearan ce of biologically h ealthy den tal an d oral tissu esand den tal esthetics,
wh ich aims to repair an d cor rect esth etically all oral an d den tal tissu e defects
created by u nderlyin g path ology or trauma. The former approach often relies
tradition ally on cu ttin g away sign ifican t qu an tities of biologically sou n d tissu es
an d replacin g them with ar tificial restorative materials; wh ereas the latter
focuses on th e MI repair, refu rbish men t or replacement of minimal qu antities
of defective tissues, an d often with directly placed, adh esive den tal materials.
With th ese definitions in min d, I developed th e con ten ts for th is importan t
volume with a logical th eme, startin g with the discu ssion of possible patho-
physiological aetiologies of biological tooth damage. Th ree of th e more common
MI tooth preser vin g operative solu tion s to treat su ch con dition s h ave been dis-
cu ssed an d described in detail: den tal bleach in g, th e ju diciou s u se of adh esive
resin composite restoration s to re-con stitu te teeth effectively in both th e an terior
x
an d posterior den tition , an d th e u se of MI tech n iqu es for replacin g missin g
teeth , both directly an d indirectly. The auth oritative scien tific an d clin ically
eviden ce-based con tribu tion s from carefu lly selected world-class experts in th ese
areas of MI operative den tistry h ave h igh ligh ted th e way in wh ich h igh -qu ality
esth etics can be ach ieved with min imal biological cost an d acceptable lon gevity,
with ou t lon g-term detrimen t to th e patien t. In all cases, commu n ication amon g
den tist, team an d patien t is of paramou n t impor tan ce in en su rin g th e patien ts
expectation s are appreciated, man aged an d met. Some of th e h igh -qu ality, con -
temporary operative tech n iqu es detailed in this volu me may requ ire fur th er
edu cation / skill enh an cemen t by restorative practition ers bu t sh ou ld u ltimately
be within the remit of th ose den tal profession als tasked with takin g team care
forwards in to th e fu tu re, wh ere MI den tistry will su rely u n derpin patien t care,
an d so ben efit th e patien t an d th e profession as a wh ole.

Professor Avijit Banerjee BDS, MSc, PhD (Lond), LDS,


FDS (Rest Dent), FDS, RCS (Eng), FHEA

xi
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Ch a pt er 1
Common Clin ical Con dition s Requ irin g
Min imally Invasive Esth etic In ter ven tion
M. TH O MAS

Introduction 2
Discolouration 6
Developmental defects 6
Intrinsic discolouration 8
Extrinsic discolouration 11
Dental caries 11
Dental crowding (imbrication) 13
Missing teeth 13
Tooth wear 15
Conclusions 16
Clinical case 1 1 16
Clinical case 1 2 21
Clinical case 1 3 24
Further reading 27
References 27

1
I n t r o d u c t i o n

In t r o d u c t io n
Min imu m in ter ven tion den tistry is th e con cept of a patien t-cen tred, team-care
h olistic approach to main tain in g life-lon g oral an d den tal h ealth . Th e min -
imally invasive (MI) concept is to preserve pu lp vitality an d as mu ch n atural
tooth tissu e for a lifetime. Th e main con sideration u n derpin n in g th e MI con cept
is achievin g accu rate iden tification an d diagn osis of den tal problems at th e
earliest stage. In providin g a pro-active approach to th e preven tion of den tal
disease, MI den tistry aims to preven t the cycle of destru ctive restorative den -
tistry wh ere existin g den tal treatmen t is replaced as a resu lt of wear an d det-
erioration , leading to fu r th er preparation and weaken ing of th e remain in g tooth
stru ctu re an d con comitan t stress to th e pu lp. With an agein g popu lation an d
an in crease in the nu mber of teeth retain ed throu gh out life, th e need to preserve
n atu ral tooth tissue is of paramou n t importan ce. 1
However, MI dentistry as a pro-active approach to modern dental care mu st n ot
be in terpreted as a do n othin g techn iqu e. A clin ician adoptin g an MI approach
to den tal care is n eith er ign orin g n or avoidin g th e (often raised) esth etic issu es.
Th e MI con cept en ables an esth etic in ter ven tion to be made with min imal
h armfu l biological effect, wh ich will therefore be of ben efit in optimizin g the
n atu ral appearan ce of tooth stru cture. Advan ces in den tal materials and opera-
tive tech n iqu es en cou rage a less tradition al an d aggressive approach to be
adopted, wh ilst ach ieving an improved ou tcome an d prognosis.
In a society wh ere appearan ce an d esth etics are a drivin g factor, with h igh
expectation s for oral h ealth an d appearan ce, it is critical to iden tify den tal ch ar-
acteristics th at will impact on peoples psychosocial well-bein g. Modern den-
tistry en compasses a variety of materials an d tech n iqu es to en h an ce th e esth etic
ou tcome of managed den tal care within the MI framework. These tech niques
are explored th rough ou t th is publication . In th is ch apter some clinical con di-
tion s will be discu ssed (Table 1 .1 ) wh ere MI option s for esth etic in ter vention
may be con sidered, in clu din g:

Tooth discolou ration , including trau ma


Hypoplastic con dition s
Dental caries
Crowdin g
Missin g teeth
Tooth wear.

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TA B LE 1 . 1 CA U S ES O F D EN TA L D IS CO LO U RA TIO N

Possib le
ma n a gemen t
Ca use of d iscoloura t ion Pa t hology Visua l cha nges op t ions

Developmental
defects

Hereditary
defects

Amelogenesis Fourteen different Yellow-brown to Bleaching


imperfecta subtypes. Disturbance of dark yellow
Micro-abrasion
mineralization or matrix of appearance
enamel formation Composite bonding

Dentinogenesis Type I disorder of type I Bluish or brown in Bleaching


imperfecta collagen appearance,
Bonding
opalescence on
trans-illumination Veneers

Type II hereditary Opalescent primary Bonding


opalescent dentine teeth.
Veneers
Enamel chips away
Full coverage crowns
to expose EDJ. Once
dentine exposed,
teeth show brown
discolouration

Type III brandywine Outward similar Bonding


isolate hereditary appearance to Types
Veneers
opalescent dentine I and II. Multiple
pulpal exposures in Full coverage crowns
primary dentition.
Replacement of
Dentine production
teeth may be
ceases after mantle
required if severe
dentine has formed

Metabolic
disorders

Alkaptonuria Incomplete metabolism of Brown Bleaching


tyrosine and phenylalanine. discolouration
Bonding
Promotes build-up of
homogentisic acid Veneers

Congenital Deposition of bile pigments Purple or brown Bleaching


hyperbilirubinaemia in the calcifying dental discolouration
Bonding
tissues
Veneers

Congenital Accumulation of porphyrins Red-brown Bleaching


erythropoietic in teeth discolouration. Red
Bonding
porphyria uorescence under
ultra-violet light Veneers

3
I n t r o d u c t i o n

TA B LE 1 . 1 Continued

Possib le
ma n a gemen t
Ca u se of d iscolou ra t ion Pa t h olog y Visual cha n ges op t ions

Vitamin D Defects in enamel matrix Pitting and Bleaching


dependent rickets formation yellow-brown
Micro-abrasion
discolouration
Bonding

Epidermolysis Pitting of enamel, possibly Pitting and Bleaching


bullosa caused by vesiculation of yellow-brown
Micro-abrasion
the ameloblast layer discolouration
Bonding

EhlersDanlos Areas of hypoplastic Pitting and brown Bleaching


syndrome enamel and irregularities in or purple-brown
Micro-abrasion
region of EDJ discolouration
Bonding

Pseudo- Defects in enamel matrix Pitting and Bleaching


hypoparathyroidism formation yellow-brown
Micro-abrasion
discolouration
Bonding

Molar incisor Unknown aetiology. Asymmetrical Bleaching


hypomineralization Hypomineralized enamel appearance in arch.
Micro-abrasion
(MIH) affecting incisors and Enamel defects vary
permanent rst molars from white to yellow Bonding
to brown areas

Intrinsic
discolouration

Acquired
defects

Trauma Pulpal haemorrhage may Grey-brown to black Bleaching


lead to accumulation of
haemoglobin or other
iron-containing haematin
molecules within the
dentine tubules

Internal resorption Increased volume of pulpal Pink Extirpation and


space and pulpal tissue obturation of pulpal
space

Systemic infectious Generalized hypoplasia due Pitting or grooving Bleaching


disease, e.g. rubella to disturbance of the leading to yellow-
Micro-abrasion
developing tooth germ brown
discolouration Bonding
Veneers

4
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TA B LE 1 . 1 Continued

Possib le
ma n a gemen t
Ca use of d iscoloura t ion Pa t hology Visua l cha nges op t ions

Localized infection Localized hypoplasia due Pitting or grooving Bleaching


to disturbance of the leading to yellow-
Micro-abrasion
developing tooth germ brown
discolouration Bonding

Excessive uoride Enamel most often Flecking to diffuse Bleaching


intake affected. Change in mineral mottling. Colour
Micro-abrasion
matrix from hydroxyapatite changes range from
to uorapatite chalky white to dark Bonding
brown appearance

Administration of Chelation to form Depends on type of Bleaching


tetracycline complexes with calcium tetracycline used,
Bonding
ions on the surface of dosage and duration
hydroxyapatite crystals, of administration. Veneers
mainly in dentine but also Yellow or brown-
in enamel grey discolouration

Amalgam Migration of tin ions into Grey-black Bleaching


the dentine tubules discolouration to
Bonding using
dentine
opaque materials

Eugenol and phenol Staining of the dentine Orange-yellow Bleaching


containing discolouration
endodontic
materials

Extrinsic
discolouration

Direct Food and drink, e.g. Usually multi-factorial. Varies from mild Good oral hygiene
stains tea, coffee, red Chromogens incorporated yellow to more
May bene t from
wine. Smoking into the plaque or acquired severe brown-black
bleaching
pellicle discolouration

Chromogenic Incorporated into plaque Varies from yellow Good oral hygiene
bacteria to green-black
May bene t from
discolouration
bleaching

Indirect Chlorhexidine and Precipitation of Brown to black Good oral hygiene


stains other metal salts in chromogenic polyphenols discolouration
May bene t from
mouthrinses onto tooth surface
bleaching

Caries Cariogenic bacteria, Demineralization and White spot lesion to Micro-abrasion


fermentable eventual proteolytic black arrested decay
Bonding
carbohydrate, destruction of organic
susceptible tooth matrix Direct or indirect
surface, time restoration

EDJ, enameldentine junction.

5
D e v e l o p m e n t a l D e f e c t s

Fig. 1.1 Anterior view of a patient suffering from discolouration from wear, cavitation and staining
around the margins of existing restorations, requiring esthetic modi cation.

D is c o l o u r a t io n (Fig. 1.1)

Discolou ration of th e teeth may occu r for a nu mber of reason s, in clu din g:

Developmen tal defects


Intrin sic discolou ration , in cludin g trau ma
Extrinsic discolou ration .

In addition, teeth become darker with age du e to th e con tinu ing deposition of
secon dary den tin e an d th e gradual wear of en amel allowin g th e colou r of th e
u n derlying den tin e, an d to some extent the pu lp, to become more profou nd. Any
ch an ge th at affects th e ligh t tran smittin g an d reflective proper ties of teeth may
result in a patients request for esthetic in terven tion . Th is may be ach ieved by
th e u se of materials to replace or cover defective or missin g tooth stru ctu res, bu t
tech n iqu es to alter th e appearan ce of th e teeth , su ch as tooth wh iten in g treat-
men ts, may be adopted wh ich requ ire min imal or n o removal of sou n d en amel
an d dentin e an d rely on treatin g the cause of the discolou ration rather than
maskin g its effects.

De v el o pm en t a l Def ec t s
Developmen tal defects can pose an esth etic problem,2 as well as th e teeth bein g
more pron e to wear an d th e damagin g effects of th e caries process. In addition,
6
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Fig. 1.2 Anterior clinical view showing developmental pitting and staining affecting the maxillary
dentition, suitable for MI esthetic intervention with direct resin composite restorations.

developmen tal defects may resu lt in symptoms of sen sitivity an d su rface rou gh -
ness, both combining to in crease levels of plaqu e biofilm reten tion (Fig. 1.2 ).
An early diagn osis is th erefore importan t to en able carefu l plan n in g an d
man agemen t.
Hereditary defects, su ch as hypodon tia, amelogen esis imperfecta an d den tin o-
gen esis imperfecta, may affect th e primary an d secon dary den tition equ ally.
Man agemen t of defects in th e primary den tition requ ires con sideration of th e
ch ilds self-perception an d th e paren tal expectation of treatmen t ou tcomes in
addition to fu n ction al con cern s an d den tal care in experien ce, wh ich will n atu-
rally be presen t at a you n g age. An esth etic in terven tion , u sin g a biological MI
approach, may provide th e oppor tu n ity for a positive in itial treatmen t experi-
en ce an d en able a good rapport an d motivation to be establish ed, makin g fu r th er
man agemen t on developmen t of th e secon dary den tition easier to accept later
in life (Figs 1 .3 and 1 .4 ).
Metabolic disorders, su ch as alkaptonu ria, congenital hyperbiliru bin aemia or
con gen ital eryth ropoietic porphyria, wh ilst rare, will resu lt in discolou ration of
th e den tition du ring development. Enamel defects may also be observed in cases
of vitamin D-depen den t rickets, epidermolysis bullosa, Eh lersDanlos syn drome
an d pseu do-hypoparathyroidism. 3
Acqu ired defects, resu ltin g from trau ma, systemic in fectiou s disease, localized
in fection , excessive flu oride in take, or from admin istration of tetracyclin e
7
I n t r i n s i c D i s c o l o u r a t i o n

Fig. 1.3 Anterior view showing stained and pitted teeth with worn incisal Fig. 1.4 The post-operative view of the case in Figure 1.3, following
edges. This was diagnosed as a mild case of amelogenesis imperfecta. restoration with porcelain laminate veneers.

an tibiotics du rin g ch ildh ood or to th e moth er du rin g pregn an cy, may affect th e
den tal tissu es to a varying degree. Esth etic consideration s, wh en a mild defect
in th e developmen t of one or more teeth h as occur red, may n ot be sign ifican t
at a youn g age. However, as adu lthood approach es, an d social pressu res affect-
in g appearan ce become a more seriou s con cern , deman ds for esthetic in terven -
tion may become in creasin gly prevalen t.

In t r i n s i c D i s c o l o u r a t io n
In trin sic discolou ration occu rs wh en ch romogen s are deposited with in tooth
tissu es. Th is is u su ally with in th e den tin e an d, on ce developmen t of th e tooth
is complete, will be of pulpal origin (Fig. 1 .5 ). However, stain in g agen ts may

Fig. 1.5 Anterior view of a patient with a grey upper left central incisor with wear to the distal-incisal
corner. The appearance of this tooth could be improved by bleaching and resin composite direct restoration.
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en ter th e tooth th rou gh defects in th e tooth stru ctu re. Th is will occu r in th e
cariou s lesion an d may also occu r arou n d th e periph ery of existin g restoration s.
Crackin g of the en amel, as a resu lt of trau ma, may also allow extern al stain in g
agen ts to en ter th e tooth stru ctu re. Den tin e may also become exposed as a resu lt
of tooth wear or gin gival recession , allowin g extern al stain in g compou n ds to
en ter any paten t tu bu les an d in tertu bu lar den tin e.

Pu lpal h aemor rhage may lead to discolou ration of th e tooth du e to the accu -
mu lation of h aemoglobin or oth er forms of iron -contain in g h aematin molecules
with in th e den tin e tu bu les.4 Bacterial invasion may resu lt in fu rth er breakdown
of th ese blood produ cts leadin g to differin g degrees of discolou ration . If th e
tooth h as been devitalized by trau ma bu t th e pulp ch amber remain s in tact,
bacterial invasion will n ot occu r an d re-vascu larization may resu lt in th e tooth
revertin g to its n ormal colou r.5 A clear diagn osis of th e cau se of discolou ration
may th erefore lead to th e most min imal of in ter ven tion s in order to ach ieve an
acceptable esth etic ou tcome. If discolou ration of th e tooth was cau sed by blood
pigmen ts, agen ts can be developed specifically to remove or break down th e
haematin molecu le with in th e den tin e tu bu les in a tooth whiten in g procedu re
(see Ch apter 3). The cau se of th e discolou ration is th erefore removed as opposed
to th e affected tooth stru ctu re.

Restorative den tal materials may also affect th e colou r of the teeth. Eu gen ol an d
ph enol-con tain in g en dodon tic materials may stain den tine, causin g a darken -
in g effect. Wh en an amalgam restoration is removed, a residu al darken in g/
sh adowin g of th e den tin e may be n oticed, du e to th e leach in g of tin ion s in to
th e adjacen t den tin e.6

Th e deposition of tetracyclin e with in teeth du ring developmen t h as been cited


frequ en tly as a cau se of in trin sic discolou ration , bu t n ew cases will become
in creasin gly rare as a resu lt of th e improved awaren ess of th e issu es regardin g
th e use of tetracyclin e du ring pregn ancy and breastfeeding and in ch ildren up
to 1 2 years of age. Th e effect of tetracyclin e on teeth is dependen t on th e medi-
cation u sed, th e dosage an d th e period of admin istration . Affected teeth h ave a
yellowish or brown-grey appearan ce, wh ich is worse on eruption bu t can fade
with time, althou gh anterior teeth are affected by in ciden t n atu ral light ch an g-
in g th e colou r to brown as a resu lt of ph oto-oxidative ch emical processes.
However, MI wh iten in g treatmen t over an exten ded period can produ ce a pleas-
in g esth etic resu lt with ou t th e n eed for removal of sou n d tooth stru ctu re in
many cases (see Ch apter 2 ).

Excessive flu oride ion admin istration an d in take will affect ameloblast fun ction
du rin g en amel formation an d matu ration (Fig. 1 .6). Th e effects are related to
age an d dose an d both th e primary and secon dary dentition may be affected by
9
I n t r i n s i c D i s c o l o u r a t i o n

Fig. 1.6 Anterior clinical view showing a case of white spot hypoplasia, thought to have resulted from
excessive uoride intake by the patient as a youngster.

th e resu ltin g flu orosis. Th is may man ifest as small areas of fleckin g th rou gh to
opaque mottlin g of the en amel (Fig. 1 .7 ). An in creased porosity of th e en amel
may resu lt in extrin sic stain deposition produ cin g an in tern al effect 5 (Fig. 1 .7 ).
Similar hypoplastic effects to th e en amel may occu r locally following infection
or trau ma to th e primary den tition affectin g the u nderlying, developing second-
ary tooth germ. A large nu mber of matern al or foetal condition s, su ch as in fec-
tion or vitamin an d min eral deficien cy, may h ave a more gen eralized effect on
th e developin g den tition . Th e ou tcome in terms of requ irin g an esthetic in ter-
ven tion will vary depen din g on severity of the con dition an d th e in dividual
patients demands, but th e prin ciples of MI care can still be applied when con -
siderin g th e degree of operative interven tion requ ired. Again, care plan n ing will
cen tre arou n d a tru e diagn osis of th e cau se of discolou ration an d an u n der-
stan din g of th e h istological location of th e pigmen ts/ ch romogen s involved
directly with in th e tooth stru ctu re. This will affect whether treatmen t will
involve the removal of such molecules or maskin g th eir effects physically, but
always u sing MI tech niqu es.
10
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Fig. 1.7 Anterior clinical view showing a case of hypoplasia with associated brown discolouration
affecting the labial surfaces of the two upper central incisors.

Ex t r i n s i c D i s c o l o u r a t i o n
Ch romogen s affectin g th e tooth su rface may be derived from a wide variety of
sou rces. Examples in clu de smokin g tobacco produ cts, tan n in s from tea, coffee,
red win e an d polyph en ol compou n ds wh ich provide th e colou rin g to foods.
Extern al stain in g is u su ally mu lti-factorial an d is tran sien t, bein g removed with
meticu lou s oral hygien e, th e stain in g bein g a result of th e ch romogen s bein g
in corporated in to su rface plaqu e biofilm or acquired pellicle. Chromogen ic bac-
teria with in plaqu e may also produce a stain in g effect if allowed to stagn ate lon g
term. Exposu re of den tin e, as a resu lt of tooth wear or gin gival recession , may
resu lt in th e extern ally sou rced ch romogen s bein g in corporated in to th e den tin e
tu bu les and intertubu lar dentin e structure.
Th e u se of ch lorh exidin e in mouth rin ses to redu ce gin gival in flammation h as
led to an in creased in ciden ce of su rface stain in g, alth ou gh th is h as been reported
with mou th wash es con tain in g oth er compou n ds. Th e stain in g mech an ism is
th ou ght to be du e to precipitation of chromogenic polyph en ols with in food an d
drin k, and cau sed by ch lorhexidin e adsorbed on to th e tooth su rface.7 Again ,
however, th e staining can be removed straigh tforwardly and a good esth etic
ou tcome can be ach ieved with th e min imu m of in terven tion .

D en t a l Ca r ies
Th e con sequ ences of den tal caries may resu lt in an esth etic in ter vention bein g
requ ired to restore th e appearan ce of th e teeth as well as th eir fu n ction an d
stren gth . Th is may be as a resu lt of cavitation resu ltin g from th e advan ced caries
process leadin g to th e even tu al u n dermin in g of th e stru ctu ral in tegrity of th e
11
D e n t a l C a r i e s

tooth . However, th e early cariou s lesion will produ ce a ch an ge in th e appearan ce


of the enamel surface as demin eralization causes porosity within th e prismatic
stru ctu re of en amel. As th e demin eralization process con tinu es, th e ch aracter-
istic frosty wh ite appearan ce of th e white spot lesion becomes visible du e to a
ch an ge in th e relative local refractive in dex with in th e en amel lesion . Th e
in creased tooth su rface porosity may permit dietary ch romogen s to become
trapped, produ cing the darker appearan ce of th e ar rested brown spot lesion.
Wh en th e lesion h as spread in to th e den tin e, th is will u n dermin e even tu ally th e
overlyin g en amel an d, before cavitation occu rs, a greyish sh adowin g may be
visible on th e tooth su rface. Within th e den tine lesion , colou r changes may
resu lt from th e Maillard reaction , wh ere bioch emical reaction s occu r between
carbohydrates an d proteins in th e presen ce of an acid environmen t produ ced by
th e action of bacteria with in th e lesion . However, th is effect is n ot u n iform an d
dietary ch romogen s will also con tribu te to th e ch anges in appearance of cariou s
den tine if exposed for a su fficien t time (Fig. 1 .8).
As the carious lesion, in its early stages, is repairable, optimal man agement
depends on accu rate early detection , diagn osis an d in ter ven tion before gross
demin eralization an d proteolytic destru ction requ ire a more invasive operative
approach . Risk assessment to identify high or low susceptibility to the disease
allows appropriate stan dard or active preven tive care an d a non -operative pre-
ven tive care approach to be adopted. Historically, caries has been classified based
on a system of past experience of th e disease as originally proposed by G.V.
Black.8 However, in th e 2 0 1 1 Un ited Nation s declaration on th e con trol an d
preven tion of non-commun icable diseases, th e importance of oral h ealth was
ackn owledged an d h igh lighted. Th is h as led to th e developmen t of a global pro-
gramme aimed at developin g an d implemen tin g a n ew paradigm for caries man -
agement based on a preven tive approach to health care. 9 Plaqu e con trol, dietary

Fig. 1.8 Anterior clinical view of dental caries affecting the upper incisor and canine teeth. Excavation
and esthetic MI reparative intervention is required.
12
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modification an d the u se of flu oride sh ou ld therefore be regarded as stan dard


care for th e con trol of den tal caries to allow preven tive, n on -invasive remin er-
alization treatmen ts to be effective. Th is MI approach will aim to preserve th e
biological an d stru ctu ral in tegrity of th e tooth in th e lon g term.
An MI biological approach sh ou ld also be adopted wh en operative in terven tion
is requ ired for treatmen t of a cavitated, progressin g cariou s lesion .1 0 Th is
approach involves:

Excavation of th e biologically u n repairable, diseased en amel an d den tin e


on ly, keepin g cavities as small as possible.
Physically an d ch emically modifyin g/ optimizin g th e remain in g cavity walls
in order to restore cavities with su itable restorative adhesive materials,
wh ich will:
Suppor t an d stren gth en th e remainin g tooth structure.
Promote remineralization an d poten tially h ave an tibacterial activity.
Seal off any remain ing bacteria from th eir nu trien t supply, so ar restin g
th e caries process in th e tooth .
Restore th e appearan ce an d fun ction , en abling and en h an cin g th e ability
of th e patien t to remove th e su rface plaqu e biofilm, with su itable lon g-
term su ccess.

D e n t a l C r o w d i n g (I m b r i c a t i o n )
Crowdin g of teeth may lead to a patient requ est for an esth etic in terven tion.
Carefully plann ed an d ju diciou sly u sed orthodon tic align men t can provide a
biologically sen sitive, MI meth od of overcomin g th e adverse esth etic con se-
qu en ces of crowdin g. Alth ou gh orth odon tic treatmen t may n ot provide a qu ick
improvemen t, th e lon g-term con sequen ces of a more rapidly execu ted, tissue-
destru ctive restorative approach are th e an tith esis of an MI, biologically sou n d
an d u ltimately lon g-term stable approach to den tal care, in providin g an accept-
able esthetic ou tcome with teeth in stable final position s. 1 1

M i s s i n g Te e t h
Missing teeth may requ ire replacemen t to restore fu n ction al an d/ or esth etic
harmony. Wh en teeth are extracted, movemen t of adjacen t an d opposin g teeth
may occu r, disru ptin g th e establish ed occlu sal pattern an d leadin g to alteration s
in comfor t an d fu nction of th e remain ing den tition. Th e effects of an abn ormal
occlu sion are su bject to con tinu in g debate th rou gh ou t th e den tal profession ,
13
M i s s i n g T e e t h

with a rapidly expan ding literatu re: research based an d empirical. Similarly, th e
care approach adopted in cases wh ere an abn ormal occlu sion h as been iden tified
is su bject to mu ch discu ssion and varyin g opin ion s. Th is may range from
min imu m in ter ven tion to maximu m preparation an d re-align men t, adoptin g
eith er a conformative or a re-organ ized approach .
Wh en con siderin g th e replacemen t of missin g teeth , it is th e respon sibility of
th e clin ician to be convin ced, alon g with th e patien t, th at th e replacemen t will
produ ce sign ifican tly more ben efit th an harm. Con sideration sh ou ld be given to
appearan ce, occlu sal stability, ability to masticate, speech , reten tion of the posi-
tion of th e remain in g teeth , restoration of th e ver tical dimen sion of occlu sion
an d other particu lar circu mstances, su ch as th e ability of win d in stru men t
players to create an embouch u re. If th e balan ce is strongly in favou r of replace-
men t, th e clin ician mu st decide on th e most su itable tech n iqu e for replacemen t.
Th ese in teractive discussions between th e den tist an d the patien t mu st be fran k
an d hon est, outlin in g all th e poten tial ben efits and pitfalls and mu st be compre-
h en sively docu men ted. Indeed, commu nication an d docu mentation are the cor-
n erstones to su ccessfu l patien t man agemen t.
Th e option s available will in clu de:

A removable partial den tu re, wh ich may be made with a metal base,
an acrylic base or from a flexible material.
A removable bridge retained u sin g precision attachments, telescopic
retain ers, or a combin ation .
A fixed bridge retained with fu ll or partial coverage extra-coron al
restoration(s), in lay(s), or adh esive win ged abu tmen t(s). Th e design of
th e bridge may be can tilevered from a sin gle adjacen t tooth , or involve
abu tments on eith er side of th e space to be filled. In addition , a variety of
materials may be con sidered for con stru ction of th e restoration , all requ irin g
differen t thicknesses for optimal mechanical an d esthetic proper ties to
provide sufficien t stren gth an d appearan ce. All of these factors, in tu rn ,
affect th e degree of preparation requ ired to th e remaining teeth an d
th erefore th e degree of in ter ven tion requ ired (see Ch apters 8 and 9 ).
Th e placemen t an d restoration of a den tal implan t or implan ts.

Today, in some parts of th e world, implan ts are a relatively common den tal
procedu re;12 th ey h ave th e advan tage over altern ative option s for th e fixed
replacemen t of a missin g tooth or teeth in th at min imal/ n o biological or physi-
cal alteration to th e adjacen t h ard tissu es is n ecessary. Implan ts wou ld th erefore
appear to be the u ltimate MI approach to th e replacemen t of a missing tooth or
teeth . However, alteration to th e u n derlyin g h ard an d soft tissu es may be requ ired
14
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in order to provide su fficien t su pport for th e fixtu re(s) an d restoration . Th ere-


fore, alth ou gh min imal in terven tion may be applied to th e remain in g den tition ,
su rgical in terven tion may be a n ecessary part of th e procedu re in order to
ach ieve a su ccessfu l ou tcome. However, as h as been demon strated in on e of th e
clin ical cases in th is ch apter, an acceptable esth etic ou tcome, in appropriate
circu mstan ces, may still be ach ieved with ou t th e u se of su rgical in ter ven tion to
replace missin g h ard an d soft tissu es.

To o t h W e a r
Tooth wear, also kn own as tooth su rface loss, is in creasin g in prevalence an d
severity. Th e in ciden ce of moderate tooth wear is in creasin g in you n g adu lts
alth ou gh th e overall in ciden ce of severe tooth wear appears to be less common ;1 3
th is in dicates an in creased requ iremen t for dental care to man age th is condi-
tion 1 4 (Fig. 1 .9).
Th e MI con cept for th e esth etic man agemen t of th e wear to teeth requ ires an
accu rate diagn osis of th e aetiological factors of erosion , attrition , abrasion an d/
or abfraction , wh ich often occu r in combin ation to varyin g degrees. Th is will
th en allow th e cau se(s) of tooth wear to be man aged an d an appropriate care
strategy to be implemen ted, wh ich aims to:

Preser ve remain in g tooth tissu e


Achieve an esth etic improvemen t
Restore an d provide lon g-term stability to th e den tition .

Fig. 1.9 An anterior view showing the result of erosive wear affecting the labial surface of the two upper
central incisor teeth.
15
C l i n i c a l C a s e 1. 1

In order to meet th ese aims, th e approach to restorative care sh ou ld involve th e


u se of su itable tech n iques and materials to protect an d ensu re th e su rvival of
remain in g tooth tissu e. Th is approach accepts th at th ere sh ou ld be th e n eed
for repair an d renewal of restoration s as requ ired in stead of th e fur th er loss of
sou n d tooth tissu e th rou gh fu r th er destru ctive tooth preparation .1 5 Th e u se of
resin composite materials, with min imal lon g-term pu lpal or stru ctu ral compli-
cations to th e tooth , is a more con ser vative and esth etically acceptable alterna-
tive to th e u se of porcelain restoration s.1 6 Th e lon g-term con sequen ces to the
den tition from extensive preparation to th e tooth stru ctu re an d pu lpal damage
as a resu lt of u sing convention al indirect tech n iqu es can n o longer be advocated
rou tin ely wh en advan ces in materials an d cemen ts n ow allow an MI, biologi-
cally based approach to th e restoration of th e worn den tition .

Co n c l u s io n s
Clin ician s h ave a respon sibility to patien ts to meet th eir esth etic desires an d
aspirations by u sin g techn iqu es th at are min imally tissu e destru ctive, biologi-
cally sou n d an d eth ical in order to provide satisfactory sh ort-term an d lon g-term
solu tion s to clin ical con dition s requ irin g in terven tion . Th e golden ru le, wh ich
h as been qu oted many times th roughou t history, to do u n to oth ers wh at you
wou ld h ave th em do to you* sh ou ld be kept very mu ch in mind wh en makin g
treatmen t decision s at all times.

C l i n i c a l C a s e 1.1
Th ere is a false perception th at MI den tistry equ ates to always car ryin g ou t th e
least amou nt of operative den tistry an d con fining this to th e simplest procedu res.
As th is case demon strates, an MI approach to dentistry does n ot preclu de the
u se of involved an d potentially complex procedu res such as implan t den tistry.
A female patien t, aged 5 8, presented with a missing u pper right cen tral in cisor
tooth (Fig. C1 .1.1 ). Th is had been lost several years previously as a result of
trau ma an d sh e h ad worn an acrylic based removable partial den tu re sin ce th en .
Her presentin g concern was to con sider an alternate meth od of replacemen t
an d h ave a tooth of improved appearan ce an d ch aracterization rather than th e
den tu re cu r rently provided.
Examin ation revealed that th e upper righ t cen tral incisor tooth an d the fou r
th ird molar teeth were absen t. Th e remain in g teeth were sou n d with a nu mber
of small restorations presen t. No active caries was detected. An acrylic based

* THE HOLY BIBLE, NEW INTERNATIONAL VERSION, NIV Copyright 1973, 1978, 1984,
2011 by Biblica, Inc. Used by permission. All rights reserved worldwide.
16
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Fig. C1.1.1 Retracted anterior view without the denture in place, showing the missing UR1 tooth space.

removable par tial den tu re replaced th e missin g in cisor tooth . Th is h ad a reason -


able fit with a scalloped margin to the adjacen t upper righ t lateral in cisor an d
upper left central in cisor teeth . Th e retention was provided by claspin g to th e
first molar teeth . Th e den tu re tooth was a stock tooth made of a sin gle resin
material an d was a poor match in colou r, sh ape an d size to th e adjacen t teeth .
Th e gin gival tissu e ben eath th e den tu re in th e saddle area an d arou n d th e adja-
cen t teeth was in flamed. Th e scalloped design of th e den tu re arou n d th e adja-
cen t teeth was a plaqu e reten tive factor an d th is lead to a localized loss of
periodon tal attach men t to th ese teeth with probin g depth s of 5 mm an d bleed-
in g on probin g. On smilin g, th e u pper lip retracted to th e gin gival th ird of th e
maxillary den tition, without exposin g th e gin gival margin. On closu re, th ere
was an in creased overbite with an in cisal overjet of 2 mm.
Radiograph ic examin ation (Fig. C1 .1.2 ) showed th at th ere was loss of bon e
su ppor t to th e adjacen t teeth as well as a redu ced alveolar con tou r in th e posi-
tion of th e missing tooth , resu lting from the loss of th is tooth several years ago.
Th ere was su fficien t volu me to en able con sideration of th e placemen t of a dental
implan t.
Options were discu ssed for th e replacement of th e missin g upper righ t central
in cisor tooth . Th ese were:

Provision of a n ew removable partial den tu re, of improved design to remove


th e plaqu e stagn ation featu res associated with th e cu r ren t den tu re, an d
17
C l i n i c a l C a s e 1. 1

Fig. C1.1.2 Initial peri-apical radiograph showing


bone levels/quality prior to implant placement.

u sing a cu stomized resin tooth to improve the appearance over th e cu r rent


stock den tu re tooth . Th e patien t, h owever, wish ed to avoid a den tu re if
possible, althou gh sh e recogn ized th e improvemen t in appearan ce that
could be gain ed usin g a cu stomized tooth .
Provision of fixed bridgework, of a resin bon ded design to th e adjacen t in cisor
teeth . However, th e redu ced level of periodon tal su pport to th e adjacen t teeth
was a con cern regardin g th e lon g-term effect to th ese teeth of th e addition al
loadin g th at would result from th eir use, eith er sin gly or in combin ation , as
bridge abu tment(s). In addition, th e in creased overbite did not provide space
for an abu tment win g to be fitted withou t th e need for preparation of th e
18
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Fig. C1.1.3 Shade-taking photograph for the replacement tooth.

abu tmen t tooth or teeth or redu ction of th e opposin g in cisors. Occlu sal space
cou ld h ave been provided u sin g orth odon tic tech n iqu es involvin g applian ces
or th e use of the Dah l techn iqu e for tooth in trusion.
Placemen t an d restoration of a den tal implan t. Assessmen t of th e alveolu s
revealed th at th ere was su fficien t bon e volu me an d den sity for th e
placement of a den tal implan t fixture. Alth ough th ere was a redu ced hard
an d soft tissue height compared to th e rest of th e maxillary arch , th e
position of th e lip lin e on smilin g mean t that th is area was n ot of an
esth etic con cern in con siderin g th e fin al ou tcome of th e restoration .

After docu men ted discu ssion with th e patien t, a decision was made to proceed
with th e placemen t an d restoration of a den tal implan t (Fig. C1 .1 .3 ). In itial
su rgery for th e placemen t of th e implan t involved raisin g a small mu co-periosteal
flap, preparation of th e osteotomy site u sin g a series of preparation drills, an d
placemen t of th e implan t fixtu re. Th e h ealin g abu tmen t was fitted at th e time
of fixtu re placemen t, removin g th e requ iremen t for secon d su rgical in ter ven -
tion . An adh esive bridge was provided to act as an in terim replacemen t of th e
missing tooth durin g th e primary ph ase of osseoin tegration . A cou rse of
19
C l i n i c a l C a s e 1. 1

Fig. C1.1.4 Final peri-apical radiograph after


implant placement and restoration showing good
osseointegration.

treatmen t involvin g debridement of th e existin g pockets and in trodu ction of a


n ew oral hygien e regimen for the patien t lead to h ealing of th e inflammation of
th e soft tissu es in th e u pper in cisor region , an d a redu ction in probin g depth s to
2 mm was recorded after 3 months.
Followin g a 3 -mon th period of osseoin tegration (Fig. C1.1 .4 ), a cu stomized
abu tmen t was milled to provide su ppor t for an all-ceramic crown . Th is was
ch aracterized to match th e remain in g den tition an d con tou red to allow n o
in terferen ces on excu rsive movemen ts of th e man dible. Th e u se of clin ical ph o-
tography en abled good ch aracterization details to be reprodu ced in th e fin al
20
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Fig. C1.1.5 Retracted post-operative anterior view showing the acceptable nal esthetic result.

restoration (Fig. C1 .1 .5). Th e proximal con tou r allowed easy an d effective in ter-
den tal clean in g to be ach ieved.
Th is case demonstrates an MI approach to tooth replacemen t, respectin g th e
biology of th e oral tissu es. In con siderin g th e patien t requ iremen ts for comfor t
an d appearan ce, a den tal implan t cou ld be placed with a sin gle su rgical proce-
du re with ou t au gmen tation of th e existin g h ard an d soft tissu es.

C l i n i c a l C a s e 1.2
Th is clin ical case study demonstrates th e u se of an MI resin composite tech n iqu e
to alter th e sh ape of localized microdontia, affecting a lateral in cisor tooth
(Fig. C1 .2 .1).
A 1 9 -year-old fit an d well female patien t presen ted requ estin g an improvemen t
in th e appearan ce of h er teeth . Sh e was con cern ed specifically with th e appear-
an ce of a peg-sh aped u pper righ t lateral in cisor tooth (Fig. C1 .2 .2 ). Th is h ad
been of similar appearan ce sin ce eru ption , bu t sh e h ad n ot sou gh t treatmen t as
sh e h ad n ot been so con sciou s of its appearan ce. In research in g th e option s for
21
C l i n i c a l C a s e 1. 2

Fig. C1.2.1 Retracted anterior pre-operative clinical view in occlusion. Fig. C1.2.2 Retracted right-hand side anterior clinical view showing the
full extent of the diminutive lateral maxillary incisor.

h er treatmen t prior to presen tation, she en qu ired if sh e was a su itable can didate
for ven eers to her upper teeth.
An in itial examin ation revealed the presen ce of 1 4 teeth in both maxillary an d
man dibu lar arch es with th e th ird molar teeth absen t. Th ere was n o h istory of
tooth restoration an d n o caries was detected. Th e periodon tal h ealth was good
with an excellent stan dard of oral hygien e eviden t. There was a cross bite in th e
premolar an d molar region on th e righ t-h and side with a shift in th e mandibu lar
midlin e position to th e righ t by h alf a u n it. However, can in e gu idan ce was
main tain ed on lateral excu rsive man dibu lar movemen ts an d th ere were n o sign s
or symptoms of any fu r th er ch an ges to th e masticatory system.
Th e u pper righ t lateral in cisor tooth was smaller in size proportion ately to th e
adjacent teeth (Fig. C1 .2.2 ). Th ere was a slight diastema between th e maxillary
cen tral in cisors, bu t th e u pper left lateral in cisor was of propor tion ate size to
th e remain in g teeth .
Th e patien t h ad been an ir regu lar den tal atten dee as sh e h ad n ot experien ced
problems with h er teeth and th erefore h ad not prioritized regular visits to a
den tist as par t of h er lifestyle. She was an avid viewer of reality television sh ows,
h owever, and h ad seen tran sformation s bein g made to den tition s by smile make-
overs. Th is h ad in flu en ced h er decision to requ est th e u se of ven eers to ch an ge
th e appearan ce of h er teeth .
A detailed discu ssion revealed that h er con cern was limited to the appearan ce
of on ly on e tooth . Her perception of veneers was th at th ese cou ld be provided
with out the n eed for any preparation to th e teeth an d wou ld last a lifetime.
Althou gh little h ard tissu e preparation wou ld be requ ired to provide
22
c h a pt er 1
Co m m o n Cl i n ic a l Co n d i t io n s Re q u i r i n g M i n i m a l l y I n v a s i v e Es t h e t i c In t er v en t io n

Fig. C1.2.3 Retracted right-hand side post-operative view after the UR2 has been built up with an
esthetic direct resin composite.

th in porcelain laminate veneers to all th e u pper in cisor teeth , so ach ieving a


symmetrical relation sh ip between th ese, th e man agemen t of th is case was
limited to th e reversible bon din g of resin composite materials to th e u pper righ t
lateral in cisor tooth in order to resh ape th is tooth to match th e adjacen t teeth
more closely.
Th e upper righ t canine an d all fou r in cisors were isolated u sin g ru bber dam, a
split dam tech n iqu e allowin g u n restricted access to th e u pper righ t lateral
in cisor tooth . Gin gival retraction cord was placed to retract th e labial gin gival
margin an d separation strips placed between th e adjacen t teeth . Acid etch in g
was car ried ou t to th e den tal en amel an d direct bon din g of resin composite
materials was car ried ou t to resh ape th e tooth . Fin ish in g an d polish in g was
car ried ou t u sin g u ltra-fin e diamon d bu rs, polish in g discs an d mops (Fig. C1 .2 .3 ).
Th is case demonstrates th e use of a simple, reversible clin ical tech n iqu e to
ach ieve an improvemen t in th e appearan ce of th e den tition for a patien t with
th e min imal amou n t of in ter vention an d biological risk. Th is also demonstrates
th e importan ce of a full and detailed docu men ted discu ssion with th e patient
wh en plan nin g th e appropriate man agemen t of a case in order to meet th e
requ est an d requ iremen t of th e patien t u sin g th e most appropriate clin ical
tech nique.
23
C l i n i c a l C a s e 1.3

C l i n i c a l C a s e 1.3
Th is clin ical case demon strates th e u se of an MI micro-abrasion tech n iqu e to
improve den tal appearance.
An 1 8 -year-old fit and well female presen ted complain ing of a mottled appear-
an ce to her teeth (Fig. C1.3 .1 ). Sh e remarked th at th is appearan ce h ad been
presen t sin ce th e teeth h ad eru pted into position, bu t th is h ad cau sed h er n o
con cern s regardin g h er appearan ce u n til n ow, as sh e was plan n in g to leave h ome
to commen ce u n iversity stu dies. However, on discu ssin g th e appearan ce of h er
teeth , h er on ly con cern was to improve th e appearan ce of th e two u pper cen tral
in cisor teeth . Sh e also did not wish to make th ese two teeth appear perfect as sh e
was aware th at th is wou ld n ot match with h er remain in g teeth . Sh e was also
aware of th e importan ce of an MI approach as sh e h ad a frien d wh o h ad received
treatmen t with porcelain lamin ate ven eers wh o h ad experien ced problems with
sen sitivity an d th e ven eers debon din g on repeated occasion s.
Examin ation revealed a h ealthy dentition with n o restorations present. Twen ty-
eigh t teeth were presen t, with early in dication of all fou r th ird molar teeth
du e to erupt shortly. No caries was presen t, h er oral hygien e was excellen t,
an d all soft tissu es were in good condition . Th ere was a mottled appearance to
th e en amel of all teeth , produ cin g a wh ite striated appearan ce, with brown

Fig. C1.3.1 Retracted anterior view showing the hypoplastic upper central incisors.
24
c h a pt er 1
Co m m o n Cl i n ic a l Co n d i t io n s Re q u i r i n g M i n i m a l l y I n v a s i v e Es t h e t i c In t er v en t io n

Fig. C1.3.2 Retracted anterior view, on completion of micro-abrasion and addition of nano-hybrid resin
composite.

discolou ration an d ch ippin g of th e en amel on th e in cisal th ird aspect of both


upper cen tral in cisor teeth . Th ere was a small amou nt of brown discolou ration
an d min or areas of ch ippin g to th e remain in g maxillary teeth (Fig. C1 .3 .2 ).
From th e h istory an d examin ation , a diagn osis of en amel hypoplasia was con-
clu ded, of u n kn own origin . Th e patien t h ad n ot been brou gh t u p in an area with
a h igh level of flu oride in th e water su pply an d h ad n ot received, to h er kn owl-
edge, flu oride su pplemen ts du rin g h er developmen t. Her siblin gs did n ot h ave
th e same characterization to their teeth .
Discussion with the patien t helped to explain th e option s available for treatmen t
of th e u pper cen tral in cisors as well as for th e remain in g den tition in order to
improve th e appearan ce. Th is in clu ded the option s for tooth wh iten in g, micro-
abrasion and localized resin composite restorations. However, th e treatmen t
agreed an d con sen ted for was to provide micro-abrasion an d localized resin
composite restoration to th e two maxillary cen tral in cisor teeth on ly. Micro-
abrasion was car ried ou t u sing Opalu stre (Ultraden t), consistin g of 6 .6 % hydro-
ch loric acid togeth er with silicon e carbide par ticles (par ticle size 2 0 1 6 0 m)
in a water solu ble paste, followed by localized bon din g of a n an ohybrid resin
composite of h igh tran slu cen cy. Fin ish in g was car ried ou t u sin g polish in g discs,
composite polish in g paste, an d a polish in g mop.
25
C l i n i c a l C a s e 1.3

Th e fin al esth etic resu lt was pleasin g to th e patien t an d ach ieved h er wish es of
providin g a localized improvemen t in th e appearan ce of h er den tition . Th is MI
treatmen t tech n iqu e permitted preservation of th e existin g tooth stru ctu re. Th e
patient is also aware of fu rther treatmen t being available to alter the appearance
of h er teeth fu r th er sh ou ld she wish th is in th e future.

ES S EN TI A LS

Minimum intervention oral care is the concept of a patient-centred, holistic, team-care approach
to maintaining life-long oral and dental health.
The biological concept of MI dentistry aims to preserve natural tooth tissue and pulp vitality for
a lifetime.
The main consideration for the MI concept is achieving the accurate identi cation and diagnosis
of dental problems at the earliest stage.
A clinician adopting an MI approach to dental care is not ignoring or avoiding the esthetic issues
of dental treatment.
The rst rule of dentistry, do no harm, is an essential requirement of biological MI dentistry when
applied to clinical conditions requiring esthetic intervention.

P A TIEN TS F A Q S

Q. Wha t st a ins t eet h?


A. Stained teeth can be caused by drinking tea, coffee, red wine, colas and consuming other
stain-producing foods such as berries, soy sauce, mustards and ketchups. Smoking will also stain
the teeth.

Q. How d o I stop my t eet h st a ining?


A. Avoid smoking. Limit the amount of coffee, tea and other stain producing foods you eat. Brush
your teeth regularly with a good quality toothbrush and toothpaste, for 2 minutes at a time. Visit
your dentist regularly for examination and professional cleaning.

Q. Wha t is t oot h whit ening?


A. Tooth whitening is a technique used to treat mild to moderate staining to the teeth. A strong
oxidizing agent is used to lighten/bleach the teeth and is a conservative and often highly effective
way to brighten your smile.
Teeth with yellow stains are the easiest to lighten, but the process does not affect any crowns,
veneers or other dental restorations that you have.
The average treatment time is 46 weeks, depending on the severity of the stain, but you may
notice results after just a few days.

Q. Wha t is b ond ing?


A. Bonding is the application of a composite-resin material to the tooth surface. This requires
treatment of the tooth surface using a mild acid to enable bonding to be effective and long lasting,
but does not require preparation of the tooth structure. This is an effective technique for treatment
of stained teeth and can also be used to reshape teeth.
It may be advisable to wear a nightguard to protect the bonding if you are prone to clenching or
grinding the teeth.

26
c h a pt er 1
Co m m o n Cl i n ic a l Co n d i t io n s Re q u i r i n g M i n i m a l l y I n v a s i v e Es t h e t i c In t er v en t io n

Further reading
Banerjee A, Watson TF. Pickards Manual of Operative Dentistry. 9th ed. Oxford: Oxford Univer-
sity Press; 2011.

Kelleher M. Ethical issues, dilemmas and controversies in cosmetic or esthetic dentistry.


A personal opinion. Br Dent J 2012;212:3657.

Kelleher MGD, Bom m DI, Austin RS. Biologically based restorative management of tooth wear.
Int J Dent 2012;2012:Article ID 742509.

Palmer RM, Smith BJ, Howe LC, Palmer PJ. Implants in Clinical Dentistry. London: Martin
Dunitz; 2002.

Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J
2001;190:30916.

Re f e r e n c e s

1. Kateb E-L, Heming M. Dentistry in a decade: Recent lessons from the Adult Dental Health
Survey. Dent Update 2011;38:6589.

2. Cof eld KD, Phillips C, Brady M, et al. The psychosocial impact of developmental dental defects
in people with hereditary amelogenesis imperfecta. J Am Dent Assoc 2005;136:62030.

3. Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J
2001;190:30916.

4. Marin PD, Bartold PM, Heithersay GS. Tooth discolouration by blood: an in vitro histochemical
study. Endod Dent Traumatol 1997;13:1328.

5. Weatherall JA, Robinson C, Hallsworth AS. Changes in the uoride concentration of the labial
surface enamel with age. Caries Res 1972;6:31224.

6. Wei SH, Ingram MI. Analysis of the amalgam tooth interface using the electron microprobe. J
Dent Res 1969;48:317.

7. Addy M, Moran J, Grif ths A, Wills-Wood NJ. Extrinsic tooth discolouration by metals and chlo-
rhexidine. Surface protein denaturation or dietary precipitation? Br Dent J 1985;159:
2815.

8. Black GV. A Work on Operative Dentistry: The Technical Procedures in Filling Teeth. Chicago:
MedicalDental Publishing; 1917.

9. Fisher J, Johnston S, Hewson N, et al. FDI Global Caries Initiative; implementing a paradigm shift
in dental practice and the global policy context. Int Dent J 2012;62(4):16974.

10. Banerjee A, Watson TF. Pickards Manual of Operative Dentistry. 9th ed. Oxford: Oxford Univer-
sity Press; 2011.

11. Kelleher M. Ethical issues, dilemmas and controversies in cosmetic or aesthetic dentistry.
A personal opinion. Br Dent J 2012;212:3657.

12. Palmer RM, Smith BJ, Howe LC, Palmer PJ. Implants in Clinical Dentistry. London: Martin
Dunitz; 2002.
27
R e f e r e n c e s

13. The UK Health and Social Care Information Centre. Adult Dental Health Survey 2009: summary
report and thematic series. <www.ic.nhs.uk/ pubs/ dentalsurvey-fullreport09>; 2011.

14. Vant Spijker A, Rodriguez JM, Kreulen CM, et al. Prevalence of tooth wear in adults. Int J Pros-
thodont 2009;22(1):3542.

15. Kelleher MGD, Bom m DI, Austin RS. Biologically based restorative management of tooth wear.
Int J Dent 2012;2012:Article ID 742509.

16. Nalbandian S, Millar BJ. The effect of veneers on cosmetic improvement. Br Dent J
2009;207(2):Article E(3).

28
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Ch a pt er 2
Den tal Bleach in g: Materials
M. KELLEH ER

Introduction 32
How teeth become discoloured 32
Chemistry of bleaching 34
Carbamide peroxide 35
How hydrogen peroxide works 35
Safety of carbamide peroxide 36
Systemic defence mechanisms against hydrogen peroxide 37
Dental sensitivity 37
Tooth resorption 38
Effects on the hardness of teeth 39
Pulp considerations 39
Effects of bleaching on soft tissues 39
Amalgam restorations 40
Tooth-coloured restorative materials 40
Managing patient expectations 42
Adhesive bonding and colour rebound 42
Chairside or in-of ce bleaching 44
Claims made regarding dental bleaching 46
Patient at risk groups 47
Assessing ef cacy and effectiveness of dental bleaching 48
Mouthrinses and toothpastes 48
Further reading 48
31
H o w T e e t h B e c o m e D i s c o l o u r e d

In t r o d u c t io n
Den tal bleach in g (tooth wh iten in g) solves th e min imally invasive man agemen t
dilemma regardin g th e treatmen t of discolou red teeth with out damaging th em
stru ctu rally or biologically, in eith er th e sh or t or th e lon g term. Bleach in g is a
ch emical process involving th e oxidation of organic material th at is broken down
to produ ce less complex molecu les. Most of th ese smaller molecu les are ligh ter in
colou r th an th e larger complex molecu les from wh ich th ey origin ated.

H o w Te e t h Be c o m e D i s c o l o u r e d (Fig. 2.1)

Th e min imal in terprismatic protein aceou s matrix presen t in en amel acts like a
wick drawin g u p ion s an d small molecu les from extrin sic oral fluids. Complex
molecu les in clu din g pigmen ts an d dyes stain th is in terprismatic matrix. A
pigment is a coloured substan ce composed of a colou r-bearing group (a ch romo-
ph ore) an d oth er molecu les. Pigmen ts may, or may n ot, attach to th e organ ic
matrix with in th e in terprismatic spaces. A dye is a pigmen t with reactive
(hydroxyl or amin e) grou ps th at can attach to organ ic matter. Common dyes
with in th e hu man diet come from ch ocolate, coffee, tea, cu r ry sauces, tomato
sau ces an d red win e. Melan oidin s are formed from th e breakdown produ cts
of cooked vegetable oils an d are also a common cau se of den tal discolou ration
(see Box 2 .1).
Metal compou n ds can in teract with dyes to form larger compou n ds th at produ ce
differen t colou rs of stain . Iron an d copper-con tainin g metallic compoun ds are
often involved in causin g darker in trin sic den tal stain s.

The type o initial discolouration a ects bleach-


ing e ectiveness and shade retention
Discolouration due to ageing or f uorosis
changes shade more quickly than teeth discol-
BOX 2 . 1 oured due to tetracycline drugs
CLIN ICA L RELEV A N CE O F Di erent tetracycline drugs produce di erent
TYP ES O F D I S CO LO U RA TI O N discolourations
Bleaching tetracycline-stained teeth in the
yellow/brown range o ten requires 69 months
and is easier than bleaching those tetracycline-
stained teeth in the blue/grey discolouration
range. Remember this by Yellow-brown WILL
bleach, blue-grey MAY bleach

32
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

interprismatic stable large molecules


spaces with ring or double bond
structures
HO2+ R large
H2O2 R molecules
R
O+ R

HO2+ disrupts rings


HO2+ R CH CH CH CH R
H2O2
HO2+ disrupts
O+ double bonds
O

HO2+ R CH CH CH R
H2O2 OH OH
O+ HO2+
smaller
molecules
within enamel H2O2
have less O+
colour

Fig. 2.1 Diagram outlining how teeth become discoloured. Fig. 2.2 Diagram outlining the mechanism of action of hydrogen
peroxide, degrading larger molecules into smaller molecules that are
lighter in colour. Some of these can then escape from the tooth, thereby
producing a lighter looking tooth.

Th e oxidative bleaching process involves the breakdown of ring stru ctu res an d
other con secu tive, con ju gated dou ble bon ds in complex molecu les. Th is resu lts
in a loss of colou r cau sed by u n wan ted dark molecu les in th e n on -cellu lar
matrix. Hydrogen peroxide works by convertin g th ese large molecu les in to alco-
hols, keton es and termin al carboxylic acids. As th ese are smaller molecu les th ey
are th en capable of bein g expelled th rou gh th e tooth stru ctu re an d from its
surface. Th e n et ou tcome is th at th e tooth is bleach ed an d th ereby appears
ligh ten ed in colou r (Figs 2 .2 and 2 .3 ).
33
C h e m i s t r y o f B l e a c h i n g

Fig. 2.3 The pigments and dyes have been bleached from the mandibular anterior teeth but remain in
the labial surfaces of the maxillary anterior teeth.

C h e m i s t r y o f Bl e a c h i n g
An oxidation/ redu ction (redox) reaction takes place du rin g bleach in g, wh ere
the hydrogen peroxide (Box 2 .2 ) oxidizing agent releases free radicals with
u n paired electrons, th ereby becomin g redu ced in the process. Th e discolou red
molecu les with in teeth accept th e u n paired electron s an d become oxidized, with
a con comitant redu ction in th e overall discolou ration . Hydrogen peroxide pro-
du ces differen t free radicals, n amely HO2 an d O, both of wh ich are high ly
reactive. The perhydroxyl ion (HO2 ) is th e stron ger an d more reactive of th e two
free radicals. For HO2 to be made readily available, th e bleachin g material needs
to be alkalin e. Th e optimal pH for HO2 release is approximately pH 1 0 .

The empirical ormula or hydrogen peroxide


is H2O2
The structural ormula is HOOH
BOX 2 . 2
CH EM ICA L F O RM U LA E O F The molecular weight o hydrogen peroxide is 34.0
H YD RO GEN P ERO XID E It is a rapidly reacting and unstable material
From October 2012, the EU limit or use by dentists
or other dental pro essionals with suitable train-
ing, will be 6% hydrogen peroxide, which is equiv-
alent to approximately 18% carbamide peroxide

34
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

C a r b a m i d e Pe r o x i d e
Th e empirical formu la for carbamide peroxide is CO(NH2 )2 H2 O2 . Th e structu ral
formu la is:

NH2 O
C HO OH
NH2

Th e molecu lar weigh t of carbamide peroxide is 9 4 .1 .


Carbamide peroxide is a stable compou n d th at slowly releases abou t on e th ird
of its volu me as hydrogen peroxide. In oth er words, a 1 0 % carbamide peroxide
gel will release about 3 .5% hydrogen peroxide slowly over 3 4 h ou rs wh ile a
21 % carbamide peroxide gel will release slowly abou t 7 % hydrogen peroxide.

H o w H y d r o g e n Pe r o x i d e W o r k s
Th e bleachin g effect is caused by th e degradation of high molecu lar weight,
complex organ ic molecu les th at reflect a specific wavelen gth of ligh t respon sible
for th e colou r of th e stain in th e den tal su bstrate. Th e degradation produ cts h ave
relatively low molecu lar weigh ts an d resu lt in a redu ced colou r reflectan ce. Th e
bleach in g process resu lts in a redu ction or elimin ation of th ose molecu les
cau sin g th e discolou ration . Both en amel an d den tin e ch an ge colou r as a resu lt
of th e passage of th e peroxide th rou gh th e tooth tissu es.
Du rin g den tal bleach in g th e low molecu lar weigh t hydrogen peroxide readily
pen etrates th rou gh in terprismatic en amel to en ter den tin e an d, even tu ally, th e
pu lp. Th e free radicals h ave u n paired electron s th at react rapidly with , an d
attack, most organ ic molecu les, gen erating fu rth er free radicals. Th ese react
with oth er u n satu rated bon ds, resu ltin g in th e disru ption of th e electron con -
figuration of th ose molecules. Hydrogen peroxide is capable of u ndergoin g
nu merou s reaction s, in clu din g molecu lar additions, su bstitu tion s, oxidations
an d redu ction s. It is a stron g oxidan t an d can form other free radicals by h omo-
lytic cleavage. Th e variou s ch emical reaction s produ ce a ch an ge in th e absorp-
tion en ergy of the large discolou red molecu les with in the en amel an d den tine
an d these are broken down in to smaller molecu les with th e con comitan t loss of
th e u nwan ted discolou ration .
In the process of bleach ing, h ighly pigmen ted carbon rin g compou n ds within
th e tooth can be broken down an d tu rn ed into relatively simple ch ain molecu les.
Many of th ese chain s h ave con secu tive conju gated dou ble bon ds that are broken
su bsequ en tly in to sin gle bon ds. Th ese ch emical reaction s resu lt in hydroph ilic
35
S a f e t y o f C a r b a m i d e P e r o x i d e

10% carbamide peroxide solution is equivalent


to 3.5% hydrogen peroxide and also contains
6.5% urea
Bleaching with carbamide peroxide is slower,
BOX 2 . 3 sa er and longer lasting but it needs more time
to be e ective as the hydrogen peroxide is
B LEA CH IN G D IF F EREN CES
released slowly
B ETWEEN CA RB A MID E
P ERO XID E A N D H YD RO G EN Hydrogen peroxide on its own is unstable and
P ERO XID E? breaks down in minutes into a perhydroxyl ree
radical (HO2) and then into H2O + O2
Urea breaks down into carbon dioxide and
ammonia, elevating the pH, helping the bleach-
ing by increasing the hydrogen peroxide release
period, and allowing penetration well into the
tooth structure

colou rless, or ligh tly pigmen ted, stru ctu res. Complex molecu les, in par ticu lar
th ose formin g metallic compou n ds, appear dark wh ereas simpler molecu les
appear ligh ter. By breaking the larger molecules in to smaller ones, most of th e
exogenou s stain s are dissipated.
Th e terms wh iten in g or ligh ten in g, wh ile in common u sage, are con fu sin g
an d do n ot describe bleachin g which is du e to a chemical reaction . Ligh ten ing
or wh iten in g, for instan ce, cou ld refer to the removal of su perficial or extrin sic
stain s wh ereas bleach in g is a deeper an d n ot readily reversible process.
Th eoretically, if th e bleach in g process con tinu es in defin itely, damage cou ld
occu r to th e en amel matrix protein s. Optimal bleachin g involves ch anging th e
teeth to an esth etically pleasin g tooth sh ade, u su ally agreed in advan ce with th e
patient, wh ile still preservin g the hardness, h ealth an d strength of th e den tal
min eral an d matrix protein s.
For differen ces between bleach in g with carbamide peroxide an d hydrogen per-
oxide, see Box 2 .3 .

Sa f e t y o f C a r b a m i d e Pe r o x i d e
Carbamide peroxide is formed from hydrogen peroxide an d u rea. Urea is a n ormal
body con stitu en t and th us h as n o adverse biological con sequen ce. Hydrogen
peroxide is fou nd in all cells as an en dogen ou s metabolite. Th e h u man liver, th e
principal site of its metabolism, produ ces abou t 2 7 0 mg of H2 O2 per h ou r.
A standard 1 .2 mL tube of 1 0% carbamide peroxide gel contain s approximately
0 .12 mg of carbamide peroxide so th ere is a very wide clin ical safety margin
relative to th e livers rou tin e metabolism. Moreover, th e viscou s carbamide per-
oxide in a bleaching gel an d th e released hydrogen peroxide th at migh t escape
36
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

from th e applicator tray is decomposed rapidly by salivary catalase an d peroxi-


dases. Th is en su res th e biological safety of th e clin ical bleach in g process at th e
con cen tration s u sed for tradition al den tal bleach in g (1 0 % carbamide peroxide
in a cu stom-made mou th gu ard is th e cu r ren t gold stan dard).

Sy s t e m i c D e f e n c e M e c h a n i s m s Ag a i n s t
H y d r o g e n Pe r o x i d e
All cells con tain protective en zymes again st hydrogen peroxide (catalase, per-
oxidases an d selen iu m-depen den t glu tath ion e peroxidases). Th e h igh est levels
are fou n d in th e liver, du odenu m, spleen , blood, mu cou s membran es an d kidn ey.
Most of the catalase is fou n d in red blood cells th at can degrade hydrogen per-
oxide within a few minu tes. Th e overall decomposition reaction of hydrogen
peroxide in th e presen ce of catalase is:

H2 O 2 + H2 O 2 2H2 O + O 2 (water and oxygen )

In th e presen ce of peroxidases the reaction is:

H2 O 2 + 2RH 2H2 O + R R

Hydrogen peroxide solu tion s below 35 % are classified dermally as a n on -ir ritan t.
Th ere is n o eviden ce in the available literatu re th at hydrogen peroxide is a skin
sen sitizer in h u man s. However, occasion al positive patch tests h ave been reported.
Biologic membran es are permeable to hydrogen peroxide. Hydrogen peroxide is
taken u p readily by cells of the oral mu cosa, bu t is metabolized rapidly. Th ere is
un certain ty as to th e exten t to wh ich hydrogen peroxide en ters th e blood circu -
lation from th e bleach in g process, given th e variable qu an tities of existin g
endogenou s hydrogen peroxide. In 1 9 8 5 th e toxicity of hydrogen peroxide was
reviewed by th e In tern ation al Association for Research on Can cer (IARC), an d
in 1 9 93 by Li an d th e Eu ropean Cen tre for Ecotoxicology an d Toxicology of
Ch emicals. These reviews concluded th at th ere are no reason s for con cern abou t
th e u se of hydrogen peroxide in th e concen tration s employed in den tist-
prescribed at-h ome bleach in g.

D e n t a l Se n s i t i v i t y
Temporary den tal hypersen sitivity is a well-docu men ted adverse effect of
bleach in g. Approximately 7 0 % of patien ts experien ce some sen sitivity du rin g
nigh tgu ard vital bleach in g u sin g 1 0 % carbamide peroxide. Th is sensitivity is
mild and tran sitory, u su ally persistin g for abou t 2 4 h ou rs following th e
37
T o o t h R e s o r p t i o n

com pletion of bleach in g. In creased sen sitivity is associated main ly with th e u se


of h eat and very mu ch h igh er con cen tration s of hydrogen peroxide in attempts
to accelerate th e bleach in g process. Th e predictors for patien ts developin g den tal
sen sitivity in vital teeth are:

Existin g den tal sen sitivity (or a pre-existin g reversible pu lpitis).


Th e use of h igh er concen tration s of carbamide or hydrogen peroxide.
Ch an gin g th e bleachin g gel more than once a day/ night.
Usin g h eat as an adju n ct to accelerate the redox reaction s.

To o t h Re s o r p t i o n
Th ere are n o reports of 1 0 % carbamide peroxide (equ ivalen t to 3 .5 % hydrogen
peroxide) held with in a mouthgu ard, cau sin g h ard tissu e resorption . Resorption
occu rs frequ ently as a result of trau ma to teeth (Fig. 2 .4 ). The severity of
damage to a tooth is related to th e type of inju ry su stained, the force involved
an d wh eth er th e tooth was dislodged, in tru ded or laterally luxated. Severe
damage or excessive dryin g of th e periodon tal ligamen t, th e time ou t of th e
mou th or a failu re to store th e tooth properly, all sign ifican tly in crease th e risks
of resorption of a trau matized tooth. Th e risks of late resorption are also related

Fig. 2.4 Cervical resorption produces a pink discolouration (pink spot) due to the blood in the
resorbing vascular tissue below the thin enamel surface. The UR1 had a history of two episodes of trauma
and one course of orthodontic treatment, but none of bleaching.
38
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

to damage to th e cementum, con tamin ation of the root, or a failu re to en dodon-


tically treat or splint the already badly damaged tooth appropriately.
Cer vical resorption is occasion ally observed in bleach ed, root-filled teeth bu t
on ly wh en a very h igh con cen tration of hydrogen peroxide (3 0 3 8 %) is applied
in con ju n ction with h eat to th e already damaged root or oth er tooth su rfaces.

Ef f e c t s o n t h e H a r d n e s s o f Te e t h
Th ere are nu merou s laboratory stu dies to sh ow th at peroxide-contain in g tooth
bleach in g produ cts do n ot affect th e en amel microstru ctu re. Th e abrasion resist-
an ce of en amel is not lowered by bleach in g, n or is its microh ardness or min eral
con ten t. The critical pH for en amel is 5 .5 , below wh ich th e hydroxyapatite
min eral ion s dissociate. Th e vast majority of carbamide peroxide produ cts h ave
a pH of 6 .5 to 7 . Even if a h igh con cen tration of hydrogen peroxide is u sed, th ere
is n o redu ction in th e h ardn ess of en amel or den tin e, let alon e dissolu tion of
tooth stru ctu re.

Pu l p C o n s i d e r a t i o n s
Hydrogen peroxide pen etrates readily an d qu ickly to reach the pu lp. Th e h igh er
th e con cen tration , th e more rapidly it appears in th e pu lp. Followin g exposu re
to hydrogen peroxide, histological stu dies h ave sh own a mild inflammatory
respon se th at is limited to th e su perficial layers of th e pu lp immediately su b-
jacen t to th e den tin epu lp in terface.
Th ese observation s are con sisten t with th e mild discomfor t repor ted by patien ts
as early as 1 5 minu tes followin g th eir teeth bein g exposed to hydrogen peroxide
for th e pu rpose of bleach in g them. Despite th e u ptake of hydrogen peroxide, th e
pu lp appears to su ffer n o ir reversible damage as a con sequ en ce of bleach in g,
even wh en u sin g u p to 4 0 % hydrogen peroxide on in tact teeth . Th ere are n o
reports of teeth becomin g n on -vital even with very prolon ged (6 9 mon th s) u se
of 1 0 % carbamide peroxide in stu dies wh ere patien ts were followed u p over
7 years later. 1

Ef f e c t s o f Bl e a c h i n g o n So f t Ti s s u e s
Th e American Dental Association Guidelines for the acceptance of peroxide products
were publish ed in 1 9 94 . 2
Th ese gu idelin es required an evalu ation of th e effects of bleach in g on th e soft
tissu es of th e mou th, in clu din g the ton gue, lips, palate an d gin givae. To date,
39
T o o t h - C o l o u r e d R e s t o r a t i v e M a t e r i a l s

Fig. 2.5 Carbamide peroxide at 10% was used to bleach the natural teeth Fig. 2.6 After bleaching the maxillary and mandibular teeth, the lower
to match an existing old ceramic crown rather than replacing it with a incisors black triangle disease was reduced with direct resin composite
darker one. at no biological cost. Note, the free gingival graft, present for 32 years,
was not affected by the bleaching and the resin composite bonding
(usually abbreviated to B&B).

n one of th e publish ed stu dies on th e u se of 1 0% carbamide peroxide h ave


reported any adverse effects on th e variou s soft tissu es of th e mou th . Wh ere mild
tran sien t damage to gin gival tissu es h as occu r red, it appears to h ave been related
to physical trau ma cau sed by a poorly fittin g mou th gu ard or gel tray.
In n igh tgu ard vital bleach in g, du rin g wh ich th e carbamide peroxide is con -
tain ed with in a cu stomized mou th gu ard, th e risks of adverse effects on soft
tissu es are limited (Figs 2 .5 and 2 .6 ).

Am a l g a m Re s t o r a t i o n s
Some laboratory studies h ave demon strated th e release of small amou n ts of
mercu ry from den tal amalgam restoration s wh en bleach ed. Th e levels are well
with in the limits of mercu ry exposu re established by the World Health Organ iza-
tion (WHO) an d do n ot pose a risk to patien ts. Notwith stan din g th ese fin din gs, it
is pruden t to replace any amalgam restoration s in an terior teeth with temporary
tooth -colou red restoration s prior to bleach in g. Th is will avoid th e very limited
risk of producin g a green discolouration cau sed by th e cor rosion of copper, a
common con stitu en t of den tal amalgam restoration s (Figs 2 .7 an d 2 .8 ).

To o t h -C o l o u r e d Re s t o r a t i v e M a t e r i a l s
Tooth -colou red restorative materials are n ot affected by th e bleach in g process
an d as a con sequ ence, th ey may appear darker followin g bleachin g relative to
th eir adjacen t n atu ral teeth . It is importan t for a den tist to discu ss th is with
40
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

Fig. 2.7 Palatal amalgams should be removed and replaced prior to Fig. 2.8 Removal of the amalgam restorations and replacement with
bleaching thin anterior teeth. direct resin composite stops the theoretical risk of teeth turning green
during bleaching.

Fig. 2.9 The upper left lateral incisor had a discoloured mesial resin Fig. 2.10 The darker maxillary teeth will bleach but the existing
composite restoration and the tooth itself was darker than the adjacent restorations will not. Lighter natural teeth will match the bridge better,
canine crown, a light coloured, bonded metal/ceramic bridge abutment. but the composite restorations within them will need to be changed in
order to match the newly bleached teeth.

patien ts before th ey agree to bleach th eir teeth . Patien ts are frequ en tly u n aware
of wh ich of th eir teeth h ave restoration s.
Expen sive and poten tially tissu e destru ctive re-makes of previously well colou r-
match ed crown s or oth er in direct restoration s can be at a sign ifican t biological
an d fin an cial cost for patien ts wh o h ave u sed over-th e-cou n ter or in tern et-
sou rced bleach in g produ cts, with ou t previou sly con su ltin g a den tist for advice
on the risks of restoration colou r mismatch cau sed by bleach ing of th e n atu ral
tooth tissu es (Figs 2.92 .1 1).
41
Ad h e s i v e B o n d i n g a n d C o l o u r R e b o u n d

Fig. 2.11 New resin composite restorations were


placed 1 week after cessation of nightguard vital
bleaching with 10% carbamide peroxide. The
natural teeth were now a better colour match for
the pre-existing UL3 to UL5 bridge which therefore
did not need to be changed because it was
originally lighter in colour than the adjacent teeth.
If it had been darker, then bleaching the natural
teeth could have meant changing the bridge,
possibly at very signi cant biological and nancial
costs to the patient. This bleaching approach and
resin composite replacement treatment were
minimally invasive, safe biologically and cost-
effective for the patient.

M a n a g i n g Pa t i e n t Ex p e c t a t i o n s
Patien ts who h ave sou rced an d used su ch bleach in g produ cts or devices described
above, may presen t to th e den tist su bsequ en tly requ estin g th e replacemen t of
their n ow apparen tly darker restoration s. Some are su rprised at th e h idden
costs of th e exten sive an d often invasive operative den tistry requ ired in placin g
n ew restorations in order to match th eir n ewly bleach ed teeth.
In man agin g th ese esth etic bleach in g cases, it is imperative th at th e den tist an d
their team evalu ate th e real con cern s th e patien t h as regardin g th eir den tal
esth etics. Bleach in g is a min imally invasive process bu t its limitation s for th e
in dividu al case mu st be explain ed an d discussed with the patient. Patien ts
expectation s of available levels of esth etic cor rection mu st be man aged by th e
den tal team. These discu ssion s must be clearly docu men ted, with sign ed copies
given to th e patient. Th e u se of digital ph otographic records, with suitable refer-
en ce sh ade tabs in clu ded, mu st be en cou raged, before, du rin g an d after treat-
men t is complete, in order to h elp allay any fu tu re con cern s th e patien t may
h ave. It must be made clear th at th e effects of den tal bleach ing are n ot perma-
n en t. Th e balance between th is biologically favou rable approach and the tissu e-
destru ctive operative option (crown s, ven eers) sh ou ld be explained fully. Relapse
is covered in Box 2 .4 .

Ad h e s i v e Bo n d i n g a n d
C o l o u r Re b o u n d
Bon d stren gth s between en amel an d resin -based restoration s are redu ced for
th e first 2 4 h ou rs after bleach in g. Th ereafter, th ere is n o differen ce in th e bon d
stren gth s of composite resin to bleach ed or n on -bleach ed en amel.
42
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

Bleaching with carbamide peroxide is ollowed by


a colour relapse in 46 weeks depending on the
BOX 2 . 4
concentrations used. Higher concentrations
RELA P S E demonstrate aster and greater colour change
initially but also longer and greater colour rebound.
The colour usually stabilizes by 6 weeks at a level
still signi cantly di erent rom baseline

Colou r rebou n d is a term u sed in bleach in g to describe ch an ges in th e colou r


of teeth after bleach in g. Th ese effects are lin ked to the loss of oxygen from teeth
an d any associated rehydration if th e teeth h ave been isolated u n der a ru bber
dam. Rebou n d, wh ilst largely completed in th e first 2 4 h ou rs after bleach in g,
may take u p to 7 days to stabilize. Th erefore, it is pru den t to delay post-bleach in g
restorative procedu res for a week after completion of bleach ing to allow stabili-
zation of th e colou r before tryin g to colou r match restoration s, particu larly if
th ese are in direct restoration s, to ensu re optimal colou r match in g an d bon d
stren gth .
Any residu al oxygen still left with in th e teeth can produ ce in adver ten t oxygen
in h ibition of a resin composite lu tin g cemen t. As a precau tion , th erefore, it is
sen sible wh en plan n in g any su ch restoration s for completion after bleach in g, to
con fiscate th e mou th gu ard from th e patien t on e week ah ead of th e preparation
stage for any su ch in direct restoration s. By doin g th is th e patien t will n ot be able
to fur th er bleach th eir teeth prior to takin g th e sh ade, or indeed between prepa-
ration an d fittin g of th e su pposedly defin itive restoration s.
Th e patien t sh ould also be warn ed not to u se any sor t of over-th e-cou n ter
bleach in g produ ct du rin g th is time, as th is wou ld affect th e composite lu tin g
bon d stren gth s an d possibly also th e colou r match of th e fin al restoration s. If
th e patien t is still un su re about h avin g ach ieved th eir desired colour ch an ge, it
is wise to postpon e th e su pposedly defin itive restorative treatmen t u n til th ey
con firm th at th ey are h appy to proceed with it. For in formation on colou r regres-
sion after n igh tgu ard vital bleach in g, see Box 2 .5 .

The American Dental Association (ADA) seal o


BOX 2 . 5 approval requires that 85% o the original colour
CO LO U R REGRES S IO N A F TER change is maintained at 3 months and that 75% is
N IG H TG U A RD V ITA L maintained at 6 months. To date, only nightguard
B LEA CH IN G vital bleaching with 10% carbamide peroxide
bleaching products have gained this ADA seal o
approval, which is based on multiple randomized,
double blind, controlled clinical trials

43
C h a i r s i d e o r i n - O f f i c e B l e a c h i n g

C h a i r s i d e o r i n -O f c e Bl e a c h i n g
Chairside bleach in g is car ried ou t in th e dental su rgery ch air u sing relatively
h igh con centration s of u n stable, rapidly reactin g, hydrogen peroxide u su ally in
the ran ge of 15 3 8 %. Hydrogen peroxide at a con cen tration of 2 5 % is equ iva-
len t to 7 5% carbamide peroxide; 3 8 % hydrogen peroxide is equ ivalen t to 1 1 4 %
carbamide peroxide. For comparison pu rposes th is is more th an 1 1 times th e
con cen tration of th e safer an d more stable 1 0 % carbamide peroxide material
u sed n ormally for n igh tguard vital bleachin g in a customized tray (see Box 2 .6 ).
Th e h igh er the con cen tration of hydrogen peroxide, th e greater th e risk of h arm
to soft tissu es or eyes from acciden tal con tact, an d su itable protection mu st be
worn by both th e patien t an d operatin g team to prevent in ju ry/ bu rn s.
Ch airside bleach in g can an d often does cau se soft tissu e damage. To avoid su ch
damage, strenuous effor ts n eed to be made to protect all th e patien ts soft tissu es.
Th e u se of a ru bber dam or an oth er form of effective isolation is essen tial
wh en u sin g th e h igh est con cen tration s (Fig. 2 .1 2 ). Damage appears as a wh ite
bu rn of th e epith eliu m an d su ch burn s are painfu l and distressin g for th e patient
(Fig. 2 .1 3 ).
In th e even t of an adverse soft tissu e reaction , th e area sh ou ld be wash ed th or-
ou gh ly an d th e patien t reassu red. Th e pain ful area n ormally takes a few days to
a week to h eal. Scar rin g is n ot u su ally a problem, as the u lceration is superficial.
Bu rn s to th e fin gers or ch eek can h appen if th e material is tou ch ed acciden tally
(Fig. 2 .1 4 ).

The use o bleaching lights during in-o ce


(chairside) techniques has, to date, not been
shown in any randomized controlled, double
blind, independent clinical trials to improve the
longevity or e ectiveness o bleaching
Immediate change in the light-activated mat-
BOX 2 . 6 erial seems more likely to be related to the
chemical catalyst employed rather than to the
I N O F F ICE ( CH A IRS ID E) V S
bleaching light itsel
N IG H TGU A RD V ITA L
B LEA CH IN G Dehydration e ect o isolation and having the
teeth ull o oxygen at that stage accounts or
much o the initial colour change
Tetracycline-stained teeth in the yellow range
are easier to lighten than those tetracycline
products causing a blue/grey discolouration;
showing that in-o ce (chairside) techniques are
not nearly as good as nightguard vital bleaching
with 10% carbamide peroxide at 3 or 6 months

44
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

Fig. 2.12 Chairside bleaching using 38% hydrogen peroxide with Fig. 2.13 White gingival epithelium burn following leaking of the high
paint-on dam and OptraGate retractor in position. concentration hydrogen peroxide onto the thick periodontal tissues. This
super cial epithelium sloughs off quickly leaving a red, painful ulcerated
area that may affect temporarily adequate oral hygiene procedures in
this area.

Fig. 2.14 Painful burn caused by accidental contact of the nger with 38% hydrogen peroxide when
cleaning up after chairside bleaching.

45
C l a i m s M a d e R e g a r d i n g D e n t a l B l e a c h i n g

C l a i m s M a d e Re g a r d i n g
D e n t a l Bl e a c h i n g
Some manu facturers of bleach in g products, or the den tists u sing these, advo-
cate u sin g th e n igh tgu ard approach with 1 0 % carbamide peroxide for a few
weeks prior to u n dertakin g ch airside bleach in g. As so-called eviden ce for th e
su pposed efficacy of th is treatmen t protocol, th e before photograph s are taken
often before any bleach ing h as occu r red or, in deed, sometimes before any pre-
operative clean ing of th e teeth has been car ried out to remove any extrin sic
stain s, but certain ly wh en th e teeth are still hydrated an d with n o extra oxygen
in th em. The after ph otograph s are th en taken immediately wh en th e ru bber
dam comes off, i.e. before th e teeth can rehydrate or colou r reboun d h as
occu r red, which u su ally takes a few days. Th is dubiou s ph otograph ic practice
can easily mislead patien ts in to th in kin g th e treatmen t on offer produ ces dra-
matic ben eficial resu lts.

Ideally, th e comparative sh ade ch an ge ph otograph sh ou ld be taken at least 1


week after th e bleach in g is complete to h ave any credibility, an d sh ou ld be
u n der taken by a person wh o h as n o vested interest in th e produ ct bein g u sed
an d preferably u sin g an objective colorimeter referen ce in dicator.

An oth er approach marketed to patients for rapid resu lts is to car ry ou t power
bleach in g in th e surgery with 2 2 3 8 % hydrogen peroxide first and th en get th e
patient to complete th e n igh tguard vital bleach ing at h ome with 10 % or 15 %
carbamide peroxide to main tain th e bleach in g effect. Th ere h as been n o differ-
en ce fou n d at th e 3 - or 6 -mon th stage of th e resu lts with th is approach as
opposed to the more straigh tforward, cost effective an d mu ch safer n ightguard
vital bleach in g with ju st 1 0% carbamide peroxide in a cu stomized tray.

Th ere is, h owever, an extra fee claimable by th e den tist for th e ch airside bleach -
in g and the possibility of extra pu lp sen sitivity for th e patien t, together with a
risk of soft tissue damage du e to th e h igh concen tration s of hydrogen peroxide
u sed in th e in-office/ ch airside/ in -surgery bleach in g. In ciden tally th ese terms
all mean th e same thin g, i.e. bleach in g with high con cen tration s of chemically
catalysed hydrogen peroxide. Th e ph otograph ed sh ade ch an ges, wh ich are
sometimes fur th er en han ced by openin g u p a cou ple of th e F stops on th e
camera between th e before an d after ph otograph s or u sin g software to en h an ce
th e sh ade ch an ge, sadly do n ot last, as ju dged from in depen den t, u n biased trials.
At 3 or 6 mon th s su ch resu lts are n o better than th ose ach ieved with ordinary
proven n igh tgu ard bleach ing wh ich can be obtain ed more safely an d at a frac-
tion of th e cost or risks to th e patien t.

46
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

Fig. 2.15 Tetracycline-stained teeth cannot be


bleached effectively with chairside or in-of ce
bleaching. Prolonged nightguard vital bleaching
with 10% carbamide peroxide will work eventually
(68 months) on yellow/brown tetracycline stained
teeth but will not work well on grey or blue
tetracycline-stained teeth.

Th ere is an in terestin g, subtle, bu t importan t issu e of respon sibility for th e


den tal colou r ch an ge. With ch airside bleach in g th e den tal profession al is respon -
sible solely for gettin g a satisfactory result as ju dged by th e patien t. In terms of
th e time requ ired to ach ieve this chan ge, it usually involves four separate
appoin tmen ts of approximately an h ou r each , with th e time for isolation an d
protection or clean u p time n ot in clu ded in th at h ou r, to get a resu lt similar to
th at ach ievable by a patien t bleach in g th eir teeth , in th eir own time an d at th eir
own pace, with n igh tgu ard vital bleach in g. Th e su btlety in th e tran sfer of
respon sibility is th at with n igh tgu ard vital bleach in g it is th e patien ts respon-
sibility to obtain th e colou r ch an ge th ey wan t, regardless of h ow lon g it takes
th em to do so. Th at is par ticu larly important wh en dealin g with , for example,
tetracyclin e stainin g, wh ere th e stable tetracyclin e orthoph osph ate is located
deep with in th e den tine an d takes many mon th s of treatmen t to bleach ou t
(Fig. 2.15 ).

Pa t i e n t a t Ri s k G r o u p s
Th e on ly individu als kn own to be at any risk from bleach in g with hydrogen
peroxide are patien ts with very rare con dition s su ch as acatalasaemia or glu cose-
6-ph osph ate dehydrogen ase (G6 PD) deficiency. Th is makes th e in dividu al more
su sceptible to th e activity of peroxide as th ey are less capable of metabolizin g it.
Acatalasaemia is a rare con dition with an in ciden ce of 0 .2 %. G6 PD is a disorder
of eryth rocytes in wh ich th e metabolic problems of th e affected cells resu lt in
in adequ ate detoxification of hydrogen peroxide. Th e in ciden ce of G6 PD defi-
cien cy in Eu rope is abou t 0 .1 %.

47
M o u t h r i n s e s a n d T o o t h p a s t e s

As s e s s i n g Ef c a c y a n d Ef f e c t i v e n e s s
o f D e n t a l Bl e a c h i n g
American Den tal Association (ADA) guidelines for en dorsin g bleachin g systems
or produ cts are strict and require manu facturers to sh ow both th e safety-in-use
of produ cts an d their efficacy. Th e data requ ired for their seal of approval
in clu des:

Fin din gs from two ran domized prospective dou ble blin d clinical trials,
involvin g th e comparison of th e test material with a non -active con trol
material.
Th e assessmen t of the effects of treatmen t over a period of 2 6 weeks.
Th e measu remen t of tooth colou r at th e star t an d at th e en d of treatment
u sing two different systems of colour measu remen t.
Colour du ration measuremen ts sh ould take place at 3 an d 6 mon th s to
assess wheth er th e colou r improvement is maintain ed. It is a requ irement
for th e ADA seal of approval th at 8 5 % of any colou r ch an ge is main tained
at 3 months an d 7 5% of colou r ch an ge is main tained at 6 month s.

M o u t h r i n s e s a n d To o t h pa s t e s
Over-th e-cou n ter mou th rin ses su ch as Bocasan (Oral B, P&G) an d Peroxyl
(Colgate Palmolive) are available freely. Bocasan releases approximately 7%
hydrogen peroxide and Peroxyl contain s 1 .5% hydrogen peroxide. Th e con cen -
tration s of hydrogen peroxide in mou th rin ses do n ot bleach teeth . Th ey may,
h owever, have some min or, sh or t-term, beneficial effect on oral hygien e an d
possibly in th e man agement of cer tain extrin sic stain s.
Tooth paste can remove su perficial extrin sic stain on ly. No tooth paste can bleach
teeth becau se th e maximu m hydrogen peroxide con cen tration allowed in tooth -
pastes by EC law is 0 .1 % an d at th at level it is u seless becau se it is immediately
in activated by salivary catalase an d peroxidases.

Further reading
Cooper JS, Bokmeyer TJ, Bowles WH. Penetration of the pulp chamber by carbamide peroxide
bleaching agents. J Endod 1992;18:31517.

ECETOC. Joint assessment of commodity chemicals No. 22: Hydrogen peroxide (Cas. No. 7722-
84-1). Brussels: European Centre for Ecotoxicology and Toxicology of Chemicals; 1993.

Feinman RA, Madray G, Yarborough D. Chemical, optical and physiologic mechanisms of


bleaching products: a review. Pract Periodontics Aesthet Dent 1995;3:326.
48
c h a pt er 2
D e n t a l Bl e a c h i n g : M a t e r i a l s

Frysh H. Chemistry of bleaching. In: Goldstein RE, Garber DA, editors. Complete Dental Bleach-
ing. Chicago: Quintessence Books; 1995. p. 2532.

Haywood VB. History, safety and effectiveness of current bleaching techniques and applications
of the night guard vital bleaching technique. Quintessence Int 1992;23:47188.

Heithersay GS, Dahlstrom SW, Marin PD. Incidence of invasive cervical resorption in bleached
root- lled teeth. Aust Dent J 1994;39:827.

IARC. Hydrogen peroxide: evaluation of the carcinogenic risk of chemicals to humans. IARC
Monographs 1985;36:285314.

International Symposium on Non Restorative Treatment of Discolored Teeth. Chapel Hill, North
Carolina, September 2526, 1996. J Am Dent Assoc 1997;128(Suppl.):1S64S.

Kelleher M. Ethical issues, dilemmas and controversies in cosmetic and aesthetic dentistry.
A personal opinion. Brit Dent J 2012;212(8):3657.

Kelleher MG, Roe FJ. The safety-in-use of 10% carbamide peroxide (Opalescence) for bleaching
teeth under the supervision of a dentist. Br Dent J 1999;187:1904.

Li Y. The safety of peroxide-containing at-home tooth whiteners. Compend Contin Educ Dent
2003;24:3849.

Patel V, Kelleher M, McGurk M. Clinical use of hydrogen peroxide in surgery and dentistry why
is there a safety issue? Brit Dent J 2010;208(2):614.

Schulte JR, Morrissette DB, Gasior EJ, et al. The effects of bleaching application time on the
dental pulp. J Am Dent Assoc 1994;125:13305.

Sterrett J, Price RB, Bankey T. Effects of home bleaching on the tissues of the oral cavity. J Can
Dent Assoc 1995;61:41217, 420.

Re f e r e n c e s

1. Leonard RH Jr, Van Haywood B, Caplan DJ, Tart ND. Nightguard vital bleaching of tetracycline-
stained teeth: 90 months post treatment. J Esthet Restor Dent 2003;15(3):14252.

2. American Dental Association Council on Dental Therapeutics. Guidelines for the acceptance of
peroxide containing oral hygiene products. J Am Dent Assoc 1994;125:11402.

49
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Ch a pt er 3
Den tal Bleach in g: Meth ods
M. KELLEH ER

Introduction 52
History and development 53
Patient management and expectations 53
Nightguard vital bleaching clinical protocol 54
Management of discoloured, non-vital
anterior teeth 76
Problems and troubleshooting 89
Restorative alternatives to bleaching non-vital,
discoloured teeth 91
Further reading 96

51
I n t r o d u c t i o n

In t r o d u c t io n
Th e aim of th is ch apter is to con sider th e in dication s for n igh tgu ard vital bleach -
in g (NgVB) an d to ou tlin e th e clin ical tech n ique. Clin ical assessmen t, tray
design s an d issu es pertain in g to existin g restoration s are discussed.
NgVB has revolution ized min imally invasive (MI) tooth preser ving esth etic den -
tistry in th at it produ ces a safe, effective an d eviden ce-based meth od of improv-
in g th e appearan ce of discoloured teeth . NgVB involves the patien t placing a
viscou s 1 0 % carbamide peroxide gel in a cu stomized mou th guard th at is worn
by th e patien t while asleep (Figs 3.13 .3 ).

Fig. 3.1 Discoloured teeth in a 60-year-old patient before bleaching.

Fig. 3.2 Scalloped bleaching trays with viscous 10% carbamide peroxide Fig. 3.3 Appearance of the teeth after 3 weeks of bleaching.
gel within them in situ.
52
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

H ist o r y a n d De v el o pm en t
Carbamide peroxide is an oxygen -releasin g an tiseptic an d appears in variou s
ph armacopoeia as su ch . It was th e treatmen t of ch oice for tren ch mou th in
World War On e (1 9 1 4 1 9 1 8 ), th e n ame given at th at time to acu te n ecrotizin g
ulcerative gin givitis (ANUG/ AUG/ Vin cen ts in fection ). Th is destru ctive, rapidly
progressive gu m disease was common in soldiers in th e tren ch es du rin g th e Great
War du e to th e combin ation of smokin g, stress an d lack of effective oral hygien e.
Th e u se of a viscou s gel formu lation within a cu stomized mou th gu ard with
reservoirs was described by Haywood an d Heyman n in 19 8 9 , based on th e
empirical post-or th odon tic u se of carbamide peroxide in fin ish ers (clear retain -
ers) by Klu smier in 19 6 2 to redu ce periodon tal in flammation after or th odon tic
treatment. Klu smier n oted th at a side effect of th is treatmen t, u ndertaken pri-
marily for gin gival h ealth reasons, was to ligh ten th e colou r of th e teeth .
Haywood an d Heyman n from 1 9 8 9 on wards were respon sible largely for th e
fu rth er clin ical developmen t an d th e scien tific evalu ation of th e tech n iqu e. Th ey
based th ese developmen ts on earlier separate works by Klu smier, Wagn er, Au stin
an d Mu n ro, wh o n oted in depen den tly th e ligh ten in g of teeth as a side effect of
usin g carbamide peroxide in th e man agemen t of gin gival tissu e con dition s.
Th e most acceptable evidence for good clin ical practice is based on th e resu lts
of prospective ran domized, dou ble-blin d, con trolled clin ical trials. Su ch trials
are relatively rare in den tistry, bu t a nu mber of su ch trials h ave con firmed th e
safety an d efficacy of NgVB. Colou r ch an ges h ave been reported as lastin g for
up to 4 years. Teeth can be re-bleach ed safely or tou ch ed u p easily u sin g th is
tech nique, u sually takin g ju st 1 n igh t per week of th e time requ ired to get th e
origin al colou r ch an ges. In oth er words, if it took 4 weeks to get a satisfactory
colou r chan ge in itially, it will take just 4 n igh ts of bleach in g to tou ch u p to th e
in itial bleach ed colou r.

Pa t i e n t M a n a g e m e n t a n d Ex p e c t a t i o n s
Assessmen t of patien t expectation s of th e ou tcomes of bleach in g is impor tan t
an d sh ou ld be car ried ou t at th e earliest opportu n ity. With NgVB, th e main issu e
is patien t complian ce in wearin g th e mou th gu ard con tain in g th e bleach in g gel
for th e requ ired periods of time. Patien ts wh o gag at th e impression stage are
un likely to be particu larly complian t with th is bleachin g tech n iqu e.
If patients in dicate an in terest in den tal bleaching (or tooth wh itening), it is
good practice to h ave in formation packs available for them. Th is gen eral in for-
mation can be placed on th e practice (or h ospital) website, or emailed/ posted to
patien ts prior to con su ltation in order to give th em basic, regu lated an d reliable
53
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

What outcome do you wish to achieve?


Have you tried any other treatment to whiten or
bleach your teeth? I so, how did you f nd the
results?
BOX 3 . 1 What do you think has caused your problem?
P A TIEN T Q U ES TIO N N A IRE: What would you consider a satis actory solu-
P RE- EXA M IN A TIO N tion? (Please note, i somebody answers very
white teeth, be aware that their expectations
may be too high and these will need managing.
Somewhat lighter teeth is a much more realis-
tic treatment objective)
How long do you think treatment might take to
achieve your desired result?

in formation on den tal bleach in g an d time also to reflect on th e advan tages an d


disadvantages ahead of their den tal con su ltation appoin tmen t. This can redu ce
misun derstan din gs cau sed by the in ju diciou s relian ce on th e In tern et as a
sou rce of reliable or allegedly accu rate patien t in formation .
Th ere is n o reason to avoid th e u se of occlu sal coverage trays in patients with a
h istory of temporoman dibu lar dysfun ction (TMD). It is pru dent, h owever, to
warn patien ts with a h istory of TMD th at th ey may experien ce some mild dis-
comfort. Th ere are n o repor ts of patien ts u n dergoin g NgVB complain in g of TMD
du rin g or after the bleach in g process. In contrast, some TMD patien ts may expe-
rien ce some relief of th eir symptoms, given th at th e soft bleach in g tray may
double as a soft TMD device or a so-called occlusal bitegu ard.
A pre-examin ation qu estionn aire may be a u sefu l adju n ct prior to the con sulta-
tion (see Box 3 .1 ).

N i g h t g u a r d Vi t a l Bl e a c h i n g
C l i n i c a l Pr o t o c o l
Th e protocol for NgVB is based on th at developed by Haywood and Heyman n
(1 9 8 9 ) an d is as follows:

A th orou gh h istory is taken , a detailed clin ical examin ation is car ried ou t
and a differen tial diagnosis is made in respect of th e cause(s) of the den tal
discolou ration .
Restorations in the target area an d in the adjacent and opposin g teeth are
recorded. Ven eers or crown s are ch arted, as th ese, togeth er with oth er
existin g restoration s, will n ot ch an ge colou r with bleach in g an d may need
costly replacemen t if th ey n o lon ger sh ade match after bleach in g.
54
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.4 Recession and erosion are already


obvious on the upper teeth. An air blast onto
these teeth detects individual sensitivity pre-
bleaching and this information needs to be
recorded. These teeth are likely to become more
sensitive when bleaching and this will probably
therefore affect patient compliance. The patient
has a thin periodontal biotype in both upper and
lower jaws that could recede further if the
bleaching tray edges were left rough and
damaged them physically.

A n ote is made as to th e biotype of th e periodon tal tissu es (Fig. 3 .4 ).


A 3 -in -1 syrin ge is u sed to blow air arou n d th e teeth to be bleach ed an d
any sen sitivity is recorded. Patien ts sh ou ld be warn ed th at if any teeth are
sen sitive at th e time of th is in itial examin ation th at th ese teeth are likely to
get mu ch more sen sitive with bleach ing. Patien ts presentin g with sensitivity
may n eed to bleach for 1 2 h ou rs on ly at a time, rath er th an for th e typical
overn ight period. In su ch cases, satisfactory bleach ing resu lts will take a
proportion ately lon ger time to be ach ieved.
Tooth wear (tooth su rface loss) cau sed by ch emical erosion is n oted as th e
affected teeth may be sen sitive and become hypersensitive temporarily with
bleach in g. Attritional tooth wear rarely causes an issu e wh en bleachin g.
Th e sh ade is agreed with the patien t by referen ce to a valu e-orien tated
(ligh t to dark) den tal sh ade gu ide (Box 3 .2 ). Th is shade is recorded in th e
n otes an d a written record of this agreed shade shou ld be given to the

The yellower the teeth are at baseline, the


greater the magnitude o the bleaching
response in most cases. Only moderately dark
yellow/brown teeth will bleach predictably
BOX 3 . 2
EF F ECT O F TH E I N ITIA L Blue/grey teeth due to some o the tetracyclines
S HAD E are very di f cult to bleach
Younger subjects experience greater lightening
o their teeth but o ten su er more relapse. Nev-
ertheless, most o the initial shade improvement
remains at 6 months post-treatment using NgVB
o moderately dark yellow/brown teeth

55
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.5 The shade tab should be photographed


beside the teeth. The letter and the number
should be clearly visible for the patients
photographic records in case of any dispute as to
the tooth colour prior to bleaching or relating to
ef cacy of bleaching. The brown-yellow
discolouration is due to a combination of
oxytetracycline and demethylchlortetracycline,
both of which are stable compounds deep within
the dentine and usually take 69 months to
bleach. Chairside bleaching is of no use in such
cases.

patien t with a diagram or clin ical ph otograph of any restoration s presen t


and visible (Fig. 3.5 ).
Patien t expectation s must be assessed carefu lly. If a patien t wh ose teeth are
already wh ite, with referen ce to a sh ade gu ide tab, in sists th at th ey are still
too dark, it is probably u n wise to proceed with bleach in g as th e ou tcome
from th e patien ts perspective is u n likely to be satisfactory. A diagn osis of
possible dysmorph oph obia (body dysmorph ic disorder or distortion of body
image) migh t n eed to be considered in th ese cases.
Radiograph s, if appropriate, ju stifiable an d in dicated clinically, are taken
and a n ote is made of any relevan t fin din gs, in clu din g th e periapical statu s,
sclerosis, atypical pu lp morph ology or size (Fig. 3 .6 an d see Fig. 3.1 1).
Th e option of bleach in g on e arch rath er th an both or a sin gle, darken ed
tooth preferen tially (Figs 3 .7 an d 3 .8 ) sh ould be discu ssed with th e patien t.
It sou n ds cou n ter-in tu itive to many den tists, bu t a su rprisin g nu mber of
patien ts wish on ly to h ave one arch bleached, u sually th e arch with most
visible teeth when they smile an d th is is sometimes also for fin an cial
reason s.

For advan tages an d disadvan tages of tray-applied NgVB bleach in g, see Box 3 .3 .
In th e case depicted in Figu res 3 .6 3 .8 , on ly wh en th e upper righ t cen tral
in cisor is as ligh t as the others shou ld a fu ll tray be u sed to bleach th e remain in g
arch . Note, it is in advisable to accomplish th is th e other way arou nd, i.e. bleach -
in g all teeth to star t with an d th en tryin g to bleach fu r th er th e darker on e,
preferentially, at th e en d. Th is is becau se if, for any reason , bleachin g fails to get
the darkest tooth as ligh t as th e oth ers at the end of bleach in g, then th e
56
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.6 The radiograph shows


shortening and sclerosis of the
clinically darker coloured upper
right central incisor by comparison
with the upper left one.

A B

Fig. 3.7A,B The short, sclerosed upper right central incisor should be bleached preferentially for a few
weeks rst because the increased amount of tertiary dentine, which is clear on the radiograph, causes it
to appear darker. On the positive side, it should not be sensitive when bleaching because of the
obliteration of dentine tubules and a reduction in the pulp space observed on the diagnostic radiograph.
57
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.8 A single-tooth


bleaching tray is used to
bleach one tooth
preferentially. Cutting
windows in the bleaching
tray over the adjacent
teeth allows the salivary
peroxidase and catalase to
inactivate the carbamide
peroxide immediately on
contact with the saliva,
and thereby avoiding
bleaching the adjacent
teeth unintentionally.

treatmen t will have appeared to make th e problem of th e darker tooth worse by


comparison . If there h as been any previou s attempt to con ceal th e darker tooth
with direct resin composite, for example, th en all th e resin tags created in th e
previous adh esive bon din g process n eed to be cut back to at least 5 0 m below
th e en amel su rface an d th e wh ole of th e labial an d palatal su rfaces ch eck
etched by applyin g stan dard ph osph oric acid gel to th e su rfaces for 1 5 seconds,
wash in g it off, dryin g it carefu lly with a 3 -in -1 syrin ge an d ch eckin g th at th e
su rfaces appear frosty wh ite. Any u n altered areas probably still h ave retain ed
resin composite tags with in th e en amel th at will preven t su bsequ en tly th e
bleach in g process. These will n eed to be removed to allow more effective bleach-
in g. However, if a porcelain veneer is in place, it is possible to place th e reser voir
for th e 1 0 % carbamide peroxide on th e palatal aspect of th e tooth an d this will
allow slow bleach in g with th e hydrogen peroxide passin g th ou gh th e palatal
en amel, palatal den tin e, pu lp, labial den tin e an d fin ally throu gh to th e residu al
labial enamel, wh ere it will be stopped by th e resin h oldin g th e porcelain ven eer
in position (Fig. 3 .9).

Advantages o at-home NgVB include it being


known to be the gold standard with the most
long-term evidence or its e f cacy and sa ety
It causes less post-operative discom ort

BOX 3 . 3 Lower cost o the initial treatment and easy top


up treatments or the patient
TRA Y- A P P LI ED N G V B
B LEA CH IN G : A D V A N TA G ES / Less chair time or the dentist
D IS A D V A N TA G ES
The main disadvantage with home bleaching is
that it takes time and relies on good compliance
by the patient
Trays have to be designed and f t properly to
stop salivary enzymes destroying the hydrogen
peroxide that is released gradually rom the
viscous carbamide peroxide

58
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.9 It is possible to bleach teeth slowly with the use of a palatal reservoir to hold the 10%
carbamide peroxide gel.

Any stru ctu ral or h istological abn ormalities of en amel an d den tin e, th e
exten t an d sufficien cy of any restoration s and the presen ce or absen ce of
any periodon tal con dition s sh ou ld be n oted (Figs 3 .10 3 .12 ).
Ch eck th e patien ts gag reflex by ru n n in g a fin ger alon g th e expected
exten sion of th e bleach in g tray.
If patien ts retch , or are u n able to tolerate impression s/ h avin g an applian ce
in th eir mou th for prolon ged periods wh ile awake or asleep, th en NgVB is
u n likely to be su ccessful.
Patien ts wh o retch frequ en tly can h ave a h istory of h avin g h ad an invasive
procedu re su ch as ton sillectomy or extraction of teeth u nder general

Fig. 3.10 Dentinogenesis imperfecta (hereditary opalescent dentine) in a Fig. 3.11 Radiographs of the patient in Figure 3.10 showing complete
patient aged 17 years. obliteration of the pulp canals at age 17 years.
59
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

A B

Fig. 3.12A,B Dentinogenesis imperfecta before and after 8 months of bleaching with 10% carbamide
peroxide used within the mouthguards.

anaesthesia. Patien ts wh o have experien ced a difficu lt gen eral an aesth etic
frequ en tly sh ow great relu ctan ce to h ave an applian ce in th eir mou th . It is
pru dent to discuss such details as part of th e patien ts h istory, prior to
incu r ring the costs of makin g th em customized bleaching trays. Retch in g
wh en an impression is bein g taken may be a warnin g of fu tu re difficu lties
with wearin g a mou th guard.
Th e altern ative option s to bleach ing must be discu ssed. Patien ts sh ou ld be
informed that any existing restorations will not chan ge colou r and that
th eir presen ce on on ly on e su rface of th e tooth can in h ibit complete
bleach in g. Ensu re th at all orthodon tic resin adh esive cement is removed
down to sou nd en amel after any fixed appliance or th odontic treatment
phase h as been completed. In this case the teeth n eed to be ch eck etch ed
briefly with ph osph oric acid to en su re th e complete removal of any adh esive
resin cemen t, as described previou sly.
If existin g restoration s are cu r rently ligh ter, the patien t sh ould be advised
th at bleach in g can ligh ten th e n atu ral teeth to h elp improve th e colou r
match .
If th e n atural teeth are lighter th an adjacen t restoration s with in the
bleach in g target area, th en fu r th er bleach in g will make th e situ ation look
worse. Patien ts with existin g restorations need to be warn ed to con trol th e
rate of bleach in g an d n ot to over-bleach th e n atu ral teeth . It is pru den t to
limit the amoun t of bleach in g gel given to su ch patien ts an d to review th em
at 1-week in ter vals. Patien ts need to be told th at if th e n atu ral teeth star t to
go ligh ter than th eir restorations, they must stop bleach in g immediately
and return to the surgery for reassessment.
60
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

On ce th e care plan is agreed, an d con sen t gain ed, an algin ate impression of
th e teeth is th en taken . It is advisable to u se a fin ger to wipe or sweep some
alginate aroun d all th e occlu sal an d labial aspects of the dried teeth prior
to in sertion of th e loaded tray. Th is min imizes th e formation of air bu bbles
an d h elps produ ce an accu rate cast. Th is, in turn , will allow a well-fitting
bleach in g mouthgu ard (also called a bleach in g tray) to be constructed. The
teeth to be bleach ed are iden tified on th e laboratory in stru ction card, togeth er
with an in dication of the outlin e an d extension of the tray. Th e teeth to be
bleach ed are blocked ou t with plaster or resin (see tray design ). Th is is u sually
done for each tooth on th e cast from one first molar arou nd to th e other.
Th e th ickn ess of th e material to be u sed in th e con stru ction of th e tray
n eeds to be specified as th is is a customized medical device an d covered by
th e EC Medical Devices Directive (MDD). Th e tray material sh ou ld be stron g
in th e thin section. A 1 mm clear preheated blan k is usu ally su itable. If th e
patient is a bru xist, a thicker material (2 mm) is in dicated. Th e material
sh ou ld be adapted easily an d capable of bein g fin ish ed to a smooth edge to
preven t trauma to the gingival tissues an d tongu e. It shou ld be n on -
allergenic, stable, and easy to clean .

Tr a y D e s i g n
Th e purpose of the tray is to hold th e gel in con tact with th e teeth to be bleach ed.
Different design s of tray are indicated dependin g on th e viscosity of the bleach -
in g gel. Poorly design ed or badly made trays will n ot produ ce th e desired ou tcome.
For th e effects of tray design, see Box 3 .4 . If th ere are specific teeth that n eed
localized bleach in g, a u sefu l clin ical tip is to first dry th e teeth con cern ed prior

An evaluation o the e ect o tray design on the


degree o colour change using 15% carbamide
peroxide suggested that trays with reservoirs
had signif cantly greater amounts o colour
change initially than trays without reservoirs,
but had more sensitivity than such trays with
10% carbamide peroxide
BOX 3 . 4
Reservoirs are sensible i the carbamide perox-
EF F ECT O F TRA Y D ES IG N ide gel is viscous to allow the tray to sit near the
necks o the teeth and thereby prevent inactiva-
tion o the gel by salivary enzymes at the cervi-
cal areas o the teeth
Failure to bleach the necks o the teeth is o ten
due to poor f t o the trays thereby leaving the
gel short o the gingival areas or open to inacti-
vation by the ever present salivary peroxidase or
catalase enzymes

61
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.13 Localized brown uorosis with banding and white uorosis. In Fig. 3.14 The teeth are dried with a 3-in-1 syringe and some hybrid resin
this case removing the brown uorosis is the patients priority. Patients composite shade C4 is applied over the darkest brown part of the
should be warned that the white uorosis (secondary ecking) will not be un-etched enamel and photocured in position.
removed but will probably be less obvious when viewed against the
bleached teeth.

Fig. 3.15 Bleaching tray in position with reservoirs to hold the 10% Fig. 3.16 A window has been cut in the bleaching tray over the lateral
carbamide peroxide gel just over the brownest areas of the two central incisors to allow the protective salivary enzymes access to destroy any
incisors. perhydroxyl ions that spread onto these teeth and thereby prevent any
inadvertent bleaching.

to scu lptin g temporarily some resin composite of a con trastin g sh ade, wh ich is
th en limited to th e target areas on ly. Th is is th en ligh t cu red in position with ou t
th e u se of etch in g or adh esive (Figs 3 .1 3 3 .2 0 ).
An algin ate impression is taken , with th e cu red resin composite maskin g th e
darkest areas. The composite is th en removed an d the patien t given an oth er
appoin tmen t to fit the cu stomized tray. Wh en th e algin ate is cast, the resin com-
posite addition s will appear as positive excesses on th e model that will match
exactly wh ere th e gel reser voirs are requ ired. No fu rth er block ou t of th e models
62
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.17 The tray extends from the upper rst molar to rst molar to aid Fig. 3.18 The lower tray has the reservoirs just over the brownest
retention and stability of the tray in situ with the reservoirs over the labial surfaces of the lower incisors. The areas over the mandibular canines have
of the central incisors and the windows cut out over both laterals. been cut back to allow the salivary peroxidase and catalase access to these
teeth, and thereby prevent undesirable bleaching of the lower canines.

Fig. 3.19 The bleaching trays with the 10% carbamide peroxide gel in Fig. 3.20 Clinical appearance after 8 weeks of bleaching with 10%
position. carbamide peroxide.

is requ ired becau se, wh en th e heated th ermoplastic material is su cked down


on to th e model to make th e bleach ing tray, th e reser voirs will be in th e cor rect
position s.
A win dow is cu t over th ose teeth th at are n ot to be bleach ed so th at th e protec-
tive salivary peroxidase and catalase can in activate the gel an d stop any
un wan ted bleach in g of th e adjacent teeth .

Trays with or without reservoirs?


Th e n eed for a reservoir is depen dent largely on th e viscosity of th e bleach in g
material. Carboxypolymethyl cellulose (carbopol) is a th icken in g agen t th at is
63
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

added to carbamide peroxide. The in creased viscosity limits movement of the gel
an d preven ts salivary ingress ben eath th e mouthgu ard. It is importan t to be able
to seat the tray an d still keep th e carbamide peroxide bleach ing gel in th e cor rect
position . It is impossible to compress a gel: it can on ly be displaced.
It is importan t to design th e tray so as to avoid gel comin g in to u n n ecessary
con tact with soft tissu es. Th e bleach in g effect can n ot be limited to an area of
the teeth covered by the reser voir areas. However, reservoirs h elp to en su re th at
most of th e effective bleach in g gel is h eld over th e target areas.
Th e presen ce of reser voirs also h elps th e loaded tray to seat fu lly on th e teeth .
If th e tray does n ot seat properly, it will u su ally be sh ort at th e gin gival margin s,
wh ich may resu lt in a failu re to bleach adequ ately th e cervical aspects of th e
target teeth . If th e necks of th e teeth are n ot covered by th e tray th en the pro-
tective salivary en zymes can react readily with th e u n protected bleach in g gel
an d rapidly in activate th e hydrogen peroxide, th ereby stoppin g any effective
bleach in g in th ose areas.
Some commen tators h ave su ggested th at reservoirs are u n necessary and th at
trays with ou t reservoirs are more econ omical. Trays with reservoirs can in deed
be bulkier an d requ ire in creased volumes of bleaching material. Th e cou nter
argumen t is th at if th ere is an inadequ ate amou nt of bleachin g gel in th e target
areas th en trays with out reservoirs are a false economy. Keeping saliva away from
the gel helps keep it active for lon ger periods. Reservoirs h old th e viscou s bleach -
in g gel in th e tray for several h ou rs and this allows the gel to con tinue releasing
low levels of perhydroxyl ion s, th ereby su stain in g th e bleach in g process.
If th ere is a ven eer of any type on th e labial aspect of th e tooth , th en th e reser-
voir sh ou ld be placed on th e palatal aspect of the tooth so th at the 10 % carbamide
gel will accu mu late preferen tially on th at side (Fig. 3 .9 ). No perhydroxyl ion will
pen etrate any restorative material. Th e bleachin g peroxide ion s will, h owever,
pen etrate th rough the palatal enamel, palatal den tine and den tal pulp to reach,
albeit slowly, the dentin e and enamel of th e labial aspect of th e tooth. In th is
way, existin g porcelain ven eered teeth can be ligh ten ed to a degree, bu t it can
be a slow process an d th e patient n eeds to be in formed an d eviden ce of th e warn-
in gs n eeds to be documen ted, to provide verification that the patient un derstood
abou t th e issu es in advan ce an d agreed to con tinu e with treatmen t.
Th e viscou s n atu re of th e bleach in g gel also h as th e advan tage of improvin g
th e trays reten tiven ess. Viscou s 1 0 % carbamide peroxide materials are design ed
for u se with a reser voir an d a list of th ose materials with the American Dental
Association (ADA) seal of approval is available from th eir website.
Th e block-ou t material u sed to create th e reservoirs is u su ally placed on th e
labial aspects of th e teeth on th e cast. Blocking ou t sh ou ld stop abou t 1 mm
64
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D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.21 Scalloped trays with reservoirs on the labial aspect. The material used for blocking out stops
short of the incisal tips.

short of the in cisal tip. Th e in cisal tip is pu re enamel an d th is area bleach es


readily with ou t th e n eed for an overlyin g reser voir (Fig. 3 .2 1 ).
Th e reser voirs can be of differen t sizes, dependin g on specific circu mstan ces.
Th e more bu lbou s or darker th e tooth , th e greater is the n eed for a reservoir.
If th e n ecks of th e teeth are to be bleached, the reser voirs sh ould exten d over
th e gin gival margin bu t in su ch a way th at the tray does n ot pin ch th e soft
tissu es an d is still capable of holding th e gel in th e cer vical region s. In su ch
cases, it is pru den t to ch eck th at th e patien t does n ot h ave th in , friable periodon -
tal tissu es th at may be trau matized by the exten ded tray (see Fig 3 .4 ).
Con train dication s for th is meth od of bleachin g are limited bu t cau tion n eeds to
be exercised wh en th e clin ical examin ation reveals a redu ced width of th in
attached gin giva an d marked pre-operative cer vical sen sitivity. Th ese con dition s
also restrict altern ative treatmen ts, su ch as ceramic ven eers or direct resin com-
posite bondin g, th ereby limitin g th e opportu n ity to satisfy these patien ts esth etic
deman ds.

Scalloped trays (Fig. 3.22)


Scalloped trays follow th e gin gival margin s. Wh en th e tray material h as been
adapted to th e model, a perman en t in k pen can be u sed to draw th e ou tlin e of
th e u n derlying gingival margin on the labial aspect of th e clear tray material.
Th e tray is th en removed from th e cast an d cu t alon g th is ou tline with sh arp
65
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.22 A scalloped tray with a mark made with black permanent ink on the palatal aspect to remind
the patient which tooth to bleach. One disadvantage of scalloped trays is that some patients nd the
margins on the lingual/palatal aspects irritating to the tongue, even when nished and smoothed.

scissors. Scissors h ave been design ed specifically for th is pu rpose an d can produ ce
a tray with a smooth edge th at is well tolerated by the ton gue. If th e scallopin g
is position ed sh ort of the gin gival margin , some gel will extru de over th e gin gival
tissu es. Th is gel will be qu ickly in activated by salivary catalase an d peroxidase
an d con sequ en tly the necks of th e teeth may fail to bleach.

Straight-line trays (Fig. 3.23)


Straigh t-lin e trays have been advocated on th e groun ds th at th ey are easy to
con stru ct an d h old an appropriate volu me of bleach in g material over th e cer vi-
cal margin s of th e teeth . Th ese trays exten d approximately 2 mm beyon d th e
gin gival margin s an d ten d n ot to ir ritate the ton gu e. A disadvan tage is th at by
h avin g bleach in g material h eld over the gin gival tissu es, th ere may be a mild,
tran sien t soft tissue reaction to the gel. Some den tists u se th is style of tray with
6 % hydrogen peroxide (th e EC 2 0 1 2 legal limit) for an hou r at a time. If th at is
to be don e on an empirical basis, th e material sh ou ld be u sed sparin gly an d th e
patient sh ou ld be instru cted to swallow, breath in h ard to try to dry th e teeth
an d immediately in sert th e tray with th e 6 % hydrogen peroxide gel. Th is is in
order to try to exclu de the salivary peroxidase from in activatin g rapidly th e
u n stable hydrogen peroxide gel.
66
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D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.23 Soft tissue redness caused by a tight tting straight-line tray (i.e. cut straight across and not
scalloped to follow the gingival margins) used with hydrogen peroxide gel. Reservoirs are indicated with
this type of tray. They can be placed on the palatal as well as the labial aspects of the teeth, although this
can make the tray somewhat bulky.

Single-tooth trays (Figs 3.243.26)


Sin gle tooth trays are design ed to bleach in dividu al teeth . In su ch cases, a stan d-
ard tray is adju sted by trimmin g it away from th e labial aspect of th e adjacen t
teeth . By cu tting away th e tray, the salivary enzymes inactivate any hydrogen
peroxide comin g in contact with th e adjacen t teeth th at will n ot th erefore bleach .

Combination trays
Combination trays are u sed in situ ation s wh ere, for example, it is plan n ed to
bleach th e can in es an d on e cen tral in cisor on ly. Combin ation trays are produ ced
by modifying stan dard trays to hold th e gel over the target teeth on ly. Cu ttin g
win dows makes a tray less reten tive an d relatively flimsy. It is importan t to
in corporate reten tion in su ch trays by exten din g th em in to n ormal u n dercu ts
in th e premolar an d molar region s.

La b o r a t o r y Te c h n i c a l Pr o c e d u r e s

An accu rate plaster cast of th e arch to be bleach ed is produ ced. Th e cast


sh ou ld be h orsesh oe sh aped an d h ave su fficien t bu lk to en su re adequ ate
stren gth an d rigidity. Th e base of th e cast is trimmed to be parallel to th e
occlusal plane.
67
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.24 Close-up of the labial aspect of a single tooth tray with the windows cut over the adjacent
teeth to avoid bleaching them inadvertently.

Fig. 3.25 It is only the discoloured upper left central incisor that requires bleaching.

68
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.26 The appearance after use of a single tooth tray and 10% carbamide peroxide for 2 months.

Block-ou t resin is placed over th e target teeth an d ligh t cu red in position


(Fig. 3 .2 7 ).
Cold mou ld seal is applied to th e cast to h elp with th e removal of th e
vacu u m-formed th ermoplastic material.
Th e th ermoplastic ethyl vinyl acetate comes in variou s th ickn esses. If th ere
is clinical eviden ce of tooth wear, or parafu n ction al activity, a th icker sh eet
of material sh ou ld be u sed (2 mm).
Th e modified cast is placed on th e platform with th e occlu sal aspect
facin g the plastic sh eet. Th e th ermoplastic material is heated u ntil it goes
clear an d is th en adapted to th e cast in a vacu u m-formin g mach in e (Figs 3 .2 8
an d 3 .2 9 ).
Followin g adaptation , th e tray material is allowed to cool (Fig. 3 .3 0 ).
Excess material is removed with sh arp scissors an d a scalpel blade. If
th e n ecks of th e teeth are dark, th e material is trimmed back so th at it ju st
covers th e gin gival tissu es on th e cast. Ch eck for any sh arp edges u sin g
you r fin ger.
Fin ish th e tray with bu rs, a scalpel an d appropriate polish in g systems
(Fig. 3 .3 1 ).

69
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.27 Target teeth blocked out with a contrasting colour resin on the cast.

Fig. 3.28 The thermoplastic material is heated. Fig. 3.29 The cast on the table of the vacuum-forming machine with the
occlusal aspects facing upwards.

C l i n i c a l Pr o c e d u r e s

Fitting the tray


Th e fit of th e tray is checked. Th ere shou ld be n o blan ch in g of the soft
tissu es. Th is is especially impor tan t to ch eck if th e gin gival tissu es are th in
an d may be damaged by ill-fitting or sh arp margins. Th e patien t sh ou ld be
70
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D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.30 Bleaching tray material adapted to the cast.

Fig. 3.31 The trays have been modi ed to bleach the right canines and rst premolar teeth and to avoid
bleaching the upper and lower incisors.

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N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Fig. 3.32 The target teeth marked with a permanent felt tip pen on the outer aspect of the tray, to help
the patient identify which teeth are to be bleached.

asked to iden tify any u ncomfortable areas with th eir ton gu e. Th ese areas
sh ou ld be adju sted as n ecessary.
Th e teeth to be bleach ed can be marked on th e ou ter su rface of th e tray
with a permanen t felt tip pen . This h elps th e patien t identify wh ere to place
th e bleach in g gel (Fig. 3 .3 2 ).
Th e accu racy of the clinical ph otograph s obtain ed at th e con sultation
appoin tmen t is ch ecked with th e patien t an d th en replaced in th e n otes. Th e
agreed shade is con firmed with reference to th e value orien tated sh ade
gu ide (ar ran ged from ligh test to darkest) an d con firmed in th e clin ical
records. Th e patien t is given a n ote of th e agreed existin g sh ade.
Th e appropriate amoun t of 1 0 % carbamide peroxide is given to th e patien t
alon g with written in stru ction s (Box 3 .5 ). High er con cen tration s of
carbamide peroxide bleach in g gel may be prescribed bu t th ere is little
scien tific eviden ce of any real ben efits in doin g so. High er con cen tration s
can produ ce a more rapid respon se in some patien ts, bu t th ere is also an
increased risk of sen sitivity in others.
Th e patien t is given a protective (or th odon tic retain er style) box for safe
storage of th e bleach in g tray wh en n ot in u se an d in stru ction s on tray
main ten an ce.
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D e n t a l Bl e a c h i n g : M e t h o d s

1. Brush your teeth thoroughly in the normal


ashion
2. Remove the tip rom the syringe containing
the 10% carbamide peroxide gel and push out
a little o the contents into the appropriate
parts o the tray towards the deeper and ront
parts o the mould o each tooth to be
bleached
3. Place gel in the tray on the cheek and the
tongue side o the back teeth. About hal to
three quarters o the syringe will usually be
necessary i doing a whole arch o teeth
4. Seat the tray over the teeth and slowly press
down irmly
5. A inger, a tissue, or a so t toothbrush should
be used to remove excess gel that will low
beyond the edge o the tray
6. Rinse gently and do not swallow. The tray is
usually worn overnight whilst sleeping but as
long as it is worn or at least 2 hours, this will
BOX 3 . 5
be e ective
IN S TRU CTIO N S F O R
P A TIEN TS O N TH E U S E O F 7. In the morning remove the tray and brush the
1 0 % CA RB A M ID E P ERO XID E residual gel rom the teeth. Rinse out the tray
in cold water only and brush it to remove the
residual gel. Store it in a sa e container
8. One or both trays can be worn overnight
9. I bleaching upper and lower teeth, it is best
to bleach one arch at night and the other or
at least 2 hours during the day
10. Do not eat, drink or smoke while wearing the
bleaching tray
11. Carbamide peroxide should not be exposed
to heat, sunlight or extreme cold

Notes
1. It is counterproductive to change the bleach-
ing gel more than once a day, as this has been
shown to increase sensitivity, which in turn
tends to delay completion o bleaching
2. It will probably take about 36 weeks to
achieve a satis actory result. Your dentist will
advise you about your individual problems
but the general rule is to keep bleaching until
the teeth are an acceptable colour

73
N i g h t g u a r d V i t a l B l e a c h i n g C l i n i c a l P r o t o c o l

Diagnosis Y/N
Radiographs Y/N

BOX 3 . 6 Photographs Y/N


A CLIN ICA L RECO RD CH ECK- Discuss options with patient Y/N
LI S T F O R B LEA CH I N G
Discuss option o single arch bleaching Y/N
S H O U LD IN CLU D E TH E
F O LLO WIN G IN F O RM A TIO N Consent Y/N
WITH D A TES
Impressions Y/N
Mouthguard inserted Date:
Material used and quantity:
Time o recall:

A log form sh ou ld be given to the patien t to record the use of the bleach ing
trays an d th e amou n t of material u sed.
Patien ts wh o experien ce sen sitivity of their teeth can be advised to u se
tooth paste con tain in g 5 % potassiu m n itrate bu t preferably with ou t any
n-lau ryl su lph ate, wh ich is a su rfactan t th at can cau se gin gival soreness in
rare cases.

Evaluation o colour change


Sequen tial photographs sh ou ld be taken to record chan ges in colour at review
appoin tmen ts, preferably with the same ambient ligh t an d camera settin gs. All
ch anges in colou r sh ou ld be recorded in th e patien ts clin ical records (Box 3 .6 ).

Sensitivity
About 7 0 % of patien ts experience sign ifican t sen sitivity wh ile bleach ing. If th is
h appens, bleach in g shou ld be stopped for a day or two an d th en recommen ced
on an every secon d or th ird n igh t basis. Fluoride gel or tooth paste can be used
to treat sensitive teeth . Th is can be placed in th e tray an d worn at n igh t. Tooth-
paste with 5% potassiu m nitrate an d with ou t n-lau ryl su lph ate is also
recommen ded.
Acidic drinks and fru it shou ld be avoided as th ese are kn own to cau se sen sitivity.
Very rarely, temporary discomfor t of th e gu ms, lips an d ton gu e can occu r. Th is
u su ally reduces wh en bleach ing stops.

Re-bleaching
Re-bleach ing n ormally takes 1 n igh t for each week of th e original cou rse. If it
took 4 weeks to bleach initially, it will take 4 n igh ts to top u p th e bleach ing.
74
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D e n t a l Bl e a c h i n g : M e t h o d s

ES S EN TI A LS : B LEA CH I N G D O S A N D D O N TS F O R TH E D EN TIS T

Do
Take a history. Record the shade in the notes
Make a diagnosis o the cause(s) o the discolouration
Discuss options/costs
Discuss the guarantees plus the time to touch up
Check or secondary white ecking in uorosis
Check i the patient has a gag re ex/retches
Block out casts as appropriate
Control the amount o bleach issued
Have advice sheets on alternative treatments, e.g. veneers
Check or the presence o resin composite restorations
Check on the radiographs or resin composites
Warn that resin composites will not bleach and will have to be replaced
Check or the presence o veneers, crowns, bridges in both arches
Warn that these will not bleach and may need to be redone i the natural teeth change
colour
Keep high concentration hydrogen peroxide products separate rom standard carbamide
peroxide products and do not delegate this to anyone inexperienced in case they give
patients the wrong concentration material. EU law is specif c as to who can dispense
extra gel

Do not
Promise unrealistic results (e.g. a dazzling Hollywood smile)
Encourage patients to use stronger concentrations o carbamide peroxide or change the gel more
than once a day
Believe unsubstantiated claims rom manu acturers o special new materials
Use higher concentrations than are legally allowed, i.e. 6% hydrogen peroxide = 18% carbamide
peroxide
Use non-ADA approved bleaching products
Believe all products are the same
Delegate the distribution o extra bleaching material to sta without checking

75
M a n a g e m e n t o f D i s c o l o u r e d , N o n -Vi t a l An t e r i o r Te e t h

Ma n a g em en t o f Disc o l o u r ed ,
N o n -Vi t a l An t e r i o r Te e t h
Ai m s
To con sider:

Termin ology an d meth ods of dealin g with dead (non -vital) discolou red
teeth
Describing the in side/ outside bleach in g tech n ique.

Ou t c o m es
Th e den tal profession al will be made more aware of predictable MI approach es
to man agin g discolou red, dead, root-filled an terior teeth .

As s e s s m e n t
Th e su ccessfu l man agemen t of discolou red n on -vital teeth is based on an accu -
rate diagnosis followed by detailed care plan n in g. A comprehen sive h istory
sh ould be taken , in cluding details of even ts th at may h ave contribu ted to th e
discolou ration . A detailed clin ical examin ation , inclu din g special investigation s
as in dicated clin ically, shou ld then follow.
A focu sed approach will reduce th e ch ances of overlookin g critical in formation
to avoid failu re of treatmen t. Patien t in pu t is critical. A fu ll an d fran k discu ssion
of in dividu al patien ts perceptions of th eir problem is especially importan t in
assessin g wh ether or n ot th ey have realistic expectation s of th e possible outcome
of treatmen t. Whatever care plan is agreed, it sh ou ld provide th e best possible
prospects for a du rable, predictable, esthetically pleasin g an d cost effective result
for th e patient. Th is sh ou ld also be achieved with th e least possible biological
damage, u sin g an MI approach .
Patien ts with a low lip lin e may accept a mildly discolou red, dead, root-filled
an terior tooth wh ile th ose with a h igh lip line may fin d any discolou ration u n ac-
ceptable. Su ch discolou ration is often th e reason for seekin g treatmen t (Fig.
3 .33 ). Improvin g th e appearan ce of a discolou red, n on-vital an terior tooth can
h ave a profoun d effect on th e patients self-confiden ce an d oral h ealth (Fig.
3 .34 ). Marked discolou ration of teeth can be a seriou s han dicap th at impacts
on a persons self-image, self-confidence, physical attractiven ess an d, possibly,
employability.
76
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D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.33 The discoloured appearance of the non-vital upper right central incisor and the sclerosed
upper left central and lateral incisors.

Fig. 3.34 The appearance after 3 days of inside/outside bleaching of the upper right central incisor and 2
months of conventional tray bleaching with 10% carbamide peroxide of the discoloured left central and
lateral incisors.
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M a n a g e m e n t o f D i s c o l o u r e d , N o n -Vi t a l An t e r i o r Te e t h

Ae t i o l o g y (s e e C h a p t e r 1)
Th e most common cau se of discolou ration in dead n on -vital teeth is th e pres-
en ce of residu al pulpal h aemor rh agic products. Th ese are most likely to be
retain ed in th e pu lp h orn spaces an d in th e cervical region . Th e discolou ration
is cau sed u su ally by breakdown produ cts of h aemoglobin an d oth er h aematin
molecu les, wh ich may permeate in to th e den tin e of th e tooth from th e in side.
Den tal trau ma can be a cau se of discolou ration of dead n on -vital an terior
teeth . Patien ts may n ot give a clear h istory of th e relevan t trau ma. Th e discol-
ou ration , whose on set may be gradu al, is often pain less an d may on ly become
apparen t wh en oth ers commen t on it. Discolouration of a n on -vital tooth may
also be an inciden tal fin din g in a rou tine den tal examin ation .
In corporatin g blood or oth er stain s in to th e tooth / restoration in terface may
cau se, or su bstan tially con tribu te to, discolou ration . Materials u sed in en dodon -
tic procedu res, in clu din g root can al sealan ts con tain in g silver, eu gen ol, poly-
an tibiotic pastes, an d compou n ds con tainin g ph en ol may cau se darken in g of th e
root den tin e over time. En dodon tic metal poin ts, pin s an d posts in ser ted in to root-
filled an terior teeth are a possible cau se of discolou ration . In addition , leakage
of restoration s may be a causative/ con tributing factor (Figs 3 .3 5 3 .3 8).

Mec h a n is m s o f D is c o l o u r a t io n
Wh en teeth su ffer sign ifican t trau ma th ere is disru ption of th e pu lp con ten ts
an d its blood su pply. Th is can result in haemor rh age into th e den tine an d su b-
sequ en t tooth discolou ration . Th e exten t to wh ich th e produ cts of pu lp degrada-
tion con tribu te to tooth discolou ration remain s u n clear. It is con sidered th at
pu lpal isch aemia an d su bsequen t pulp death , in th e absen ce of bacterial con-
tamin ation , does n ot produ ce den tal discolou ration to th e same exten t as cata-
stroph ic h aemor rh age in to th e pu lp ch amber an d th e pu lpden tin e complex.
Followin g h aemor rh age, th e h aemoglobin molecu les may be fou n d in th e coron al
den tine close to th e pu lp. Th ey do n ot ten d to pen etrate far into th e den tin e
tu bu les. Th is largely explain s why in side/ ou tside bleach in g produ ces su ch sat-
isfactory resu lts.
Any meth ods attemptin g to remove discolouration followin g trau ma an d h aem-
or rh age into th e pu lp ch amber sh ou ld focu s initially on the physical and th en,
later, th e ch emical removal of th ese breakdown produ cts. The pu lp ch amber is
su r roun ded by den tin e an d isolated from any inflammatory or h ealin g respon se
in the adjacen t soft tissu es. Therefore, n ormal h ealing, wh ich occu rs, for
example, with a soft tissue bru ise, an d th e even tu al resolu tion of discolou ration
in th e tissues, can not occu r. If th e pu lp does not sur vive followin g trau ma an d
78
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D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.35 Leaking and poorly sealed access cavity in discoloured Fig. 3.36 Thorough ultrasonic removal of the debris is essential to
root- lled teeth with metal pins in the incisal tips causes discolouration. eliminate old blood breakdown products.

Fig. 3.37 Discoloured, dead root- lled upper right central incisor before Fig. 3.38 Result following inside/outside bleaching for 2 days and
inside/outside bleaching and rebuilding with direct resin composite followed 1 week later by direct free-hand resin composite repair without
without pins or a post. retentive pins or a post. No sound tissue was removed during this
minimally invasive (MI), biologically respectful treatment.

haemor rh age, th en h aematin molecu les remain with in th e pu lp ch amber an d


con sequ en tly th e tooth appears discolou red. On th e oth er h an d, if re-vascu lar-
ization occu rs an d th e pu lp su r vives, th e tooth can revert to its n ormal colou r
with in 2 3 mon th s.

Re v i e w
Th e colour of teeth can be mon itored by u sin g a sh ade gu ide or by takin g clinical
ph otograph s with a sh ade tab beside th e tooth . A record sh ou ld be kept. Follow-u p
79
M a n a g e m e n t o f D i s c o l o u r e d , N o n -Vi t a l An t e r i o r Te e t h

reviews of root can al treatmen t sh ou ld in clu de a ch eck for discolou ration u sin g
th e sh ade gu ide or ph otograph as a referen ce. If discolou ration is obser ved, it is
better to in ter ven e soon er rather th an later. Later discolou ration may in dicate,
amon gst oth er possibilities, leakage or degradation of th e endodontic sealer or
th e material sealin g th e access cavity. Delayin g treatmen t may well resu lt in th e
discolou ration becoming more difficu lt to man age successfu lly.

I n s i d e / O u t s i d e Bl e a c h i n g (Figs 3.393.54)
Prior to u n der takin g in side/ ou tside bleach in g th e dead tooth sh ou ld be root-
filled in a stan dard fashion un der ru bber dam isolation, u sin g copiou s amou n ts
of hypoch lorite ir rigation . Hypoch lorite is a bleach ing agen t main ly u sed as an
an tiseptic in en dodon tics, wh ich also removes a degree of discolouration.
In side/ ou tside bleach in g involves placin g 1 0 % carbamide peroxide gel simu ltan -
eou sly on to an d in side a discolou red root-filled tooth , u su ally with th e aid of a
single tooth cu stomized bleach in g tray. This allows pen etration of hydrogen
peroxide both intern ally an d extern ally with th e bleach in g gel bein g protected
from salivary deactivation by th e tray itself.
Prior to bleach in g, th e con ten ts of th e pu lp ch amber sh ou ld be clean ed th or-
ou gh ly for 5 minu tes with a very fin e ultrason ic or airson ic tip. Th e root filling
sh ou ld be cu t back with th e u ltrason ic or airson ic device to a level of approxi-
mately 3 mm below th e en amelcemen tu m ju n ction . Popu lar advice is to seal
off th e root canal fillin g with radiopaque glass ion omer or zin c polycarboxylate
cemen t. However, in th e real clin ical situ ation , it can be difficu lt tech n ically to

Fig. 3.39 A discoloured upper left central incisor that has been root- lled Fig 3.40 An ultrasonic tip is used for 510 minutes within the canal to
twice previously. The upper right central was sclerosed. Note the white vibrate blood products out physically and also any residual resin
uorosis on both teeth. composite tags in the dentine. This is more of an MI procedure than the
use of burs.
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Fig. 3.41 The right angled needle attached to the syringe containing 10% Fig. 3.42 The patient is told to wear the mouthguard all the time, with
carbamide peroxide gel is inserted into the deepest part of the chamber fresh 10% carbamide peroxide gel in it, including whilst asleep, but not
and used to ll up the whole chamber down to the gutta percha root when eating or drinking. During the day, the gel is changed every two
lling, usually approximately 3 mm below the enamelcementum hours.
junction. Note the mid-labial vertical crack in this tooth.

Fig. 3.43 The bleaching tray in the regions of both central incisors is Fig. 3.44 The tray has been extended over the left central incisor that is
lled with 10% carbamide peroxide gel and inserted immediately to cover having inside/outside bleaching, but is short in the cervical region of the
both central incisors. The tray is cut back to provide windows over the upper right central that is not to be bleached at this stage. Two windows
lateral incisors in order to avoid bleaching them inadvertently. have been cut over the upper lateral incisors to allow the salivary
peroxidase and catalase to stop unintentional bleaching of the lateral
incisors.

place su ch a material to seal th e gu tta perch a root fillin g accu rately en ou gh


with ou t th e flu id restorative material bein g drawn down th e in tern al den tin e
walls by capillary action . Th is situ ation will compromise effective bleachin g of
th e n eck of the discoloured tooth because th e carbamide peroxide gel cann ot
pen etrate th rou gh any restorative cemen ts. Flowable composite or compomer
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Fig. 3.45 The upper left central incisor took 3 days and nights to bleach. Fig. 3.46 Always bleach the darkest tooth rst until it is lighter than the
Only when it was lighter than the upper right central incisor was the upper others before considering any other adjacent bleaching. Differently
right central incisor bleached with a conventional tray with 10% designed trays are required for different situations. Pre-operative clinical
carbamide peroxide, but with windows cut back over both lateral incisors. photograph.
Note that both the crack and the white uorosis appear less obvious
against a lighter background.

Fig. 3.47 The post-operative result was acceptable to the patient as it Fig. 3.48 The post-operative result was acceptable to the patient and he
preserved tooth tissue. did not want other teeth bleached.

sh ou ld be avoided becau se th ese are especially liable to flow in to th e n eck of th e


ch amber. If th at h appen s, it is impossible to bleach th e n ecks of th e discolou red
teeth . Conversely, a restorative cemen t of h igh er viscosity is u n likely to flow
adequ ately to seal the gutta perch a root filling effectively at th e depth s of th e
pu lp ch amber.
In cases of marked cervical discolou ration , it is both possible an d sen sible to
u n der take bleach ing withou t sealing over th e root fillin g, provided patien t co-
operation is optimal an d th e access cavity can be kept bath ed con stan tly in 1 0 %
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D e n t a l Bl e a c h i n g : M e t h o d s

Fig. 3.49 Three


discoloured and dead
teeth following a sports
injury. The upper right
central incisor was grossly
discoloured and there was
signi cant soft tissue
damage.

Fig. 3.50 A periapical


radiograph showing the
root- lled teeth with the
gutta percha cut back to
well below the enamel
cementum junction.
(Endodontics by Mr Gavin
Seal).

carbamide peroxide with in th e protective sin gle tooth bleach in g tray for th e few
days involved. Th is is becau se carbamide peroxide is a well proven oxidizin g
an tiseptic th at, if ch an ged every 2 h ours by th e patien t an d protected with in
th e bleaching tray being worn con stantly, will readily an d effectively in h ibit
Gram-n egative an aerobic bacteria. Any tooth-coloured restorative material on
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M a n a g e m e n t o f D i s c o l o u r e d , N o n -Vi t a l An t e r i o r Te e t h

Fig. 3.51 The results of inside/outside bleaching after 2 days. Fig. 3.52 The teeth were deliberately over-bleached to allow for
rebound in colour.

Fig. 3.53 The access cavities allowed for direct line access to apices but Fig. 3.54 The access cavities sealed with radiopaque and opaque white
have not destroyed the structural strength/integrity of the teeth, most of glass ionomer cement that is injected into the chambers with a ne
which is manifest in the still intact marginal ridges. needle. If these teeth ever need re-bleaching, white glass ionomer cement
is much easier to see and remove than resin composite. Note how little of
the palatal structure of the teeth has been lost and this has minimized
further damage to the traumatized teeth.

th e extern al or in tern al su rfaces of th e tooth mu st be removed before bleach in g,


as the hydrogen peroxide can n ot pen etrate th rou gh th ese.
Th e en dodon tic access cavity is left open , bu t covered in side an d ou tside with
th e bleach in g gel in th e protective tray except very briefly wh en eatin g an d
drinking, for the 24 day du ration of th e inside/ ou tside bleaching procedu re.
Du rin g th e bleach in g procedu re, patien ts n eed to be advised to avoid tan n in -
con tain in g foods su ch as cu r ries, tomato-con tain in g sau ces an d dark colou red
flu ids (red win e, coffee or stron g tea) u n til th e access cavity is restored. Th e
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D e n t a l Bl e a c h i n g : M e t h o d s

wor ry about disru ption of th e root fillin g an d th e, largely th eoretical, bacterial


con tamin ation of th e root fillin g in terface n eeds to be con sidered again st th e
requ iremen t for an acceptable esth etic resu lt in th e cervical region wh ere th e
en amel is on ly 0 .7 mm th ick. It sh ou ld be remembered th at failu re to bleach
th e neck of the tooth adequ ately cou ld n ecessitate a destru ctive procedure,
in clu din g th e possible provision of a post an d core restoration th at will lead to
hu gely predictable radicu lar bacterial con tamin ation . Th e 1 0% carbamide per-
oxide gel, both with in th e tooth an d in th e tray, is ch an ged every 2 h ou rs an d
last th in g at n igh t. Th e more often th e gel is ch an ged, th e more rapid th e bleach -
in g will be. Wh en ch an gin g th e gel, in par ticu lar after eatin g, th e access cavity
is flu sh ed ou t u sin g a blu n t, fin e n eedle th at is attach ed to a syrin ge of th e gel
in order to gain access to th e n eck of th e discolou red tooth (see Fig. 3 .4 1). Du e
to its viscou s n ature, th is syringing effect removes any trapped food debris and
en su res th at th e cavity is filled with fresh , active, 1 0 % carbamide peroxide gel.
Th e patien t is in stru cted to stop bleach in g wh en th ey are satisfied with th e degree
of ligh ten in g of th e tooth . It is acceptable for th e tooth to be bleach ed a little
ligh ter to allow for rebou n d of th e colou r. Th e patien t is reviewed after 2 3 days
to assess colou r changes an d to limit th e time the access cavity is left open.
Following su ccessful completion of bleach in g, u su ally after 2 3 days, th e pu lp
chamber is once again clean ed ou t th orou gh ly with th e aid of an u ltrason ic tip.
Th e tooth is th en restored provision ally with contrastin g wh ite-colou red glass
ion omer cemen t. Followin g bleach in g, th e tooth frequ en tly appears to be ligh ter
th an th e adjacent tooth . Th is is u nderstandable given th e redu ction in th e
volu me of dentin e with in the root-filled tooth.
A resin composite restoration sh ou ld n ot be placed immediately followin g com-
pletion of th e bleach in g process, becau se oxygen will be released from th e tooth
for u p to a week. Th is cou ld compromise th e resin composite adh esive bon d an d
th ereby resu lt in micro-leakage. Conven tional, radiopaque, wh ite glass ion omer
cemen t is prefer red becau se it is easier to see an d remove if requ ired at any stage.
As resin composites are difficu lt to remove from with in th e tooth with ou t in ad-
vertently removing residu al sou n d tooth stru ctu re, th ere are ben efits to select-
in g a wh ite sh ade an d radiopaqu e glass ion omer cemen t to replace lost den tin e.
It is possible to check th at the appearan ce of the restored tooth will be accept-
able by leavin g some water in side th e access cavity and placin g th e selected
material, on a trial basis, to ch eck th at it will ach ieve th e desired ou tcome. A
trial assessment of th e colour is preferable to having to remove a defin itive res-
toration that fails to ach ieve th e desired ou tcome.
Obviou sly, if there is any con cern abou t th e en dodon tic statu s, the tooth sh ou ld
be re-root treated prior to commen cin g any in side/ ou tside bleach in g.
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Wa l k i n g Bl e a c h Te c h n i q u e
It is impor tan t to min imize stru ctu ral damage to in itially avu lsed, discolou red
teeth . En dodon tic treatmen t with pu lp extirpation an d prelimin ary ch emo-
mech an ical debridemen t sh ou ld be commen ced after 2 weeks of flexible splin tin g
following th e acciden t, an d before th e risks of inflammatory root resorption
start to in crease.
En dodon tic access sh ou ld be in a straigh t line to th e apex, an d th e min imu m
amou n t of sou n d tooth tissu e sh ou ld be removed du rin g th e process in order to
main tain th e residu al stru ctu ral stren gth of th e trau matized crown s. On ce
en dodon tic obtu ration h as been completed, th e teeth can ben efit from in side/
ou tside bleach in g, which is more effective th an th e tradition al walkin g bleach
techn iqu e u sin g sodiu m perborate, which wh en mixed with water produces 7 %
hydrogen peroxide.
Wh en 6% hydrogen peroxide is mixed in to a slu r ry/ paste with sodiu m perbo-
rate an d sealed in th e tooth , as a version of th e walkin g bleach tech n iqu e, th is
combin ation releases a total of 1 7.6 % hydrogen peroxide (i.e. above EU limits).
If 1 2 % hydrogen peroxide is mixed into a paste with sodium perborate, th is
produ ces a total of 2 5.6 % hydrogen peroxide (which is over fou r times the EU
limit), wh ich has to be sealed effectively into th e discoloured tooth (Table 3 .1 ).
Th ese con cen tration s are 5 8 times th e con cen tration of 1 0 % carbamide per-
oxide an d so increase dramatically th e biological damage risk, as discu ssed pre-
viou sly. On ce th e wet slu r ry/ paste is placed in th e access ch amber, it starts
effer vescin g th en qu ickly an d th e pressu re can blow th e temporary sealin g
material ou t of th e access cavity with in th e first h ou r. Th is resu lts in an open
access cavity with th e effect of th e hydrogen peroxide nu llified by salivary per-
oxidase an d catalase gain in g access to th e pulp ch amber. Th ere is n o protective
mou th gu ard as is th e case with in side/ ou tside bleach in g.

TA B LE 3 . 1 TH E CO N CEN TRA TI O N S O F RELEA S ED H YD RO G EN


P ERO XID E F RO M D IF F EREN T B LEA CH IN G A G EN T
F O RM U LA TIO N S

Hyd rogen p eroxid e concent ra t ion

10% carbamide peroxide 3.5%

Sodium perborate and water 7.0%

Sodium perborate with 6% hydrogen peroxide 17.6%

Sodium perborate with 12% hydrogen peroxide 25%

'Power' or 'chairside' or 'in-o f ce' bleaching 1538%

86
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Pr o t o c o l f o r I n s i d e / O u t s i d e Bl e a c h i n g

First appointment
1. Make an d record th e diagn osis.
2. Take clin ical referen ce ph otograph s.
3. Ch eck th e periapical statu s of th e tooth with a lon g con e periapical
radiograph . Be satisfied th at th e root space is obtu rated satisfactorily
(Fig. 3 .5 0 ).
4. Un dertake any necessary en dodon tic revision prior to startin g in side/
outside bleach in g.
5. Ch eck th at th e tooth is asymptomatic an d has a favourable progn osis.
6. Use a sh ade guide to estimate the shade before treatmen t. Agree th e
sh ade with th e patien t, record it in th e clin ical records an d give th e
patien t a copy.
7. Warn th e patien t th at any existin g match in g restoration s with in th e
target an d adjacen t teeth will n ot bleach . After bleach in g, su ch
restorations may well appear to be a darker colou r th an th e bleach ed
n atu ral tooth . Su ch restorations may n eed to be replaced. In all su ch
cases th e patien t sh ou ld be warn ed of th is esth etic an d fin an cial
con sequ en ce of bleach in g an d replacemen t of restoration s.
8. A diagram of th e existin g restoration s is made an d given to th e patien t,
with a copy bein g kept in the clinical records.
9. Discu ss other treatmen t option s, high ligh ting th e MI n ature of bleach in g.
10 . Ch eck th e patien t is n ot allergic to peroxide or plastic an d th at female
patien ts of ch ildbearing age are not pregnan t or breastfeedin g.
11 . Provide th e patien t with a written care plan an d estimates an d obtain
con sen t.
12 . Provide th e patien t with written in struction s an d demon strate wh at th e
treatmen t involves.
13 . Make con temporan eou s n otes that th is protocol h as been completed.

Making the tray


An alginate impression is taken an d cast in the laboratory. Proprietary resin or,
failin g th at, plaster is u sed to block ou t th e cast on th e labial an d palatal aspects
of th e target tooth , providin g th e desired exten t an d depth of th e in ten ded
reservoirs.
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Cold mou ld seal is applied to th e cast. Soften ed bleach in g tray material is th en


vacu u m formed to th e cast an d once cooled is removed. Labial windows are cu t
ou t over the adjacent teeth with sh arp scissors so th at on ly th e target tooth (or
teeth ) is covered. Any gel th at strays on to th e adjacen t teeth will be in activated
by th e patien ts salivary peroxidase or catalase.

Second appointment
1. Check the bleach in g tray for fit an d comfor t, an d th at th e patien t is able
to place an d remove it. Ch eck that th ey can u se the an gled tip on th e
syrin ge of bleach in g gel (Fig. 3 .4 1 ).
2. Remove th e access cavity restoration and redu ce th e root fillin g as
n ecessary to a level 2 mm below th e en amelcemen tum jun ction. A fin e
u ltrason ic or airson ic tip is the simplest way to do th is. Th e pu lp chamber
is ch ecked for any residu al debris. Th e pu lp cornu ae an d cervical region
are clean ed u ltrasonically or airsonically for at least 5 minu tes (Fig.
3 .4 0). The root fillin g can th en be sealed off, if desired, bu t take care n ot
to allow any restorative material to cover th e discolou red labial den tin e
walls. Radiopaqu e, wh ite glass ion omer cemen t is su itable for th is
purpose. It shou ld be allowed time to set fu lly (3 4 minutes).
3. It is pru den t to ch eck etch th e in side of th e tooth to see if all th e exposed
den tin e takes on a cleaned appearance, in dicatin g th at th e su rfaces h ave
been properly prepared an d are free of any residu al tooth -colou red fillin g
material, in particu lar resin composite. Any resin composite on th e labial
aspect of the tooth sh ou ld be removed. Th e ou tside of th e tooth sh ou ld
also be etch ed with phosph oric acid. A frosty appearan ce will con firm
th at th e en amel is free of any resin composite tags.
4. The 10 % carbamide peroxide gel is in jected directly in to the chamber
of th e tooth u sin g a medium bore needle attach ed directly to a syringe
of th e material (Fig. 3.4 1). Th e tray with gel in th e reser voirs on ly is
inser ted into th e mou th . Excess gel is wiped away with gau ze.
5. Provide th e patien t with en ough gel and written in stru ction s.
Demon strate again an d ch eck th at the patien t kn ows what to do. Ch eck
th at th e patien t can in ser t th e gel effectively in to the tooth usin g th e
syrin ge an d an gled n eedle tip.
6. If th e patien t is u n able to place th e gel effectively, an immediate fall back
situ ation is for th e den tist to seal some carbamide peroxide in th e pu lp
space an d h ave th e patien t u se th e tray to car ry ou t extern al bleach in g.
However, th is is n ot as effective as in side/ ou tside bleach in g.
88
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D e n t a l Bl e a c h i n g : M e t h o d s

Instructions or patients
1. Remove th e top from th e syrin ge con tain in g th e 1 0 % carbamide peroxide
gel. Screw th e su pplied blu n t standard right-angled n eedle tip on to th e
syrin ge. In ser t th e tip of th e n eedle in to th e cavity on th e in side of th e
tooth to be bleach ed an d fill with th e gel.
2. Load th e appropriate part of th e bleaching tray with th e 1 0 % carbamide
peroxide gel. A mark made on th e outside of the tray with a permanen t
ink pen will help iden tify that part of th e tray to be loaded.
3. Inser t th e tray an d remove any excessive gel with a fin ger or a soft
tooth bru sh .
4. Rin se the mou th gen tly with water an d spit ou t.
5. Wear th e tray at all times, except wh en eatin g or clean in g.
6. Every 2 h ou rs and last th in g at nigh t, ch an ge the gel in side th e tooth an d
also in th e tray. Clean th e in side of th e tooth by flu sh in g it out with th e
n eedle on th e bleachin g gel.
7. Th e tray can be clean ed with cold water on ly and a tooth bru sh .
8. Avoid highly colou red foods su ch as cu r ries, tomato-con tain in g sauces,
and dark colou red fru its. Red win e, coffee an d stron g tea must be avoided
u ntil bleach in g h as been completed an d th e tooth is sealed with a fillin g.
9. If th ere are any problems, contact th e practice immediately.
10 . Stop bleaching wh en th e tooth is th e desired colou r.

Pr o b l e m s a n d Tr o u b l e s h o o t i n g
Po o r Pa t i e n t C o m p l i a n c e
Appropriate patien t selection an d clear in stru ction s sh ou ld min imize th is
problem. In ability or u n willin gn ess to follow th e in stru ction s will lead to failu re
or prolon ged treatmen t time. Th e patien t mu st u n derstan d th eir respon sibilities
an d role in th eir treatment. In side/ outside bleach in g sh ou ld n ot be u n dertaken
wh en a patien t is n ot well kn own to th e practition er or th ere are problems of
poor manu al dexterity or of limited u n derstan din g of wh at is involved.
Th e patien t mu st h ave reason able manu al dexterity an d mu st be able to place
th e gel with in th e tooth . Th is can be ch ecked before makin g th e tray an d
openin g the access cavity by testing wh eth er th e patien t is able to h old th e
syrin ge effectively again st th e in side of th e tooth . If th e patien t is u n able or
un willin g to do th is, then altern ative treatmen t option s sh ou ld be con sidered.
89
P r o b l e m s a n d T r o u b l e s h o o t i n g

Patien ts complain rarely about food gettin g into the access cavity. Th is sh ou ld not
create any great difficu lty, assu min g th e patien t is properly briefed an d capable of
placing an d u sing th e bleach ing gel syrin ge to flu sh ou t any food debris.

Th e N e c k o f t h e To o t h D o e s N o t Bl e a c h
Th e n eck of th e tooth does n ot bleach wh en some restorative material residu e,
u su ally resin composite, is bon ded to th e intern al den tin e walls. Magnification
sh ou ld be u sed to en su re complete an d safe removal of all materials coverin g
the den tin e, th ereby allowing it to be bleached. It is pru den t to ch eck etch th e
in side of the tooth where a frosty appearance indicates th at its su rface is free of
residu al tooth -colou red materials.
Failu re to redu ce th e root fillin g to a level well below th e en amelcemen tu m
ju nction will h in der the pen etration of th e bleach in g agen t in to th e dentin e at
th e n eck of th e tooth . Fu rth ermore, th e tray n eeds to be exten ded cervically to
cover th e gin gival margin to h old th e bleach in g gel in an d arou n d th e cervical
region . En amel is on ly approximately 0 .7 mm th ick in th e cervical region an d
th erefore it is impor tan t th at th e u n derlyin g discolou red den tin e is adequ ately
bleach ed. Th e n eedle on th e syrin ge h elps to en sure th at th e gel is deposited in to
th e deepest part of th e cavity below th e cemen toen amel ju n ction .

Fa i l u r e t o Bl e a c h
If th e tooth fails to bleach despite appropriate clin ical tech n iqu e an d good patien t
complian ce, th e sou rce of th e discolou ration is probably n ot pu lpal blood in
origin . A h istory of an amalgam restoration in th e palatal access cavity may be
th e cau se. Metal ion s, wh ich migrate from th e amalgam in to th e adjacen t tooth
stru ctu re, are mu ch more resistan t to bleach in g th an th e molecu les origin atin g
from the pu lp. If any amalgam is left in th e tooth du rin g bleach in g, th e tooth
may take on a green tinge. It is essential to remove all amalgam debris by u ltra-
son ics from with in th e tooth before u n der takin g in side/ ou tside bleach in g.
Th e presen ce of a labial porcelain ven eer mean s th e reser voir mu st be placed on
the palatal aspect as th e porcelain is imper viou s to th e hydrogen peroxide. With
th is approach th e tooth can be bleach ed su ccessfu lly with ou t removin g th e
porcelain ven eer.

C o m b i n e d Ae t i o l o g y o f D i s c o l o u r a t i o n
Wh ere a tooth h as been discolou red, for example, by tetracyclin e th erapy an d
trau ma, th en th e combin ation of discolou ration may be very difficu lt to man age
effectively.
90
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D e n t a l Bl e a c h i n g : M e t h o d s

Wa l k i n g Bl e a c h
Th is tradition al tech n iqu e involves th e u se of a mixtu re of water an d sodiu m
perborate th at is sealed temporarily in to th e pu lp ch amber of th e discolou red,
root-filled tooth . Th e difficu lty with th is tradition al approach is th at th e con-
tinu al oxygen effer vescence from th e hydrogen peroxide frequ en tly blows th e
temporary dressin g ou t of th e back of th e tooth an d th e wet environ ment makes
it difficu lt to reseal th e cavity. As a resu lt, the hydrogen peroxide may n ot be
con tain ed adequ ately in th e tooth for lon g en ou gh to bleach th e tooth 1 0 %
carbamide peroxide gel can be sealed with in th e tooth , bu t it is n ot as effective
as in side/ ou tside bleach in g.

C h a i r s i d e / i n -Su r g e r y Bl e a c h i n g
Ch airside bleachin g involves th e u se of h igh con cen tration (3 0 3 8 %) hydrogen
peroxide, sometimes togeth er with h eat applied both in side an d ou tside th e
tooth. This tech nique involves th e use of a material that is abou t 1 0 times th e
stren gth of hydrogen peroxide released from 1 0 % carbamide peroxide and well
above EU limits.
Ru bber dam or ligh t-cu red dam mu st be u sed, given th e cau stic n atu re of th e
bleach in g agen t. If th is aggressive clin ical tech n iqu e is u sed in side th e tooth ,
th e root fillin g mu st be carefu lly sealed off an d care taken to avoid pen etration
of th e bleach in g gel th rou gh to th e periodon tal ligamen t. Th e h igh con cen tra-
tion hydrogen peroxide u sed may damage th e periodon tal ligamen t an d
compromise th e clin ical ou tcome. Abou t 2 % of teeth h ave a defect at th e en amel
cemen tu m ju n ction an d very h igh con cen tration material may damage th e
periodontal ligamen t if it leach es ou t in th at area. Extern al resorption h as been
reported with th is approach , wh ich , in effect, bu rn s th e periodon tal ligamen t
du e to th e very h igh con cen tration of hydrogen peroxide an d h eat. In side/
ou tside bleach in g u ses a material th at is on e-ten th of th e con cen tration th at is
involved in ch airside bleach in g (Table 3 .1) an d is biologically ben ign as well as
legal u nder EU law.

Re s t o r a t i v e Al t e r n a t i v e s t o Bl e a c h i n g
N o n -Vi t a l , D i s c o l o u r e d Te e t h (see also Table 3.2)
Ve n e e r s
Th e placement of a ven eer on a deeply discolou red anterior tooth will n ot
provide a satisfactory resu lt. Th e u n derlyin g discolou ration is often most n otice-
able in th e cervical region wh ere, after preparation , th ere is very little, if any,
91
R e s t o r a t i v e Al t e r n a t i v e s

TA B LE 3 . 2 S U M M A RY O F TH E M A N A G EM EN T O F D IS CO LO U RED
N O N - V ITA L A N TERIO R TEETH : F RO M LEA S T TO
M O S T IN V A S IV E

Review

e
v
i
t
c
Insid e/out sid e b lea ching wit h 10% ca rb a mid e p eroxid e

u
r
t
s
e
Wa lking b lea ch t echniq ue

d
t
s
a
e
10% carbamide peroxide releases 3.5% hydrogen peroxide

L
Sodium perborate and water releases 7% hydrogen peroxide
Sodium perborate and 18% hydrogen peroxide mixed together as a paste releases
approximately 25% hydrogen peroxide

Ext erna l b lea ching

Chairside bleaching or home bleaching or a combination o both


Chairside bleaching using heat and a high concentration (3038%) o hydrogen peroxide
(highest risk o resorption)

Rest ora tive t echniq ues

Veneers direct composite

e
Veneers indirect composite

v
i
t
c
u
Porcelain veneers

r
t
s
e
d
Crown, with or without a post

t
s
o
M
Extraction and prosthetic replacement

en amel to con ceal th e u n derlyin g den tin e an d th e ven eer h as to be at its th in n est
in that area. To mask th e discolouration, it may be n ecessary to produ ce a thick
over-con tou red ven eer, in clu din g an opaqu e layer, wh ich compromises th e
appearan ce of th e ven eer an d will n ot match the oth er incisors. Conversely,
preparation for a veneer involvin g greater tooth redu ction in th e cer vical area
exposes a sign ificant amou nt of discolou red dentin e. It is common to fin d th at
discolou ration gets worse th e deeper th e preparation , as dark den tin e, in th e
cer vical region, is n o lon ger masked by the tran slu cen t en amel an d th e darkest
den tine is nearest th e pulp space.
A th ick opaque ven eer placed on a discolou red tooth will not match the adjacent
more tran slu cen t teeth . Th e life expectan cy of a th ick ven eer bon ded to deep,
discolou red den tine is u n certain. What is clear is th at on ce the patien t has had
a ven eer, th e tooth will h ave been weaken ed fu r th er by u p to 3 0% an d th e ven eer
will requ ire a lifetime of mainten an ce, with the possibility of th e fu r th er loss of
tooth tissu e, as an d wh en , th e ven eer n eeds to be replaced.
92
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

C r o w n s a n d Po s t C r o w n s
Preparation s for crown s are destru ctive of th e remain in g tooth tissu e. Prepara-
tion of a root-filled tooth for a conven tional crown often resu lts in a post bein g
necessary to su pport a replacemen t core. Su ch an approach does n ot address
th e discolouration with in th e remaining root den tine. Gingival recession fre-
qu en tly exposes th e margin of th e crown an d th e discolou red root den tin e. Th is
is likely especially in a youn g patien t wh en fu ll matu ration of the gin gival tissu es
is likely to resu lt in an u n sigh tly gin gival appearan ce. Th e esth etic issu es associ-
ated with th e provision of a sin gle an terior crown , in particular a post crown ,
are well docu men ted.
An aggressive, in direct restorative approach to th e man agemen t of discolou red
dead teeth weaken s greatly th e remain ing tooth tissu es, is biologically an d
fin an cially costly, an d may resu lt in catastroph ic root failu re soon er rath er th an
later. Recen t developmen ts in tooth -colou red resin bon ded post systems h ave n ot
overcome all th e in heren t structu ral stren gth disadvan tages of th e post crown
approach to dealin g with th ese esth etic problems.
In side/ outside bleach ing h as reduced dramatically the in ciden ce of un accept-
able appearan ce of dead discolou red teeth . It removes th e discolou ration wh ile
main tainin g the stru ctu re of th e tooth . Th is is par ticu larly importan t when a
high lip line exposes th e gin gival margin s.

P A TI EN TS F A Q S

Q. Wha t ca uses t oot h d iscoloura t ion?


A. Tooth discolouration is caused by external (extrinsic) or internal (intrinsic) colourants or a
combination o both (Table 3.3).

Q. Wha t ha p p ens d uring b lea ching?


A. Hydrogen peroxide penetrates through the enamel and dentine reacting with the discolouration
within the tooth. Discolourations, including those on external tooth sur aces, are oxidized.
Discolourations in enamel usually bleach relatively quickly while those in dentine usually take much
longer to bleach.

Q. Are t here a ny cont ra ind ica tions t o b lea ching t eet h?


A. Yes. Existing f llings, veneers and crowns in the same or opposing jaw will not change colour. I
tooth-coloured restorations match the existing teeth be ore bleaching, they will appear darker a ter
the natural teeth have been bleached. This may mean that existing restorations, veneers or crowns
may need to be replaced ollowing bleaching. This may add greatly to the cost o treatment. Please
ask your dentist to check or these be ore any bleaching.

93
R e s t o r a t i v e Al t e r n a t i v e s

Q. How much will it cost ?


A. This varies according to the system being used, the severity o the problem, the condition o the
discoloured teeth and the amount o time and material needed to achieve a satis actory result.
Please ask your dentist or a quotation.

Q. Will I ha ve t o sleep wit h t he mout hgua rd in p osit ion?


A. Sleeping with the mouthguard in position is the most e ective way o keeping the bleaching gel
in contact with the teeth or prolonged periods o time. I this is a problem, and provided the
loaded tray can be worn or at least 2 hours each day, bleaching will be e ective but will simply
take longer than would otherwise be the case.

Q. Are t here a ny sid e effect s?


A. The majority o patients su er some tooth sensitivity during treatment. This resolves usually
within a ew days once bleaching has stopped. I the teeth are sensitive be ore bleaching, they will
probably become more sensitive during bleaching. There have been no reports o long-term side
e ects o using tray or mouthguard bleaching with 10% carbamide peroxide. Even prolonged
(69 months) use o this nightguard type o bleaching has been shown to be sa e with no teeth
needing root f llings or being damaged in any other way.

Q. Ca n sensit ivit y b e red uced ?


A. There are a number o ways o controlling sensitivity. Desensitizing toothpastes (usually those
containing 5% potassium nitrate) can be used or 2 weeks prior to bleaching. Alternatively,
desensitizing toothpaste can be placed in the mouthguard and applied or about 30 minutes be ore
each period o bleaching. The toothpaste is then replaced with the bleaching gel. To limit the risk
o sensitivity, the mouthguard with the bleaching gel may be worn or 12 hours only, rather than
overnight. I the teeth are sensitive prior to bleaching, the gel should not be applied more than
once a day and the mouthguard should be worn only or a ew hours. Higher concentration
bleaching agents, o carbamide peroxide, should not be used.

Q. Which t oot hp a st e should b e used when b lea ching?


A. There is some evidence that brushing with toothpaste containing 5% potassium nitrate or
2 weeks prior to bleaching helps reduce the risk o sensitivity. Normal toothpaste is usually used
during bleaching. NO toothpaste can bleach teeth but brushing with a good quality toothpaste
can help reduce stain ormation.

Q. How long will b lea ching t a ke?


A. This depends on the cause o the discolouration and patient compliance. It usually takes between
2 and 6 weeks o nightguard (at home) bleaching or normal teeth to become lighter. Tobacco
discolouration takes 36 months to bleach provided the patient stops smoking. Yellow/brown
tetracycline discolouration may take up to 9 months to bleach. Deeply coloured blue/grey
tetracycline discolouration is very di f cult to bleach satis actorily but there is usually some
improvement with very prolonged bleaching (more than 9 months).

Q. Is cha irsid e (a lso known a s p ower or in-surgery) b lea ching b et t er t ha n night gua rd
vit a l (home) b lea ch in g?
A. The short answer is no. There is very limited scientif c evidence supporting the long-term e f cacy
o light assisted chairside bleaching. The gold standard is nightguard vital bleaching using 10%
carbamide peroxide. This method has the American Dental Association (ADA) seal o approval. Light
assisted chairside bleaching may be use ul or patients unable to tolerate wearing a mouthguard
and in rare situations in which a kick-start to bleaching might be advantageous.

94
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Q. How long d oes b lea ching la st ?


A. The e ects o NgVB last on average 23 years be ore there is any noticeable deterioration. The
colour change can remain stable or up to 7 years, but bleached teeth may need some touching up
or top-up bleaching at 23 yearly intervals. I additional bleaching is required, the time taken is
normally much less than that required or the initial bleaching. As a general rule, top up bleaching
takes 1 night or each week taken to complete the initial bleaching.

Q. Wha t is t he b est ma t eria l t o use?


A. The most extensively researched material is 10% carbamide peroxide, releasing 3.5% hydrogen
peroxide. The typical presentation is a thick gel or use in a customized mouthguard made rom an
accurate impression o the teeth.

Q. Why not use over-t he-count er p rod uct s a s a d vertised on TV a nd in ma ga zines?


A. Bleaching is managed best by a dentist who can diagnose the cause o the discolouration, assess
the risks o any possible adverse e ects and supervise bleaching (which may be part o more
extensive treatment). This helps avoid colour mismatching o teeth and restorations. Many o the
over-the-counter products have no proo o their sa ety or e f cacy. Some products contain acids
that may etch and damage the teeth and others contain titanium dioxide, as used in white paints.
The titanium dioxide may appear to whiten teeth, but the e ect is almost always very short-lived.
Many o the claims made in respect o over-the-counter products are misleading. Boil and bite
mouthguards or use with over-the-counter bleaching gels do not f t well. As a consequence they
can be uncom ortable and may ail to protect the gel rom deactivation by the saliva, thereby
producing disappointing results.

Q. Are whit ening t oot hp a st es effect ive?


A. Whitening toothpastes primarily only remove superf cial stains. Most supposedly whitening
toothpastes contain only 0.1% hydrogen peroxide. None o these toothpastes have been shown to
be e ective at bleaching intrinsic discolouration. Regular toothpaste used together with a proper
brushing technique is equally as e ective as more expensive whitening toothpastes at removing
superf cial tooth stains.

Q. How much p eroxid e gel is swa llowed d uring b lea ching wit h a mout hgua rd ?
A. About 25% o the carbamide peroxide in the tray is swallowed. Most o the hydrogen peroxide
that escapes rom the tray is immediately inactivated by saliva be ore it is swallowed. Exposure to
hydrogen peroxide is at its highest when the nightguard is inserted initially. The exposure reduces
rapidly over time.

Q. Is swa llowing hyd rogen p eroxid e ha rmful?


A. Not at all. Most o the hydrogen peroxide released into the mouth during bleaching is inactivated
immediately by normal saliva be ore being swallowed. Any gel that is swallowed is inactivated in
the stomach. Any hydrogen peroxide that is absorbed and enters the circulation is very quickly and
e ectively inactivated by the red blood cells.

95
F u r t h e r r e a d i n g

TA B LE 3 . 3 CA U S ES O F TO O TH D IS CO LO U RA TIO N

Colour Ca use

Extrinsic coloura nt s

Brown or black Tea/co ee/iron

Yellow or brown Poor oral hygiene/tea

Yellow/brown/black Tobacco/marijuana

Green/orange/black/brown Bacteria

Red/purple/brown Red wine

Int rinsic coloura nt s

Grey/brown/black Pulp death with haemorrhage

Yellow/grey/brown Pulp necrosis without haemorrhage

Brown/grey/black Endodontic or other (e.g. amalgam) materials within the tooth

Yellow/brown Pulpal obliteration/sclerosis

Brown/white lines/spots Fluorosis. Excessive uoride swallowed during tooth development

Black Sulphur

Brown or grey Minocycline taken a ter tooth ormation (adult teeth)

Yellow/brown/grey/blue Tetracycline taken during tooth development


Doxycycline a ter tooth ormation
Remember: 'yellow/brown will bleach; blue/grey may bleach'

Pink Internal resorption

Grey/brown/black Dental caries

Yellow/brown Ageing

Ot h er ca uses of d iscolou ra t ion

Yellow/brown Amelogenesis imper ecta

Brown/violet/yellow brown Dentinogenesis imper ecta

Brown Inborn errors o metabolism, e.g. phenylketonuria

Black Porphyria

Further reading
Baldwin DC. Appearance and aesthetics in oral health. Community Dent Oral Epidemiol
1980;8:24456.

Barbosa CM, Sasaki RT, Flrio FM, Basting RT. In uence of in situ post-bleaching times on resin
composite shear bond strength to enamel and dentin. Am J Dent 2009;22(6):38792.

96
c h a pt er 3
D e n t a l Bl e a c h i n g : M e t h o d s

Dawson PF, Sharif MO, Smith AB, Brunton PA. A clinical study comparing the ef cacy and
sensitivity of home vs combined whitening. Oper Dent 2011;36(5):4606.

Friedman S, Rotstein I, Lib eld H, et al. Incidence of external root resorption and aesthetic
results in 58 bleached pulpless teeth. Endod Dent Traumatol 1988;4:236.

Hasson H, Ismail AI, Neiva G. Home-based chemically-induced whitening of teeth in adults.


Cochrane Database Syst Rev 2006;(4):CD006202.

Haywood VB. Frequently asked questions about bleaching. Compend Contin Educ Dent
2003;24:32438.

Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989;20:1736.

Haywood VB, Leonard RH, Neilson CF, Brunson WD. Effectiveness, side effects and long-term
status of nightguard vital bleaching. J Am Dent Assoc 1994;125:121926.

Heithersay GS. Invasive cervical resorption: an analysis of potential predisposing factors. Quin-
tessence Int 1999;30:8395.

Heithersay GS, Dahlstrom SW, Marrin PD. Incidence of invasive cervical resorption in bleached
root lled teeth. Aus Dent J 1994;39:827.

Heymann HO. Tooth whitening: facts and fallacies. Br Dent J 2005;198(8):514.

Kelleher MG. The Daughter Test in aesthetic (esthetic) or cosmetic dentistry. Dent Update
2010;37(1):511.

Kelleher MG, Djemal S, Al-Khayatt AS, et al. Bleaching and bonding for the older patient. Dent
Update 2011;38(5):2946, 298300, 3023.

Kelleher M. The law is an ass: ethical and legal issues surrounding the bleaching of young
patients discoloured teeth. Fac Dental J 2014;5(2):5667.

Kugel G, Gerlach RW, Aboushala A, et al. Long-term use of 6.5% hydrogen peroxide
bleaching strips on tetracycline stain: a clinical study. Compend Contin Educ Dent 2011;
32(8):506.

Leonard RH Jr, Bentley C, Eagle JC, et al. Nightguard vital bleaching: a long term study on
ef cacy, shade retention, side effects, and patient perceptions. J Esthet Restor Dent
2001;13:35769.

Leonard RH, Van Haywood B, Caplan DJ, Tart ND. Nightguard vital bleaching of tetracycline-
stained teeth: 90 months post treatment. J Esthet Restor Dent 2003;15:14252.

Matis BA, Hamdan YS, Cochran MA, Eckert GJ. A clinical evaluation of a bleaching agent used
with and without reservoirs. Oper Dent 2002;27:511.

Matis BA, Wang Y, Jiang T, Eckert GJ. Extended at-home bleaching of tetracycline-stained teeth
with different combinations of carbamide peroxide. Quintessence Int 2002;33:64555.

Meireles SS, Heckmann SS, Leida FL, et al. Ef cacy and safety of 10% and 16% carbamide per-
oxide tooth-whitening gels: a randomized clinical trial. Oper Dent 2008;33(6):60612.

Nathwani NS, Kelleher M. Minimally destructive management of amelogenesis imperfecta and


hypodontia with bleaching and bonding. Dent Update 2010;37(3):1702, 1756, 179.

97
F u r t h e r r e a d i n g

Nutting EB, Poe GS. Chemical bleaching of discoloured endodontically treated teeth. Dent Clin
North Am 1967;65562.

Patel V, Kelleher M, McGurk M. Clinical use of hydrogen peroxide in surgery and dentistry why
is there a safety issue? Br Dent J 2010;208(2):616.

Poyser NJ, Kelleher MG, Briggs PF. Managing discoloured non-vital teeth: The inside/ outside
bleaching technique. Dent Update 2004;31(4):20410, 21314.

Ritter AV, Leonard RH, St George AJ, et al. Safety and stability of nightguard vital bleaching
912 years post treatment. J Esthet Restor Dent 2002;14:27585.

Rosenstiel SF, Gegauff AG, Johnson WM. Randomised clinical trial of the ef cacy and safety of
a home bleaching procedure. Quintessence Int 1996;27:41324.

Russell CM, Dickinson GL, Johnson MH, et al. Dentist-supervised home bleaching with ten per
cent carbamide peroxide gel: a six month study. J Esthet Dent 1996;8:17782.

Settembrini L, Gultz J, Kaim J, Scherer W. A technique for bleaching non-vital teeth: inside/
outside bleaching. J Am Dent Assoc 1997;128:12834.

Spasser HF. A simple bleaching technique using sodium perborate. New York State Dent J
1961;27:3324.

Sulieman M, MacDonald E, Rees JS, et al. Tooth bleaching by different concentrations of car-
bamide peroxide and hydrogen peroxide whitening strips: an in vitro study. J Esthet Restor Dent
2006;18(2):93100, discussion 101.

World Health Organization. Oral Health for the 21st Century. Geneva: WHO; 1994.

98
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Ch a pt er 4
Direct An terior Esth etic Den tistry With
Resin Composites
A. D O Z IC , H . D E KLO ET

Introduction 102
Decision making 102
Direct anterior esthetics 111
Seminal literature 116
Further reading 116
References 116

10 1
D e c i s i o n M a k i n g

In t r o d u c t io n
Du e to th e excellen t adh esion to en amel an d den tin e, an d th e esth etics an d
adaptability of resin composite dental restorative materials, it is possible to place
resin composite restoration s directly in th e oral cavity, preser vin g a maximu m
qu an tity of h ealthy tooth tissue as compared to many altern ative in direct
meth ods. Th e goal of th is ch apter is to sh ow th e care plan n in g requ ired an d
detailed operative procedures involved with h an dling resin composites, focu sing
on techn iqu es u sed to ach ieve an optimal esthetic ou tcome with min imally
invasive procedures. The u nderpin n in g min imally invasive care ph ilosophy is
based upon the remit th at the u ltimate esth etic benefits of the ou tcome mu st be
su perior to the operative an d biological risks taken. In oth er words, th e ben efits
mu st ou tweigh th e risks.
Th e cases presen ted in th is ch apter h ave been selected from many patien ts com
plainin g of compromised esth etics. Th ese patien ts decided to be treated with
direct resin tech n iqu es after carefu l care plan n in g an d extensive explan ation s/
discussions of advan tages, disadvan tages an d even tu al risks of all differen t treat
men t option s. Several cases are described in detail in order to sh are th e pragmatic
restorative approach an d to en cou rage den tists to con sider direct resin composite
as a material of choice in many cases of compromised anterior appearance.
Many clin ical situ ation s cou ld be man aged with a direct resin composite min i
mally invasive approach in stead of depen din g on orth odon tic or fixed prosth o
dontic methods. Examples in clu de widen in g of a n ar row u pper jaw (Fig. 4 .1 ),
closin g diastemata (Fig. 4 .2 ), replacin g lost tooth su bstan ce in cases of severe
erosion an d wear (Fig. 4.3 ), resh aping teeth to camou flage crowdin g (Fig. 4.4),
maskin g gin gival recession an d in terden tal black trian gles after th e periodon tal
treatmen t (Fig. 4.5 ), refu rbish ing tech n ically acceptable bu t u n esth etic fixed pro
sth odon tic restoration s (Fig. 4 .6), remodellin g dislocated in cisors, can in es an d
premolars (Fig. 4 .7 ), replacemen t of missin g teeth (Fig. 4 .8 ), masking discolou r
ations (Fig. 4 .9 ) an d reshapin g teeth with developmen tal disorders (Fig. 4 .10 ).

D ec is io n M a k in g
Appropriate treatmen t decision s can be ach ieved between the patien t an d th e
den tist/ den tal team th rou gh verbal an d visu al commu nication .

Ve r b a l C o m m u n i c a t i o n
Before any esthetic treatmen t takes place, th e den tist mu st be su re that th e h opes
an d expectations of th e patien t h ave been un derstood fully an d th at th ey are
aware of th e possible ou tcome an d risks of any poten tial rectifyin g treatmen t. 13
10 2
c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

A B

Fig. 4.1 A 38-year-old male patient with tapered maxillary arch form,
moderate overbite, midline displacement and restored anterior teeth (#21
endodontically treated) has expressed a wish for an esthetic improvement
to his smile. (A) Unesthetic appearance of the maxillary anterior teeth.
(B) The rst phase of treatment was to enhance colour of #21 and to
correct the shape and position of the two central incisors. (C) One-and-a-
half years later, the patient asked for further esthetic correction. This was
C accomplished by placing direct resin composite facings/veneers from #14
to #25.

A B

Fig. 4.2 A central diastema can be an unacceptable feature to many patients. To achieve optimal
esthetics, it is sometimes advisable to reshape minimally all four incisors to prevent the excessive
widening of the central incisors leading to a loss of proportion for these teeth. (A) The diastema is caused
by a mild hypoplasia of the upper incisors. For that reason orthodontics was not the rst choice solution
for this 54-year-old female. (B) By removing 0.5 mm of the distal surface of the central incisors, enough
space was created to widen all four incisors and a harmonic distribution of the maxillary anterior teeth
was achieved.
10 3
D e c i s i o n M a k i n g

A B

Fig. 4.3 Wear and erosion can cause not only functional problems, but also an unesthetic appearance.
Once the cause has been dealt with, minimally invasive operative dental treatment may be necessary to
prevent further loss of tooth substance. (A) The main complaint by this 24-year-old male was sensitivity
of almost all his teeth, anterior and posterior, together with the sharp incisal edges. (B) In this case, direct
resin composite was used to restore the original form and function. In the future it will be possible to
treat posterior teeth individually with more de nitive and invasive restorations if necessary.

A B

Fig. 4.4 The main reason for dental crowding causing an esthetic concern is the uneven light
distribution among the upper incisors. If there is a stable occlusion and a disinterest in pursuing
orthodontic correction, a pragmatic, minimally invasive solution using direct resin composite build-ups
can satisfy many patients. (A) A 3 mm arch length discrepancy resulted in protrusion of #11 and #22,
rotation of #12 and retrusion of #13, #21 and #23 in this 35-year-old female. (B) By thinning minimally the
buccal enamel of the protruded and rotated teeth, shortening the incisal edges of the retruded teeth and
reducing the central incisors mesially slightly, it was possible to create aligned upper teeth.

Communication ladder
Patien ts verbal evaluation of their esthetic con cern s an d th e impact of th is
problem on their daily life.
Patien ts evalu ation of their esthetic wish es, expectation s an d requ iremen ts.
Dentists recognition of the clinical problem.
Evalu ation of th e techn ical possibilities an d risks of differen t treatmen t
option s.
10 4
c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

A B

Fig. 4.5 Periodontal surgery aims to improve the periodontal health but can jeopardize the esthetics of a
smile. (A) Recession in this case not only resulted in compromised esthetics but also in wear, discolouration
and sensitivity of the exposed root surfaces. The black interproximal triangles were the most important
reason to seek further restorative treatment for this 42-year-old female. (B) Without removing any tooth
substance the natural anatomical crowns were lengthened towards the new gingival level. The original
shape of the tooth crowns was restored in resin composite to the current gingival margin. Gingival shade
indirect and direct composites now exist to enable a gingival effect.

A B

Fig. 4.6 In many cases, so-called permanent restorations become unesthetic after several years in situ.
(A) Five-year-old crowns made from porcelain fused to metal were a social problem for this 57-year-old
woman, who was reluctant to smile in public. (B) After removing the cervical porcelain and metal, an
opaque colour modi er (Kolor + Plus, Kerr) and opaque resin composite were used to reach a satisfactory
cervical result.

Estimation of th e biological costs, i.e. th e amou n t of tooth su bstan ce to be


removed, lon g term progn osis of th e teeth (pu lp vitality) an d of th e
restoration , failu re rates an d fu tu re con sequ en ces.
Den tists graded ju dgmen t of th e cu r ren t appearan ce an d th at of th e
expected esth etic outcome. For example, the cur ren t appearance may be
ju dged as 5 an d th e esth etic ou tcome ju dged between 7 an d 8 , ou t of 1 0.
Usin g th is su bjective ju dgmen t meth od th e den tist can set u p th e patien ts
expectation s on a par with wh at is ach ievable realistically, to overcome
fu tu re disappoin tmen t or disagreemen t.3
10 5
D e c i s i o n M a k i n g

A B

C D

E F

Fig. 4.7 Missing incisors (agenesis, trauma) can create severe esthetic issues, even when a diastema is
closed by orthodontic treatment. (A) Tooth #21 was lost in an accident 40 years before the photograph
was taken. It resulted in an asymmetrical, unesthetic look at the age of 56. (B) The left lateral is changed
into a central, #23 in tooth #22 position and the rst premolar is altered visually to appear like a canine.
To make the esthetic outcome more pleasing, #11 and #12 (porcelain crown) have been treated with
direct resin composite facings. (C) When two or more front teeth are lost by trauma, orthodontic
treatment alone may not be suf cient to create an acceptable nal result. In children, auto-
transplantation may be a treatment option to help compensate for the loss of upper front teeth. (D) Two
lower premolars were used to create central incisors, the canines changed into laterals and the rst
premolars into canines. (E) The smile of the patient, prior to this minimally invasive adhesive dentistry,
was atypical and unesthetic. (F) After the treatment this 14-year-old boy was pleased with the nal result.

10 6
A B

Fig. 4.8 Sometimes orthodontics may not be the rst treatment choice, especially when a tooth is lost at
an older age. (A) Tooth #23 was lost 10 years earlier due to trauma (root fracture) and the xed adhesive
partial prosthesis made subsequently debonded many times in this 47-year-old female. (B) To enhance
the esthetics, not only was a direct resin composite adhesive bridge constructed, but also the remaining
anterior teeth were treated with direct resin composite facings.

A B

Fig 4.9 Discolouration of teeth has, in many cases, an endodontic cause (see Cha p t er 1). Non-vital
bleaching is the rst treatment option (see Ch a p t e rs 2 a nd 3). When this is not successful, a direct facing/
veneer can be used to mask the discoloured tooth surface. (A) The discoloured central incisor #21 was
protruded thus permitting the placement of direct labial veneers on the adjacent incisors in a 32-year-old
male. (B) Following this care plan, there is less need to cut back the tooth to mask the discolouration. In
other words, the more #11 is built up, the less invasively #21 has to be cut back.

A B

Fig. 4.10 Hypoplasia of lateral incisors is a common phenomenon and can compromise anterior
esthetics. (A) Sometimes it can be necessary to build up the neighbouring teeth, but in the case of this
22-year-old male, there was an ideal space to create a natural, well-proportioned lateral incisor. (B) In
most cases with hypoplastic incisors, it is wise not only to build up the mesial and distal surfaces, but also
to make a labial facing because the hypoplasia includes the buccal surface too.

10 7
D e c i s i o n M a k i n g

Vi s u a l C o m m u n i c a t i o n
A relatively simple, n on invasive meth od to improve commun ication with
patients is to sh ow th em, before any operative in ter ven tion is car ried ou t, th e
esth etic resu lt th at cou ld be ach ieved with th e su ggested treatmen t.

Digital imaging
Usin g digital imagin g an d image processin g, a ran ge of esth etic adju stmen ts an d
ou tcomes can be illu strated ou tside the oral cavity (Fig. 4.1 1 ). However, it is
importan t to acqu ire clinical ph otograph s, after gain in g fu ll written con sen t,
with con trolled ligh tin g con dition s (e.g. ring flash or ambient ligh tin g)4 6 in
order to h ave a faithfu l an d standardized represen tation of any esth etic ch an ges
in th e n atu ral environ ment.
Th e stan dardized ph otograph of th e origin al clin ical situ ation can be adju sted
digitally to present a mu ltitude of esth etic resu lts, u sing image processin g soft
ware (e.g. Corel Pain tSh op Pro X4 ), a graph ic pen tablet (Wacom Bamboo One),
an d th e meth odology developed by th e au th ors.7 ,8

Direct resin composite mock-up


Th is refers to pre treatmen t resin composite bu ild u p with ou t etch in g/ bon din g.
On e of th e greatest advan tages of th e direct, in tra oral mock u p is th e possibility

A B

Fig. 4.11 Dental imaging is an ideal way to present the post-treatment results to the patient for
comment and analysis. The patient can judge the outcome and communicate their wishes precisely
before the actual treatment is carried out, and can also get acquainted with the new situation. (A)
Recently made porcelain veneers did not ful l the esthetic desires of this 18-year-old woman. Dental
imaging was used to understand more fully what her expectations were. (B) In this separate hypoplasia
case, dental imaging was used to see if the planned build-ups could offer a natural looking distribution of
tooth width across the front teeth.
10 8
c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

of h avin g a real life esth etic dry ru n , prior to th e actu al star t of any invasive
treatment, of the restoration outcome in terms of size, shape and colour.9 ,1 0
Moreover, a patien t can visu alize an d experien ce th e ch anges in th eir mou th
an d offer a ju dgmen t before any physical treatmen t commen ces. Th is close
patien tden tist in teraction will h elp in crease tru st an d th e acceptan ce of th e
fin al post treatmen t esth etic alteration s.3 Finally, the dentist can use th is oppor
tu nity to discover possible techn ical operative ch allenges that will h ave to be
overcome du rin g th e treatmen t.
Th is procedu re is an excellen t way to assess the effect of ambien t ligh t con di
tion s on treatmen t ou tcomes (th e objective daily condition s u nder which hu man s
perceive each oth ers teeth an d su r rou n din g tissu es). Moreover, ph otograph s of
th e mock u p can help th e dentist and patien t ju dge how tooth / restoration posi
tion may in flu en ce th e su rface ligh t reflection an d its perception in th e origin al
an d fin ally adju sted clin ical situ ation s (Fig. 4 .1 2 ).
Resin composite mock u ps can also be observed u n der u ltra violet in ciden t
ligh tin g to h elp ju dge th e optical flu orescen ce match in g between th e teeth an d
th e selected resin composite sh ade (Fig. 4.13 ).

Colour determination
Th e fu n damental colou r destin ation for resin composite restoration s can be
determin ed u sin g a VITA sh ade gu ide or an electron ic device, wh ich measu res
th e full colour spectru m 11 ,12 (e.g SpectroSh ade, MHT, Italy) (Fig. 4 .1 4 A). Th e

A B

Fig. 4.12 Retroclined and retruded anterior teeth do not catch enough light compared to the other teeth
in daylight. (A) In this mild Angle Class II/2 case the centrals appeared discoloured. Photographs are taken
with tube luminescent (TL) lighting from the ceiling. (B) With a mock-up (temporary resin composite
facings placed without etching) the dentist and patient can judge the effect of the alterations. This
procedure is also suitable for the determination of colour.
10 9
D e c i s i o n M a k i n g

A B

Fig. 4.13 Ultra-violet light makes the internal natural dental uorescence visible (emission of blue light
by radiation with ultra-violet light). There are large differences in uorescence between teeth and
restorative materials. (A) Ultra-violet light revealed two edge-repairs on teeth #11 and #21 and a thin
resin composite veneer on #21 that lacked natural uorescence. (B) When using a resin composite with
moderate uorescence, the new restorations are almost invisible, even under ultra-violet light.

A B

Fig. 4.14 Colour perception and selection is critical, especially when only one tooth is to be treated.
(A) Digital means for colour determination (e.g. SpectroShade) can help a dentist judge colours more
objectively. (B) In contrast to the standard, commercially produced VITA shade guide made from
porcelain, a self-made in-house resin composite shade guide is more versatile.

colou r of most con temporary resin composites developed for layerin g tech n iqu es
can be selected usin g layerin g keys, wh ere th e colou r an d tran slu cen cy param
eters are separated (Fig. 4 .1 4 B). 13 1 5 Th e fin est colou r tu n in g can be accom
plish ed usin g th e polymerized resin composite material itself placed directly on
th e su rface of th e teeth to be restored. Wh en resin composite itself is u sed to
determine colou r, it is impor tant to respect all optical characteristics of teeth
in clu din g the relative th ickness of th e enamel/ den tine, hu e, ch roma, valu e,
tran slu cen cy an d flu orescen ce (Fig. 4.1 5). 11 1 7

Resin composite build-up


In order to determin e th e amou n t of tooth tissu e wh ich may h ave to be removed
to create a h armon iou s an d esth etic resu lt (e.g. in a severe crowdin g case), it
can be u sefu l to make a resin composite bu ild u p on a plaster model of th e
110
c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

Fig. 4.15 Perhaps the best way to determine the colour of the restoration is to test the selected resin
composite on the tooth to be treated, without the use of acid etching. Polymerization and polishing to
judge the nal colour are mandatory.

origin al tooth position s. Th is procedu re will be discu ssed in detail in th e clin ical
section later (see Ch apter 5 .2 , Figs C5 .2 .9C5 .2 .15 ).

D i r e c t An t e r i o r Es t h e t i c s
Th e or th odontic cor rection of an terior mal occlu sion s is often con sidered th e
least invasive treatmen t option . However, several aspects of or th odon tic treat
men t requ ire carefu l con sideration .
Or th odontic treatmen t involves bone remodellin g an d often a movemen t of teeth
th rou gh th e alveolar bon e. Th e in creased activity of osteoclasts sh ou ld be con
sidered invasive at a cellu lar level, as any excessive, u n con trolled activity can
lead to excessive bon e loss or root resorption . 18 ,19 Fu rth ermore, patien ts discom
fort over th e du ration of fixed or th odon tic treatmen t, an d th e lack of main te
nan ce an d/ or effectiven ess of patients oral hygien e procedures, du e to th e
position of or th odontic brackets an d reten tion wires, are often un derestimated
detrimen tal factors. Th e adverse con sequ en ces of redu ction in oral hygien e
complian ce du rin g orth odon tic treatmen t are th e resu ltin g wh ite spot cariou s
lesion s, wh ich occur in areas of plaqu e stagnation aroun d brackets, an d th e
associated gin gival or periodon tal path ologies th at n eed to be man aged lon g
after th e removal of orthodon tic brackets.20
Du e to exten sive research an d developmen t of strong an d du rable dental adh e
sives an d esth etic restorative materials, resin composites can be u sed for th e
visu al camou flage of abn ormally position ed teeth as a direct, min imally invasive
altern ative to some orth odon tic an d prosth odon tic treatmen t option s. Moreover,
111
D i r e c t An t e r i o r E s t h e t i c s

direct restorative procedu res involving resin composite restorations are often
n ecessary as an adju nct to orth odon tic treatmen t, to complete th e fin al, often
more su btle, esth etic resu lts. 2 1
Th e cases described in th is ch apter were treated with Filtek Su preme XTE
layered resin composite system (3M ESPE, USA). This material was h eated to
5 0 C in a composite heater (Ease it, Rnvig, DK) to reduce its viscosity an d
th u s in crease its physical adaptability to th e tooth su rface du rin g placemen t.
Th e optical properties of Filtek Su preme XTE are excellen t an d in most cases
th e desired colou r an d tran slu cen cy were reach ed u sin g th e reddish h u e (A),
mediu m valu e/ ch roma (2 ) an d th e body ph ase (B) of th e composite. Th is ph ase
of th e resin composite h as a moderate tran slucen cy an d is more heavily filled
th an th e en amel ph ase. Th at is why th e valu e remain s relatively u n ch an ged
wh en th e th ickn ess of th e material in creases. Th is is a very importan t qu ality,
especially wh en varyin g th ickn esses of resin composite n eed to be added to
adjacent teeth. Th e high ly tran slucen t en amel ph ase (E) was not u sed fre
qu en tly by th e au th ors because of th e h igh in flu en ce of its th ickn ess on th e
total valu e of th e restoration . Th e ph en omen on wh ereby th e valu e of th e res
toration falls wh en th e th ickn ess of a tran slu cen t ph ase of composite in creases
h as been well described in the dental literatu re. 2 2,2 3 In cases where the wh ole
tooth th ickn ess is to be restored (Class IV), th e en amel ph ase as well as th e
den tine phase (opaque version) of th e resin composite can be very usefu l.
Th e den tin e ph ase is u sed to bu ild u p th e mamelon s an d th e en amel ph ase to
accentu ate the presence of mamelon s in th e in cisal region of th e treated tooth
(Fig. 4 .1 6 AG).
Profession als mu st be aware of th e critical optical beh aviou r of tran slu cen t
materials, wh ere colou r valu e decreases with in creased material th ickn ess. 22 ,23
Th erefore, it is often n ot su fficien t to u se on ly th e th in en amel tab provided by
th e manu factu rer to determin e th e tran slu cen cy of th e tooth (Fig. 4 .16 B). It is
advisable to make an in dividu alized colou r tab, tryin g ou t differen t th icknesses
an d ph ases of resin composite un til the optimal resu lt is foun d. The ideal optical
resu lt with Filtek Su preme XTE, accordin g to th e au th ors in th e cases discu ssed,
was ach ieved with th e moderate tran slu cen t, mediu m opacity resin composite
(A2 B) on th e vestibu lar (labial) tooth su rface, an d th e h igh ly tran slu cen t resin
composite added on ly between th e mamelon s.
Direct placemen t of esth etic resin composites can be u sefu l in th e min imally
invasive man agement of some clin ical cases of tooth wear. Where on ly an terior
teeth are worn , the n ecessary space for restoration can be ach ieved by in creas
in g th e distan ce between the an tagonist teeth (Dah l prin ciple). Th anks to th is
well described ph en omen on , selective invasive tooth redu ction can be avoided
in many cases.24 26
112
c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

A B

C D

Fig. 4.16 This 30-year-old male patient was not satis ed with the appearance of his crown (#11). He also
wished to have his lateral and other central incisor restored with crowns so that his smile would look
more harmonious. (A) After clinical evaluation and having discussed all the possible consequences of
different treatments, a minimally invasive, pragmatic esthetic solution to restore the lateral and central
incisors (#21 and #12) with direct resin composite layering followed by a porcelain crown on #11 was
advised and agreed with the patient. (B) Teeth #22 (translucent) and #23 (chromatic) were used to
determine the colour and translucency for the Class IV restorations of #21 and #12 using the
manufacturers shade tabs (Ivoclar Vivadent). The transparent tab served to establish the level of
transparency in the thinnest incisal portion of the tooth. (C) In this case, a palatal putty impression was
used to make an individualized mould/index to aid the direct build-up of the Class IV restorations. The
incisal part of the mould was cut out to prevent any interference from the putty index with the shaping
process of the mamelons. Te on tape was used to provide isolation from the adjacent teeth. The
mamelon build-ups were accomplished using opaque dentine shade, while the enamel (translucent
phase) was applied between them. (D) After the Class IV restoration was completed, the veneering
procedure on #21 was facilitated using an AutoMatrix band which served to isolate the tooth from its
adjacent neighbours.
Continued

113
D i r e c t An t e r i o r E s t h e t i c s

E F

G H

Fig. 4.16 Continued (E) With the AutoMatrix band in place, the bonding procedure was repeated. (F) After
etching, rinsing and drying, the adhesive was applied. (G) After the direct resin composite layering
procedure, the matrix was removed and the veneer shaped using ne diamond burs. (H) The nal appearance
of the restored dentition after the veneering of the #12, polishing and replacing the crown on #11.

In a past stu dy of 1 0 0 7 patien ts it was observed th at 2 2 % h ad more th an 1 0 %


of th eir teeth surfaces worn to an u nacceptable degree. 2 7 Th e au th ors th erefore
con clu ded th at th e excessive wear in th e you n ger age grou p (2 0 3 0 years) was
du e main ly to den tal erosion . Above th is age, wear was the resu lt of more gen
eralized attrition du e to clen ch in g an d grin din g h abits.
In cases of severe tooth wear th e treatmen t ration ale mu st be additive. Resin
composite may be th e material of ch oice as it adh eres to any tooth su rface,
which h as been sh aped by the characteristic wear type. Contrary to th is, den tal
porcelain is a brittle material th at n eeds more tooth preparation to establish
smooth an d roun ded su rfaces for su pport. Th is makes porcelain a less th an
adequ ate material for the minimally invasive treatment of wear, despite its
su blime optical proper ties. Th is pragmatic approach to th e treatmen t of tooth
wear, involvin g resin composite adh esion to en amel an d den tin e, h as been well
described in th e literature.2 5
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c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

A drawback of th e min imally invasive direct resin composite approach is th e


un certain ty of long term restoration reten tion an d esth etics, wh ich will be
depen den t u pon th e patien ts diet, smokin g h abits, den tal hygien e an d ch ewin g
habits. Therefore, treatmen t with resin composite can n ot be con sidered as fin al.
Den tists n eed to review and mon itor their patien ts over su bsequ ent years, con
tinu ing n on operative preven tive care, oral hygien e advice, an d periodic polish
in g or refu rbish men t/ repair of any damaged or worn restoration su rfaces.
However, th e reparability of resin composites an d th e fact th at treatmen t is
reversible sh ou ld be con sidered as advan tageou s. Moreover, a restoration th at
can be adju sted simply as many times as n eeded an d with an in stan t, predictable
resu lt th at is relatively in expen sive, may be con sidered th e ideal restorative
option . 25

ES S EN TI A LS

Due to excellent adhesion and nature-emulating optical properties, resin composites can be used
to build up naturally looking restorations directly in the mouth. Some indirect techniques, which
are more invasive and more expensive, can therefore be avoided or postponed.
Handling properties of contemporary resin composites allow for direct shaping and re-shaping
in order to mimic the esthetic smile values. Patients who do not wish for an invasive procedure
or prolonged orthodontic treatment can be managed successfully with this approach.
Building up teeth with resin composite is a reversible and constantly optimizing, dynamic process.
Other operative techniques are therefore not excluded. If age or wealth of patients is an important
issue, restoring with resin composite can provide a very good substitute, prior to planned implant
surgery or more invasive, xed prosthodontics.

P A TI EN TS F A Q s

Q. How well a re resin comp osit e rest ora t ions xed t o my t eet h? Will t hey fa ll off when I
chew vigorou sly?
A. Adhesion of contemporary composites to enamel and dentine is excellent if applied judiciously.
Only heavy biting forces could cause chipping of the composite. It is the responsibility of the dentist
to establish a correct occlusion and articulation, but it is the patients responsibility to avoid
extreme forces, e.g. nail biting, Sellotape tearing, etc.

Q. Does t he a p p ea ra nce of t hese rest ora t ions d et eriora t e over t ime a nd how long will it
b e b efore I wou ld n eed n ew ones?
A. Resin composites will abrade and stain over time depending on the material type and patients
habits. When an adequate resin composite is chosen and thorough instructions are given to patients, it
is the authors experience that the esthetics can remain acceptable up to 10 years or more.

Q. If I d ecid ed t o ha ve t he re sin comp osit e removed a nd t o ha ve p orcela in rest ora tions


or t o und ergo orthod ont ic t rea t ment , would t his still b e p ossib le?
A. If necessary, resin composites can be easily removed from tooth surfaces, leaving healthy tissue
underneath. The tooth surface is still suitable for bonding procedures with porcelain and also with
new resin composite material and bonding of orthodontic brackets.

115
D i r e c t An t e r i o r E s t h e t i c s

Seminal literature
Burke FJT, Kelleher GDM, Wilson N, Bishop K. Introducing the concept of pragmatic esthetics,
with special reference to the treatment of tooth wear. J Esthet Restor Dent 2011;23(5):
27793.
This article shows that resin composite restorations, bonded using a three-step bonding procedure,
provide reliable restorations for worn teeth. The esthetic result might not conform to the highest prin-
ciples of dental esthetics, but represents an effective way of protecting teeth from further tooth surface
loss while improving patient-perceived esthetics.

Gresnigt MM, Kalk W, zcan M. Randomized controlled split mouth clinical trial of direct lami
nate veneers with two micro hybrid resin composites. J Dent 2012;40(9):76675.
In this article different micro-hybrid composite materials were used to test the survival rate on intact
teeth and on teeth with existing restorations. After sandblasting with Co Jet (3M ESPE) there was no
signi cant difference between the two groups.

Rosa M, Zachrisson BU. Integrating space closure and esthetic dentistry in patients with missing
maxillary lateral incisors: further improvements. J Clin Orthod 2007;61(9):56373.
This article describes how one can further improve clinical esthetic results, using orthodontic space
closure along with cosmetic nishing using composite materials in patients with missing incisors.

Further reading
Dozic A. Capturing Tooth Color. Electronic Tooth Color Measurement. Thesis, ACTA Dental
School, Amsterdam University; 2005.
In order to select the appropriate colour of the resin composite, it can be valuable to measure the colour
spectrum of the teeth.

Goldstein CE, Goldstein RE, Garber DA. Imaging in Esthetic Dentistry. Improving Visualization
in your Practice. Chicago: Quintessence Publishing; 1998. p. 718.
Standardized digital imaging can be used as an effective visualization tool in dentistry.

Kloet de H. Esthetische Tandheelkunde met Facings van Composiet Materiaal. Acta Qual Pract
2006;1(5):2637.
The patients expectations should be managed at a safe and realistic level using grades to describe the
appearance of the smile before and after actual treatment.

Kois DE, Schmidt KK, Raigrodski AJ. Esthetic templates for complex restorative cases: rationale
and management. J Esthet Restor Dent 2008;20:23950.
Resin composite mock-ups are an excellent method for trying out the shape of the new restorations
directly in the mouth.

Talarico G, Morgante E. Psychology of dental esthetics: dental creation and the harmony of the
whole. Eur J Esthet Dent 2006;(4):30212.
Proper care planning is essential for patient satisfaction of the esthetic outcome.

Villarroel M, Fahl N, De Sousa AM, De Oliveira OB. Direct esthetic restorations based on trans
lucency and opacity of composite resins. J Esthet Restor Dent 2011;23:7388.
Resin composite itself can be used to determine the appearance of planned restorations.

Re f e r e n c e s

1. Maio G. Being a physician means more than satisfying patient demands: an ethical review of
esthetic treatment in dentistry. Eur J Esthet Dent 2007;2(2):14751.
116
c h a pt er 4
D I R EC T AN T ER I O R ES T H ET I C S

2. Talarico G, Morgante E. Psychology of dental esthetics: dental creation and the harmony of the
whole. Eur J Esthet Dent 2006;1(4):30212.

3. Kloet de H. Esthetische Tandheelkunde met Facings van Composiet Materiaal. Acta Qual Pract
2006;1(5):2637.

4. Bengel W. Mastering Digital Dental Photography. Reproducible Conditions. London: Quintes


sence Publishing Co; 2006. p. 11015.

5. Goldstein RE, Garber DA. Improving aesthetic dentistry through high technology. J Californian
Dent Assoc 1994;22(9):239.

6. Goldstein CE, Goldstein RE, Garber DA. Imaging in Esthetic Dentistry. Improving visualization
in your practice. Chicago: Quintessence Publishing; 1998. p. 718.

7. Dozic A, de Kloet de H. Improving aesthetics in a narrow jaw with composite, Part I. Dent Today
2011;30(6):10811.

8. Dozic A, de Kloet H. Improving aesthetics in a narrow jaw with composite, Part II. Dent Today
2011;30(7):11822.

9. Kois DE, Schmidt KK, Raigrodski AJ. Esthetic templates for complex restorative cases: rationale
and management. J Esthet Restor Dent 2008;20:23950.

10. Roeters J, Kloet de H. Handboek Esthetische Tandheelkunde. Nijmegen: STI; 1998. p. 1418.

11. Dozic A. Capturing Tooth Color. Electronic Tooth Color Measurement. Thesis, ACTA Dental
School, Amsterdam University, Amsterdam; 2005. p. 2333.

12. Chu SJ, Trushkowsky RD, Paravina RD. Dental color matching instruments and systems. Review
of clinical and research aspects. J Dent 2010;38(2):216.

13. Baratieri LN, Araujo E, Monteiro S Jr. Color in natural teeth and direct resin composite restora
tions: essential aspects. Eur J Esthet Dent 2007;2(2):17286.

14. Magne P, So WS. Optical integration of interproximal restorations using the natural layering
concept. Quintessence Int (Berl) 2008;39(8):63343.

15. Dietschi D. Optimizing smile composition and esthetics with resin composites and other con
servative esthetic procedures. Eur J Esthet Dent 2008;3(1):27489.

16. Vanini L, Mangani F, Klimovskaia O. Conservative Restoration of Anterior Teeth, Part I. Viterbo
Italy: ACME English edition; 2005.

17. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB. Direct esthetic restorations based on trans
lucency and opacity of composite resins. J Esthet Restor Dent 2011;23:7388.

18. Pizzo G, Licata ME, Guiglia R, Giuliana G. Root resorption and orthodontic treatment. Review
of the literature. Minerva Stomatol 2007;56(12):3144.

19. Brezniak N, Wasserstein A. Orthodontically induced in ammatory root resorption. Review of


the literature. Angle Orthod 2002;72(2):17584.

20. Ardu S, Castioni NV, Banbachir N, Krejci I. Minimally invasive treatment of white spot enamel
lesions. Quintessence Int (Berl) 2007;38(8):6336.

21. Rosa M, Zachrisson BU. Integrating space closure and esthetic dentistry in patients with missing
maxillary lateral incisors: further improvements. J Clin Orthod 2007;61(9):56373.
117
R e f e r e n c e s

22. Schmeling M, Meyer Filho A, Andrada MAC, Baratieri LN. Chromatic in uence of value resin
composites. Oper Dent 2012;35(1):449.

23. Schmeling M, Andrada MAC, Maia HP, Araujo EM. Translucency of value resin composites used
to replace enamel in strati ed composite restoration techniques. J Esthet Restor Dent
2012;24(1):538.

24. Reis A, Higashi C, Loguercio AD. Re anatomization of anterior eroded teeth by strati cation with
direct composite resin. J Esthet Restor Dent 2009;21:30417.

25. Burke FJT, Kelleher GDM, Wilson N, Bishop K. Introducing the concept of pragmatic esthetics,
with special reference to the treatment of tooth wear. J Esthet Restor Dent 2011;23(5):
27793.

26. Mizrahi B. The Dahl principle: creating space and improving the bio mechanical prognosis for
anterior crowns. Quintessence Int (Berl) 2006;37:24551.

27. Smith BGN, Robb ND. The prevalence of tooth wear in 1007 dental patients. J Oral Rehabil
1996;23:2329.

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Ch a pt er 5
Direct Esth etics: Clin ical Cases
H . D E KLO ET, A. D O Z IC

121
C LI N I C AL C AS ES

In t r o d u c t io n
In th is ch apter, th e tech n ical min imally invasive operatin g prin ciples discu ssed
in Ch apter 4 are illu strated in a series of fou r clin ical cases. In each , th e in terac-
tion between th e patien t an d th e den tist is paramou n t in man agin g patien t
expectation s an d perceived ou tcomes. Th e clin ical tech n iqu es depicted, alth ough
requ irin g sign ificant levels of manu al dexterity an d skill, can be gain ed th rou gh
practice and attendan ce on postgraduate master class cou rses.

C l i n i c a l C a s e 5.1

Fig. C5.1.1 A 43-year-old male complained of the poor appearance of his smile
and the uneven distribution of his front upper teeth. This affected him adversely
to the extent that he was reluctant to smile in public.
Fig. C5.1.2 After a full assessment of the patient and explanation of the
decision making process and potential outcomes, it was clear that direct resin
composite restorations would be adequate to ful l his needs and expectations.
In this case it was necessary to remove minimal but suf cient quantities of
dental tissue, which would otherwise interfere with achievement of an ideal
esthetic result.

Fig. C5.1.3 In this Class II Division II case, the mesio-labial aspect of the lateral
incisors had to be removed. Building up neighbouring teeth is preferable
whenever possible to grinding down healthy tooth tissue, but there are
situations in which some selective and minimal tooth removal is inevitable.
Another reason not to remove tooth substance is the risk of introducing occlusal Fig. C5.1.4 An occlusal view which shows clearly the arch length discrepancy in
discrepancies, e.g. labial veneers on lower teeth or in crossbite situations. the maxillary central incisor region.
122
c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.1.5 The lateral incisors have been ground selectively, guided by the Fig. C5.1.6 Existing restorations that are of good quality, opacity and colour
continuing presence of enamel. During this process no local anaesthesia was can be maintained and air-abraded preceding the adhesive procedure.1,2
administered, permitting the patient to discern between enamel and dentine. Insuf cient or questionable restorations should be removed, and carious lesions
should be managed minimally invasively with suitable excavation procedures.
Insuf cient restorations located cervically should be maintained in this stage, as
they facilitate the placement of rubber dam isolation.

Fig. C5.1.7 For controlled working conditions, rubber dam isolation is advisable Fig. C5.1.8 A rubber dam clamp is placed on a distally positioned premolar or
in this phase. The prepared teeth can be checked with gingivae retracted, molar to create a dump where it is easy to perform suction. The tooth surface
without bleeding or saliva contamination, which compromise visibility and an (enamel and dentine) can be etched effectively or treated with a self-etch
ef cient bonding procedure. Etching and bonding can be performed for all bonding system. It is of utmost importance to follow precisely the clinical
surfaces in one step and there is no danger of contamination of gingivae or instructions for the speci c product.
mucosa with potentially hazardous chemicals. A prerequisite for reliable
bonding is a clean substrate that can be achieved by air abrading with
aluminium oxide (27 m alumina) powder.

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Fig. C5.1.9 Using clear matrix strips (Directa, Sweden), the palatal, incisal and Fig. C5.1.10 Once the basic framework of the restorations has been placed, the
proximal surface restorations are built up incrementally using a strong hybrid restoration contours can be adjusted to the correct length and labial pro le. This
resin composite. Diastemata and interdental black triangles are closed and the can best be done after the removal of the rubber dam.
position/level of the incisal edges established. The excess material is guided
towards the incisal edge, where it can be removed more easily. Special care is
taken to avoid overhangs in the cervical region. Sometimes it is advisable to
make a putty mould/index for the construction of the palatal surface (Chapter 4,
Fig. 4.16C), but in most cases a free-hand technique using custom matrices is
suf cient. Indeed, in some instances, the rubber dam may prevent the putty
index from seating fully, so precluding its use.

Fig. C5.1.11 Finally, occlusion and articulation are checked. At this stage, any Fig. C5.1.12 The direct resin composite veneers can be placed. A free-hand
pre-existing insuf cient cervical restorations can be removed and the gingival method is only possible when partial coverage of the labial surface is required.
cavities can be modi ed as necessary. When the planned direct laminate veneer restoration extends to gingival or
sub-gingival level, a matrix can be of great help in avoiding contamination
during the bonding procedure.

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Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.1.13 A clear matrix (e.g. Contour-Strip, Ivoclar Vivadent) or a stiffer Fig. C5.1.14 The matrix can be supported inter-proximally by wedges or with
metal matrix used in this case (e.g. AutoMatrix, Dentsply), that can be curved to polymerized resin placed on the outer surface of the matrix. Within the matrix,
follow the cervical contour of the tooth to be treated, should be placed carefully the bonding procedure is performed once more. In this case, a three-step
using ne at plastic instruments to guide the matrix into place without etch-and-rinse system (Type 1, 4th generation) is used.
traumatizing the gingival tissues.

Fig. C5.1.15 Primer and resin are applied separately and polymerized. At this Fig. C5.1.16 The resin composite is ejected slowly and with great care,
stage, a grey tint can be used in the incisal area to offer a level of translucency. depending on its viscosity, taking care not to displace the matrix. A high
A nal composite layer covers the tint so the translucency stays in the depth. viscosity composite can be heated (e.g. Ease-it composite heater, Rnvig) to
make syringing less hazardous. A better ow of resin composite will facilitate its
adaptation on the tooth surface and helps prevent the inclusion of air voids.

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C LI N I C AL C AS ES

Fig. C5.1.17 The resin composite is spread over the labial surface and adapted Fig. C5.1.18 The nal modelling can be performed with silicone tips (e.g.
in the shallow space between the surface and the matrix with clean metal TPEN2, Micerium). In the cervical part a high chroma, opaque material is adapted
instruments. and polymerized; in the middle third a shade with less chroma is applied and to
the incisal area a more translucent, higher value shade is advisable. The different
shades are placed in incremental layers over each other like roof tiles to enable a
smooth transition from one to another.3,4

Fig. C5.1.19 If required, special characteristics can be built in with white tints to Fig. C5.1.20 After polymerization the matrix is removed, the facing is again
create chalky spots and cracks; the same can be done with brown and ochre photo-polymerized and contoured coarsely to the correct shape. Then the next
characterizers. tooth is veneered.

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c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.1.21 Finally, all restorations are sculpted with ne diamond nishing Fig. C5.1.22 The occlusal view reveals the harmonious continuity of the labial
burs, creating surface texture and natural looking incisal edges and embrasures. surface pro le, utilizing the space available.
The polishing is performed using Sof-Lex (3M ESPE) and Politip-P green polishers
(Ivoclar Vivadent). The patient is instructed to perform effective oral hygiene.5

Fig. C5.1.23 The esthetic result was acceptable to the patient and his social
boundaries were lifted. It is advisable to recall the patient within 23 months to
re-assess the patients preventive behaviour, including checking his oral
hygiene/motivation and gingival condition, and to review the restorations and
perform any necessary adjustments in shape and to complete the nal polishing.

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C LI N I C AL C AS ES

C l i n i c a l C a s e 5.2

Fig. C5.2.2 Patients esthetic complaints were related to the unevenness of the
gums, the colour of the old restorations, the crowding and the rotated position
of the maxillary central incisors.

Fig. C5.2.1 Portrait view of a 56-year-old female who was not satis ed with the
appearance of her upper front teeth, 2 years after periodontal surgery was
completed.

Fig. C5.2.3 Lateral view of the upper front teeth illustrated the rotation and Fig. C5.2.4 Occlusal view of the maxillary front teeth shows clearly the arch
retroclination of the maxillary central incisors. length discrepancy.
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c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.2.5 Ambient light photograph of the patients smile where the effects of Fig. C5.2.6 Direct mock-up using unbonded resin composite to evaluate the
incident light and casting shadows are visible. change in shape, thickness and colour. Patient can see and feel the difference.

Fig. C5.2.8 Dental image processing using ambient light to show the change in
the light and shadow areas.
Fig. C5.2.7 Dental image processing of the possible results, after the correction
of discrepancies to meet the patients wishes and expectations, enhances the
communication between the two parties about various management options,
their risks and potential outcomes.

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C LI N I C AL C AS ES

Fig. C5.2.9 In this case it was decided to fabricate a direct resin composite
build-up rst on a duplicate plaster model.

Fig. C5.2.10 Plaster model of the original clinical situation, incisal view.

Fig. C5.2.12 The model is prepared for the addition of the material (resin
composite wax-up), frontal view.

Fig. C5.2.11 Carving the model with a scalpel to distinguish the reduction of
thickness.

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c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.2.14 The model is waxed-up using a low viscosity resin composite.

Fig. C5.2.13 From the incisal aspect, the amount of tooth substance to be
removed is visible clearly.

Fig. C5.2.16 A minimal reduction in tooth substance, guided by the carved


plaster model as shown in Figures C5.2.12 and C5.2.13.

Fig. C5.2.15 The incisal view shows the alteration in the position of the new
labial tooth surfaces.

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C LI N I C AL C AS ES

Fig. C5.2.17 The poor quality restorations are removed and the teeth inspected Fig. C5.2.18 Rubber dam isolation is achieved using ligatures of waxed dental
for the presence of secondary caries. oss to assure a dry working eld and clear access to the cervical regions of the
teeth.

Fig. C5.2.19 The mesial, distal and incisal direct resin composite build-ups are Fig. C5.2.20 The restorations are completed and ready for contouring.
created using a three-step (Type I) bonding procedure with clear matrix strips
(Directa), inter-proximally.

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c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.2.21 The teeth are shaped with ne grit diamonds to establish the basic Fig. C5.2.22 After removing the rubber dam the occlusion was checked, the
labial contours and pro les. length of the incisors and the position of the incisal edges were determined.

Fig. C5.2.23 The placement of the direct resin composite facings is facilitated Fig. C5.2.24 The AutoMatrix is positioned just sub-gingivally in the cervical
by using the AutoMatrix MR (Dentsply) as shown in the previous case. area, at an angle of 45 to help create a natural emergence pro le. Chalky spots
and microcracks are imitated using white characterizer (Kolor + Plus, Kerr).

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C LI N I C AL C AS ES

Fig. C5.2.25 Consecutively, the four maxillary incisors were veneered using the Fig. C5.2.26 The AutoMatrix on tooth #22 was removed. The nal labial contour
same procedure described above. of this tooth has still to be established.

Fig. C5.2.27 All teeth are polished using ne diamond burs and silicone rubber Fig. C5.2.28 The occlusal view clearly demonstrates the amount of added
Politip-P green cups (IvoclarVivadent). material in the incisal aspect.

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c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.2.29 Portrait before treatment (ambient light with ll-in ash). Fig. C5.2.30 Portrait with reshaped and resin composite treated teeth.

135
C LI N I C AL C AS ES

C l i n i c a l C a s e 5.3

Fig. C5.3.1 Frontal view of the maxillary anterior teeth of an 18-year-old female
suffering from missing lateral incisors. Five years ago, upon completion of the
orthodontic treatment (aimed to close the diastemata), her dentist tried to
camou age the missing teeth with composite build-ups on teeth #11, #21, #13,
#23, #14 and #24. Fig. C5.3.2 The treatment proposed, using Paint Shop Pro image processing
software (Corel), gives the patient the opportunity to appreciate the alterations
that could be made and give adequate, informed feedback.

Fig. C5.3.3 Lateral view shows the cross-bite between teeth #14 and #43 and Fig. C5.3.4 Permanent palatal orthodontic retention wire had to be removed
the retroclination of both the maxillary and mandibular anterior teeth. prior to the commencement of treatment.

136
c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.3.5 From this image it is clear that after removing the original resin Fig. C5.3.6 After placing the rubber dam as described previously, the teeth are
composite masking restorations by the previous dentist, the labial curvature of air-abraded with alumina powder to aid the bond of new resin composite to any
the canines has been attened somewhat to transform them into a more lateral residual resin composite left on the teeth after the previous restorations were
incisor labial pro le. removed.

Fig. C5.3.7 The resin composite restoration framework (mesial, distal and Fig. C5.3.8 After removal of the excess resin composite, the new incisal level is
incisal) is constructed using Directa Clear Matrix inter-proximally with special determined.
attention given to the midline position.

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C LI N I C AL C AS ES

Fig. C5.3.9 This frontal image shows that the cross-bite shown in Figure C5.3.3 Fig. C5.3.10 The new, more pronounced position of the labial surfaces was
has been corrected successfully. achieved with the use of AutoMatrix NR.

Fig. C5.3.11 The high-value body composite shade was applied to enhance the Fig. C5.3.12 After contouring, it is clear that the emergence pro le, achieved
re ection of the light from the labial surface line angles, suggesting an even with the direct labial veneers, is natural and that the vertical axes of the
more protruded tooth position. maxillary anterior teeth appear more natural than in the original situation.

Fig. C5.3.13 Viewing occlusally, the central incisors appear wider than the Fig. C5.3.14 Directly after the treatment, the teeth are polished with special
canines, because they were transformed successfully into lateral incisors. attention given to the labial surface texture and form, recreating importantly the
re ective line angles mesially, distally, cervically and incisally, thus providing an
acceptable natural-looking result.
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c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

C l i n i c a l C a s e 5.4

Fig. C5.4.1 A 37-year-old male patient displaying only a few millimetres of his
central incisors during a tight-lipped smile. Clearly, he is embarrassed to show
his upper front teeth.

Fig. C5.4.3 Image processing with Paint Shop Pro software (Jasc) showing the
original situation, the proposed treatment using minimally invasive direct resin
composite restorations and the projection of the proposed changes on the
original situation to estimate the necessary lengthening of the teeth. This
process helps communicate clearly to the patient the operative treatment
options, the risks and the nal results, and helps match the restorative outcome
to the patients expectations.

Fig. C5.4.2 The wear of his upper front teeth is severe and the existing
restorations are discoloured.

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C LI N I C AL C AS ES

Fig. C5.4.4 Occlusal view of the initial situation showing the extreme wear of Fig. C5.4.5 Frontal view after partial removal of the existing poor quality resin
the palatal surfaces and the exposure of dentine that has become stained over composite restorations.
time.

Fig. C5.4.6 Occlusal view shows the minimal removal of tooth substance, Fig. C5.4.7 The rst step was the construction of new palatal surfaces on teeth
enough to create space for the direct resin composite build-ups to follow. #12 and #22, using a free-hand direct technique described in the previous cases.
An alternative technique in this type of case might have been to wax-up the
palatal surfaces on a plaster model and manufacture a clear rigid acrylic palatal
splint from the laboratory. This splint could then be used to help guide and
position clinically the placement of resin composite.

14 0
c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.4.8 After the palatal surfaces of the two lateral incisors were created, Fig. C5.4.9 The main reason to begin the procedure with the palatal build-ups
the central incisors are then built up, also using AutoMatrix NR. is to help position and retain the rubber dam for controlled working conditions
and de ning initial pre-determined occlusal stops.

Fig. C5.4.10 The rubber dam with ligatures in situ; this provides protection to Fig. C5.4.11 The palatal aspect of the canines is constructed with free-hand
the adjacent teeth and soft tissues from air-abrasion, acid etching and applying direct placement of resin composite and the teeth are ready for lengthening.
the bonding agent.

14 1
C LI N I C AL C AS ES

Fig. C5.4.12 The second step is to establish the exact proportions/dimensions Fig. C5.4.13 The join between the palatal restorations and the incisal resin
of the teeth and the position of the midline. composite is checked from the occlusal aspect. This should be seamless as fresh
increments of resin composite fuse on photo-polymerization due to the presence
of the undisturbed air-inhibited layer on the palatal composites.

Fig. C5.4.14 The altered contours of the teeth are visible clearly after the Fig. C5.4.15 The third step (placement of the direct labial resin composite
removal of the excess composite. veneers) commenced after the removal of the rubber dam and the establishment
of occlusion and articulation.

14 2
c h a pt er 5
Dir ec t Es t h e t i c s : C l i n i c a l C a s e s

Fig. C5.4.16 This image shows how effectively the labial surface of the canine is Fig. C5.4.17 The procedure continued with labial incremental layering of
isolated and de ned with an AutoMatrix and a wooden wedge. Within the owable resin composite with respect to the shade map assessed for the teeth.
matrix, the bonding procedure is performed as described previously. Cervical part mostly A3.5B (chromatic and less translucent body composite),
mid-labial part A3B and the incisal part A2B (higher value, less chroma and
moderate translucency).

Fig. C5.4.18 In the incisal area, chalky spots and microcracks are added using Fig. C5.4.19 Finally, the surfaces are polished with So ex (3M ESPE) discs
white characterizer (Kolor + Plus, Kerr). After removal of the matrix the labial (coarse to ne) and polishing cups (Politip P green, Ivoclar Vivadent).
surfaces are shaped using a ame-shaped diamond bur (Horico FG249U010) and
the palatal surfaces are contoured using a pear-shaped diamond bur (Komet
FG379EF023lg).

14 3
R e f e r e n c e s

Fig. C5.4.20 The labial composite surface pro les are distributed naturally and Fig. C5.4.21 The 3-month review of the patient shows excellent gingival health,
harmoniously within the available space. natural surface luster and texture of the restorations. The patient reported
excellent function and was not disturbed by a slight change of overbite caused
by the lengthening of the maxillary anterior teeth.

Fig. C5.4.22 The post-treatment image shows natural looking incisal edges, the
incisal translucency and the chalky, hypoplastic spots. The nal result is
satisfactory to the patient.

Re f e r e n c e s

1. zcan M. The use of chairside silica coating for different dental applications: a clinical report.
J Prosthet Dent 2002;87:46972.

2. Gresnigt M. Clinical and Laboratory Evaluation of Laminate Veneers. Netherlands: Thesis,


Dental School Groningen University; 2011.

3. Dozic A, de Kloet H. Improving aesthetics in a narrow jaw with composite. Part I. Dent Today
2011;30(6):10811.

4. Dozic A, de Kloet H. Improving aesthetics in a narrow jaw with composite. Part II. Dent Today
2011;30(7):11822.

5. Meijering ACH. A Clinical Study on Veneer Restorations. Netherlands: Thesis, Dental School
Radboud Nijmegen University; 1997.

14 4
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Ch a pt er 6
Direct Posterior Esth etics:
A Man agemen t Protocol for th e Treatmen t of
Severe Tooth Wear with Resin Composite
J . H AMBU RG ER, N . O P D AM, B. LO O MAN S

Introduction 148
Treatment options 148
The Nijmegen direct shaping by
occlusion approach 150
Seminal literature 157
References 157

14 7
T r e a t m e n t O p t i o n s

In t r o d u c t io n
Tooth wear is a con cern in den tistry bu t diagn osis is often difficu lt du e to its
mu lti-factorial aetiology. Th e main cau ses for tooth wear (tooth su rface loss) are
a combination of both erosion (more common in th e you n ger popu lation) and
attrition (bru xism, fou n d more commonly in th e older population ). Du ring th e
early stages fu rther tooth wear may be preven ted by redu cing acid con su mption
or prescribin g an acrylic occlusal n igh tguard to preven t attrition du e to bru xism.
Wh en tooth wear is more severe, leadin g to exten sive loss of tooth su bstan ce,
restorative operative treatmen t is requ ired an d gen eral den tal practition ers can
feel less confiden t in managin g these patients. Sometimes a total rehabilitation
in clu din g in creasin g th e occlu sal ver tical dimen sion s an d re-organ izin g the
occlu sion h as to be performed. In th is chapter a minimally invasive, tooth tissu e
preser ving an d direct operative recon stru ction protocol with relatively low costs,
good predictability an d su fficient lon gevity is ou tlined and discussed.

Tr e a t m e n t O p t i o n s
Wh en ever a patien t visits a den tal practice with severe tooth wear or is refer red
to a specialist, a compreh ensive verbal h istory (an amn esis) mu st be obtained to
h elp elu cidate the patien ts n eeds, h opes an d expectation s of th e dental care
requ ested. Does th e patien t experien ce tooth wear as a problem or is it ju st th e
refer rin g den tist wh o is con cern ed abou t th e state of th e patien ts den tition .
Fu nction al problems cau sing patients su fferin g an d resu ltin g from severe tooth
wear in clu de sen sitivity, problems with mastication an d/ or problems with th e
resultin g esth etics. In situation s where n o direct treatmen t is requ ested by th e
patient, th e need for restorative in ter vention mu st be qu estioned, especially if
th e den tist feels th at postpon in g any treatmen t will n ot resu lt in a more exten -
sive or complicated operative care plan in th e fu tu re. In th ose cases it may be
advisable to mon itor an d review th e condition , with study models and in tra-oral
ph otograph s, to see if th ere is any con tinued active progression, as well as
focussin g non -operative preven tive patien t care on eradicatin g all aetiological
factors. Several indices (for example, BEWE [basic erosive wear examin ation ] or
TWI [tooth wear in dex]) exist to h elp den tists with th is. With th e BEWE in dex,
th e su rface affected most severely in each sextan t is recorded u sin g a fou r-level
score an d th e cu mu lative score is classified an d match ed to risk levels wh ich
gu ide th e man agement of th e con dition . 1 Th is scorin g system is straigh tforward
bu t its main disadvan tage is th at it is design ed for erosive wear alon e. Becau se
tooth wear often h as a mu lti-factorial aetiology, th is in dex alon e migh t be in su f-
ficien t for mon itorin g pu rposes. An oth er more gen eral in dex is th e Smith an d
Kn igh t TWI.2 Several others are described, bu t un for tu nately non e are accepted
14 8
c h a pt er 6
D I R EC T P O ST ER I O R EST H ET I C S

in tern ation ally as th e gold stan dard meth od for measu rin g an d mon itorin g
tooth wear. Moreover, patien ts su fferin g from severe tooth wear are often clas-
sified in th e high est categories with in th ese in dices. Th is, in tu rn , makes th e
in dices less h elpfu l for mon itorin g an d decidin g wh en is th e best momen t to
in ter ven e operatively. For th is pu rpose, sequ en tial den tal stu dy casts are th e
simplest meth od u sed to compare tooth wear stages over time. Wear progression
an d patien ts expectation s of treatmen t are importan t factors in decidin g th e
righ t momen t to commen ce restorative work. Th e possible disadvan tages of
restorative option s an d th e limited lon gevity of every invasive restorative treat-
men t sh ou ld be explain ed clearly to th e patien t. Du rin g th is in formed an d well-
docu men ted con sen t, a mu tu al decision can be made con cern in g wh eth er to
start restorative in terven tion or con tinu e with th e mon itorin g process.
Wh en th e decision to commen ce operative treatmen t is made, th ere are several
option s to ch oose from. A brief overview of th e option s follows, bu t it sh ou ld be
noted that, to date, n o treatmen t tech n ique is properly eviden ce based or su p-
ported by ample h igh -qu ality clinical stu dies/ trials.

In d i r e c t O p t io n s
In direct treatmen t implies the use of restoration s th at are manu factured ou tside
th e patien ts mou th an d cemen ted to th e tooth to gain reten tion . Restoration s
in clu de crown s, bridges, porcelain facin gs/ ven eers an d in direct resin composite
restoration s. The den tal tech n ician models th e morph ology of th e restoration s
in stead of th e den tist. From case repor ts, th ere are con siderable variation s in
th e materials u sed wh ich include glass-ceramic, gold an d porcelain fu sed to
metal crowns. 3 5 Th e disadvan tages of th is in direct approach in clu de th e rela-
tively high cost, the invasive n atu re of th e care an d th e in creased risk of poten-
tially catastroph ic failures in the mediu m to lon g term. 6 ,7
In direct resin composite restorations are also an option u sed to treat patien ts
with severe wear. Positive treatmen t ou tcomes8 are described as well as n egative
resu lts.9 Advan tages of in direct resin composite restoration s compared to crown s
in th e treatmen t of patien ts with severe tooth wear in clu de a redu ced su scepti-
bility to fractu re an d th e redu ced overall in itial fin an cial ou tlay.

D ir ec t Opt io n s
Direct resin composite restoration s can be u sed to treat patients with severe
tooth wear. Resin composite has been proven to be a restorative material deliver-
in g good lon g-term resu lts;1 0 1 4 however, non e of th e quoted referen ces describe
th e treatment of patien ts with severe tooth wear. Promising clinical resu lts in
patien ts with severe tooth wear treated with direct resin composite are described
14 9
Th e N i j m e g e n D i r e c t Sh a p i n g b y O c c l u s i o n Ap p r o a c h

in several case reports. 15 19 However, in a ran domized clin ical trial in 20 0 6 , th e


au th ors con clu ded th at the use of composites for restoring worn posterior teeth
was con train dicated given th e h igh failu re rate after 3 years. 9 In contrast,
h owever, promising clinical results were repor ted in a case series of a n on-
invasive tech niqu e for posterior vertical bite recon stru ctions u sing direct resin
composite.2 0 2 1 A stu dy in 2 0 11 , with a mean obser vation time of 4 years,
sh owed min imal failu re an d h igh patien t satisfaction .7 In th is stu dy, patients
were treated accordin g to th e meth od described later in th is ch apter.
Treatin g patien ts with severe tooth wear operatively can be deman din g tech n i-
cally for gen eral den tists. Treatmen t su ccess is h igh ly depen den t on th e clin ical
skills of th e operator an d th eir appreciation of th e biological an d mech an ical
con sideration s of th e par ticu lar case. Modellin g th e an atomy of teeth directly
in the mou th can be difficu lt an d time con su min g. Un til now, a formal treatmen t
protocol for u sin g direct resin composites to restore severely worn teeth at an
in creased vertical dimension h as not been described in th e literature. Past case
reports do n ot provide mu ch more in formation oth er th an th at teeth are adju sted
in occlusion .22 A meth od u sin g a semi-direct tech n iqu e in clu des restorin g th e
an atomy by mean s of a pre-fabricated template. 2 0 ,21

Th e N i j m e g e n D i r e c t Sh a p i n g b y
O c c l u s i o n Ap p r o a c h
In th is section , th e treatmen t protocol u sed in th e Depar tmen t of Den tistry of
th e Radbou d Un iversity Medical Cen ter in Nijmegen (Th e Neth erlan ds) will be
described,7 an d th e aim is to sh ow th e essen tials of th is man agemen t protocol
as it differs from other, more stan dard procedures. Th e approach described here
in clu des min imal preparation of teeth , redu ced costs an d increased outcome
predictability. A novelty in th is tech niqu es protocol is the direct sh aping by
occlu sion (DSO) techn iqu e. The principle beh ind DSO is to obtain an occlusion
at th e n ew in creased ver tical dimension by gettin g th e patien t to close in to th e
soft u n cu red resin composite prior to its polymerization , u sin g pre-determin ed
an d pre-fabricated pu tty occlu sal stops to gu ide th e new ver tical dimen sion .
Wh en a patien t is refer red to th e Departmen t of Den tistry of th e Radbou d Un iver-
sity Medical Cen ter in Nijmegen , th e first appoin tmen ts in clu de takin g an exten -
sive verbal history (an amn esis) an d a compreh en sive dietary an alysis. Moreover,
in tra-oral clinical pre-operative photograph s, bitewin g an d dental panoramic
radiographs an d impression s for stu dy casts are made (Figs 6 .1 6 .3).
A patien t-cen tred care plan , in clu din g emph asis on man agin g th e cau ses of th e
on going tooth wear, as well as th e expected costs of treatmen t, is discussed
with th e patien t. After mu tu al, documen ted in itial approval, n on -bonded resin
150
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D I R EC T P O ST ER I O R EST H ET I C S

Fig. 6.1 Anterior, frontal view (teeth in intercuspal position [ICP]) of a Fig. 6.2 Occlusal views of the maxilla showing severely worn teeth with
patient with severe tooth wear. multiple areas of exposed dentine.

Fig. 6.3 Occlusal views of the mandible showing severe tooth wear. Lower left rst molar has lost all the
enamel on the occlusal surface.
151
Th e N i j m e g e n D i r e c t Sh a p i n g b y O c c l u s i o n Ap p r o a c h

Fig. 6.5 Direct, non-bonded resin composite mock-ups placed on teeth


#1323.
Fig. 6.4 An esthetic concern existed because the anterior teeth were
markedly shortened and irregular, so affecting adversely the patients
appearance.

Fig. 6.6 The patient evaluated the esthetic appearance of these mock-ups directly in situ.

composite mock-u ps overlyin g th e maxillary an terior teeth (# 1 3 2 3 ) are placed


directly an d evaluated with th e patient to establish th e desired esthetic appear-
an ce (Figs 6 .46.6 ).
After th e compreh en sive clin ical assessmen t of th e severity of th e tooth wear
an d docu mented discussions abou t the realistic treatmen t ou tcomes an d poten -
tial con cern s, con sen t is gain ed an d the in crease in occlu sal ver tical dimen sion
(OVD) is determin ed, with th e u se of a den tal semi-adju stable ar ticu lator with
maxillary an d man dibu lar casts mou n ted in maximu m in tercu spal position
(ICP). Th e space requ ired for th e restoration of fu n ction al an atomy an d th e
esth etics of th e den tition are th e primary factors in decidin g th e amoun t by
which to in crease th e OVD. An oth er factor taken into consideration is th e
min imu m ver tical space requ ired to accommodate an adequ ate th ickn ess of th e
152
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D I R EC T P O ST ER I O R EST H ET I C S

restorative material, in order to en su re th e in trin sic stren gth / fractu re tou gh n ess
of th e fin al restoration is maximized.
Th is newly determined vertical dimension is tran sfer red to th e patien ts mou th
usin g silicon e occlu sal stops. Th ese stops are manu factu red on th e stu dy casts
mou nted in th e dental ar ticulator. After separation of th e casts with petroleu m
jelly, two small por tion s of h eavy bodied silicon e or pu tty are applied to th e occlu -
sal su rfaces in th e molar region s an d th e articu lator is closed, at th e in creased
vertical dimen sion , u ntil th e silicon e is set fu lly. Th e silicone stops are adjusted
with a scalpel blade to permit freedom of man dibu lar movemen t in th e h orizon tal
plan e wh en occlu din g at th e in creased vertical dimen sion . Su bsequ en tly, th ese
occlu sal stops are placed in th e mou th . Usin g a gu ided closu re tech n iqu e, th e
retru ded con tact position is determin ed u sin g impression material.2 3 Bite regis-
tration is th en u sed to remou n t th e casts in cen tric relation at the new in creased
vertical dimen sion . Two n ew silicon e stops in th e posterior area are th en made
an d u sed in tra-orally to copy th e desired n ew relation sh ip in th e mou th .
Th e restorative procedu re starts with th e lower an terior teeth (# 3 343 ) after
wh ich the upper an terior teeth are recon stru cted. A metal matrix ban d (Toffle-
mire nr. 1 1 ) is positioned an d secu red with wooden wedges, from th e palatal
side, an d is adju sted u sin g a h igh speed bu r so th at th e ban d is n ot in con tact
with th e lower an terior teeth wh en th e patien t closes th eir mou th with th e stops
in situ . Su bsequ en tly, th e adh esive procedu re (preferably u sin g a th ree-step etch
an d rin se system) is performed. Before th e first layer of hybrid resin composite
is placed, a th in layer of flowable resin composite can be applied an d left u n cu red
to improve adaptation at the ou tlin e (snow-plough tech n ique).24 For larger
defects th e resin composite is placed in cremen tally bu t th e fin al occlu sal layer
of composite sh ou ld be applied in bu lk. Th e lower an terior teeth are coated
th in ly with petroleu m jelly an d the patien t is asked to close th eir mou th in to th e
silicon e stops, after wh ich th e composite is cu red from th e bu ccal side. After 4 0
secon ds, th e patien t can open th eir mou th an d th e ph otocu rin g is con tinu ed
from th e occlu sal su rface. Su bsequ en tly a labial ven eer restoration is made u sin g
a su itable an terior resin composite. Th e ven eer restoration con sists of a den tin e
sh ade an d an en amel sh ade, an d fin ally a tran slu cen t in cisor sh ade is u sed to
mimic in cisal translu cen cy. Th e fin ish in g procedure of th e restoration must be
delicate in order n ot to disru pt th e already establish ed morph ology an d esth etic
appearan ce. Sequ en tially, all maxillary an terior teeth (# 1 3 2 3 ) are treated
accordin g to th e same procedu re.
To en su re th e cur ve of Spee is main tain ed, th e maxillary first premolars are bu ilt
up in lin e with th e can ines, withou t makin g occlu sal con tact with th e lower
teeth . Usin g th e DSO tech n ique, the lower premolars are restored into contact
with th e u pper first premolars (Figs 6 .76.1 0).
153
Th e N i j m e g e n D i r e c t Sh a p i n g b y O c c l u s i o n Ap p r o a c h

Fig. 6.7 After placement of the matrix and wedges, the resin composite Fig. 6.8 The antagonist teeth are separated with a thin layer of
is applied. petroleum jelly.

Fig. 6.9 The patient occludes into the uncured resin composite and the Fig. 6.10 Initial photocuring of the resin composite is performed
vertical relationship is guided by the restored anterior teeth. in occlusion.

After th e premolars h ave been restored, the man dibu lar posterior teeth are
sh aped an d completed u sin g h an d in stru men ts. Th e silicon e stops are n ow n ot
requ ired as th e new OVD is stabilized by th e n ewly recon stru cted an terior teeth
an d premolars. Fin ally, th e remain ing upper posterior teeth are treated following
th e same described tech n iqu e (Figs 6.11 6.13 ).
154
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D I R EC T P O ST ER I O R EST H ET I C S

Fig. 6.11 An anterior view of the nal restored dentition. Fig. 6.12 Final result for the maxillary teeth after direct minimally
invasive DSO treatment.

Fig. 6.13 The nal result for the restored mandibular teeth.

155
Th e N i j m e g e n D i r e c t Sh a p i n g b y O c c l u s i o n Ap p r o a c h

Ad va nt a ges
Occlusion achieved in a simple and predictable
way
Generally, cuspal lateral guidance occurs natu-
rally using this treatment technique because of
the anatomy and the inter-digitation of teeth
Maximum thickness of resin composite is
achieved resulting in an increased strength of
the nal restorations
As this is a minimally invasive technique, bio-
logical damage is reduced to a minimum
The DSO technique falls within the remit of
techniques dentists can learn and use in their
general daily practice. The method by which
BOX 6 . 1
teeth are treated sequentially using a matrix and
A D V A N TA G ES A N D wedges to separate them is similar to the stan-
D IS A D V A N TA G ES O F TH E dard techniques used to restore teeth with
D S O TECH N IQ U E conventional resin composites. The nishing
and polishing are also relatively easy when the
matrices and wedges are placed properly

Disa d va n t a ges
As the occlusal morphology has to be modelled
directly intra-orally, this method compared to
an indirect technique could be clinically more
time consuming and challenging to the
operator
When using the DSO technique, rubber dam
isolation is not possible. Its presence would
prevent the patient from occluding or using
the silicone stops for creating the measured
increase in occlusal vertical dimension. Thus,
care is required to expel as much intra-oral
moisture as possible using cotton wool rolls,
absorbent cellulose pads and careful suction

Th e treatmen t order is n ot rigid an d can be adapted accordin g to th e patien ts


situ ation . Th ere migh t be cases in wh ich th e man dibu lar fron t teeth are n ot
worn down severely. In th at case, lower fron t teeth are n ot restored an d th e
treatmen t star ts with th e maxillary an terior teeth . For advan tages an d disad-
van tages of th e DSO tech n iqu e, see Box 6 .1 .

Ev i d e n c e
Th e DSO tech n iqu e h as been u sed for several years in th e Departmen t of Den -
tistry of th e Radbou d Un iversity Medical Cen ter in Nijmegen an d th e resu lts are
promising;7 h owever, this paper by Hambu rger et al does n ot describe the DSO
156
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D I R EC T P O ST ER I O R EST H ET I C S

tech nique implicitly, bu t in all th e repor ted cases, th is techn iqu e was u sed.
Th erefore, it can be con cluded th at th is well controlled step-by-step tech n iqu e
of treatin g patien ts with severe tooth wear cou ld be a reliable meth od of direct
man agemen t.

P A TI EN TS F A Q s

Q. Is it a p a inful t rea t ment op t ion?


A. Fortunately, in general it is not a painful treatment method. As mechanical tooth preparation is
limited to only producing a bevelled nishing margin or some minimal resistance form, teeth are
not sensitive and the biological integrity of the pulp is not put at risk when compared to more
invasive indirect restorative treatments.

Q. How much t ime d oes a genera l ca se ta ke?


A. It takes between 3 and 5 sessions, each of 34 hours duration, to restore a full dentition.

Q. Wha t is t he longevit y of t he d irect rest ora t ions?


A. Long-term results are not yet available and have to be determined by a prospective clinical study.
This is currently being undertaken at the Radboud University Medical Center in Nijmegen. Based on
initial experiences, life expectancy of these direct, minimally invasive restorations is between 10 and
15 years. Thereafter, refurbishment/repair can be carried out as required. Reasons for treatment
failure may be related to the initial cause of the tooth wear which must be elucidated and treated
primarily before any operative care is undertaken. It is conceivable that patients with tooth wear
wear mainly caused by mechanical aspects like bruxism may exhibit failures sooner than patients
with tooth wear mainly due to chemical aspects like erosion. These causes, as well as the direct
restorative care offered, must be carefully managed.

Seminal literature
Bartlett D, Sundaram G. An up to 3-year randomized clinical study comparing indirect and
direct resin composites used to restore worn posterior teeth. Int J Prosthodont 2006;
19(6):61317.

Hamburger JT, Opdam NJ, Bronkhorst EM, et al. Clinical performance of direct composite resto-
rations for treatment of severe tooth wear. J Adhes Dent 2011;13(6):58593.

Re f e r e n c e s

1. Bartlett D, Ganss C, Lussi A. Basic erosive wear examination (BEWE): a new scoring system for
scienti c and clinical needs. Clin Oral Investig 2008;12(Suppl. 1):S658.

2. Smith BG, Knight JK. An index for measuring the wear of teeth. Br Dent J 1984;
156(12):4358.

3. Dahl BL. The face height in adult dentate humans. A discussion of physiological and prostho-
dontic principles illustrated through a case report. J Oral Rehabil 1995;22(8):5659.

4. Fradeani M, Bottachiari RS, Tracey T, et al. The restoration of functional occlusion and esthetics.
Int J Periodontics Restorative Dent 1992;12(1):6371.
157
R e f e r e n c e s

5. Stewart B. Restoration of the severely worn dentition using a systematized approach for a pre-
dictable prognosis. Int J Periodontics Restorative Dent 1998;18(1):4657.

6. Groten M. Complex all-ceramic rehabilitation of a young patient with a severely compromised


dentition: a case report. Quintessence Int 2009;40(1):1927.

7. Hamburger JT, Opdam NJ, Bronkhorst EM, et al. Clinical performance of direct composite resto-
rations for treatment of severe tooth wear. J Adhes Dent 2011;13(6):58593.

8. Magne P, Stanley K, Schlichting LH. Modeling of ultrathin occlusal veneers. Dent Mater
2012;28(7):77782.

9. Bartlett D, Sundaram G. An up to 3-year randomized clinical study comparing indirect and


direct resin composites used to restore worn posterior teeth. Int J Prosthodont 2006;19(6):
61317.

10. Chrysanthakopoulos NA. Placement, replacement and longevity of composite resin-based res-
torations in permanent teeth in Greece. Int Dent J 2012;62(3):1616.

11. Da Rosa Rodolpho PA, Donassollo TA, Cenci MS, et al. 22-Year clinical evaluation of the per-
formance of two posterior composites with different ller characteristics. Dent Mater
2011;27(10):95563.

12. Nikaido T, Takada T, Kitasako Y, et al. Retrospective study of the 10-year clinical performance
of direct resin composite restorations placed with the acid-etch technique. Quintessence Int
2007;38(5):e2406.

13. Opdam NJ, Bronkhorst EM, Loomans BA, et al. Longevity of repaired restorations: a practice
based study. J Dent 2012;40(10):82935.

14. van Dijken JW. Durability of resin composite restorations in high C-factor cavities: a 12-year
follow-up. J Dent 2010;38(6):46974.

15. Belvedere PC. Full-mouth reconstruction of bulim ravaged teeth using direct composites: a case
presentation. Dent Today 2009;28(1):126, 128, 1301.

16. Bernardo JK, Maia EA, Cardoso AC, et al. Diagnosis and management of maxillary incisors
affected by incisal wear: an interdisciplinary case report. J Esthet Restor Dent 2002;14(6):
3319.

17. Reis A, Higashi C, Loguercio AD. Re-anatomization of anterior eroded teeth by strati cation with
direct composite resin. J Esthet Restor Dent 2009;21(5):30416.

18. Stephan AD. Diagnosis and dental treatment of a young adult patient with gastroesophageal
re ux: a case report with 2-year follow-up. Quintessence Int 2002;33(8):61926.

19. Tepper SA, Schmidlin PR. Technique of direct vertical bite reconstruction with composite and
a splint as template. Schweiz Monatsschr Zahnmed 2005;115(1):3547.

20. Attin T, Filli T, Imfeld C, et al. Composite vertical bite reconstructions in eroded dentitions after
5.5 years: a case series. J Oral Rehabil 2012;39(1):739.

21. Schmidlin PR, Filli T, Imfeld C, et al. Three-year evaluation of posterior vertical bite reconstruc-
tion using direct resin composite a case series. Oper Dent 2009;34(1):1028.

158
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D I R EC T P O ST ER I O R EST H ET I C S

22. Reston EG, Corba VD, Broliato G, et al. Minimally invasive intervention in a case of a noncarious
lesion and severe loss of tooth structure. Oper Dent 2012;37(3):3248.

23. Wilson PHR, Banerjee A. Recording the retruded contact position: a review of clinical tech-
niques. Br Dent J 2004;196:395402.

24. Opdam NJ, Roeters JJ, de Boer T, et al. Voids and porosities in class I micropreparations lled with
various resin composites. Oper Dent 2003;28(1):914.

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Ch a pt er 7
Direct Posterior Esth etics: Clin ical Case
J . H AMBU RG ER, N . O P D AM, B. LO O MAN S

16 1
C l i n i c a l C a s e

In t r o d u c t io n
Th is ch apter illu strates a case of severe gen eralized tooth wear in a you n g
patient, wh ere th e Nijmegen approach to direct resin composite recon stru ction
was used su ccessfully. Here again , as previou sly men tioned, th e clin ical assess
men t of th e patien t an d detailed scru tiny of th e patien ts wish es an d expect
ations played a sign ifican t role in h elpin g to decide on the minimally invasive
(MI) approach to rebu ildin g h is teeth . Th is MI approach will on ly work in cases
wh ere patien t motivation is h igh an d lon g lastin g for main tain in g th eir oral
h ealth an d elimin atin g causative factors th at h ave led to tooth destru ction.

Cl in ic a l Ca se

Fig. C7.1 A 25-year-old man was referred to the Department of Dentistry of the Fig. C7.2 The verbal history showed that the patient often experiences
Radboud University Medical Center in Nijmegen (The Netherlands) to the gastro-oesophageal re ux disease (GORD). The appearance of the tooth wear
restorative clinic specializing in the management of tooth wear. During the was erosive and, therefore, the most likely aetiology was established as GORD.
examination severe tooth wear was observed. History revealed that normal The patient was advised to contact his physician who prescribed omeprazol
function was restricted due to pain from cold food and drinks, touching and 20 mg. After 2 weeks, but before the actual dental treatment had started, this
chewing, especially sweets. The patient is a chef in a high-class restaurant and already resulted in a reduction of tooth sensitivity, less thirst during the night,
suffers professionally due to his clinical restrictions during food tasting. improved general welfare and a better taste.
Due to the tooth wear, an esthetic problem existed because his anterior teeth
were markedly shortened. Oral hygiene was good, a healthy periodontium was
present and caries risk was established as low.

16 2
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

Fig. C7.3 Occlusal views of the mandible and the maxilla. From 16 to 26 the Fig. C7.4 Intra-oral view of the lower left quadrant. The tooth wear extends
palatal cusps and the occlusal surfaces have been severely damaged. Palatal into dentine at several locations. Typical for erosive tooth wear, the resin
cusps of the upper premolars have totally disappeared, resulting in multiple composite restorations in tooth 36 stand proud from the occlusal surface.
dentine exposures. In the lower molars most of the occlusal enamel has already
disappeared. (BEWE score = 18.)

16 3
C l i n i c a l C a s e

A B

Fig. C7.5A,B Anterior view in and out of occlusion showing extruded mandibular anterior teeth, due
to erosive wear of the palatal surfaces of the maxillary teeth. Tooth 21 shows a marked decrease in
crown length.

Fig. C7.6 Bitewing radiographs con rm the low caries risk and good periodontal status. Considerable
wear on the occlusal surfaces can be observed.

16 4
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

A B

C D

Fig. C7.7AE Gypsum casts were articulated in intercuspal position


using an Artex articulator (Girrbach Dental, Germany). The vertical
dimension was raised 4.5 mm by adjusting the articulators incisal pin
and using a hydrophilic vinyl polysiloxane registration material (Star
VPS, Danville, USA), bilateral stops registering this new vertical
E dimension were made in the posterior region. These stops were
removed from the casts and attened on their occlusal surfaces.

16 5
C l i n i c a l C a s e

A B

Fig. C7.8AC Both stops were placed in the patients mouth to replicate the new occlusal vertical
dimension (OVD) position clinically. To x the new occlusal relation in intercuspal position or retruded
contact position the stops were relined with registration material.

16 6
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

A B

Fig. C7.9AC Based on this bite registration and a direct mock-up on teeth 1323, a diagnostic wax-up
model was made to get an understanding of the new dental relationship.

16 7
C l i n i c a l C a s e

Fig. C7.10A,B A rigid occlusal splint was manufactured to test the increase in OVD for a period of
3 weeks. The splint was placed on the lower teeth.

16 8
A B

C D

E F

Fig. C7.11AF To keep moisture control and vision optimal in clinical sites, an OptraGate dam (Ivoclar
Vivadent, Liechtenstein) was placed, including a tongue shield on the lingual aspect. The restorative
process commenced with building up the mandibular anterior teeth. The morphology was shaped
according to the situation in the wax-up.
16 9
C l i n i c a l C a s e

Fig. C7.12A,B The lingual aspect of the mandibular anterior teeth was restored using Clear l AP-X
(A2, Kuraray Ltd), and the labial side with direct composite veneers (Empress Direct [A2E, Ivoclar
Vivadent]). Using the silicone stops, the mandibular teeth were checked to be out of occlusion with
enough vertical space remaining to restore the maxillary anterior teeth.
170
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

A B

C D

Fig. C7.13AD A metal matrix band (Tof emire 11) was used to restore the palatal morphology of the
maxillary anterior teeth. The matrix was adjusted and preformed so that it adapted well to the palato-
cervical region.

171
C l i n i c a l C a s e

A B

C D

Fig. C7.14AE The matrix was placed palatally and secured with
proximal wooden wedges placed from the buccal aspect. The matrix
E was adjusted so that it was possible for the patient to occlude into the
silicone stops without interference from the matrix band.
172
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

A B

C D

Fig. C7.15AD After positioning the matrix, a three-step etch and rinse adhesive procedure was
performed. The 37% phosphoric acid was applied for 15 seconds, rinsed thoroughly and gently air-dried.
The primer was then applied and gently dried. Finally, the bonding agent was applied, gently dried and
light cured for 15 seconds.

173
C l i n i c a l C a s e

A B

Fig. C7.16A,B Before the resin composite was applied, a thin layer of owable resin composite (Clear l
Majesty Flow, Kuraray) was placed palato-cervically. This layer was not photocured separately.
Subsequently, Clear l AP-X (Kuraray) was extruded directly from the compule, pushing the owable
composite and resulting in optimal marginal adaptation (the snow-plough technique). After adaptation
with instruments, this rst layer of resin composite was photocured.

A B

Fig. C7.17A,B When the super cial occlusal increment of resin composite was applied, the palatal
surface was shaped using a hand instrument (ASH 49) and the mandibular anterior teeth were coated in
petroleum jelly.

174
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Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

Fig. C7.18A,B With the silicone stops in situ, the patient occluded into the uncured nal increment of
resin composite. Maintaining this position, the resin composite was photocured for 20 seconds from
the buccal aspect. The patient was asked to open his mouth and the material was photocured for a
further 20 seconds from the palatal aspect. This is called the DSO (direct shaping by occlusion)
technique.
175
C l i n i c a l C a s e

A B

Fig. C7.19AC After this gross shaping of the palatal contour, a contour strip (Ivoclar Vivadent) was
placed and a direct resin composite labial veneer restoration was placed. Firstly, a dentine-coloured
composite (A2 Dentin, Empress Direct, Ivoclar Vivadent) was applied, shaped and photocured. Secondly,
an enamel shade (A2 Enamel, Empress Direct) and, nally, the incisal shade (Opal, Empress Direct) were
applied incrementally.

176
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

Fig. C7.20A,B After application of the nal increment of resin composite, the restoration was
photocured from both the buccal and palatal aspects.

177
C l i n i c a l C a s e

A B

Fig. C7.21AC The restoration was shaped and nished using diamond burs and Sof-Lex discs (3M ESPE).

178
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

Fig. C7.22A,B While nishing the cervical margin, the gingival area was protected using a hand
instrument. Finally, ne Sof-Lex discs were used to polish the restoration.
179
C l i n i c a l C a s e

Fig. C7.23 The rst completed restoration on the maxillary right central incisor.

A B

Fig. C7.24A,B The adjacent central incisor was built up using the same procedure. During shaping and
nishing, orthodontic dividers were used to check the width:length ratios of the resin composite
restorations.
18 0
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

A B

Fig. C7.25AC Following the same DSO technique, all maxillary anterior teeth were built up in the
same way.

18 1
C l i n i c a l C a s e

A B

Fig. C7.26A,B For nal nishing, polishing cups as well as an oscillating EVA lamineer tip (Dentatus) in a
61LC handpiece (KAVO) (for sub-gingival margins) were used.

18 2
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

Fig. C7.27A,B Next, the maxillary premolars were restored. No preparation was necessary because teeth
were free of restorations or caries. Two metal matrices (Hawe Neos 1001-C Tof emire matrices) were
placed and secured with wedges.
18 3
C l i n i c a l C a s e

A B

Fig. C7.28A,B The nishing procedure was similar to those described previously. Occlusal surfaces were
modelled into the desired form so that the curve of the maxilla was optimized esthetically.

18 4
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

Fig. C7.29 The maxillary teeth to the rst premolars were now restored to the correct catenary curve.
Palatally, the occlusal contact areas with the lower incisors can be seen. From now on the silicone stops
became redundant, as the restored teeth established the new OVD and canine guidance.

18 5
C l i n i c a l C a s e

A B

Fig. C7.30A,B After the mandibular premolars were built up using the DSO technique, the remaining
posterior teeth were restored in accordance with the established occlusal plane.

18 6
A

Fig. C7.31A,B Next, the maxillary second premolars and molars were restored using the DSO technique.
The antagonists were separated with a thin layer of petroleum jelly before the patient occluded into the
uncured resin composite. Initial photocuring of the resin composite was performed in occlusion, after
which the restorations were photocured from the palatal aspect.

18 7
C l i n i c a l C a s e

A B

C D

Fig. C7.32AD The nal result of the direct minimally invasive (MI) treatment can be seen. A suitable
occlusion and intercuspation were achieved.

18 8
c h a pt er 7
Dir ec t Po s t e r io r Es t h e t i c s : C l i n i c a l C a s e

A B

Fig. C7.33AC As with Figure C7.32, the nal result of the direct MI treatment can be seen. A suitable
occlusion and intercuspation were achieved.

18 9
C l i n i c a l C a s e

M A TERIA LS U S ED

OptraGate (Ivoclar Vivadent)


Star VPS (Danville) bite registration material
To f emire matrix 11, Hawe Neos 1001-C
Plastic contour matrix (Ivoclar Vivadent)
Phosphoric acid 37% (DMG)
Clear l SA Primer (Kuraray)
Clear l Photo Bond (Kuraray)
Clear l AP-X (Kuraray): or occlusal and palatal/lingual sur aces
Empress Direct (Ivoclar Vivadent): or buccal sur aces in the esthetic zone
So -Lex discs (3M ESPE)
Polishing cups (Ivoclar Vivadent)
EVA lamineer tip (Dentatus) in a 61LC handpiece (KAVO)

190
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Ch a pt er 8
Min imally Invasive Replacemen t of
Missin g Teeth : Par t 1
L. MAC KEN Z IE

Introduction 194
Prevalence of tooth loss 194
Aetiology of tooth loss 195
Reasons for replacing lost teeth 195
Options for the management of missing teeth 196
Metalceramic resin-bonded bridges 205
Guidelines for success with resin-bonded
bridgework 210
Management of failure in resin-bonded
bridgework 220
Clinical case 8 1: minimally invasive simple
cantilever bridge 222
Clinical case 8 2: resin-bonded bridgework 226
Acknowledgements 253
Further reading 253
References 254

193
P r e v a l e n c e o f T o o t h Lo s s

In t r o d u c t io n
Th e average person will n ot retain th eir complete adu lt den tition for a lifetime
an d wh ile th e au tomatic replacement of missing teeth with a fixed or removable
applian ce is often u n necessary, tooth loss in th e esth etic zon e is of seriou s
con cern in most societies. Many patien ts will seek restorative treatmen t an d
ju dge th e ou tcome on th e basis of esthetics rath er th an fu n ction .
Con temporary prosth odon tics offers a ran ge of option s for th e replacemen t of
lost or absen t teeth , bu t with each one there is a biological cost to pay for th e
remain in g n atu ral den tition an d th e su ppor tin g periodon tal tissu es.
Th is ch apter an d Ch apter 9 describe th e relative merits of min imally invasive
prosth odontics for tooth replacemen t with emph asis on th ose tech n iques that
preser ve th e maximu m amoun t of h ealthy tooth tissu e.

Pr e v a l e n c e o f To o t h Lo s s
Adu lt den tal h ealth h as sh own a continu ou s improvemen t sin ce the 1 9 60 s an d
for you nger adu lts th e prospect of retain in g a considerable nu mber of h ealthy
teeth th rou gh ou t a lon g life h as n ever been h igh er. Tooth loss, h owever, remain s
common place. Th e latest exten sive su rvey from th e Un ited Kin gdom 1 reveals
th at th e average adu lt h as between 2 7 an d 3 2 teeth (an d approximately 1 8
sou n d, u n restored teeth ). Wh ile th e prevalen ce of caries an d periodon titis con -
tinu es to redu ce, exten sive disease persists (Fig. 8 .1 ) and is con centrated in a
relatively small propor tion of adu lts.1

A B

Fig. 8.1A,B Advanced periodontitis resulting in tooth loss presents numerous management di f culties.
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Ae t i o l o g y o f To o t h Lo s s
Wh ile teeth may be lost du e to trau ma or be missin g for developmen tal reason s,
th e vast majority of teeth lost in adu lth ood are as a resu lt of caries, periodon titis
or extraction at th e en d of a cycle of restoration replacemen t an d repair th at is
sometimes refer red to as th e den tal cou n tdown.
In th is respects it is h opefu l that preven tive strategies and the wide ran ge of
modern minimally invasive operative tech n iqu es will h elp redu ce the in ciden ce
of tooth loss in fu tu re gen eration s.

Re a s o n s f o r Re p l a c i n g Lo s t Te e t h
Th e aim of con temporary MI den tistry is to h elp patien ts maintain healthy oral
tissu es for a lifetime. However, it is a well-reported fact that many tradition al
restorative procedu res h ave th e opposite effect, especially in th e case of tooth
replacemen t. 2,3
To redu ce the risk of sh orten ing th e lifespan of an abutment or adjacent/
opposin g teeth , it is essen tial for practition ers to con sider carefu lly th e risks an d
ben efits of in terven tion . Th e most common ly cited reason s for restoration of a
missing tooth are based on :

Esth etics
Fu n ction
Psych ological factors
Ph on etics
Preven tion of tooth movemen t.

Es t h e t i c s
Methods for cosmetic tooth replacemen t date back over 20 0 0 years4 an d in
modern den tal practice, patient deman d for esth etic tooth -colou red restoration s
has never been h igh er. Tooth loss in th e esth etic zon e may seriou sly affect a
patien ts appearan ce an d most will en qu ire abou t restorative option s.4,5 Con tem-
porary den tistry offers a ran ge of tech n iqu es u sin g materials design ed to blen d
in con spicu ou sly with th e patien ts remain in g den tition an d practitioners mu st
select th e most appropriate, min imally invasive esth etic option for each in di-
vidu al case.
195
O p t i o n s f o r t h e M a n a g e m e n t o f M i s s i n g T e e t h

Fu n c t i o n
Historically, tooth loss was often followed by reflex replacemen t on th e basis of
restorin g masticatory fu n ction . However, it is a well-docu men ted fact th at mas-
ticatory efficien cy is possible with relatively few teeth 6 an d therefore practition-
ers mu st exercise extreme cau tion wh en prescribin g tooth replacemen t on a
fu nction al basis.

Ps y c h o l o g i c a l Fa c t o r s
Preven tion of tooth loss is on e of th e most common ly cited reason s for patien ts
visitin g th eir dentist an d wh en gaps occu r th ey can h ave a con siderable impact
on self-con fiden ce.

Ph o n e t i c s
Wh ile tooth loss may h ave a reversible, sh ort-term impact on speech pattern s,
it may also h ave a catastrophic effect on certain patients abilities to play mu sical
in strumen ts.

Pr e v e n t i o n o f To o t h M o v e m e n t
It is a common ly cited reason th at tooth replacemen t sh ou ld be prescribed to
preven t u nfavourable or th odontic movemen t resu lting eventu ally from the
su dden disequ ilibriu m th at follows tooth loss. 4 However, variou s stu dies h ave
demon strated th at su ch ch an ges may n ot occur 7 ,8 (Fig. 8 .2 ) an d that, even if
th ey do, th e clin ical con sequ en ces are often n egligible.
Before plan n in g restorative treatmen t it is importan t to con sider th e eviden ce
with regard to tooth movemen t. Th is information sh ou ld be balan ced with th e
possible deleteriou s con sequ ences of over-eruption, tipping, drifting or rotation
of teeth adjacen t to or opposin g a space (Boxes 8 .1 an d 8 .2).
In su mmary, th e rou tin e restoration of eden tu lou s areas sh ou ld be avoided.
Carefu l mon itorin g for poten tial problems an d advice on oral hygien e protocols
will avoid the provision of u n necessary restorative procedu res.

Opt io n s f o r t h e M a n a g em en t o f
M i s s i n g Te e t h
Th e remain der of th is ch apter an d Ch apter 9 describe th e ran ge of option s cur-
ren tly available for th e man agemen t of lost or absen t teeth (Box 8 .3 ), with
particu lar referen ce to th e biological cost associated with each and emphasis
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Fig. 8.2 Tooth loss o ten results in no clinically signif cant orthodontic movement o adjacent or
opposing teeth.

Fig. 8.3 Incomplete dental arches should be care ully monitored or signs o tooth movement that may
complicate restorative treatment.
197
O p t i o n s f o r t h e M a n a g e m e n t o f M i s s i n g T e e t h

Increased caries and periodontitis risk via plaque


accumulation and food trapping
Increased dif culty in oral hygiene measures
BOX 8 . 1
P O S S I B LE N EG A TIV E Loss of esthetics
CO N S EQ U EN CES O F TO O TH Reduction in masticatory ef ciency
M O V EM EN T F O LLO WIN G
EXTRA CTIO N Loss of space for prospective restorative treat-
ment (Fig. 8.3)
Decreased support for axial loading/tooth
mobility
Loss of prospective xed bridge abutments

Over-e ru p t ion
Some teeth show no sign of over-eruption 7
In the majority of cases, over-eruption is slight
(<2 mm)7,8
There is a lower risk of over-eruption if antag-
onist is lost in adulthood 8

Tip p in g

BOX 8 . 2 The majority of teeth (62%) show no signs of


tipping 8
EV ID EN CE F O R TO O TH
M O V EM EN T F O LLO WIN G If movement has not occurred within 5 years of
EXTRA CTIO N extraction, it is unlikely to occur7
Tipping is more common where mesial rather
than distal contacts are lost
Tipping is more common in the mandible 8
Molar tipping of >15 is more common in the
maxilla 8

Mesia l d rift
More likely if extraction occurs at <12 years of
age 7
Reduced tendency if patient is >36 years of age 7

given to th ose techn iqu es th at requ ire the least or n o tooth preparation at all.
For each option th e systematic, logical sequ en ce of examin ation , diagn osis an d
care plan n in g is implicit an d described on ly wh en relevan t.

N o n -O p e r a t i v e M a n a g e m e n t
Wh en patien ts presen t with in complete den tal arch es, th e nu mber on e con sid-
eration sh ou ld be th e preser vation of th eir remain in g teeth an d th ey sh ou ld be
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Non-operative management
Re-implantation
Wilkinsons extractions
Orthodontics

BOX 8 . 3 Transplantation
M A N A GEM EN T O P TIO N S Removable prosthodontics
F O R MIS S IN G TEETH
Implants
Fixed prosthodontics
Minimally invasive conventional bridges
Metalceramic adhesive bridges
Resin composite adhesive bridges
All-ceramic adhesive bridges

Fig. 8.4 Non-operative management should be the f rst consideration when assessing edentulous spaces.

in formed thorough ly of th e biological con sequ en ces of operative in ter vention . 5


Kn owing wh en to ch oose masterly inactivity4 (Fig. 8 .4 ) over operative den-
tistry for the lon g-term ben efit of patien ts is a key skill in itself.

Re -I m p l a n t a t i o n
Even th e latest restorative tech n iqu es h ave limitation s in replicatin g accu rately
th e complex anatomical, fu nction al and optical proper ties of natu ral teeth.
Th erefore if a tooth is avu lsed or ren dered mobile (su blu xed) followin g trau ma,
frequ en tly th e most esth etic an d con servative treatmen t option is to try to pre-
serve th e n atu ral tooth .
199
O p t i o n s f o r t h e M a n a g e m e n t o f M i s s i n g T e e t h

Th e complete displacemen t of th e tooth from th e socket may be con sidered as a


tru e den tal emergen cy. Man agemen t requ ires immediate tooth re-implan tation
as the progn osis is determin ed prin cipally by th e time elapsed sin ce avu lsion.
For case-specific in formation , in clu din g man agemen t details for su blu xation ,
extru sion an d in tru sion , visit: h ttp:/ / dentaltrau maguide.org/ 9

Ea r l y Ex t r a c t i o n s
First permanen t molars are likely can didates for prematu re loss as th ey are
affected common ly by caries, restorative procedu res an d developmen tal defects.
If th e lon g-term progn osis for th ese teeth is con sidered poor, th ey may be elec-
tively extracted allowin g forward movemen t of th e secon d perman en t molars
in to th eir place. Th e timing of such procedu res is critical to su ccess:

Lower first permanen t molars of poor progn osis sh ou ld be extracted wh en


calcification of th e in ter-radicu lar den tin e of th e lower secon d molar is
visible radiograph ically. (Den tal age of 8 9 years.)
For th e upper first molars the timing of extraction s is less critical an d an
acceptable result may still be obtained u p to 1 112 years as lon g as molar
crowdin g is presen t.

Or t h o d o n t ic s
Wh ile employed common ly to cor rect crowded malocclu sion s, well-execu ted
orth odon tics is also an ideal min imally invasive option for space closure resu lt-
in g from missin g teeth . It may be u sed to close gaps completely or combin ed with
oth er restorative tech niqu es to optimize th e esthetic ou tcome.
In th is respect, orth odon tics is u sefu l in th e an terior esth etic zon e, for example
in th e management of hypodontia involvin g u pper lateral in cisors.
After th ird molars and mandibu lar secon d premolars, u pper lateral in cisors are
th e most common con gen itally missin g teeth .1 0 Un fortu n ately, self-cor rection
by approximation of adjacen t teeth is rare and operative treatmen t is often in di-
cated. Figu re 8.5 shows an acceptable esth etic ou tcome that u sed or th odon tics
an d min imal en amel re-con tou rin g to treat missing lateral in cisors an d an
ectopic first premolar.

Tr a n s p l a n t a t i o n
Th is rarely u sed option involves th e extraction of an u n saveable tooth an d tran s-
plan tation of a healthy replacemen t that has been extracted from elsewh ere in
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A B

Fig. 8.5A,B Minimally invasive management o hypodontia and an ectopic premolar using orthodontics
and enamelplasty.

A B

Fig. 8.6A,B Clinical and radiographic images, taken 30 years post-operatively, o a lower third molar
transplanted into a lower right f rst molar extraction socket. Courtesy o Dr J. McCubbin.

th e mou th. Figu re 8 .6 sh ows a lower left th ird molar th at was tran splan ted to
replace an u n restorable lower righ t first molar 3 5 years previou sly.

Re m o v a b l e Pr o s t h o d o n t i c s
Removable prosth odon tics is th e oldest meth od of tooth replacemen t 5 an d is still
employed widely, particu larly for th e restoration of lon ger span s. Removable
partial den tu res (RPDs) may be con sidered as on e of th e least invasive option s
for replacemen t of missin g teeth , as lon g as th ey are design ed carefu lly an d
main tained scru pu lou sly. Th is is illu strated in Figure 8.7 wh ere an upper canine,
20 1
O p t i o n s f o r t h e M a n a g e m e n t o f M i s s i n g T e e t h

A B

Fig. 8. 7AC A 40-year-old cobaltchromium, removable partial denture restoring a missing upper canine.

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A B

Fig. 8.8A,B Implant-retained restorations (A) completely preserve adjacent teeth and carry a
signif cantly better long-term prognosis than traditional prosthodontic techniques (B).

lost 4 0 years previou sly, h as been replaced by an RPD worn continu ou sly an d
removed on ly for clean in g (n ot to be recommen ded rou tin ely!).

Im p l a n t s
Implant-retained restorations may be con sidered as the treatment of ch oice for
th e esthetic restoration of missin g teeth where su rgical, restorative an d eco-
nomic factors permit. 5,1 1 With carefu l plan n in g an d operative tech n iqu es th ey
have a good progn osis an d often avoid completely the invasive treatmen t of oth er
sou n d teeth (Fig. 8 .8 A).

Fi x e d Pr o s t h o d o n t i c s
Fixed bridgework can car ry an u n acceptably h igh risk to th e lon g-term h ealth
of a patien ts den tition .2 4 Therefore, th e ju stification for restorin g any space
usin g fixed prosth odon tics mu st be con sidered carefu lly an d th e poten tial for
complication s or ir retrievable catastroph ic failu re assessed an d ou tlin ed to th e
patien t at th e ou tset. In th is respect, fixed/ fixed bridgework may be sin gled ou t,
as th ere are few procedu res more destru ctive th an th e preparation of mu tu ally
parallel abu tmen t teeth for conven tion al bridgework4 (Fig. 8 .8 B).

Si m p l e C a n t i l e v e r Br i d g e w o r k
On e meth od of min imizin g poten tial complications associated with fixed pros-
th odontics is to u tilize simple cantilever design s th at requ ire preparation of on ly
20 3
O p t i o n s f o r t h e M a n a g e m e n t o f M i s s i n g T e e t h

A B

Fig. 8.9A,B (A) Simple cantilever bridges are esthetic and are easy to maintain. (B) Minimally invasive
abutment preparation accommodates alloy only in areas that will not be seen.

on e abu tment tooth . In addition to avoiding th e n eed for parallel abu tmen ts,
simple can tilevers are con sidered to be:

Easier to optimize esth etically5


More amen able to plaqu e control (Fig. 8 .9 A)
More amen able to failu re detection if de-cemen tation occu rs, and
th erefore repair.

Poten tial disadvan tages relate to th e application of leverage forces on abu tmen ts
du rin g fu n ction an d th ese may be min imized by:

Limiting span len gth to one pontic


Selectin g cases with redu ced occlu sal forces
Avoidin g pontic-only loadin g
Design in g to min imize non-axial loadin g
Min imizing tooth redu ction in areas where esth etic porcelain is
u nn ecessary (Fig. 8 .9 B).
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Fig. 8.10 Missing upper f rst premolars restored


with bridges using traditional retainers (upper
right) compared to a minimally invasive three-
quarter gold retainer.

Pa r t i a l C o v e r a g e Br i d g e Re t a i n e r s
Th is is probably th e least u sed design for fixed bridge retain ers,5 wh ich is u n for-
tu nate as it confers a nu mber of advan tages:

More con ser vative tooth preparation (Fig. 8 .1 0 )


Main ten an ce of en amel, th erefore su itable for previou sly restored,
weaken ed teeth
Redu ced involvemen t of gin gival margin s
Margin s are more accessible to oral hygien e measu res
Exposed axial tooth su rfaces facilitate pu lp testin g
Fit may be assessed readily
Versatile path of in sertion
Simpler cemen tation tech n iqu e.

Th ese advan tages mu st be weigh ed again st poten tial disadvan tages:

Metal display (Fig. 8.11 ) may be u n acceptable esth etically to some patien ts
Less rigid castin g is u n su itable for lon g span s
Less reten tive, th erefore optimu m axial len gth is essen tial.

Th e most common con temporary u se of par tial coverage retain ers is for th e
fabrication of metal frameworks in metalceramic resin -bon ded bridges.

M e t a l C e r a m i c Re s i n -Bo n d e d Br i d g e s
Th e well-docu men ted complication s of aggressive tooth preparation h ave stimu -
lated research , datin g back over 4 0 years, in to more min imally invasive
20 5
M e t a l C e r a m i c R e s i n - B o n d e d B r i d g e s

Fig. 8.11 Patients must be aware o the need or metal display when using this retainer design.

tech n iqu es for tooth replacemen t. In 1 9 7 2 , Alain Roch ette was th e first to
describe a revolution ary non -mu tilatin g, non -ir ritatin g tech n iqu e1 2 su itable
for tooth replacemen t th at employed adh esive resin and required no tooth
preparation.
Wh ile u n perforated design s for defin itive resin -bon ded bridges (RBBs) are n ow
favou red in vir tu ally all pu blished reports,13 ,1 4 on occasion they may also deliver
long-lasting restorations (Fig. 8.1 2).1 3 RBB tech n iqu es h ave con tinu ed to evolve
an d offer sign ifican t advan tages over tradition al fixed prosth odon tics1 3,1 5 to su ch
an exten t th at th ey may be considered as the n ext best option to den tal implan ts
for th e predictable, esth etic restoration of sh or t-span eden tu lou s spaces where
adjacent teeth are min imally, or completely, un restored. 16

Ad v a n t a g e s o f Re s i n -Bo n d e d Br i d g e s

Conservative
RBB design promotes min imally invasive tooth preparation compared to tradi-
tion al tech n iqu es.1 3 ,15 ,17 Preparations con fin ed to en amel are fu n ction ally an d
biologically superior, particularly for you ng patien ts with relatively large pulps. 4
20 6
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Fig. 8.12 Fixed/f xed resin-bonded bridge with Rochette design in continuous service or more than 30
years. Courtesy o Dr J. McCubbin.

Wh en th e occlu sion is favou rable, su ch as replacemen t of missin g lower in cisors


(Fig. 8.13 ), tooth preparation may be avoided en tirely.

Minimum long-term damage


Failure of RBBs is rarely catastroph ic for abu tmen t teeth , compared to tradi-
tion al tech niqu es. 11 ,13 In addition th ey are readily reversible17 an d may be
employed as tran sition al restoration s or as temporary prosth eses prior to implan t
procedu res.

Esthetics
RBBs h ave h igh patient satisfaction rates in esth etic terms1 3 and, with carefu l
case selection an d design in g, th e optical properties of abu tmen t teeth remain
un affected (Fig. 8.14 ).

Versatility
Althou gh RBBs are frequ en tly employed for replacemen t of an terior teeth , th ey
have been sh own to be su ccessfu l for restorin g posterior spaces in both maxillary
an d man dibu lar arch es. 18
20 7
M e t a l C e r a m i c R e s i n - B o n d e d B r i d g e s

Fig. 8.13 Lingual resin-bonded bridge retainers on lower anterior teeth will o ten not be visible,
allowing rigid retainer designs with minimal (or no) tooth preparation.

Fig. 8.14 Resin-bonded bridges are popular with patients and preserve the esthetics and integrity o
abutment teeth.

Patient popularity
Min imal drillin g con fin ed to en amel is popu lar with patien ts4 an d often obviates
the n eed for local an aesth etic4 an d provision al restorations. As well as min imal
biological cost, if cor rectly prescribed an d execu ted, RBBs h ave been sh own to
h ave a good cost/ ben efit ratio in financial terms. 1 3
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A B

Fig. 8.15A,B Sub-optimal design and technique will result in premature ailure o resin-bonded bridges.

D i s a d v a n t a g e s o f Re s i n -Bo n d e d Br i d g e w o r k
While they offer sign ifican t advan tages over oth er modes of tooth replacemen t,
it is an u n for tu nate fact th at RBBs h ave n ot been accepted widely by all
den tal profession als. Th is may be a resu lt of poor person al experien ce or from a
gen eral, u n deser ved1 3,1 6 ,19 perception th at th ey are u n su itable as lon g-lastin g
restoration s. For practitioners to prescribe RBBs with con fiden ce, it is essen tial
to u n derstand th eir limitation s, con tra-indication s an d poten tial disadvan tages,
as ou tlin ed in th e followin g text.

Technique sensitivity
As with all adh esive procedu res, su ccessfu l lon g-lastin g restoration s will on ly
resu lt if case selection , design , preparation , manu factu re an d lu tin g procedu res
are all optimized. Operator experien ce h as been sh own to h ave a sign ifican t
effect on su ccess1 3 an d h igh failu re rate is th e likely ou tcome of poor tech n iqu e
(Fig. 8.1 5). Th is will th en resu lt in loss of patien t an d operator con fiden ce in
th is meth od of tooth replacemen t. 4 ,15

Esthetics
Wh ile adh esive bridges made en tirely from tooth -colou red materials (see
Ch apter 9 ) are in creasin g in popu larity, most of th e cu r rent lon g-term data
per tain s to metalceramic RBBs. In certain clin ical situ ation s, for example th in
an terior teeth an d occlu sal su rfaces of posterior teeth (Fig. 8 .16 A), metal display
may be u nacceptable to some patien ts. Fu rth ermore, if abu tmen t teeth are poor
esth etically, RBBs offer little poten tial for ch an gin g th eir appearan ce (8 .16 B). 4,5 ,1 1
20 9
G u i d e l i n e s f o r Su c c e s s w i t h Re s i n -Bo n d e d Br i d g e w o r k

A B

Fig. 8.16 Cantilever resin-bonded bridge replacing a lower f rst molar. When planning metalceramic
RBBs patients must be in ormed well regarding retainer designs that will be visible.

Trial cementation and temporization


Th e n atu re of RBBs u su ally makes it impossible to cemen t restoration s provi-
sion ally for diagn ostic pu rposes an d in ter-appoin tmen t temporary restoration s
presen t ch allen ges in fabrication an d reten tion .

Longevity
Variou s stu dies repor t a wide ran ge of failu re rates for adh esive bridgework.1 3 ,15 ,20
Th e reason s attribu ted most common ly to failu re are:
Poor case selection
Inadequ ate retainer design
Fau lty bonding procedu re
Occlu sal factors.
Wh ile gen eral su r vival rates are n ot as en cou ragin g as for some oth er in direct
tech n iqu es, carefu l adh eren ce to th e followin g gu idelin es sh ou ld resu lt in pre-
dictability and deliver lon gevity rates en joyed by rou tin e u sers.
Regardless of restoration lon gevity rates, th e biological advan tages of RBB mu st
be emph asized to patien ts, along with the fact th at failu re is rarely disastrou s
compared to conven tion al fixed prosth odon tics.1 3,1 6 Fin ally, if failu re occurs
(an d restoration s remain acceptable) th ey may often be re-cemen ted, in creasin g
th eir fu n ction al lon gevity.13 ,2 1

G u i d e l i n e s f o r Su c c e s s w i t h
Re s i n -Bo n d e d Br i d g e w o r k
Atten tion to detail is essen tial for su ccessfu l RBBs.5,1 3,1 7 Wh ile precise ru les are
lacking du e to controversy among in depen den t practition ers an d research ers,
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careful stu dy of fou r decades of eviden ce-based literatu re provides a set of


gen eral gu idelin es, wh ich may be divided in to:

Patien t factors
Clin ical factors
Operator factors
Laboratory factors.

Pa t i e n t Fa c t o r s
So th at th e patient can make an in formed decision regarding RBB, detailed
an swers sh ould be offered to th e frequ en tly asked qu estion s in terms th at are
un derstan dable for each in dividu al patien t. As th e restoration appearan ce will
be on e of th e patien ts prin cipal con cern s,4,5 th e expected esth etic outcome
sh ou ld be commun icated clearly at th e ou tset. Th is may be facilitated by ref-
eren ce to ph otograph ic images of similar cases.

C l i n i c a l Fa c t o r s
Wh en selectin g cases for RBBs, detailed assessmen t of th e gen eral state of th e
mou th sh ou ld be car ried ou t to in clu de: th e presen ce of oth er eden tu lous areas,
risk of caries an d periodon tal disease an d th e n ecessity of restorative treatmen t
elsewh ere. Particu lar atten tion sh ou ld be given to th e followin g areas.

Abutment teeth
As qu ality adh esion is a prerequ isite for su ccess, su fficien t en amel qu ality mu st
be available for bon din g. Case selection mu st n ot rely on h eavily restored or
mobile teeth , or on con ditions where axial len gth is su b-optimal. 1 1,1 3 ,1 7 Clin ical
an d radiograph ic assessmen t mu st reveal optimu m periodontal an d en dodon tic
con dition s an d th e n eed for replacemen t of existin g restoration s sh ou ld be
investigated.

Span length
Regardless of material, RBB retain ers are th in n er an d more flexible th an th eir
fu ll-coverage cou n terparts. Lon ger pon tic span s will su bject th e castin g an d th e
adh esive bon d to greater stresses an d th is situ ation will be exacerbated on mas-
tication or parafu nction .4 Better lon g-term resu lts h ave been demon strated for
RBBs th at replace ju st on e tooth with a single pontic. 4 ,13
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G u i d e l i n e s f o r Su c c e s s w i t h Re s i n -Bo n d e d Br i d g e w o r k

Pontic space
Wh ere tooth movemen t has resu lted in an u n n atu rally n ar row or wide pon tic
space, adh esive bridges offer little scope for cor rection by modification of abu t-
men t teeth . 4,5

Occlusal factors
For lon g-term su ccess, RBB design s sh ou ld n ot in trodu ce occlu sal in terferen ce4
an d th e need to re-con tou r opposin g or adjacent teeth shou ld be con sidered. A
diagnosis of severe parafun ction gen erally preclu des RBB tech n iqu es. 14

Maintenance
As with all indirect restorations, lon g-term su ccess will only resu lt with optimal
patien t complian ce regardin g oral hygien e an d avoidan ce of excessive loads. The
importan ce of regu lar recall con su ltation s sh ould be stressed from the outset to
allow carefu l monitoring, refin emen t and repair. Th e n eed for immediate assess-
men t if failu re is su spected sh ou ld be emph asized. (Man agemen t protocols for
RBB failu re are described u n der Man agemen t of failu re in resin -bon ded bridge-
work on p. 2 1 8 .)

O p e r a t o r Fa c t o r s
It is an accepted fact th at th e experien ce an d tech n ical skill of th e den tist is th e
most importan t factor govern in g th e su ccess or failu re of any adh esive proce-
du re in dentistry. This is certain ly th e case for adh esive bridgework. For lon g-
lasting, esthetic restoration s, tech n iqu e mu st be optimized with regard to th e
following:4 ,1 3,1 6,1 7
Bridge design
Pontic design
Abu tment preparation design
Impression techn iqu e
Cemen tation .

Bridge design
Th ere is great variability of opin ion regarding th e design for adh esive bridges
an d most data refers to an terior bridgework, bu t research from variou s lon g-
term clin ical stu dies provides u sefu l gu idelin es for maximizin g su ccess. As with
conven tion al bridgework, retain er design may be divided in to:
Simple can tilever
Fixed/ fixed
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Fixed/ movable
Hybrid.

Simple cantilever design


Eviden ce su ggests th at can tilevers are recommen ded for an terior adh esive
bridges, as in creased failu re rates h ave been demon strated for fixed/ fixed
design s. 11 ,1 3,1 4,2 1
For posterior adh esive bridges, eviden ce from well con trolled clin ical trials is
lackin g1 9 bu t th ere is growin g eviden ce th at can tilever design s may be th e treat-
men t of ch oice for almost all RBBs. 1 1
Wh ile can tilever design s will be su bject to forces of h igh er magn itu de in pos-
terior segments an d are contrain dicated in parafu nction al con dition s,4 th ey
convey th e same ben efits as th ose for conven tion al can tilever bridges, i.e. more
con servative, more cosmetic an d easier to clean .4
Note th at sprin g can tilever bridges are n ow of h istorical in terest on ly an d are
not con sidered fur th er.

Fixed/f xed designs


Th ese have th e advan tage of in creased resistan ce to occlu sal loadin g an d will
resist or th odon tic movemen t of abu tmen t teeth ;13 however, this mu st be weigh ed
carefu lly against th eir ten den cy for u n ilateral de-cemen tation , wh ich is th eir
most commonly repor ted mode of failu re. Su ch de-bon ds regu larly go u ndetected
(over 2 5 % of cases)1 3 an d may resu lt in destru ctive secon dary caries (Fig. 8 .17 ).
Oth er disadvan tages of fixed/ fixed design s:

Th ey are less con servative


Th ey are less esth etic
It is difficu lt to visu alize parallelism
Th ey are more difficu lt to manu factu re
Th ey are more difficu lt to fit/ cemen t.

Fixed/movable designs
As with conven tion al bridgework th e in corporation of a movable join t offers a
nu mber of advan tages:
Allows in depen den t movemen t of abu tmen ts, an d redistribu tes stress more
favourably on the framework and the adh esive bon d 4
Allows abu tmen ts with differen t mobility ch aracteristics to be u n ited4
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G u i d e l i n e s f o r Su c c e s s w i t h Re s i n -Bo n d e d Br i d g e w o r k

Fig. 8.17 Fixed/f xed designs are not recommended or anterior resin-bonded bridges as they have a
tendency or unilateral de-bonds that o ten go undetected and may lead to secondary caries.

Allows differing path s of in sertion in non -parallel abutment teeth 4


Often allows more con ser vative tooth preparation .

Hybrid designs
Hybrid design s have a convention al retain er at one en d an d resin -bon ded retain er
at th e oth er. They can be combined with fixed/ movable design (Fig. 8 .1 8 ) to avoid
th e poten tial h azards of differin g retain er reten tion ch aracteristics.13

Pontic design
Gingival sur ace
Modified ridge lap design s are u sed common ly for RBBs as th ey are esthetic an d
hygien ic. 4,5

Occlusal sur ace


It is recommen ded th at pon tics con tact opposin g teeth in in tercu spal position ,
bu t h ave n o gu idin g con tacts in any excu rsions,1 7 as repeated loads may dislodge
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Fig. 8.18 A 25-year-old hybrid bridge replacing two upper teeth and incorporating a movable joint to
reduce stress on the individual abutment teeth during loading. Courtesy o Dr J. McCubbin.

th e restoration . 19 Wh ile it h as been demon strated th at prescribed fu n ction al


occlu sal relation sh ips are n ot main tain ed in 5 0 % of patien ts,1 3 th e same stu dy
reported in sign ifican t effects on restoration su r vival.1 3

Abutment preparation design


Wh ile RBBs may be employed su ccessfu lly u sin g a n o-prep tech n iqu e13 and
textbook design s are con sidered tech n ically deman din g to ach ieve, practition -
ers with h igh est RBB u sage an d su ccess h ave been sh own to be in favour of
defin ite preparation .1 9
Th ere is clear eviden ce th at preparation s modified with min imal resistan ce
grooves, rest seats, gu ide plan es an d obviou s fin ish in g lin es dramatically in crease
su ccess rates,14 ,11 as they convey the followin g ben efits:11 ,1 3,1 5,2 1

In creased su rface area for reten tion


Improved en amel/ resin bon d
Improved resistan ce to displacemen t
Limited stress on adh esive bon ds
Allow su fficien t alloy th ickn ess/ rigidity an d redu ce stress on adh esive bon d
Easier to manu factu re
Precision seatin g en su red
Restoration con tou rs redu ced
Easier cemen tation .
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G u i d e l i n e s f o r Su c c e s s w i t h Re s i n -Bo n d e d Br i d g e w o r k

RB B P REP A RA TIO N : G U ID ELIN ES F O R S U CCES S (Figs 8.19 and 8.20)

Abutment preparations should remain within enamel to avoid inferior dentine bonds4,5,13,15,17
Preparations should cover as wide an area as possible, with outline form only limited by occlusal
and esthetic constraints11,13,17
Axial surfaces should be prepared for retainers that cover at least 180 of the abutment tooth
circumference. This is termed the wrap-around effect 17 and has been shown to improve restor-
ation longevity signi cantly
Proximal retainer margins should be extended as far as esthetics will allow and should be placed
in cleansable positions
Use of mutually parallel grooves can increase resistance form 14 signi cantly and compensate for
situations where wrap-around is sub-optimal
Preparation features including resistance grooves simplify prosthesis location and cementation
Posterior bridge retainers should incorporate occlusal coverage to resist the forces of displace-
ment under load 14,17
Margin design should maximize axial height but should remain supra-gingival17
Margins should be clear to the technician and placed in a cleansable position
Chamfers are popular nishing lines4 as they create room for alloys of suf cient rigidity and
reduce the risk of over-contoured restorations11
Existing restorations may be removed or modi ed to improve resistance form and increase frame-
work rigidity11,15,17
During preparation iatrogenic damage to adjacent teeth should be avoided

A B

Fig. 8.19A,B Optimum preparation design or posterior resin-bonded bridges includes: preparation
conf ned to enamel, occlusal coverage, supra-gingival margins and no occlusal contact on restoration
margins.

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A B

Fig. 8.20A,B Optimum preparation design or posterior resin-bonded bridges includes: preparation
conf ned to enamel, occlusal coverage, supra-gingival margins and no occlusal contact on
restoration margins.

Impressions
As precision fit is a fu n damen tal requ iremen t for su ccessfu l RBBs, impression
materials, equ ipment an d techn iqu e sh ou ld be optimized. Su pra-gingival margin
design often obviates th e n eed for gin gival retraction , bu t impression s sh ou ld be
checked carefu lly to en su re that all preparation featu res are captu red accurately
(Fig. 8.21 ).

Cementation
Moistu re con trol is critical if th e bridge is to bond properly to th e tooth . Use of
a ru bber dam (Fig. 8 .2 2) optimizes isolation , bu t carefu l tech n iqu e is requ ired
to preven t it interferin g with seatin g th e prosthesis. Chemically active dual-cu re
lu tin g cemen ts are favou red for cemen tation of metalceramic RBBs an d are
described in Case 2 below.
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G u i d e l i n e s f o r Su c c e s s w i t h Re s i n -Bo n d e d Br i d g e w o r k

Fig. 8.21 Impressions should record RBB preparation details accurately.

Fig. 8.22 Rubber dam isolation optimizes moisture control during all stages o resin-bonded bridge
cementation.
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A C

Fig. 8.23 Detailed laboratory prescriptions (A), trial preparations and diagnostic wax-ups (B) enhance
communication between operator and technician. Restoration at 28 years a ter cementation (C). Courtesy
o Dr J. McCubbin.

La b o r a t o r y Fa c t o r s

Communication
Th e versatility of RBBs often resu lts in restoration s with design features u n iqu e
to each clinical case. Commun ication between operator an d den tal techn ician
is paramou n t an d may be enh an ced by:

Face-to-face con tact


Illu strated prescription s4 (Fig. 8.2 3A)
Clin ical ph otography
Trial preparation s
Use of diagn ostic wax-u ps4 (Fig. 8 .23 B)
Margin markin g an d articulation ch ecks by the operator.

Materials
High stren gth alloys are recommen ded for RBBs as th ey offer resistan ce to
ben din g an d wear, even in th in section .

CLIN ICA L TI P S

Thickness 0.50.7 mm should give suf cient RBB retainer rigidity for most alloys, but may reduce
to approximately 0.3 mm in cervical areas to avoid over-contour.

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M a n a g e m e n t o f Fa i l u r e i n R e s i n -Bo n d e d Br i d g e w o r k

Non -preciou s alloys are usu ally ch osen as th ey:4 ,13 ,15 ,1 7

Are more rigid (stiff) th an preciou s alloys


Optimize bonding and su pport for veneering porcelain s
Develop high bond stren gths with ch emically active lu ting resin s, wh ich
may be fu rth er en hanced by su rface treatmen ts.

Th e predomin an t su rface treatmen t for RBBs con sists of air-abrasion with


alumin a particles (san dblastin g/ grit-blastin g), 4 ,1 4,2 1 wh ich in creases th e su rface
area for micro-mechanical bon din g an d promotes ch emical in teraction with
lu ting resin s.

M a n a g e m e n t o f Fa i l u r e i n Re s i n -
Bo n d e d Br i d g e w o r k
Wh en RBBs fail it is importan t to diagn ose th e aetiology to en able improvemen ts
in fu tu re procedures. De-cemen tation is th e most common mode of failu re
observed for RBBs13 and is cau sed predomin an tly by:

Coh esive fracture with in th e lutin g cemen t layer 4 ,14


Adh esive failu re of th e cement bon d to metal win gs, leavin g a cemen t layer
on th e tooth . 4

Failu re of can tilevers u su ally involves total de-bon d with little or n o warn in g.
Patien ts shou ld be made aware of th is at the ou tset and if failu re occu rs th e
patient sh ou ld be advised to:

Retain th e restoration in a safe place to avoid damage13


Return immediately for diagn osis of th e mode failu re and assessment
regardin g th e possibility of re-cementation followin g any necessary
adju stments. 13

Re -C e m e n t i n g Re s i n -Bo n d e d Br i d g e s
If failed RBBs are acceptable, th ey may be re-cemen ted to in crease th eir fu n c-
tion al life.1 3,2 1 To optimize su ccess, all traces of lu tin g resin sh ou ld be removed
from th e restoration 4 (ideally by san dblastin g or occasion ally by heat treatmen t)
an d from th e tooth surface, wh ich can be ch allen ging an d car ries th e risk of
altering th e prepared su rface. 4 In addition , it sh ou ld be expected th at th e lifespan
of re-cemented restoration s will be redu ced and th is requ ires commu nication to
th e patien t.14
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If bridges are u n su itable for re-cemen tation , th ey may be re-u sed as temporary
restoration s by convertin g metal wings to a perforated Roch ette design. 4

M a n a g e m e n t o f U n i l a t e r a l D e -C e m e n t a t i o n
As th e most prevalen t mode of failu re for fixed/ fixed restoration s is u n ilateral
de-cemen tation wh ich common ly goes u n n oticed,13 patien ts mu st be warn ed of
th e potentially seriou s consequ ences an d made aware of th e n eed for:

Vigilan t lon g-term main ten an ce1 3


Regu lar atten dan ce to en able early diagn osis.1 3

CLIN ICA L TI P S

Patients with xed/ xed RBBs should return for immediate assessment if they:13
Hear or feel breakage
Feel an unfamiliar sharp edge
Sense mobility
Feel a squelching sensation
Experience a foul taste.

If u n ilateral de-cemen tation occurs, th e simplest man agement option is to cu t


off th e de-bon ded win g an d polish th e section ed con n ector 1 1 (Fig. 8 .2 4 ). If RBB
removal is requ ired, it may be facilitated by application of a su itable sh arp or
ultrasonic in stru men t u n der th e retain er, or th e u se of specialized bridge removal
equ ipmen t.

A B

Fig. 8.24 Minimally invasive management o unilateral de-cementation o a resin-bonded bridge retainer.
221
C l i n i c a l C a s e 8 .1: M i n i m a l l y I n v a s i v e S i m p l e C a n t i l e v e r B r i d g e

C l i n i c a l C a s e 8 .1: M i n i m a l l y I n v a s i v e
Si m p l e C a n t i l e v e r Br i d g e
Assessment
A 5 0-year-old female patien t presen ted with esthetic concern s regardin g th e
appearan ce of th e upper righ t posterior teeth . Th e area of main complain t com-
prised a missin g secon d premolar with metal restoration s in adjacent teeth .
Active secon dary caries was diagnosed at th e mesial crown margin on the first
molar. Special tests con firmed positive pu lpal respon ses from all teeth an d n o
sign s of radiograph ic path ology.

Fig. C8.1.1 Esthetic concerns resulting rom missing second premolar and metal restorations.

Treatment opinions
Th e patien t was in formed of all of th e variou s man agemen t option s. A care plan
was selected to restore esth etics u sin g min imally invasive tech n iqu es an d fu ll
written con sen t was gain ed for:

Removal of the failed full veneer crown


Restoration of the space u sin g a metalceramic simple can tilever bridge
after assessment and re-preparation of th e first molar abu tmen t.

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Fig. C8.1.2 Treatment plan: remove ull veneer crown and replace with metalceramic simple cantilever
bridge.

Preparation
Crown removal revealed distal secondary caries in addition to the mesial lesion
(Fig. C8 .1 .3 A). Min imal preparation was n ecessary to optimize th e abu tmen t
tooth accordin g to convention al design prin ciples2 2 with regard to:

Occlu sal convergen ce an gles


Axial h eigh t
Margin placemen t
Ou tlin e form
Redu ction for selected materials.

Bu ccal sh ou lder an d ch amfer margin s elsewh ere were all placed su pra-gingivally
an d, followin g caries excavation , mesial an d distal proximal boxes were prepared
to en hance resistance an d reten tion form (Fig. C8 .1.3B).

223
C l i n i c a l C a s e 8 .1: M i n i m a l l y I n v a s i v e S i m p l e C a n t i l e v e r B r i d g e

A B

Fig. C8.1.3 (A) Crown preparation. (B) Preparation or simple cantilever bridge retainer.

Impression and temporization


Silicon e an d opposing algin ate impression s were obtained along with the rele-
van t occlu sal records. A provision al crown was then fabricated in acrylic u sin g
a pre-operative template impression an d cemen ted with a temporary style of
cemen t.

Materials
Th e pre-existin g preparation allowed su fficien t room for both alloy an d por-
celain with ou t th e n eed for fu rth er occlu sal redu ction . Th e restoration was
design ed an d con stru cted to:

Maximize stren gth


Maximize esth etics
Min imize fu nction al loads on th e pon tic durin g lateral excursion s.

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A B

Fig. C8.1.4 (A) Impression. (B) Temporary restoration.

A B

Fig. C8.1.5 (A) Articulated models. (B) Metalceramic simple cantilever bridge.
225
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Fig. C8.1.6 Restoration complete.

Cementation
Followin g try-in , th e restoration was cemen ted u sin g zin c ph osph ate cemen t.
Th e ou tcome was esth etically pleasin g to th e patien t an d at min imal biological
cost to th e residu al dentition . Advice regardin g maintenan ce was provided an d
an appoin tment made for review.

C l i n i c a l C a s e 8 .2: Re s i n -Bo n d e d
Br i d g e w o r k
Reason for attendance
A 40 -year-old male patien t atten ded the clin ic with a retained upper righ t
primary can in e that had fractured an d become painfu l to bite on. Th e
perman en t su ccessor h ad failed to eru pt an d h ad been extracted du rin g
adolescence.

History, examination and diagnosis


A comprehen sive history an d examin ation were car ried ou t. Special tests con -
firmed a positive pu lpal respon se from teeth adjacen t to th e fractu red primary
tooth (Fig. C8 .2 .2 A), an d periapical radiography (Fig. C8 .2 .2 B) allowed diagn o-
sis of a mid-th ird fractu re of its resorbin g root an d n o path ology related to
poten tial bridge abu tment teeth . A detailed numbered list of th e patien ts esth etic
requ iremen ts (followin g extraction of th e u n restorable primary tooth ) was made
an d intra- an d extra-oral photograph ic images obtain ed to assist care
plan nin g.
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Fig. C8.2.1 Fractured, pain ul, retained primary canine.

A B

Fig. C8.2.2 (A) Pulp test. (B) Pre-existing (recent) periapical radiograph.

227
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Occlusal examination
In tra-oral occlu sal examin ation revealed:

Stable intercuspal position between the in tact maxillary and the


man dibu lar arch es
Grou p fun ction in both left an d righ t lateral excu rsion
Over-eruption of the opposing lower can ine
Upper right primary can ine in terfered with righ t lateral excursion
Grade II mobility of the fractu red primary tooth .

Facebow tran sfer, occlu sal records an d algin ate impression s were obtain ed to
allow fabrication an d assessmen t of duplicate study models u sing a semi-
adju stable articu lator.
Occlusal registration may be su pplemen ted by lateral an d protru sive records an d
con stru ction of an in cisal gu idan ce table, to in crease accu racy wh en restorin g
an terior gu idance.

Study models
Th e u sefu ln ess of stu dy models sh ou ld n ot be u n derestimated as th ey provide a
tech n icians view th at is impossible to obtain clin ically an d allow:

Detailed occlu sal examin ation


Plan nin g of occlu sal adju stmen ts

Fig. C8.2.3 Occlusal assessment.


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A B

Fig. C8.2.4 (A) Tooth preparation index. (B) Trial preparation.

Fabrication of a tooth preparation in dex (Fig. C8 .2.4A)


Diagn ostic wax-u p
Trial preparation s (Fig. C8 .2 .4B).

Treatment options
Th e patien t was in formed of th e variou s man agemen t option s available for th e
(immediate or delayed) restoration of space following extraction of th e primary
tooth, with respect to:

Biological con sideration s


Esth etic requ iremen ts
Lon gevity estimation
Fin an cial implication s
Main tain an ce requ iremen ts.

As in any care plan it is essen tial th at th e patien ts esth etic expectation s of th e


fin al restoration are determin ed at th e ou tset an d th at th ey are in formed fu lly
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C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Fig. C8.2.5 All treatment options include extraction o the ractured primary canine.

of th e plann ed appearan ce of each restorative option . Th is can present difficul-


ties wh en RBBs th at are plan n ed as provision al/ trial restoration s are n ot u su ally
an option an d verbal description s are u n likely to give patien ts a clear perception
of th e ou tcome. This limitation may be par tly overcome u sin g:

Diagnostic wax-u ps
Resin composite prototype
Ph otograph ic images of oth er cases u sin g similar restoration s
Image man ipulation software.

If metal retain ers form part of th e proposed care plan , th ey may be


excluded immediately in situ ations wh ere metal display is u n acceptable to th e
patient.

Care plan
In th is case th e patien t gave in formed written con sen t for:

Preparation of u pper right first premolar as an abutmen t tooth for an


adh esive bridge retain er
Enameloplasty of th e opposin g over-eru pted can ine an d first premolar
Extraction of th e retain ed primary tooth
Provision of an immediate replacemen t metalceramic resin -bonded
can tilever bridge.
230
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Fig. C8.2.6 Treatment plan: immediate replacement metalceramic RBB.

Fig. C8.2.7 Shade selection.

Shade and form selection


Th e desired sh ape an d sh ade of th e porcelain pon tic was plan n ed. In tra-oral an d
extra-oral ph otograph s were taken from variou s an gles to assist commu n ication
with th e tech n ician .

CLIN ICA L TI P S

When using metal retainers on thin anterior teeth, the alloy and opaque luting resin can affect the light
transmission properties of the abutment tooth. When shade taking, it is recommended to place a
cotton wool roll behind potential abutments to estimate their likely post-cementation appearance.

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A B

Fig. C8.2.8 (A) Trial preparation o over-erupted opposing teeth. (B) Enamelplasty in ormed by trial
preparation.

Tooth preparation (opposing teeth)


Opposin g teeth were adju sted followin g pre-operative measu remen ts plan n ed on
th e mou n ted stu dy casts (Fig. C8 .2.8 A).

CLIN I CA L TIP S

Simulating adjustments to opposing (or adjacent) teeth simpli es operative intervention by:
Providing views impossible to obtain clinically
Allowing accurate reduction measurement
Reducing the risk of undesirable dentine exposure.

Axial preparation
Th e retain ed primary tooth s distal su rface was modified to preven t in terferen ce
du rin g abutment preparation , wh ich was then car ried ou t u sing a torpedo-
sh aped diamon d bu r.
Du rin g axial preparation , th e adjacen t premolar was protected u sin g a metal
section al matrix (Fig. C8 .2.9A). Preparation was con fin ed to enamel and con -
trolled with u se of a silicon e in dex (Fig. C8 .2.9 B).
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A B

Fig. C8.2.9 (A) Axial preparation. (B) Silicone preparation index.

Su ggested desirable featu res of axial preparation are:

Su pragin gival ch amfer margin s


Removal of u n dercu ts from axial walls
1 8 0 wrap-arou n d
Maximu m proximal exten sion limited on ly to min imize metal display
mesially an d preven t damage to th e adjacen t tooth distally
Margin placemen t in clean sable areas
Adequ ate space for a rigid alloy retain er
Preparation of n ear-parallel opposin g mesial an d distal su rfaces.

CLIN ICA L TI P

Close-up photographic occlusal views assist assessment of axial convergence angles and reduce the
risk of undercut and/or over-taper.

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C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

A B

Fig. C8.2.10 (A) Occlusal preparation. (B) Proximal resistance grooves.

Occlusal preparation and proximal grooves


Occlusal preparation
Th e occlu sal su rface was redu ced u sin g th e pre-operative trial preparation
(Fig. C8 .2 .1 0 B) as a gu ide. Preparation was:

Con fined to en amel


Design ed to cover th e maximum area
Limited only by esth etic con sideration s an d occlu sal restrain ts.

Proximal grooves
Parallel resistance grooves were prepared in opposin g mesial an d distal axial
su rfaces (Fig. C8 .2.10 B) u sing a th in tapered tu n gstencarbide bu r an d con fer
th e followin g advan tages:

Increased resistance form reduces stress on adh esive bon d


Increases rigidity of castin g
Precise location aids try-in and cementation
Can compen sate in con dition s with sub-optimal wrap-arou nd.
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A B

Fig. C8.2.11 (A) Preparation complete. (B) Impression.

Impression
Th e preparation was dried an d examin ed. Su pra-gin gival margin s obviated th e
need for gin gival retraction . An impression was obtain ed u sin g an addition -
cu red silicon e material in a rigid metal tray with a on e-stage pu tty/ wash tech-
niqu e. The working impression was assessed for accu racy an d an opposin g
algin ate impression obtain ed to record th e adju sted opposin g teeth .

Temporization
Th is was car ried ou t by application of flowable resin composite to th e prepared
abu tmen t tooth an d th e retain ed primary can in e. Relatively h igh volu metric
sh rin kage of conven tion al flowable resin s allows reten tion on a temporary basis
with ou t th e n eed for etch in g. Th e aims of temporization are to:

Re-establish occlu sal con tacts wh ere th ey h ave been removed


Cover rou gh prepared su rfaces
Improve esth etics
Redu ce sen sitivity in areas wh ere th e preparation h as exposed su perficial
den tine.
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C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

CLIN I CA L TIP

Minimizing the interval between preparation and tting will reduce the likelihood of deleterious
occlusal changes.

Fig. C8.2.12 Temporization with owable composite.

Fig. C8.2.13 Articulated models.

Model check
Th e articu lated workin g models were retu rn ed to th e operator to:

Mark preparation margin s


Con firm accu racy of occlu sal relation sh ip
Modify pon tic area to estimate the cor rect form of th e h ealed socket.
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A B

Fig. C8.2.14 (A) Split pontic design. (B) Assembled.

Restoration design and manufacture


Experien ced laboratory su ppor t en abled th e u se of u nu su al split-pon tic design
comprisin g:

A preciou s gold alloy framework made u p of a win g an d a pon tic core


A layer of laboratory composite to cover th e pon tic core
A separate crown made u p of esth etic porcelain to be cemen ted over th e
pontic core.

Th is design was selected becau se esth etic assessmen t was n ot possible u ntil th e
primary tooth h ad been extracted. If th e pon tic h ad been deemed u n satisfactory
at try-in , it cou ld h ave been cemen ted temporarily an d replaced with an improved
version with ou t having to distu rb th e cemen ted alloy retain er.

Materials
Alloy ramework
Type IV gold alloy was selected in this example for the following reasons:

Yellow/ gold in colou r for en h an ced esth etics


Less abrasive to opposin g den tition
Good castin g proper ties
Compatible with ven eerin g porcelain
Biocompatible
Polish able
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C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Cor rosion resistan t


Nickel an d berylliu m free (hypo-allergenic).

Th e fit su rface was san dblasted u sin g alu min a particles. Th is is th e favou red
con temporary tech n iqu e for su rface preparation as it:

Increases the surface area for cemen t wettin g


Promotes chemical in teraction with th e lutin g resin
Is a simple an d predictable tech nique
Does not requ ire expen sive equ ipmen t.

Composite
Th e alloy pon tic core was also san dblasted an d primed (Metal primer II, GC
Corp., Japan ) before application of a th in layer of laboratory composite (Gradia,
GC Corp., Japan ).

Porcelain
For stren gth an d esth etics th e pon tic porcelain was lith iu m disilicate glass
(E-max, Ivoclar Vivaden t, Liech ten stein ). Con temporary pon tic design s may be
bu llet sh aped or modified ridge lap forms. Th ey shou ld minimize soft tissu e
con tact an d be design ed to:

Resist food accumu lation


Min imize plaqu e reten tion
Facilitate cleanin g.

Fig. C8.2.15 Completed restoration on model.


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Shade test
Th e porcelain shade was tested by comparin g th e pon tic again st th e adjacen t
lateral incisor. Th is was don e immediately before dehydration , wh ich ten ds to
ligh ten teeth u n til th ey rehydrate mu ch later.

Extraction
Followin g removal of th e temporary flowable composite (usin g a sh arp h an d
in stru men t), th e fractu red primary can in e was extracted carefu lly to min imize
haemor rh age and post-operative swellin g an d resorption .

Fig. C8.2.16 Shade test.

Fig. C8.2.17 Extraction o primary canine.


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C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Isolation
Qu ality moistu re con trol is on e of th e critical parameters govern in g th e su ccess
of adh esive procedu res in dentistry.
Wh ile th e u se of a ru bber dam is n ot common in gen eral den tal practice, it is
con sidered to be th e optimu m meth od for moistu re con trol an d conveys a nu mber
of impor tan t ben efits:

Ensures complete isolation for th e entire du ration of the cemen tation


procedu re
Airway protection wh en deliverin g restoration s coated in slippery adh esive
Greater patien t comfor t
Improved visibility.

CLIN I CA L TIP S F O R IS O LA TIN G RB B P REP A RA TI O N S WI TH


A RU B B ER D A M

Build con dence by practising with simple restorations rst


Minimize the number of rubber dam holes
Minimize dam tension by leaving a space between holes in the pontic area
Place clamp on a tooth distal to the prepared one
Use specialized cord (Fig. C8.2.18) (or oss/sections of dam) to stabilize the dam

Fig. C8.2.18 Isolation with a rubber dam.


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A B

Fig. C8.2.19 (A) Try-in o retainer. (B) Try-in o pontic.

Try-in
Followin g isolation , th e preparation was clean ed carefu lly to remove th e acqu ired
pellicle u sin g dry (oil-free) pu mice in a ru bber cu p. Th e retain er was th en tried
in place (Fig. C8.2.1 9A) an d th e split-pon tic porcelain crown tried onto th e
retain er (Fig. C8 .2 .1 9 B).

CLIN ICA L TI P

Water soluble try-in pastes may be used to stabilize restorations when assessing the occlusion and
esthetics prior to isolation (in non-immediate replacement cases) and before the decision is made
for nal cementation.

Restoration surface preparation


Th e fit su rface was san dblasted to improve th e bon d stren gth with th e lu tin g
resin . Alloy fittin g su rfaces sh ou ld be clean an d free of any saliva, blood, oil or
plaqu e con tamin an ts. (It is recommen ded to clean th e restoration su rface in an
ultrason ic u n it for 2 minu tes.)
In th is case, th e fit su rface of the retain er was pain ted with a specialized su rface
primer (Alloy Primer, Ku raray Den tal, Japan ) an d left for a few secon ds prior to
cemen tation (Fig. C8.2.2 0A). Th is has been sh own to increase bond stren gth to
preciou s alloys (bu t is u n n ecessary wh en cemen tin g th e more conven tion al
non -preciou s alloy RBBs). Silane primer was applied to the fittin g su rface of the
pon tic crown (Fig. C8.2 .2 0B).
24 1
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

A B

Fig. C8.2.20 (A) Sur ace preparation o metal retainer. (B) Sur ace preparation o ceramic pontic.

Tooth surface preparation


Th e prepared su rfaces were etch ed with ph osph oric acid gel (3 0 4 0 %), wh ich
was gen tly agitated for 1 5 secon ds to give a u n iform etch pattern . Care was
taken to avoid etch ing beyon d preparation margin s, wh ere excess lu tin g resin
may bon d an d be difficu lt to accu rately remove with ou t risk of iatrogen ic damage
to th e u n derlyin g en amel.

CLIN I CA L TIP S

When etching unprepared, young enamel, the surface is more acid resistant. This uoridated,
potentially aprismatic enamel surface layer requires longer etching times. (Etching times of 3060
seconds have been advocated in various studies.)
Adjacent teeth may be protected from contamination with etch, adhesive or excess luting resin
using polytetra uoroethylene tape.

Washing and drying


Th e preparation was wash ed th orou gh ly to remove all traces of etch an t an d
dried with gentle airflow. Th e frosty appearan ce of well-etched en amel is a
reassu rin g sign of th e micro-porou s, h igh -en ergy su rface th at will promote:

Resin tag formation


High bond stren gth
In creased wettability by th e (lower su rface ten sion ) cemen t.
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Fig. C8.2.21 Phosphoric acid etch.

A B

Fig. C8.2.22 (A) Etchant washed o . (B) Frosty appearance o dried enamel.

CLIN ICA L TI P S ( D RYIN G )

Blow air (onto the rubber dam) to test that the air ow is free from contaminants
Regularly service triple-syringe seals and compressors to prevent water and/or oil contamination
of the airstream

24 3
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Fig. C8.2.23 Adhesive applied.

Adhesive
In th is case, th e Pan avia F 2 .0 du al cu re adh esive system was u sed (Ku raray Co.
Ltd, Japan ). One drop each of Panavia adh esive (ED Primer II) liqu id A and B
were dispen sed in to a mixin g well an d mixed immediately before application to
th e etch ed tooth su rface (n ot to th e restoration su rface) an d left for 3 0 secon ds.
Th e adh esive solven t was th en evaporated with gen tle airflow.

CLIN I CA L TIP S

The adhesive mixture must be used within 3 minutes after mixing


Pooling of excess adhesive should be avoided as this may speed the polymerization reaction
Panavia adhesive does not require light curing at this stage, as it may inhibit accurate seating of
the restoration

Luting resin
Pan avia F 2 .0 du al-cure lu tin g cemen t contain s 1 0 -meth acryloyloxydecyl di-
hydrogen ph osph ate (MDP) and forms h igh bon d strength s with san dblasted
alloy su rfaces an d adhesives. Oth er beneficial properties of Panavia are:

High stren gth


High rigidity
Low solubility.
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A B

Fig. C8.2.24 (A) Luting resin mixed over a wide area. (B) Luting resin applied to retainer wing.

Equ al amou n ts of paste A an d B were mixed for 2 0 secon ds (Fig. C8 .2.2 4A) an d
applied to th e win g of th e restoration as soon as possible after dispen sin g an d
mixin g (Fig. C8 .2 .24 B).

CLIN ICA L TI P S

Ensuring that there is no residual moisture on the mixing slab or spatula will also prevent reduc-
tion in working time
Variable setting times will result if Panavia is mixed inadequately
A timer may be used to measure the mixing time
Opaque shades are available to mask grey shine through in certain anterior situations
While Panavia F 2.0 paste may also be applied to the tooth surface, working time will be reduced
(to 60 seconds) as ED Primer II accelerates the set
Note: when using the chemically cured version (Panavia 21), working time may be lengthened by
mixing the cement over a wide area, as its set requires anaerobic conditions and this will prevent
polymerization of the deeper layers.

Cementation
Th e resin -coated retain er was seated an d held in place while excess cemen t was
removed u sin g a disposable bru sh .
24 5
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Accu racy of seating was confirmed immediately, before th e an aerobic settin g


reaction was too far advan ced. Th e excess was kept to a min imu m as Pan avia is
difficu lt to remove on ce set with ou t damagin g adjacen t h ard an d soft tissu es, or
th e polish ed metal framework su rface.

CLIN I CA L TIP S

The presence of preparation features simpli es cementation in terms of speed and accuracy
While cantilevers are easy to locate without accidently wiping off the luting resin, more complex
xed/ xed frameworks are more dif cult to manipulate
Fixed/movable designs may be considered to be the most dif cult in this respect, especially when
preparations have different paths of insertion and the danger of cement contamination of
movable joints ensues
For the inexperienced practitioner, practice and technique familiarization with simpler cases is
highly recommended
If a non-preparation technique has been employed, cementation can be challenging and uncom-
fortable. A very steady hand is required to accurately locate the casting wing and hold it rmly
in place for the entire duration of the setting procedure
To reduce this dif culty, castings may be made with incisal/occlusal extensions to con rm seating
precision and stabilize the casting during setting. These extensions are cut off later, although
vibrations to the new cement luting layer may have a negative effect

A B

Fig. C8.2.25 (A) Retainer seated. (B) Removal o excess luting resin.
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Dual curing
Margin al lutin g cemen t was ligh t cu red followin g th e manu factu rers in stru c-
tion s before application of oxygen in h ibiting paste (Oxygu ard II, Ku raray Co.
Ltd, Japan ) arou n d th e restoration margin s. As well as creatin g an aerobic
con dition s th at promote th e ch emical cu re, th e latest version of th e material
con tain s a catalyst to en h an ce th e settin g reaction . It was applied u sin g a dispos-
able bru sh tip and removed with a cotton wool roll an d water spray after
3 minu tes.

Crown cementation
A th in layer of u n filled resin composite was applied to th e pon tic core followin g
manu factu rers in stru ction s. Th e crown was th en filled with a translu cen t lu tin g
resin cemen t (NX3 Nexu s, Ker r).

Light curing
Th e lutin g resin was par tially ligh t cured for 1 0 secon ds (Fig. C8 .2 .28 A) an d
th e excess cement removed u sing sharp han d instru ments. Polymerization was
completed with a fu r th er 6 0 secon d ligh t cu re from all an gles.

A B

Fig. C8.2.26 (A) Marginal luting resin light cured. (B) Oxygen inhibiting paste.
24 7
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

A B

Fig. C8.2.27 (A) Adhesive applied to pontic core. (B) Luting resin applied to pontic crown.

A B

Fig. C8.2.28 (A) Light curing. (B) Minimal excess or removal.


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CLIN ICA L TI P S

Excess set cement may also be removed using diamond (or tungsten carbide) burs or polishing tips.
Light pressure and copious water spray must be employed to prevent heating of the metal
framework and softening of the adhesive layer.

Rubber dam removal


Ru bber dam was removed from u nder th e pon tic by stretch in g it bu ccally and
cuttin g with scissors. Followin g ru bber dam removal, it was possible to con firm
th at complete h aemostasis h ad been ach ieved.

Esthetic assessment
On e disadvantage of th is immediate replacement tech n iqu e is th at it was impos-
sible to con firm th at th e restoration meets esth etic requ iremen ts u n til after
cemen tation is complete. Carefu l assessmen t an d plan n in g at th e ou tset are
essen tial to redu ce th e risk of su b-optimal appearan ce.
Fu rthermore, isolation durin g the operative procedu re cau ses dehydration of
adjacen t teeth , resu ltin g in th eir ligh ter appearan ce. Th erefore, th e accu racy of
shade match in g cann ot be assessed fu lly u ntil rehydration h as occu r red at th e
review appoin tmen t.

Occlusal assessment
Th e prescribed occlu sal design was assessed u sin g ar ticu latin g paper an d sh im-
stock. Min or adju stmen ts were made u sin g bu rs an d polish ers with care n ot to
overheat th e restoration . Tun gsten carbide bu rs were favou red over diamon d

Fig. C8.2.29 Rubber dam removal technique.


24 9
C l i n i c a l C a s e 8 . 2 : R e s i n - B o n d e d B r i d g e w o r k

Fig. C8.2.30 Esthetic assessment (immediately post-op).

Fig. C8.2.31 Occlusal assessment.

bu rs, which may h ave put deep scratch es in to the alloy su rface an d been difficu lt
to polish ou t.
Th e fin al occlu sal sch eme sh ou ld h ave:

Normal contacts on all oth er teeth


Stable con tact between th e retain er and the opposing teeth in th e
intercu spal position
No contacts on th e restoration du ring excu rsions
No contacts on restoration margin s.
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Oral hygiene
Careful oral hygien e in stru ction s an d demon stration s were given on th e u se of:

Specialized powered bru sh h eads


In terden tal bru sh es
Specialized den tal floss.

Th e patien t was warned of th e dan ger of bitin g h ard foods directly on bridge
an d advised to wear a protective mou th gu ard for impact spor ts.

Review
Th e importan ce of regu lar reviews was stressed at th e ou tset. Th e recommen ded
gu idelin es for review in tervals for adh esive bridgework are 2 weeks (Fig. C8.2 .3 3)
an d mon th ly recalls du rin g th e first 6 mon th s, as most adh esive an d oth er fail-
ures are seen in this period.
At th e review appoin tmen t, min or refin emen ts (an d fin al excess cemen t
removal) were car ried ou t an d the restoration was assessed with regard to th e
followin g:

Esth etics
Occlu sion in in tercu spal position an d all excu rsion s
Presen ce of wear facets in th e restoration an d adjacen t teeth
Presen ce of plaqu e (directly or u sin g disclosin g agen ts) to assess caries risk
Periodon tal con dition , measu red by conven tional meth ods and compared to
baseline records
Abu tmen t mobility
Pu lp tests
Radiograph ic assessmen t at prescribed in ter vals (with written repor ts).

In th is case, soft tissue healin g followin g extraction of the fractu red primary
tooth was assessed in th e sh or t term and post-extraction resorption in th e
lon ger. Th is case describes a min imally invasive in direct esth etic tech n iqu e for
immediate tooth replacemen t th at was rewardin g for both patien t an d
operator.

251
A B

C Fig. C8.2.32 Oral hygiene instruction. (A) Specialized brush.


(B) Interdental brush. (C) Floss.
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Fig. C8.2.33 Restoration complete.

Ac k n o w l e d g e m e n t s
Th e au th or would like to than k h is tech n ician s Adrian and Jacqu e Rollin gs (an d
Mark Bladen , wh o assisted with th e design an d framework con stru ction for
Clin ical Case 8 .2), h is men tors Dr Adrian Sh or tall an d Dr Jim McCu bbin , for
th eir en du ring suppor t an d frien dsh ip, an d Professor Rich ard Verdi, for review-
in g th e manu script.

Further reading
Burke FJT. Resin-retained bridges: bre-reinforced versus metal. Dent Update 2008;35:
5216.

Chan AW, Barnes IE. A prospective study of cantilever resin-bonded bridges: an initial report.
Aust Dent J 2000;45(1):316.

Department of health. Adult Dental Health Survey. United Kingdom, <http:/ / www.hscic.gov.uk/
pubs/ dentalsurveyfullreport09> ; 2009.

Djemal S, Setchell D, King P, Wickens JJ. Long-term survival characteristics of 832 resin-retained
bridges and splints provided in a post-graduate teaching hospital between 1978 and 1993. Oral
Rehabil 1999;26(4):30220.

Gilmour AS. Resin-bonded bridges: a note of caution. Br Dent J 1989;167(4):1401.

Goldstein RE. Esthetics in Dentistry, vol. 2. 2nd ed. Hamilton, ON: BC Decker Inc; 2002.
253
R e f e r e n c e s

Hood JA, Farah JW, Craig RG. Modi cation of stresses in alveolar bone induced by a tilted molar.
J Prosthet Dent 1975;34(4):41521.

Hussey DL, Linden GJ. The clinical performance of cantilevered resin-bonded bridgework. J Dent
1996;24(4):2516.

Hussey DL, Pagni C, Linden GJ. Performance of 400 adhesive bridges tted in a restorative den-
tistry department. J Dent 1991;19(4):2215.

Ibbetson R. Clinical considerations for adhesive bridgework. Dent Update 2004;31(5):2546,


258, 260.

Johnsen DC. A review of orthodontic sequelae to early rst permanent molar extraction. Some
promise many pitfalls. W V Dent J 1976;50(2):912.

Livaditis GJ. Cast metal resin-bonded retainers for posterior teeth. J Am Dent Assoc
1980;110:9269.

Olin PS, Hill EM, Donahue JL. Clinical evaluation of resin-bonded bridges: a retrospective study.
Quintessence Int 1991;22(11):8737.

Rochette AL. Attachment of a splint to enamel of lower anterior teeth. J Prosthet Dent
1973;30:41823.

Shillingburg HT Jr, Grace CS. Thickness of enamel and dentine. J South Calif Dent Assoc
1973;3352.

Shillingburg HT, Sather DA, Wilson EL. Fundamentals of Fixed Prosthodontics. Chapter 28.
Kent, UK: Quintessence Publishing; 2012.

Shillingburg HT, Sather DA, Wilson EL. Fundamentals of Fixed Prosthodontics. Chapter 17.
Kent, UK: Quintessence Publishing; 2012.

Steele JG, Jepson NJ, McColl E, Swift B. Finding Ways to Improve the Effectiveness of Resin-
Bonded Bridges in Primary Dental Care. Centre for Health Services Research. University of
Newcastle upon Tyne. Report number 107; 2001.

Tay WM. Resin Bonded Bridges: A Practitioners Guide. New York: Martin Dunitz Ltd; 1992.

Van Dalen A, Feilzer AJ, Kleverlaan CJ. A literature review of two-unit cantilevered FPDs. Int J
Prosthodont 2004;17:2814.

Re f e r e n c e s

1. The NHS Information Centre. Adult dental health survey 2009. Available from: < www.ic.nhs.
uk> ; 2010.

2. Priest GF. Failure rates of restorations for single-tooth replacement. Int J Prosthodont
1996;9(1):3845.

3. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in xed prosthodon-
tics. J Prosthet Dent 2003;90:3141.

4. Tay WM. Resin Bonded Bridges: A Practitioners Guide. New York: Martin Dunitz Ltd; 1992.
254
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M i n i m a l l y In v a s i v e Re pl a c e m e n t o f Missin g Te e t h : Pa r t 1

5. Goldstein RE. Esthetics in Dentistry, vol. 2. 2nd ed. Hamilton, ON: BC Decker Inc; 2002.

6. Aukes JN, Kyser AF, Felling AJ. The subjective experience of mastication in subjects with short-
ened dental arches. J Oral Rehabil 1998;15(4):3214.

7. Love WD, Adams RL. Tooth movement into edentulous areas. JPD 1971;25:2717.

8. Kiliaridis S, Lyka I, Friede H, et al. Vertical position, rotation, and tipping of molars without
antagonists. Int J Prosthodont 2000;13(6):4806.

9. University Hospital of Copenhagen. The Dental Trauma Guide. <http:/ / dentaltraumaguide.


org> ; 2010.

10. Nelson JN, Ash MM. Wheelers Dental Anatomy, Physiology and Occlusion. 9th ed. Philadelphia:
WB Saunders; 2009.

11. Morgan C, Djemal S, Gilmour G. Predictable resin-bonded bridges in general dental practice.
Dent Update 2001;28:5018.

12. Rochette AL. Attachment of a splint to enamel of lower anterior teeth. J Prosthet Dent
1973;30:41823.

13. Djemal S, Setchell D, King P, Wickens J. Long-term survival characteristics of 832 resin-retained
bridges and splints provided in a post-graduate teaching hospital between 1978 and 1993. J
Oral Rehab 1999;26(4):30220.

14. Imbery TA, Eshelman EG. Resin-bonded xed partial dentures: a review of three decades of
progress. J Am Dent Assoc 1996;127(12):175160.

15. El-Mowafy O, Rubo MH. Resin-bonded xed partial dentures a literature review with presenta-
tion of a novel approach. Int J Prosthodont 2000;13(6):4607.

16. Tredwin CJ, Setchell DJ, George GS, Weisbloom M. Resin-retained bridges as predictable and
successful restorations. Alpha Omegan 2007;100(2):8996.

17. Livaditis GJ. Cast metal resin-bonded retainers for posterior teeth. J Am Dent Assoc
1980;110:9269.

18. Hussey DL, Pagni C, Linden GJ. Performance of 400 adhesive bridges tted in a restorative den-
tistry department. J Dent 1991;19(4):2215.

19. Steele JG, Jepson NJ, McColl E, Swift B. Finding Ways to Improve the Effectiveness of Resin-
Bonded Bridges in Primary Dental Care. Centre for Health Services Research. University of
Newcastle upon Tyne. Report number 107; 2001.

20. Creugers NH, Van t Hof MA. An analysis of clinical studies on resin-bonded bridges. J Dent Res
1991;70(2):1469.

21. Van Dalen A, Feilzer AJ, Kleverlaan CJ. A literature review of two-unit cantilervered FPDs. Int J
Prosthodont 2004;17:2814.

22. Goodacre CJ, Campagni WV, Aquilino SA. Tooth preparations for complete crowns: an art form
based on scienti c principles. J Prosthet Dent 2001;85(4):36376.

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Ch a pt er 9
Min imally Invasive Replacemen t of Missin g Teeth :
Par t 2 Tooth -Colou red Materials
L. MAC KEN Z IE

Introduction 258
Minimally invasive tooth replacement with
resin composite materials 258
Minimally invasive tooth replacement with
all-ceramic materials 272
Clinical case 9 1: direct f bre-rein orced
composite resin-bonded bridge 280
Clinical case 9 2: indirect f bre-rein orced
composite resin-bonded bridge 297
Clinical case 9 3: all-ceramic resin-bonded
bridge 305
Acknowledgements 318
Further reading 318
Re erences 319

257
M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

In t r o d u c t io n
In respon se to patien t an d profession al deman ds for more esth etic den tal materi-
als, th e fu tu re of restorative den tistry is likely to con sist en tirely of tooth -
colou red, metal-free restoration s. Rigorou s research an d developmen t is bein g
car ried ou t worldwide to en gin eer an d test den tal materials th at h ave equ ivalen t
physical proper ties to metal restorations an d, ultimately, n atural tooth struc-
tu re, allowin g th em to resist th e complex fu n ction al forces of th e oral environ -
men t an d also match th e esth etics of th e patien ts n atu ral den tition .
In addition to esth etic deman ds an d as a resu lt of a well-docu men ted h istory of
poor longevity rates for th e majority of den tal restoration s, th e dental profession
is increasingly search in g for operative tech niques that preser ve th e maximum
amou n t of tooth tissu e and do n ot h ave catastrophic results for th e su pportin g
teeth wh en failu re even tu ally occu rs.
Th is ch apter con tinu es th e th eme of th e precedin g on e, bu t describes th e latest
in novative meth ods of tooth replacemen t th at employ resin composite materials
an d high -stren gth ceramics.

M i n i m a l l y I n v a s i v e To o t h Re p l a c e m e n t
w i t h Re s i n C o m p o s i t e M a t e r i a l s
Since its adven t, use of resin composites has revolu tion ized many restorative
procedu res and promoted the u se of minimally invasive tech niques. 1 Th e latest
meth od employs resin composite restoration s con tain in g fibres to en h an ce th eir
physical proper ties1 ,2 an d is cu r ren tly th e on ly tech n iqu e th at allows den tists
to fabricate esth etic adh esive bridges of su fficien t stren gth directly with in th e
mou th .2
Wh ile th ese tech n iqu es are still con sidered to be at an experimen tal stage 3 an d
th ere are on ly a limited nu mber of lon g-term clin ical stu dies, experien ced clin i-
cian s are n ow reportin g reason able lon gevity rates from th ese restoration s4,5
(Fig. 9 .1), par ticu larly with th ose fabricated in tra-orally.4 Th ese en cou ragin g
statistics are likely to improve as design parameters an d th e materials con tinu e
to be investigated an d optimized.
Since their in trodu ction, one of th e earliest application s for resin composites
was to treat tooth loss by bon din g recently extracted or prosth etic teeth to adja-
cen t abu tmen ts6 (Figs 9 .2 an d 9 .3 ). Wh ile th ese tech n iqu es remain u sefu l as an
immediate temporary option , th ey cann ot be expected to h ave much clin ical
lon gevity as a resu lt of the poor bon d between acrylic and en amel an d th e brittle
n atu re of th e resin composite con nector. 1 Figu re 9 .4 demon strates an in n ovative
258
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B C

Fig. 9.1 Minimally invasive bre-reinforced composite FRC-RBB by one of the worlds most experienced
clinicians in this area. (A) Pre-op, (B) post-op, (C) restoration at 10 years. Courtesy of Professor P. Vallittu.

259
M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

Fig. 9.3 Composite resins may be used to temporarily attach acrylic


prosthetic teeth. Courtesy of Professor D.G. Perryer.

Fig. 9.2 Recently extracted teeth may be temporarily bonded to


adjacent teeth.

Fig. 9.4 Appearance at 27 years of an extracted lower incisor bonded to both (unprepared) adjacent
abutment teeth via a non-precious xed/ xed lingual retainer. Courtesy of Dr J. McCubbin.

260
c h a pt er 9
M I N I M A L LY I N VA S I V E R E P L A C E M E N T O F M I S S I N G T E E T H : P A R T 2

tech nique th at h as been used to overcome th ese drawbacks. This involves su p-


portin g a recen tly extracted tooth with a lin gu al metal framework bon ded to it
an d to th e adjacen t teeth with a composite.

Fi b r e -Re i n f o r c e d C o m p o s i t e
Re s i n -Bo n d e d Br i d g e s
Sin ce th e 1 9 6 0 s, variou s manu factu rin g in du stries h ave u sed fibres with th e
stren gth of metal alloys1 to reinforce composite materials. Fibre-rein forced
den tal restoration s were in trodu ced in th e 1 9 9 0 s7 to treat of a number of
common den tal problems in clu din g replacemen t of missin g teeth .
Methods for tooth replacemen t u sin g fibre-rein forced composite resin -bon ded
bridges (FRC-RBBs) may be divided in to th ose fabricated directly in th e mou th
(direct FRC-RBBs) and those that involve the more familiar indirect approach
(indirect FRC-RBBs). Semi-direct techn iqu es may also be employed wh ere par tial
con stru ction on bridge frameworks may be car ried out ch airside or in a labora-
tory with th e aim of simplifyin g in tra-oral fabrication . Both techn iqu es sh are
common advan tages an d disadvan tages an d h ave th e same gen eral clin ical
in dication s.

Indications or FRC-RBBs
FRC-RBBs are versatile restoration s th at may be u sed to restore esth etics provi-
sion ally or in th e lon ger term; th ey may be con stru cted u sin g min imally invasive
tech niques and are particu larly usefu l in situ ation s wh ere altern ative treatmen t
option s are biologically or fin an cially preclu ded (Fig. 9 .5 ). FRC-RBBs may be
used to restore esthetics in th e followin g situ ation s:

Wh ere abu tmen t teeth are u n restored or min imally restored.


For th e immediate restoration of esth etics followin g extraction or trau matic
loss of an an terior tooth.

A B

Fig. 9.5A,B Minimally invasive FRC-RBBs restoring multiple edentulous areas. Courtesy of
Dr A.C. Shortall.
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M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

Wh ere metal display may compromise esth etics, e.g. wh ere metal win gs of
tradition al RBBs may cau se grey sh in e-th rou gh on th in an terior abu tmen ts.1
To main tain space in th e developin g den tition to simplify fu tu re orthodon tic
or esthetic restorative in ter vention s. 9

FRC-RBBs may be u sed for provision al restoration s in th e followin g situ ation s:

As inexpensive, long-term temporary restorations while stabilizing oral health.


To postpone more invasive treatments su ch as implan ts.9
As con servative tran sition al restorations du ring the healin g period
followin g implan t placement. 9

CLIN I CA L TIP S

The use o FRC-RBBs usually leaves all other uture restorative options open.

FRC-RBBs may be u sed in clin ical situ ations wh ere oth er restorative options are
compromised, su ch as wh ere:

Adh esive restoration s may compensate for su b-optimal reten tion and
resistan ce form in abu tmen t teeth .
Abu tment of teeth has u nfavou rable an gu lations, an d to min imize tooth
preparation .
Mobile abu tmen t teeth may lead to in accu racies in impression takin g and
cemen tation or limit th e progn osis of more rigid restoration s. 9
Implan ts are biologically or fin ancially preclu ded.

FRC-RBBs may also be u sed wh ere patien t deman d exclu des metal restorations
for hypersensitivity or psych ological reason s.

Contra-indications or FRC-RBBs
Moisture control
As with all adh esive tech niques, th e in ability to main tain isolation th rou ghout
th e en tire procedu re will almost certain ly gu aran tee early failu re.

Functional contra-indications
Th ese meth ods sh ou ld also be avoided in clin ical situ ation s wh ere:

Th ere is in su fficient room for an adequ ate volume of suppor ting


su bstru ctu re fibres.
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Tooth loss/ movemen t h as resu lted in a lon g span .


Posterior u se car ries a h igh er risk of early failu re becau se of th e h igh er
fu nction al loads involved.
Th e less rigid framework will be su bjected to forces of h igh er magn itu de,
e.g. severe parafu nction .9

In clin ical situation s where FRC-RBB is an option , it is also importan t to con sider
th e potential advan tages an d disadvan tages relative to other tech niques (see
Box 9 .1 and the followin g text).

Technique sensitivity
Direct FRCRBB is cur ren tly th e only meth od of delivering a fun ctional an d
esth etic replacemen t tooth with min imal or n o abu tmen t preparation an d in a
sin gle appoin tmen t. 2,9
It h as been suggested th at this approach may be too tech n iqu e sen sitive for th e
average practition er. However, Clin ical Case 9 .1 (later in th is ch apter) describes
how specialized materials, equ ipmen t an d a simplified placemen t tech niqu e may
be u sed to promote th e qu ick, efficien t an d predictable replacemen t of a missin g
tooth an d Clin ical Case 9 .2 describes th e in direct altern ative tech nique car ried
ou t by a fin al year den tal u ndergradu ate at a UK den tal sch ool.

How does f bre-rein orcement work?


Fibre-reinforcemen t en h ances physical properties by stopping crack formation
an d propagation th at may lead to restoration failu re;1 th is fibre framework may
be con sidered somewh at an alogou s to th at of th e alloy in a metalceramic bridge.
Variou s clinically sign ifican t factors h ave been identified as in flu en ces on th e
ability of glass fibres to rein force composite bridges (see Box 9 .2 an d th e follow-
in g text).

Fibre type
Materials promoted for FRC-RBBs vary in con stitution , diameter an d th e way th at
th e in dividual fibres are ar ran ged in to bu ndles. Th e main materials u sed are:

Glass fibres
Ultra-h igh molecu lar weigh t polyethylen e
Kevlar fibres.

Th e most widely accepted design in Eu rope employs a su bstru ctu re comprisin g


con tinu ou s u n idirection al glass fibre bu n dles imbedded in a dimethylacrylate/
polymethylmeth acrylate resin matrix. 10
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M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

Ad va nt a ges of FRC-RBBs 1,2


Allows the immediate replacement o missing
teeth in a single visit
O ten minimal (or no) tooth preparation required
Improved esthetics derived rom use o entirely
tooth-coloured materials
Better adhesion o luting resins to bridge
ramework4
Less expensive (no laboratory ee, impression
required)
Suitable or young patients with large immature
pulp chambers and more translucent teeth
Suitable or older patients who may not tolerate
alternatives operatively or f nancially
Frequently obviates the need or local
anaesthetic
Restoration ailure may be readily repaired 4
Versatile design allows f bres to be orientated to
respond to physical requirements
BOX 9 . 1 More exible restorations allow abutment move-
A D V A N TA G ES A N D ment without stressing the tooth/restoration
D IS A D V A N TA GES O F inter ace 4
F RC- RB B S Less abrasive properties will reduce wear on
opposing teeth
FRC-RBBs have high reported patient satis ac-
tion rates

Disa d va n t a ges of FRC-RBBs 1,2


Direct placement is technique-sensitive and
requires training
Laboratory construction requires technicians to
learn a new technique
Compared to porcelain, loss o sur ace lustre
may compromise esthetics
In erior reported longevity rates (to date) versus
metal ceramic (although survival rate statistics
are improving)
Optimum designs and clinical limits have yet to
be established
Water absorption may reduce atigue limits o
restoration over time 9
Restorations may be more plaque-retentive
than alternatives
Lower cost may perhaps reduce the likelihood o
patients optimizing home care o restorations4
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Fibre type
BOX 9 . 2 Fibre volume within the restoration
F A CTO RS IN F LU EN CIN G
Adhesion at the f breresin inter ace
REIN F O RCEM EN T O F
F RC- RB B S 1 , 2 , 9 Fibre orientation
Fibre position within the restoration
Veneering composite

Fibre volume
Fractu re of th e less rigid ven eerin g composite overlyin g th e fibres is th e most
common mode of failu re observed an d h as been attribu ted to in su fficien t frame-
work support.
Optimum framework rigidity is ach ieved by in creasin g the diameter of th e cross
section . Th e greater th e nu mber of fibres with in th e restoration , th e greater its
resistan ce will be to fractu re. 5,8 Care mu st be taken , h owever, not to in corporate
too many fibres an d risk th eir exposu re durin g sh apin g and finish in g procedu res
as th is will resu lt in degradation of th e fibreresin in terface an d redu ce restor-
ation lon gevity.

Bonding of bres to the matrix


Ideally th e reinforcin g fibres shou ld be bonded to th e more flexible overlyin g
resin composite.1 Adh esion at th e fibreresin in terface allows loads to be tran s-
fer red to the fibres an d in creases th eir resistan ce to bein g pu lled ou t. Poorly
bon ded fibres to wh ich little load is tran sfer red may be described as equ ivalen t
to h avin g voids within th e material.
It is therefore impor tan t th at th e fibre framework is in filtrated (wetted) by adh e-
sive resin efficien tly.1 ,4 Th is is in flu en ced by the fibre arch itectu re and wheth er
wettin g agents are pre-impregnated* du rin g manu factu re,8 e.g. StickTech (GC,
Japan ) (Fig. 9 .6 A), or requ ire manu al impregn ation with adh esive by th e den tist
or tech n ician , e.g. Ribbon d (WA, USA) (Fig. 9.6 B).

Fibre orientation
Th e direction of th e glass fibre bu ndles in flu en ces the rein forcemen t of th e
veneerin g composite. Wh ile woven fibres offer mu lti-direction al reinforcemen t,
un idirection al fibres can be orien tated in th e direction in wh ich th e h igh est
stress is predicted in th e areas su bject to th e greatest loads. 1

* As these resins are sensitive to light, they are kept in a lightproof foil to maintain their exible
non-polymerized state until they are required.
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M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

Fig. 9.6 Unidirectional glass- bre bundles designed for bridge framework construction.
(A) Pre-impregnated with resin. (B) Dry.

Position of the bres in the framework


Fibres sh ou ld be position ed within th e prosth esis in th e location and direction
most likely to in h ibit crack propagation . Load resistan ce research 1 1 1 3 in to th e
magn itu de an d direction of stresses occu r rin g with in FRC specimen s (Fig. 9 .7)
h as demonstrated th at for fixed/ fixed designs:

Fibres with in th e pon tic sh ou ld be position ed wh ere th e restoration is


su bject to greatest ten sion .1,9 ,11 13 Th e ten sile aspect of a bridge pontic is
th at closest to th e gin givae an d so th e bu lk of fibres sh ou ld be position ed
h ere, leavin g ju st en ou gh space for ven eering composite gin givally.
Fibres should also be positioned to rein force the in terproximal con nector
areas, which is anoth er area of h igh stress. 5 ,12

Veneering resin composite


Composition of th e ven eerin g resin composite h as a sign ifican t effect on th e
rigidity an d th erefore th e lon gevity of th e fin al restoration . 13 Stu dies u sin g
hybrid or micro-filled resin composites h ave demon strated that compatibility of
fibres to th e bon din g agen t an d to th e ven eerin g composite is essen tial for
maximu m efficien cy.
Wh en u sin g direct tech n iqu es, a variety of resin composite sh ades an d stain s
may be u sed to h elp match th e esth etics of adjacen t n atu ral teeth (Fig. 9.8 ).
266
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B C

Fig. 9.7AC (A) Laboratory testing of bre-reinforced composites helps practitioners optimize
restoration design (B,C). Courtesy of Professor A. Shinya.

For in direct FRC-RBBs th e qu ality of adh esion to th e composite lu tin g cemen t


is also vital. Th e ven eerin g composite sh ou ld be optimized with regard to:

Resistan ce to fractu re from fibre framework


Co-polymerization of fibre framework an d ven eerin g composite
Physical properties
26 7
M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

Fig. 9.8 FRC-RBB is the only technique that allows the fabrication of esthetic de nitive bridges directly
within the mouth. Courtesy of Dr P. Sands.

Wear proper ties


Esth etic proper ties.

Designing FRC-RBBs
Resu lts from on goin g clin ical an d laboratory stu dies n ow provide practition ers
with a range of guidelines for optimization of FRC-RBBs. Wh en design ing a
restoration , th e followin g parameters sh ou ld be con sidered.

Tooth preparation
Th ese tech n iqu es frequ en tly requ ire little or n o tooth preparation . As with oth er
forms of bridgework, abu tmen ts shou ld be ideally u nrestored or minimally
restored. Wh ere existin g restoration s are presen t, th ey may be removed to:

Provide su fficient room for th e fibre framework


Improve retention an d resistan ce form
Preven t over-con tourin g of the adhesive retainers.
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Framework design
Fixed/ fixed design s are recommen ded for both direct an d in direct FRC-RBBs. As
it is a critical determin an t of su ccess, design s sh ou ld allow a h igh volu me of
su bstru ctu re fibres to be in corporated with in th e restoration .

Retainer design
Retain er design is th e su bject of con siderable research 14 18 an d is often based on
th e con dition an d restorative state of abu tmen t teeth. Practitioners shou ld
ch oose th e type(s) th at promote th e maximu m preser vation of tooth tissu e.
Th ey can be:

Extra-coron al (fu ll/ partial coverage)


Su rface retain ed
In lay retain ed
Hybrid/ combin ation design s.

Extra-coronal
Promisin g su rvival rates of u p to 5 years h ave been described for par tial an d fu ll
coverage retainers, alth ou gh tooth preparation is more invasive.

Surface-retained
Su rface-retain ed restoration s (Fig. 9 .9 ) are the most conser vative option an d
may be con sidered in favou rable occlu sion s th at allow su fficient room for mat-
erial. If occlu sal in terferen ces are likely to be in trodu ced, sh allow preparation s
(ideally confin ed to en amel) may be made to optimize fibre volume. Su rvival
probability h as been sh own to be lower for su rface-retain ed restoration s, 2 wh ich
have a h igh er risk of de-bon din g.5 Care is requ ired to en su re th e patien t

A B

Fig. 9.9A,B A surface-retained FRC-RBB restoring a missing upper premolar preserves all of the natural
tooth tissue of both abutments. Courtesy of Dr P. Sands.
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M i n i m a l l y I n v a s i v e T o o t h R e p l a c e m e n t

receivin g th is type of restoration is capable of main tain in g adequ ate oral h ealth
an d oral hygiene methods.

Inlay-retained
In lay-type cavities h ave been sh own to be u sefu l at resistin g rotation al forces. 5
Th ere is n o agreemen t on specific dimen sion s, bu t cavities th at are 2 mm
2 mm 2 mm are considered adequ ate. 5 For molar teeth at least two fibre
bu ndles are recommen ded an d space for th is may often be created by th e removal
of existin g restoration s.

Hybrid design
On e of th e ben efits of th ese tech n iqu es is th at th ey are versatile an d may be
adapted to each clinical situ ation , enablin g the most conser vative, min imally
invasive design (see Clin ical Case 9 .1 ).

Longevity o FRC-RBBs
Wh ilst FRC-RBBs are still regarded as experimen tal restoration s, 3 clin ical evalu -
ations at a number of cen tres worldwide have demonstrated en couragin g resu lts
for fou r or more years, usin g a ran ge of restoration s in corporating h igh fibre-
volume framework design s. Even th ou gh relatively sh ort-term clin ical data is
cu r ren tly available, th ese tech n iqu es sh ow promise an d su r vival rates can be
expected to improve as design s are refin ed an d practition ers skills for han dlin g
resin composites develop with experien ce.4

Failure
Wh ile it is difficu lt to simu late complex clin ical loadin g situ ation s in th e labora-
tory, in vitro load testin g can h elp predict th e likely mode of failu re by
investigatin g:

Fatigue resistan ce over time wh en specimen s are su bjected to repeated loads.


Lon g-term effect of water absorption.
Areas where restoration s are su bject to the greatest stresses.

Wh en reviewin g failed restoration s u sin g a n ew tech n iqu e, it is importan t to


diagnose th e cau se of failu re. This will in form improvemen ts to replacemen t or
repaired restoration s an d may in crease th eir lon gevity.
Th e most prevalen t mode of failu re repor ted is restoration fractu re.5 Th is in iti-
ates with in the more brittle ven eerin g composite material an d propagates
th rou gh to th e fibres,9 with resultan t ch ippin g or loss of considerable por tion s
of th e ven eering resin composite.
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A B

Fig. 9.10A,B A FRC-RBB replacing two anterior teeth (A) has failed after several years due to fracture of
the veneering resin composite (B).

Ultra-h igh molecu lar weigh t woven-fibre frameworks are less likely to fractu re
th an th ose fabricated from glass fibres. Fractu re of ven eering composite is th e
predomin an t form of failu re seen with th ese restoration s (Fig. 9 .1 0 ). Wh en it
occu rs, carefu l an alysis an d recordin g of th e mode of failu re will allow fu tu re
restoration s to be design ed with frameworks th at su ppor t th e ven eerin g com-
posite more effectively.
On e of th e great ben efits of composite materials over alloys an d porcelain is th at
restoration defects are often amen able to repair an d su ch tech n iqu es may be
used to prolon g th e fun ction al su r vival of th e restoration . 4
Patien ts with FRC-RBBs shou ld be monitored regu larly an d assessed with regard
to th e following:9

Fractu re/ ch ippin g involvin g ven eerin g composite


Fractu re involvin g composite an d framework
Margin al leakage
Margin al stain
Wear resistan ce
271
Al l - C e r a m i c M a t e r i a l s

An atomical form
Surface integrity/ texture/ lu stre
Shade/ colou r stability
Plaque levels, gin gival in flammation .

M i n i m a l l y I n v a s i v e To o t h Re p l a c e m e n t
w i t h Al l -C e r a m i c M a t e r i a l s
In t r o d u c t io n
Esthetics h as been demon strated as th e primary in flu en ce on the patients
perception of su ccess with regard to th e replacemen t of missin g teeth . Followin g
th e positive respon se to all-ceramic crown s th ere is n ow a ran ge of all-ceramic
restorative systems th at may be adapted for bridgework, an d th ese are con sid-
ered to be th e prospective replacemen ts for metalceramic restoration s. 19
Th e u se of all-ceramic bridges is cu r ren tly still rath er con troversial an d metal
ceramic equ ivalen ts are still con sidered optimal in terms of predictability. 20
On goin g clin ical an d laboratory testin g of a ran ge of ceramic materials is on e
of th e fastest advan cing areas in den tal materials research ; u ltimately, lon g-
term clin ical data will resu lt in more specific gu idelin es for case selection in
order to deliver predictable, fu n ction al an d esth etic su ccess.

M a t e r i a l s f o r Al l -C e r a m i c Rb b s
A variety of den tal ceramics h ave been advocated for u se in den tal bridgework
an d are n ow approachin g th e proper ties requ ired for th e esth etic an d min imally
invasive replacemen t of missin g teeth. The most recen t developmen ts involve
th e u se of zircon iayttria ceramics for th e fabrication of h igh performan ce
bridge frameworks an d are th e focu s of the following text.

Zirconiayttria bridges
Zircon ia is a ceramic with a fin e grain ed polycrystallin e micro-stru ctu re that
con fers stren gth . 19 As a resu lt it h as been in con siderable deman d for esth etic,
load-bearin g restoration s sin ce its in trodu ction to dentistry in 20 0 2.
Some con temporary zircon ia-based restorative systems contain an additional
stabilizin g oxide, based most common ly on th e ch emical elemen t yttria. 1 9 Th e
resu ltan t material is kn own as yttriu m tetragon al zircon ia polycrystal (Y-TZP).
It h as the h igh est repor ted ceramic fractu re resistance and en ables restoration s
to with stan d loads, in th in section , many times h igh er th an th ose created in
th e mou th .1 9
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Wh ile lon g span bridges may be fabricated en tirely from h igh stren gth Y-TZP,
th is may compromise esth etics as pu re zirconia is wh ite. Most con temporary
restoration s are th erefore comprised of a h igh stren gth zircon ia framework
covered with an overlyin g ven eer of conven tion al esthetic porcelain .
Wh en selectin g all-ceramic materials for th e in direct fixed replacemen t of
missing teeth , it is importan t to in form th e patien t fu lly, both verbally an d in
written form, of th eir advan tages an d disadvan tages (see th e followin g text).

Ad v a n t a g e s o f Al l -C e r a m i c Br i d g e s 1921

Strength
A bridges resistan ce to mech an ical stresses (flexu ral stren gth ) is depen den t
upon th e type of ceramic u sed in th e framework an d on the esthetic ven eerin g
porcelain u sed to cover it. Th e relative th ickn esses of each layer are also impor-
tant, as is the bond strength between the ven eer and the significan tly stron ger
Y-TZP core. 1 9

Rigidity
Y-TZP frameworks h ave a high modu lus of elasticity. This redu ces stress on th e
weaker ven eer layer an d in creases th e load-bearin g capacity of th e restoration
as a wh ole. Compatible feldspath ic ven eerin g porcelain s are design ed to match
th e modu lus of elasticity an d coefficient of th ermal expan sion of the u nderlyin g
framework.

Fracture resistance
Th e mode of failure obser ved most common ly in all-ceramic bridges is ch ippin g
or fractu re of th e brittle ven eerin g porcelain , wh ich may exten d to th e frame-
work and often involves th e pon tic/ framework conn ector area. Th is is a result
of ten sile forces on th e gin gival aspect propagatin g pre-existin g micro-cracks
with in th e material.2 0
Micro-cracks main ly origin ate at th e core/ ven eer in terface2 0 an d th e th ickn ess
ratio of th ese layers is a domin an t factor in con trollin g th e crack in itiation site
an d poten tial for failu re. Th erefore, it is essen tial to optimize th e th ickn ess of
th ese layers to ensure th at th e ceramic ven eer is u nder compressive stress and
th e core framework is un der ten sile stress.

Trans ormation toughening


Y-TZP frameworks have in creased ability to limit crack propagation (fractu re
tough ness) as the material possesses a u nique proper ty kn own as
273
Al l - C e r a m i c M a t e r i a l s

tran sformation tou gh en in g. Wh en ten sile stress forces are applied to Y-TZP, it
reacts by localized volu metric expansion (in the ran ge of 3 5 %). Th e resu ltan t
localized compressive forces squeeze fracture tips to coun teract an d ar rest prop-
agatin g cracks.2 0

Thermal conductivity
As ceramics are in sulators, an all-ceramic bridge may be selected to offer greater
pu lp protection in certain clinical situations, compared to the metalceramic
alternatives.

Biocompatibility
Zircon ia-based materials were origin ally u sed for hip replacemen ts an d exten-
sive evalu ation s h ave demon strated th at th ey are well tolerated by biological
tissu es an d th ey are a good altern ative in patien ts with proven hypersen sitivity
to metal alloys, e.g. n ickel, palladiu m.
Zircon ia frameworks also exhibit better ch emical an d dimensional stability com-
pared to other h igh stren gth ceramics, as th ey are free of th e glass compon en t
th at h as been sh own to be more su sceptible to cor rosion in saliva over th e lon g
term.2 0 In addition, th e ven eerin g porcelain may also be glazed to redu ce th e
abrasion poten tial on opposin g n atu ral an tagon ists.

Radiopacity
Zircon ia has a similar radiopacity to metals, enablin g improved lon g-term radio-
graphic mon itorin g compared to oth er tooth -coloured materials.

Esthetics
All-ceramic materials deliver increased depth of tran slucen cy allowin g a more
n atu ral light transmission th rou gh the en tire restoration . Th is eliminates the
n eed for an excessively white opaque layer to mask the grey metal su bstru ctu re.
Th e ven eerin g ceramic sh ou ld also match th e optical proper ties of th e core
material an d imitate th e polych romatic appearan ce of adjacen t n atu ral teeth
with respect to h ue, ch roma an d value an d translu cency (Fig. 9 .1 1 ).
Wh ile addition al tooth tissu e may n eed to be sacrificed to make room for th e
additional thickness required for ceramic stren gth and esth etics, su pra-gin igival
fin ish ing lines often can be employed with ou t compromising overall
esth etics.1 9
All-ceramic bridges are u seful in clin ical situ ation s wh ere metal frameworks
may compromise esth etics, in clu din g:
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Fig. 9.11 A minimally invasive ceramic bridge replacing a missing premolar (see Clinical Case 9.3) and
incorporating a Y-TZP framework supporting an esthetic veneering porcelain.

Th in / tran slu cen t an terior teeth


Cases wh ere occlu sal coverage is requ ired.

As th ere is n o n eed to mask metal su bstru ctu res, all-ceramic bridges may
promote an even more con ser vative approach in certain areas wh ere th ere is
min imal/ n o con tact on the retain ers, e.g. th e replacemen t of missin g lower
in cisors.

Marginal f t
Good marginal adaptation is essen tial to preven t:

Cemen t dissolu tion


Micro-leakage
In creased plaqu e reten tion
In creased risk of secon dary caries.

CAD/ CAM tech n ology (Fig. 9 .1 2 ) is employed in creasin gly in the fabrication
of all-ceramic restoration s, 2 0 an d cu r ren tly th ere are over 2 0 millin g systems
capable of deliverin g restoration s wh ose margin al fit is with in th e clin ically
acceptable ran ge (Fig. 9.1 3).
Wh ile available software, h ardware, camera, scan n in g an d millin g mach in es all
have inh eren t limitation s,1 9 techn ological advances will improve precision with
regard to margin al an d in tern al fit.
275
Al l - C e r a m i c M a t e r i a l s

Fig. 9.12 CAD/CAM laboratory equipment for the design and manufacture of indirect restorations. (A & J
Rollings Dental Laboratories, England.)

D i s a d v a n t a g e s o f Al l -C e r a m i c Br i d g e s
Despite th eir advan tages, cu r ren tly available bridges are con tra-in dicated in
clin ical situ ation s wh ere:

Th ere is in su fficient room for th e requ ired conn ector dimen sion s (e.g. Class
II Division II malocclu sion s). 2 0
Th ere are heavy localized stresses on con tact areas.2 0
Moisture con trol can n ot be optimized for the entire cemen tation
procedu re.

Ceramic resin -bon ded bridges sh are many of th e same disadvan tages with th eir
metalceramic cou n terparts; in addition th ey h ave th e followin g disadvan tages:

Natu ral wh ite colou r of zircon ia frameworks may compromise esth etics in
cer tain situ ation s.
Ch airside adjustmen ts are difficu lt to polish effectively.
Restorations can n ot be section ed and soldered if major modifications
are n ecessary. 20
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B C

Fig. 9.13AC Design and manufacture of a Y-TZP framework for an all-ceramic RBB. (A) Connector
design. (B) Digital framework design. (C) Completed framework. Courtesy of A & J Rollings.

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Al l - C e r a m i c M a t e r i a l s

Failed restorations may be difficu lt to remove.


Lack of defin itive design guidelines.
Lack of lon g-term clin ical studies.2 0

Longevity
Wh ile reported su rvival rates for all-ceramic bridges are variable, data from
on goin g clin ical stu dies sh ows promise. 20 Con tinu ing trials are likely to
optimize case selection fu rther with regard to choice of materials, manu factur-
in g tech niques, design consideration s and support for esthetic veneerin g
porcelain s.20

Failure
In common with other forms of bridgework, failu re may occu r du e to par tial or
total de-cemen tation , secon dary caries an d/ or periodon tal disease. However, th e
predomin ant modes of failure for ceramic RBBs in gen eral h ave been demon -
strated as:

Fractu re at the con n ector 26 between th e pon tic and the retain er.
Ch ippin g fractu res where veneerin g porcelains have been u sed.

CAD/ CAM tech n ology is u sefu l in th is respect as it allows framework an d


con n ector design s to be optimized for specific materials an d clin ical situ ation s.
(Fig. 9 .1 4 )
Wh ile Y-TZP frameworks may redu ce th e likelih ood of ir retrievable fractu re,
older restorations exhibit common ly small chippin g fractures of th e veneerin g
porcelain .19
Wh en ceramic restoration s are tested in laboratory experimen ts th at simu late
clin ical con dition s (e.g. u se of in termitten t dyn amic cyclic forces, ar tificial
saliva, temperatu re flu ctu ation s an d h u midity con trol), 1 9 resu lts ten d to in dicate
lower failu re loads compared to convention al in vitro fractu re tough ness tests.
Th is more clin ically relevan t data will h elp to in form practition ers in th e design
an d manu facture of all-ceramic bridges of the fu tu re.

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A B

Fig. 9.14AC Design and manufacture stages to optimize connector strength for an all-ceramic bridge.
Courtesy of A & J Rollings.

279
C l i n i c a l C a s e 9 .1

C l i n i c a l C a s e 9.1: D i r e c t
Fi b r e -Re i n f o r c e d C o m p o s i t e
Re s i n -Bo n d e d Br i d g e
Key refe ren ce: an excellent clin ical gu ide1 9 to fibre rein forcemen ts for min i-
mally invasive bridges is available from StickTech (GC, Japan ).

Case history
An 80 -year-old female patien t presen ted having fractu red a crown ed u pper
lateral in cisor, leavin g a root with a sub-gingival carious lesion . All treatmen t
option s were presented in clu din g an implan t-retained restoration or en dodon -
tics followed by a post-retain ed in direct restoration , bu t th ese were rejected on
fin an cial grou n ds.

Fig. C9.1.1 Fractured, carious lateral incisor.

Care plan
As immediate restoration of th e space was n ecessary for esthetic reason s, th e
decision was made to extract th e cariou s root an d employ a direct FRC-RBB by
virtue of the following favourable clin ical con dition s:

Remain in g den tition relatively in tact


Favou rable occlusal stability with n o eviden ce of parafu n ction
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Edge-to-edge occlu sion provides ample room for h igh -volu me fibre
framework
Healthy periodon tal con dition
Presen ce of su fficien t en amel for adh esion to min imally restored
abu tmen t teeth
Removal of distal Class III restoration on u pper righ t cen tral in cisor allowed
u se of an in lay retain er at negligible biological expen se.

Fig. C9.1.2 Treatment plan: direct FRC-RBB.

Design
As bridge design is a key ingredien t to su ccessfu l clinical performan ce, th e fol-
lowin g design featu res were selected.

Fixed/ xed design


Th is is recommen ded for all FRC bridges wh eth er direct or indirect, as it delivers
in creased su ppor t for retain ers an d offers greater su rface area for bon din g.
Can tilever FRC-RBBs exh ibit poorer lon gevity an d sh ould be reser ved for tem-
porary restoration s or wh ere u n su itable mobility ch aracteristics of poten tial
abu tmen t teeth prevail.
28 1
C l i n i c a l C a s e 9 .1

Retainer design
Th e prescription comprised a n on -invasive su rface retain er on th e can in e an d
an inlay retainer on the cen tral incisor requiring min imal tooth preparation .

CLIN I CA L TIP S

Hybrid veneering resin composite was chosen or strength and esthetics. A shade test was carried
out by light curing a sample o the material on the labial sur ace o the adjacent tooth. This was
done prior to isolation as teeth will dehydrate and lighten during the operative procedure and
without etching or bonding procedures.

Fig. C9.1.3 Composite shade test.

Technique tips
Resorbable cellu lose gau ze was packed into th e extraction socket to redu ce
th e risk of h aemor rh agic moistu re con tamin ation du rin g th e procedu re.
A pre-formed cellulose acetate crown form was measu red and adju sted
to fit th e space, for u se later in th e con trolled application of th e direct
composite pon tic.
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Fig. C9.1.4 Crown form for controlled pontic fabrication.

Isolation
Moistu re con trol was ach ieved u sin g a ru bber dam th at was secu red with a
clamp on a distal tooth an d th e u se of dam stabilizin g cord. Th e dam was
reflected in to the gin gival su lcu s an d a floss ligatu re u sed to fu r th er improve
isolation . Th e Class III proximal restoration was th en removed from th e cen tral
in cisor.

CLIN ICA L TI P S

As well as guaranteeing isolation, the dam also acts as a gingival matrix to control composite
adaptation gingivally. In this respect, it is important that rubber dam holes are positioned to allow
exibility during placement.

Measuring the f bre


Measu rin g precisely simplifies fibre placemen t an d avoids wastage. A piece of
dam stabilizin g cord* was u sed to measu re fibre bu n dles accu rately (Fig. C9 .1 .6 A)
before cu ttin g th e requ ired amou n t, togeth er with its silicon e beddin g (Fig.
C9 .1.6 B). Th e remain in g fibres were replaced immediately in th e ligh tproof
packet.

* Periodontal probes or dental oss are suggested alternatives, but may be harder to control or
bend around corners.
28 3
C l i n i c a l C a s e 9 .1

Fig. C9.1.5 Isolation.

Pre-impregn ated u n idirection al glass fibres were u sed (everStick, GC, Japan )
con tain in g ligh t-sen sitive mon omers th at cross-lin k du rin g polymerization to
form a mu lti-phase polymer n etwork with th e overlying resin composite.
On ce cu t, fibres sh ou ld be sh ielded from th e ligh t an d protected from con tamin -
ation as this may impair th e oxygen in hibited su rface layer that is essential to
optimize bonding with th e ven eering resin composite.
Storage recommendation : everStick produ cts sh ould be refrigerated (+2 to +8 )
bu t direct con tact with refrigerator walls shou ld be avoided.

Tooth sur ace preparation


Th e areas to be bon ded were:

Clean ed usin g a pu mice and water mix in a ru bber cu p


Rin sed with water an d air-dried
Etch ed with 37 % ortho-ph osph oric acid
Rin sed with water an d air-dried again .
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A B

Fig. C9.1.6 (A) Precise measurement. (B) Cutting of glass bres.

Fig. C9.1.7 Tooth surface preparation.

Adhesive
Adh esive resin was applied to th e en tire bon din g area an d ligh t cu red as per
manu factu rers in stru ction s. A th in layer of flowable resin composite was th en
applied to th e retain er su rfaces bu t was n ot ligh t cu red at th is stage.
28 5
C l i n i c a l C a s e 9 .1

Fig. C9.1.8 Adhesive application.

Fibre placement
On e en d of th e fibre bu n dle was placed in to th e u n cu red lin in g of flowable resin
composite in th e in lay cavity an d th e oth er en d pressed tigh tly on to th e palatal
su rface of th e can in e u sin g a specialized in stru men t (StickSTEPPER, LM in stru -
men ts, Fin lan d). Th e retain ers were ligh t cu red in dividu ally for 5 1 0 secon ds,
wh ile sh ieldin g th e rest of th e fibre bu n dle from th e ligh t u sin g th e same
in strumen t.
Wh en placin g th e fibres it is impor tan t to spread th em as widely as possible on
th e bon din g areas an d position th e pon tic framework in a form th at cu rves
towards th e gin giva to optimize rein forcemen t.

Flowable composite
A secon d th in layer of flowable resin composite was then applied to provide a
seal with su bsequ en t fibre bu n dles.

Increasing f bre volume


Addition al fibre bu ndles were added to in crease th e cross-section al diameter of
th e framework. Th is in creases th e rigidity an d resistan ce to occlu sal loadin g of
th e fin al restoration . Approximately 2 mm of space was left between th e fibres
an d th e gin giva.
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Fig. C9.1.9 Fibre placement.

Fig. C9.1.10 Flowable composite applied to bres.

28 7
C l i n i c a l C a s e 9 .1

Fig. C9.1.11 Maximizing volume of bridge framework.

Light-cure ramework
Th e en tire fibre frame was th en covered with a th in layer of flowable resin com-
posite and ligh t cu red for 4 0 seconds from all directions.

Composite placement
An initial incremen t of hybrid resin composite was applied gingivally, wh ile
depressin g the ru bber dam to create a socket-fit pon tic. Care was taken to avoid
blockin g th e embrasu re areas, wh ich wou ld h ave in creased the risk of fibre
exposu re or iatrogen ic tooth damage du rin g fin ish in g.

Crown orm preparation


Th e crown form was modified to fit over th e framework (Fig. C9 .1 .1 4 A) an d
pierced with a probe to allow composite ven tin g (Fig. C9 .1 .14 B). Th is redu ced
th e risk of voids, wh ich h ave been implicated as a possible cau se of prematu re
failu re.

Pontic construction
Th e crown form was filled with hybrid resin composite of th e pre-determin ed
sh ade (Fig. C9 .1 .15 A) and applied also over the fibre framework (Fig. C9 .1 .1 5 B).
Excess was removed with a su itable han d in stru men t.
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Fig. C9.1.12 Framework covered with owable composite and light cured.

Fig. C9.1.13 Application of gingival increment of hybrid composite.

28 9
C l i n i c a l C a s e 9 .1

A B

Fig. C9.1.14 Crown form. (A) Cut. (B) Perforated. (C) Tried in over framework.

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A B

Fig. C9.1.15 (A) Crown form loaded with composite. (B) Crown form applied to bre framework.

Gingival contour
Fin ger pressu re was applied to improve adaptation to th e framework an d to th e
in itial gingival in cremen t. Forcin g the pon tic in to th e socket also redu ces th e
poten tial risk of space u n der th e fin al restoration followin g post-extraction
resorption .

Light curing
Followin g removal of fu rth er excess material, th e restoration was ligh t cu red
from all direction s. As well as con trollin g th e sh ape of th e pon tic, th e crown
former elimin ated oxygen du rin g polymerization . Th is sh ou ld resu lt in improved
physical an d stain -resistan ce proper ties.

Crown orm removal


Careful placemen t techn iqu e sh ou ld min imize fin ish in g time followin g crown
form removal.

Finishing
Adju stmen ts were made u sin g su itable bu rs, with care n ot to damage th e
glass fibres.
291
C l i n i c a l C a s e 9 .1

Fig. C9.1.16 Crown from forced into extraction socket.

Fig. C9.1.17 Pontic light cured.

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Fig. C9.1.18 Crown form removal.

Fig. C9.1.19 Pontic adjustment.

293
C l i n i c a l C a s e 9 .1

Fig. C9.1.20 Rubber dam removal technique.

Rubber dam removal


Removal of th e ru bber dam was simplified by pu llin g from u n der th e pon tic an d
cu ttin g with scissors.

Embrasure contour
Th e con n ector area was adju sted to allow effective oral hygien e measu res an d
th e patien t was in formed in th e u se of su itable in terden tal clean in g aids.

Occlusal adjustment
As fracture of th e ven eerin g resin composite is th e mode of failu re obser ved most
common ly, carefu l adju stmen ts were made to elimin ate occlu sal in terferen ces
in all excursion s.

Restoration assessment
All aspects of th e completed restoration were examined. Th e patien t had been
warn ed previously of th e apparen t initial colou r mismatch du e to th e dehydra-
tion of th e n atu ral adjacen t teeth . Th is will rebou n d in th e n ext few days.

Review
At th e ou tset, the patien t was informed of th e importan ce of regu lar examin -
ations to assess oral hygiene, fu nction an d esth etics. Careful tech nical notes
were made at all stages to optimize fu tu re direct FRC-RBB procedu res.
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Fig. C9.1.21 Pontic shaped to allow cleaning.

Fig. C9.1.22 Pontic prior to occlusal adjustment.

295
C l i n i c a l C a s e 9 .1

Fig. C9.1.23 Restoration assessment.

Fig. C9.1.24 Restoration review.

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C l i n i c a l C a s e 9.2: I n d i r e c t
Fi b r e -Re i n f o r c e d C o m p o s i t e
Re s i n -Bo n d e d Br i d g e
Indications
In direct FRC-RBBs are in dicated for th e same clin ical situ ation s as direct, as in
th is example where cariou s lesion s required restoration on proximal su rfaces
adjacen t to a space left followin g loss of an u pper secon d premolar.
In direct fabrication is less techn iqu e sen sitive as:
Moistu re con trol is simplified.
En h an ced polymerization of composite resin s is possible with u se of h eat,
pressu re or vacu u m. Th is may improve flexu re and wear resistan ce an d
colou r stability. 8
Laboratory polish in g may also redu ce th e ten den cy for plaqu e
accu mu lation. 2 0
While tech nician s will n eed to learn a n ew tech n iqu e of RBB con struction , th is
fabrication meth od is a straigh tforward laboratory resin composite application .
Th ere are n o time-con sumin g stages, wh ere er rors may occu r du rin g waxin g,
investin g an d castin g procedu res.
In direct FRC-RBBs may be u sed also for more complex clin ical cases th at wou ld
be ch allen gin g for in tra-oral manu factu re. Research con tinu es in th eir u se for
restorin g implan t abu tmen ts, wh ere th ey may be conven tion ally lu ted or screw
retain ed.8

Minimally invasive preparation


Th e bridge was design ed to optimize fibre volu me with in th e restoration , wh ilst
preser vin g th e maximu m amou n t of residu al tooth tissu e. In itial preparation
was con fin ed to accessin g and excavating th e proximal cariou s lesion s u sin g
su itable small bu rs.

Preparation complete
Followin g min imally invasive caries removal, abutmen ts were prepared to receive
in lay retain ers. No attempt was made to remove all u n dercu ts as th is wou ld h ave
involved u n n ecessary destru ction of stron g, h ealthy tooth tissu e an d lu tin g
resin composite will be able to fill th em du rin g cemen tation .
An occlu sal cavity was prepared to treat a secon dary cariou s lesion, bu t its res-
toration was postpon ed u n til the fit appoin tmen t where th e ru bber dam isolation
wou ld optimize placemen t.
297
C l i n i c a l C a s e 9 . 2

Fig. C9.2.1 Treatment plan: minimally invasive indirect FRC-RBB.

Fig. C9.2.2 Caries excavation.

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Fig. C9.2.3 Preparation complete.

Silicone an d algin ate impression s were taken to record the u pper an d lower
arch es, respectively, an d all th ree cavities were temporized u sin g a flexible ligh t-
cu red resin design ed for th is pu rpose.

Model construction
Die ston e models were cast an d ar ticulated. Accu rate occlu sal registration and
ar ticu lation were essen tial to min imize th e n eed for adju stmen t th at may h ave:

Exposed th e fibres an d resu lted in prematu re degradation of th e fibre/ resin


in terface
Left a th in layer of ven eerin g composite th at wou ld be pron e to fractu re.

Wax was applied to block ou t u n dercu ts an d to modify th e gin gival embrasu re


sh ape, allowin g fabrication of con n ectors with hygien ic emergen ce profiles. Th e
altered cast was th en du plicated to fabricate a workin g model.

Framework construction
Th e fibre framework was fabricated to maximize th e volume of pre-impregn ated
un idirection al glass fibre bu ndles (GC, Japan) an d min imize con comitan tly th e
volume of th e less fractu re resistan t ven eering resin composite.
Addition al fibres were orien tated perpen dicu lar to th e in itial layers as th is h as
been sh own to in crease restoration stren gth . 5
299
C l i n i c a l C a s e 9 . 2

Fig. C9.2.4 Model modi cation.

Fig. C9.2.5 Framework construction.

Veneering composite placement


Fabrication was completed by in cremen tal placemen t an d ligh t cu ring of a lab-
oratory composite (Sin fony, 3 M ESPE, Seefeld, Germany) to form a ridge lap
pontic, with a reduced occlu sal table, to min imize occlusal forces. Appropriate
composite stain s were applied to improve esth etics u sin g tin ted flowable resin
composites design ed for th is pu rpose.
Du rin g con stru ction it h as been demon strated th at it is cru cial to min imize
voids. To maintain th e oxygen -inh ibited su rface layer th at maximizes bon d
stren gth between fibres an d composite in cremen ts, specialized resin (Stick-
RESIN, GC, Japan ) was applied in th in layers.
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Fig. C9.2.6 Veneering composite applied.

Try-in/f t sur ace preparation


Followin g isolation, removal of temporary restoration s an d try-in, th e fit su r-
faces were rough en ed ligh tly with a diamon d bu r (an d n ot san dblastin g, wh ich
is con train dicated for th is pu rpose) to expose fibres on th e cemen tin g su rfaces.
Th is is especially importan t wh en usin g surface-retain ed FRC-RBBs.
Th e restoration was th en wash ed with water to remove debris an d air-dried
before application of a specialized solven t-free adh esive resin (StickRESIN, Stick-
Tech , Fin lan d), wh ich is design ed to activate th e polymer n etwork with in the
fibres an d create a reliable bon d.
Th e restoration was stored in dark con dition s u n til requ ired for cemen tation an d
for at least 3 5 minu tes to allow resin / fibre in teraction .
Immediately prior to cementation , gen tle airflow was u sed to remove excess
adh esive agen t wh ich may affect th e fit. Th e restoration was th en ligh t cu red for
10 secon ds.

Tooth sur ace preparation


Tooth surfaces were prepared for cementation by:

Clean in g in lay preparation s u sin g a pu mice an d water mix in a ru bber cu p


Etch in g with 3 7 % or th o-ph osph oric acid for 1 5 secon ds. Note: th e
recommen ded en amel etch in g time for su rface-retain ed FRC-RBBs is lon ger
(4 5 6 0 secon ds)
30 1
C l i n i c a l C a s e 9 . 2

A B

Fig. C9.2.7 Fit surface preparation. (A) Roughening. (B) Application of solvent free resin.

Fig. C9.2.8 Phosphoric acid etchant applied.

Rin sing with water an d gen tle air-dryin g


Application of adh esive resin as per th e manufactu rers in stru ctions.

Cementation
Du al-cu re lu tin g resin was th en applied to th e fit su rfaces of th e restoration an d
to th e in lay preparation s. Note: ch emically cu red composite lu tin g resin s may
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Fig. C9.2.9 Restoration cementation.

also be u sed, bu t ph osph ate an d glass ion omer cemen ts are n ot su itable for
cemen tin g in direct fibre-rein forced restoration s. Th e restoration was seated an d
excess cemen t removed carefu lly u sin g a suitable bru sh .
Glycerin e gel (or su itable translu cent alternative) was applied to cover margin al
areas. Th is exclu des oxygen an d improves th e polymerization reaction du rin g
ligh t cu rin g.
Th e Class I cavity was th en restored u sin g conven tion al resin materials an d
tech niques.

Finishing
Th e occlu sion was ch ecked usin g ar ticulatin g paper an d refin ed u sing su itable
composite fin ish in g bu rs an d discs. It was importan t to avoid any exposu re
of framework fibres du rin g fin ish in g procedu res, especially in th e con n ector
areas.

Restoration check
As th e patien t presen ted with active cariou s lesion s an d was con sidered to be at
high risk of fur th er disease, fastidiou s care was taken to remove any plaqu e
reten tive factors an d to rein force th e n ecessity for th e patien t to car ry ou t effec-
tive, stan dard care preventive measures.

Review
Th e impor tan ce of regu lar reviews was establish ed at th e ou tset. Th ese reviews
were th en schedu led for su itable intervals to allow monitoring an d reinforcemen t
of plaqu e con trol, as well as th e assessmen t of fu n ction al an d esth etic factors.
30 3
Fig. C9.2.10 Occlusal assessment.

Fig. C9.2.11 Removal of plaque retention factors.

Fig. C9.2.12 Restoration review.


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C l i n i c a l C a s e 9.3: Al l -C e r a m i c
Re s i n -Bo n d e d Br i d g e
Case history
Extraction of an u pper secon d premolar was th e u n fortu n ate en d to a cycle of
repeated restoration failu res an d replacemen ts in a 3 5 -year-old male patien t.

Care plan
Followin g a su itable period of h ealin g, an d as oral hygien e, occlu sal an d perio-
don tal con dition s were favou rable, th e fu ll ran ge of treatmen t altern atives was
ou tlin ed to th e patien t. Th e risk/ ben efit ratio of each option was presen ted in
detail including th e n on -treatmen t option , wh ich was ru led ou t in th is case, for
esth etic reason s.
Th e option selected with in formed con sen t was a resin -bon ded zircon ia frame-
work ceramic bridge. Bridge design was based on esthetics and th e anticipated
occlu sal, fu n ction al forces on th e restoration . Fixed/ fixed design s are gen erally
favou rable rath er th an can tilevers th at su ffer in creased stress at th e con n ector
du e to leverage on th e pon tic. 20 Min imally invasive inlay retain ers were pre-
scribed for abu tmen t teeth 2 2 adjacen t to th e space an d were design ed to min i-
mize occlusal con tacts on th e restoration . 2 3
Th e decision was also made to investigate an d restore an in cipien t carious lesion
in th e cen tral pit of th e molar abu tmen t.

Fig. C9.3.1 Extraction of an upper premolar.


30 5
C l i n i c a l C a s e 9 . 3

Fig. C9.3.2 Treatment plan: all-ceramic RBB.

Preparation
Followin g sh ade selection an d local an aesth esia, abu tmen t preparation was
car ried ou t to optimize space requ iremen ts for th e selected materials, wh ilst
preser ving th e maximu m amoun t of tooth tissu e. General recommen ded prepar-
ation gu idelin es for all-ceramic bridges in clude:24

Wh ile ceramic wing thickness may be on ly 0.6 mm in certain clin ical


situ ation s, occlu sally n o areas of th e preparation sh ou ld allow less th an
2 mm of material to optimize stren gth . 21
Intern al line an gles sh ould be rou n ded to minimize stress on the residu al
tooth tissu e an d th e restoration . 2 0
Proximal box wall preparation s sh ould diverge, avoid u ndermin in g en amel
and optimize th e su rface area available for adh esion .
Abu tment preparations sh ould be mu tu ally parallel (alth ough u n dercu ts may
be blocked ou t if paralleling wou ld involve excessive h ard tissu e removal).
No bevels sh ou ld be placed as th is will result in thin marginal ceramic
pron e to fractu re.
Floors should be smooth (bu t do n ot n eed to be flat).
Margins sh ou ld be su pra-gin gival an d con fin ed ideally to enamel.
Cavo-su rface an gle sh ou ld be well defin ed* an d ideally with a 9 0 bu tt join t.

* When intra-oral digital impressions are employed, distinct cavo-surface angles are essential to
enable accurate recording of preparation margins.19
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Connector design
Th is is a vital factor govern in g fractu re resistan ce an d is affected sign ifican tly
by the size, sh ape an d position of th e con nector.2 0 Th e recommen ded con n ector
heigh t from interproximal papilla to margin al ridge is 4 mm for most systems. 1 9
Th ese requ iremen ts mu st be balan ced again st th e risk of closin g embrasu res an d
complicatin g plaqu e con trol procedu res for th e patien t.

Fig. C9.3.3 Abutment preparation complete.

A B

Fig. C9.3.4 (A) Bur measurement. (B) Enables minimally invasive retainer design.
30 7
C l i n i c a l C a s e 9 . 3

CLIN I CA L TIP S

Pre-operatively measuring burs will enhance precision in meeting the connector dimension
requirements or each material
Use o tapered burs will reduce the risk o undercutting and automatically creating divergent
preparations

Fig. C9.3.5 Impression.

Impression
Ceramic bridges may be manu factu red u sin g tradition al impression an d waxin g
tech n iqu es or from digital impression s captu red in tra-orally or, as in th is case,
by scann ing a model cast from a conven tional silicon e impression . An opposin g
alginate impression was u sed for construction of a model that was also proc-
essed digitally u sin g th e same n on -con tact ph oto-optical wh ite ligh t an d laser
scan n er to provide a 3 D digital occlu sal record.

Provisional restoration
In lay preparation s were restored temporarily with a flexible ligh t-cu red resin
material design ed for th is pu rpose. Th is allows easy removal with n o risk of
altering the prepared surfaces.

Computer aided design 25


A vir tu al model of th e preparation created by 3D software (Fig. C9 .3 .7A) on
wh ich th e bridge framework was design ed. Th e framework is design ed 2 0 2 5 %
larger th an the actual restoration to accoun t for shrin kage du rin g th e fin al
sin terin g stage. Th e pon tic was selected from a ran ge of option s (Fig. C9 .3 .7B)
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Fig. C9.3.6 Temporary restorations.

A B

Fig. C9.3.7 Computer aided bridge design. (A) Virtual model. (B) Pontic design. (C) Occlusal design.
30 9
C l i n i c a l C a s e 9 . 3

an d was modified to fit the ph oto-optically scann ed fun ctional impression of th e


opposin g arch (Fig. C9 .3 .7C).
Th e mach in e th en sh ran k th e pon tic digitally, to accou n t for th e desired th ick-
n ess of veneerin g porcelain , an d design ed th e con n ectors to match th e requ ire-
men ts of each material. Th e ceramicist th en modified th e framework digitally
to maximize stren gth an d su pport for th e overlyin g porcelain an d create smooth
embrasu re con tou rs to min imize stress con cen tration . 1 9

Framework manu acture


A separate u n it milled the framework from a prefabricated blank of partially
sin tered zircon ia (Fig. C9.3 .8 A). Th e material h as a ch alk-like con sisten cy (Fig.
C9 .3 .8 B) that is easily mach in able and with less wear an d tear on millin g h ard-
ware;1 9 th is redu ced th e risk of micro-cracks th at may be associated with th e
millin g of fu lly sin tered blan ks.1 9 The framework was h eated slowly an d sintered
to fu ll den sity, precisely followin g manu factu rers in stru ction s (Fig. C9.3 .8 C).

Veneering porcelain
A very th in wash of layerin g ceramic was applied to wet th e su rface of the
framework (Fig. C9 .3.9 A) an d maximize su ppor t for th e subsequen t layers of
ven eering porcelain , wh ich was then added to optimize esth etics an d match th e
polychromatic appearance of n atu ral teeth (Fig. C9 .3 .9 B).
Porcelain s with h igh fu sin g temperatu res were u sed as th ey are th e most com-
patible with zirconia. As rein forcement of th e ven eering feldspath ic porcelain is
critical to su ccess, th e manu factu rers in stru ctions sh ou ld be followed carefully
with regard to magn itu de an d rate of in crease and decrease of firin g
temperatu res.

Sur ace preparation


Th e fu ll con tou r restoration was pain ted with a glaze (Fig. C9 .3 .1 0 A) an d fired
to produ ce fit su rfaces th at may be san dblasted an d th en etch ed with hydroflu o-
ric acid to allow adh esive cemen tation . Etch in g of pu re zircon ia is impossible,
as its crystalline stru cture is too dense. Adh esion was en h an ced by pain tin g th e
fit su rfaces with a silan e primer (Fig. C9 .3 .10 B), and this was car ried out ch air-
side at th e cemen tation appoin tmen t.

Try-in
Followin g removal of th e temporary dressin g an d isolation , th e restoration was
tried in . Alth ou gh n o su rface fit adju stmen ts were n ecessary in th is case, cor-
rection s if requ ired may be car ried ou t u sin g appropriate bu rs.
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A B

C Fig. C9.3.8 Framework manufacture. (A) Milled framework.


(B) Pre-sintered framework. (C) Sintered framework.

311
C l i n i c a l C a s e 9 . 3

A B

Fig. C9.3.9 (A) Framework complete. (B) Veneering porcelain.

A B

Fig. C9.3.10 Fit surface preparation. (A) Etching of glazed surface. (B) Silane primer.

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Fig. C9.3.11 Restoration try-in.

Tooth sur ace preparation


Th e in lay preparation s were etch ed u sin g 37 % orth o-ph osph oric acid for 1 5
secon ds. Etch an t was th en th orou gh ly wash ed off th e preparation s an d dried
with gentle airflow to preven t den tin e dehydration .

CLIN ICA L TI P S : ETCH IN G

Viscous etching gel enhanced control o placement


Coloured gels reduced the risk o etching too ar beyond restoration margins, which would have
allowed excess luting resin to stick
The etchant was agitated gently with a suitable instrument to burst air bubbles and optimize the
etch pattern

Fig. C9.3.12 Abutment teeth etched.


313
C l i n i c a l C a s e 9 . 3

Adhesive
Wh ile (less tech n iqu e-sen sitive) self-etch in g cemen ts may be u sed, optimu m
adhesion is considered to be gain ed by etch an d rin se systems. A stron g du rable
bond is required for all adhesively cemented restoration s to:

Improve retention
Reduce risk of micro-leakage
In crease the restoration s resistan ce to fracture in itiation an d propagation
Allow tran sfer of occlu sal forces to the abu tmen t teeth .

Note: low film th ickn ess adhesive resin s sh ou ld be used an d pooling eliminated
to allow accu rate seatin g of th e prosth esis.

Luting cement
Resin -based or resin -modified glass ion omer cemen ts are con sidered appropriate
for th e cemen tation of adh esive all-ceramic restoration s. In this example NX3
Nexu s resin -based lutin g cemen t (Ker r, Switzerland) was ch osen as it offered th e
following benefits:

Dual-cu re en sured polymerization in areas that ligh t would not reach .


Good esth etic proper ties.
Try-in gels were available to stabilize th e restoration du ring assessmen t.
Differen t shade lu tin g resin s offered flexibility in esthetic ach ievemen t.

Fig. C9.3.13 Adhesive applied.


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Fig. C9.3.14 Luting resin applied.

Th e cemen t was mixed an d applied to th e abu tmen t preparation s u sin g a su it-


able bru sh . Th e restoration was th en seated.
Note: tradition al n on -adh esive lu tin g tech n iqu es may be u sed for fu ll or par tial-
coverage restorations an d are usefu l in clin ical situations wh ere moistu re con trol
is difficu lt.

Cementation
Th e restoration was seated and excess cement removed with a differen t (dry)
bru sh . Remain in g margin al excess was ligh t cu red for 1 0 secon ds an d removed
with a sh arp in stru men t. Th e restoration was th en polymerized so th at all
su rfaces received at least a 6 0 -secon d ligh t cu re. It h as been su ggested th at
flow of lu tin g resin s in to porcelain flaws on th e fit su rface an d su bsequ en t
shrin kage on polymerization may seal defects and reduce fractu re propagation
fu rth er.

Finishing and polishing


Followin g ru bber dam removal, the occlu sion was ch ecked in th e in tercu spal
position an d in all excu rsion s u sin g articu latin g paper. Adju stmen ts were made
usin g appropriate fin ish in g bu rs, abrasive discs an d with pastes designed for
polish in g porcelain . Copiou s coolan t an d gen tle pressu re were u sed to redu ce
th e risk of in trodu cing flaws in to th e restoration .
Th e patien t was in stru cted in the n ecessary protocols for h ome care of th e bridge
an d advised on specific oral hygien e produ cts su itable in th is respect.
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C l i n i c a l C a s e 9 . 3

CLIN I CA L TIP S

Prior to cementation, the buccal sur ace o the pontic was marked with a elt pen to reduce the risk
o incorrect orientation. It is particularly important to avoid such time-consuming errors when
chemically cured cements are used.

Fig. C9.3.15 Cementation.

Fig. C9.3.16 Oral hygiene instruction.

Restoration assessment
Th e restoration was given a fin al in spection to ch eck for any excess cemen t an d
th e patien t was th en given a mir ror to con firm th at esth etic expectation s h ad
been met.
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Fig. C9.3.17 Restoration assessment.

Fig. C9.3.18 Restoration review.

Review
Regu lar reviews were sch edu led an d are essen tial to mon itor for th e common
modes of failu re seen with all-ceramic bridges. 2 6 Lon g-term evalu ation of su c-
cessfu l (an d u n su ccessfu l) restoration s will h elp to in form fu tu re min imally
invasive esth etic restorative procedu res.
317
F u r t h e r r e a d i n g

Ac k n o w l e d g e m e n t s
Th e au th or wou ld like to than k Professor P. Vallittu , Professor A. Sh inya, Dr
Peter San ds, Professor Giles Per ryer, Dr Lu ke Green wood, Mr Glyn Th omas (Clin -
ical Case 9.2 ), Adrian an d Jacqu e Rollin gs (Clinical Case 9 .3), Dr Adrian Sh or-
tall, Dr Jim McCu bbin , Professor Rich ard Verdi, an d all th e patien ts wh o were
kind en ou gh to allow th e preceding operative procedu res to be ph otograph ed
an d used to illu strate Ch apters 8 an d 9 .

Further reading
Aida N, Shinya A, Yokoyama D, et al. Three-dimensional nite element analysis of posterior
ber-reinforced composite xed partial denture, Part 2: in uence of ber reinforcement on
mesial and distal connectors. Dent Mater J 2011;30(1):2937.

Bachhav VC, Aras MA. Zirconia-based xed partial dentures: a clinical review. Quintessence Int
2011;42:17382.

Burke FJT. Resin-retained bridges: bre-reinforced versus metal. Dent Update 2008;35:
5216.

Burke FJT, Ali A, Palin W. Zirconia-based all-ceramic crowns and bridges: three case reports.
Dent Update 2006;33:40110.

Butterworth C, Ellakwa AE, Shortall ACC. Fibre-reinforced composites in restorative dentistry.


Dent Update 2003;30:3006.

Clinical Guide. Fibre Reinforcements for Minimally Invasive Bridges. Turku, Finland: StickTech
Ltd. Available from: <www.sticktech.com> ; 2011.

Ellakwa AE, Shortall ACC, Shehata MK, Marquis PM. The in uence of bre placement and posi-
tion on the ef ciency of reinforcement of bre reinforced composite bridgework. J Oral Rehabil
2001;28:78591.

Freilich MA, Meiers JC. Fiber-reinforced composite prosthese. Dent Clin N Am 2004;48:
54562.

Freilich MA, Meiers JC, Duncan JP, et al. Clinical evaluation of ber-reinforced xed bridges.
JADA 2002;133:152434.

Garoushi S, Lassila L, Vallittu PK. Resin-bonded ber-reinforced composite for direct replacement
of missing anterior teeth: a clinical report. Int J Dent 2011;20:425.

Gnc Basaran E, Ayna E, Utasli S, et al. Load-bearing capacity of ber reinforced xed com-
posite bridges. Acta Odontol Scand 2013;71(1):6571.

Kara HB, Aykent F. Single tooth replacement using a ceramic resin bonded xed partial denture:
a case report. Eur J Dent 2012;6:1014.

Karaarslan ES, Ertas E, Ozsevik S, Usumez A. Conservative approach for restoring posterior
missing tooth with ber reinforcement materials: four clinical reports. Eur J Dent 2011;5(4):
46571.
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M I N I M A L LY I N VA S I V E R E P L A C E M E N T O F M I S S I N G T E E T H : P A R T 2

Keulemans F, De Jager N, Kleverlaan CJ, Feilzer AJ. In uence of retainer design on two-unit
cantilever resin-bonded glass ber reinforced composite xed dental prostheses: an in vitro and
nite element analysis study. J Adhes Dent 2008;10(5):35564.

Keulemans F, Lassila LV, Garoushi S, et al. The in uence of framework design on the load-
bearing capacity of laboratory-made inlay-retained bre-reinforced composite xed dental pros-
theses. J Biomech 2009;42(7):8449.

Lassila LV, Garoushi S, Tanner J, et al. Adherence of Streptococcus mutans to ber-reinforced


lling composite and conventional restorative materials. Open Dent J 2009;3:22732.

Ozcan M, Breuklander MH, Vallittu PK. The effect of box preparation on the strength of glass
ber-reinforced composite inlay-retained xed partial dentures. J Prosthet Dent 2005;93(4):
33745.

Ozyesil AG, Usumez A. Replacement of missing posterior teeth with an all-ceramic inlay-retained
xed partial denture: a case report. J Adhes Dent 2006;8(1):5961.

Song HY, Yi YJ, Cho LR, Park DY. Effects of two preparation designs and pontic distance on
bending and fracture strength of ber-reinforced composite inlay xed partial dentures. J Pros-
thet Dent 2003;90(4):34753.

Vallittu PK. Survival rates of resin-bonded, glass ber-reinforced composite xed partial dentures
with a mean follow-up of 42 months: a pilot study. J Prosthet Dent 2004;91(3):2416.

van Heumen CC, Tanner J, van Dijken JW, et al. Five-year survival of 3-unit ber-reinforced
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van Heumen CC, van Dijken JW, Tanner J, et al. Five-year survival of 3-unit ber-reinforced
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5216.

3. Jokstad A, Gke M, Hjortsj C. A systematic review of the scienti c documentation of xed


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4. Vallittu PK. Survival rates of resin-bonded, glass ber-reinforced composite xed partial
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5. van Heumen CC, Tanner J, van Dijken JW, et al. Five-year survival of 3-unit ber-reinforced
composite xed partial dentures in the posterior area. Dent Mater 2010;26(10):95460.

6. Ibsen RL. One appointment technique using an adhesive composite. Dent Surv 1973;
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7. Altieri JV, Burstone CJ, Goldberg AJ, Patel AP. Longitudinal clinical evaluation of ber-
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8. Frielich MA, Meiers JC. Fiber-reinforced composite prostheses. Dent Clin N Am 2004;48:
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9. Karaarslan ES, Ertas E, Ozsevik S, Usumez A. Conservative approach for restoring posterior
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11. Aida N, Shinya A, Yokoyama D, et al. Three-dimensional nite element analysis of posterior
ber-reinforced composite xed partial denture Part 2: in uence of ber reinforcement on mesial
and distal connectors. Dent Mater J 2011;30(1):2937.

12. Yokoyama D, Shinya A, Gomi H, et al. Effects of mechanical properties of adhesive resin cements
on stress distribution in ber-reinforced composite adhesive xed partial dentures. Dent Mater J
2012;31(2):18996.

13. Ellakwa AE, Shortall ACC, Shehata MK, Marquis PM. The in uence of bre placement and posi-
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14. Keulemans F, De Jager N, Kleverlaan CJ, Feilzer AJ. In uence of retainer design on two-unit
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15. Keulemans F, Lassila LV, Garoushi S, et al. The in uence of framework design on the load-
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16. Ozcan M, Breuklander MH, Vallittu PK. The effect of box preparation on the strength of glass
ber-reinforced composite inlay-retained xed partial dentures. J Prosthet Dent 2005;
93(4):33745.

17. Song HY, Yi YJ, Cho LR, Park DY. Effects of two preparation designs and pontic distance on
bending and fracture strength of ber-reinforced composite inlay xed partial dentures. J Pros-
thet Dent 2003;90(4):34753.

18. Xie Q, Lassila LV, Vallittu PK. Comparison of load-bearing capacity of direct resin-bonded ber-
reinforced composite FPDs with four framework designs. J Dent 2007;35(7):57882.

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321
This pa ge inte ntiona lly le ft bla nk
I N D EX
Page numbers followed by f indicate gures, t indicate tables, and b indicate boxes.

A Alloy framework, 237238


Abutment teeth, 195, 211 Alloy pontic core, 238
etching of, 313f Amalgam
Acatalasaemia, 47 as cause of discolouration, 3t5t
Acid etching, 23 restorations, 40, 41f
Acquired defects, 3t5t, 78 Amelogenesis imperfecta, 3t5t, 7, 8f
Acrylic occlusal nightguard, 148 American Dental Association (ADA), guidelines for endorsing
ADA. see American Dental Association (ADA) bleaching systems or products, 48
Adhesive Anamnesis
application of in direct shaping by occlusion (DSO) technique, 150
in all-ceramic resin-bonded bridge, 314, 314f for severe tooth wear, 148149
in direct bre-reinforced composite resin-bonded bridge, Anterior esthetic zone, orthodontics in, 200
285, 286f Artex articulator, 165f
for resin-bonded bridgework, 244, 244b, 244f Articulated working models, 236, 236f
Adhesive bonding, and colour rebound, 4243 Articulator
Adhesive bridge, 19 Artex, 165f
Adjacent central incisor, building up of, 180f semi-adjustable, with maxillary and mandibular casts,
Alkaptonuria, 3t5t 152153
All-ceramic materials, minimally invasive tooth replacement Attrition, tooth wear and, 148
with, 272278
B
advantages of, 273275
BEWE index, 148149
biocompatibility as, 274
Biocompatibility, of all-ceramic bridges, 274
esthetics as, 274275, 275f
Bite registration, 153, 167f
fracture resistance as, 273
Black triangle disease, 40f
marginal t as, 275, 277f
Bleaching. see Dental bleaching
radiopacity as, 274
Bleaching tray, 61
rigidity as, 273
Bonding, 26b
strength as, 273
Bridge retainers
thermal conductivity as, 274
lingual resin-bonded, 208f
transformation toughening as, 273274
partial coverage, 205, 205f206f
disadvantages of, 276278
Bridgework
failure of, 278, 279f
conventional, 203
longevity of, 278
xed, 203
zirconia-yttria bridges in, 272273
provision of, 1819
All-ceramic resin-bonded bridge
simple cantilever, 203204, 204f
adhesive application in, 314, 314f
Bruxist patient, tray for, in bleaching, 61
care plan in, 305, 306f
Burn
case history on, 305, 305f
cause by hydrogen peroxide, 45f
cementation of, 315, 316b, 316f
white gingival epithelium, 45f
clinical case on, 305317
computer aided design of, 308310, 309f C
connector design in, 307, 307f, 308b CAD/ CAM technology, in all-ceramic restorations, 275, 276f,
nishing and polishing of, 315, 316f 278, 279f
framework manufacture for, 310, 311f Canines
impression for, 308, 308f dislocated, remodelling of, 106f
luting cement in, 314315, 315f palatal aspect of, 141f
preparation in, 306, 307f primary, fractured
provisional restoration in, 308, 309f extraction of, 239, 239f
restoration assessment of, 316, 317f painful, retained, 227f
review of, 317, 317f Cantilever resin-bonded bridge, 210f
surface preparation for, 310, 312f Carbamide peroxide, 35, 35f, 53
tooth surface preparation for, 313, 313b, 313f vs. hydrogen peroxide, in bleaching, 36b
try-in of, 310, 313f safety of, 3637
veneering porcelain for, 310, 312f use of, instructions for patients on, 73b
i n d e x

Caries, 3t5t, 1113, 12f preparation of, 288, 290f


prevalence of, 194 removal of, 291, 293f
Carious lesion, 1213 post, 93
Cement, luting, in all-ceramic resin-bonded bridge, 314315, removal of, 223
315f Curve of Spee, maintenance of, 153
Cementation, 217, 218f
of all-ceramic resin-bonded bridge, 315, 316b, 316f D
of indirect bre-reinforced composite resin-bonded bridge, Dahl principle, 112
302303, 303f Dam stabilizing cord, 283
of minimally invasive simple cantilever bridge, 226, 226f De-cementation, 220
of resin-bonded bridgework, 245246, 246b, 246f Decision making, in direct anterior esthetic dentistry with
Chairside bleaching, 44, 45f, 91 resin composites, 102111
see also In-of ce bleaching Dental arches, incomplete, 197f, 198199
vs. nightguard vital bleaching, 44b, 93b95b Dental bleaching
Chlorhexidine, 11 adhesive bonding and colour rebound, 4243
Chromogens, 11 amalgam restorations, 40, 41f
Chromophore, 32 assessing ef cacy and effectiveness of, 48
Claims, regarding dental bleaching, 4647, 47f carbamide peroxide, 35, 35f
Clinical protocol, of nightguard vital bleaching, 5474, safety of, 3637
55f60f chairside or in-of ce, 44, 45f
Clinical record checklist, for dental bleaching, 74b vs. nightguard vital, 44b
Colour chemistry of, 34
change of, in bleaching, 74 claims regarding, 4647, 47f
determination, in resin composite restorations, 109110, contraindications to, 93b95b
110f111f cost of, 93b95b
Colour rebound, adhesive bonding and, 4243 effects of
Colour regression, after nightguard vital bleaching, 43b on hardness of teeth, 39
Colourants on soft tissues, 3940, 40f
extrinsic, 96t hydrogen peroxide, 3536
intrinsic, 96t systemic defence mechanisms against, 37
Communication, in direct anterior esthetic dentistry with managing patient expectations in, 42, 43b
resin composites materials, 3049
ladder, 104105 methods, 5098, 93b95b
verbal, 102105 chairside/ in-surgery, 91
visual, 108111 clinical procedures of, 7074, 72f, 73b74b
Composite material, 238 clinical record checklist for, 74b
Composite placement, in direct bre-reinforced composite contraindications for, 65
resin-bonded bridge, 288, 289f dos and donts for dentist, 75b
Composites, resin external, 92t
direct anterior esthetic dentistry with, 115b failure to, 90
colour determination in, 109110, 110f111f history and development of, 53
communication ladder in, 104105 inside/ outside, 8085, 80f84f, 92t
decision making in, 102111 laboratory technical procedures of, 6769, 70f71f
digital imaging in, 108, 108f neck of the tooth does not bleach, 90
direct resin composite mock-up in, 108109, 109f110f non-vital anterior teeth, discoloured, management of,
resin composite wax-up in, 110111 7689, 92t
verbal communication in, 102105 patient management and expectations in, 5354,
visual communication in, 108111 54b
direct placement of, 112 poor patient compliance, 8990
drawback of, 115 problems and troubleshooting of, 8991
ejection of, 125f restorative alternatives to, non-vital, discoloured teeth,
owable, 174f, 235, 286, 287f 9193, 92t
nano-hybrid, 25f review, 7980
photocuring of, 174f tray design and, 6167, 62f63f
for severe tooth wear, 114 walking bleach technique, 86, 91, 92t
wax-up, 110111 mouthrinses and toothpastes, 48
Congenital erythropoietic porphyria, 3t5t non-vital, 107f
Congenital hyperbilirubinaemia, 3t5t patient at risk groups, 47
Connector design, in all-ceramic resin-bonded bridge, 307, pulp considerations of, 39
307f, 308b sensitivity and, 3738
Contour teeth discolouration in, 3233, 32b, 33f
altered, 142f tooth resorption in, 3839, 38f
embrasure, in direct bre-reinforced composite resin- tooth-coloured restorative materials, 4041, 41f42f
bonded bridge, 294, 295f Dental caries. see Caries
gingival, in direct bre-reinforced composite resin-bonded Dental countdown, 195
bridge, 291, 292f Dental crowding. see Crowding
palatal, shaping of, 176f Dental erosion. see Erosion
Contour strip, 176f Dental image processing, 129f
Conventional design principles, 223 Dental implants. see Implants
Cosmetic tooth replacement, 195 Dental materials, restorative, 9
Crowded malocclusions, orthodontics for, 200 Dental porcelain, 114
Crowding, 13, 104f Dental shade guide, 5556, 56f
Crown, 93, 113f114f Dentinogenesis imperfecta, 3t5t, 7, 60f
cementation, of resin-bonded bridgework, 247, 248f Denture, scalloped design of, 1617
form of, in direct bre-reinforced composite resin-bonded Developmental defects, 3t5t, 68, 7f
bridge Diastema, closing, 103f

324
i n d e x

Digital imaging, in direct anterior esthetic dentistry with resin Enamel


composite, 108, 108f cracking of, 89
Direct composite veneers, 170f hypoplasia, diagnosis of, 25
Direct esthetics opaque mottling of, 910
anterior, 111115, 113f114f Enamelplasty, 201f
clinical cases on, 120144 Epidermolysis bullosa, 3t5t
Direct bre-reinforced composite resin-bonded bridge Erosion, 114
adhesive application in, 285, 286f tooth wear and, 148
bridge design in, 281282 Esthetic dentistry, direct anterior, with resin composites, 115b
xed, 281 colour determination in, 109110, 110f111f
retainer, 282, 282b communication ladder in, 104105
care plan in, 280281, 281f decision making in, 102111
case history on, 280, 280f digital imaging in, 108, 108f
clinical case on, 280294 direct resin composite mock-up in, 108109, 109f110f
composite placement in, 288, 289f resin composite wax-up in, 110111
crown form verbal communication in, 102105
preparation in, 288, 290f visual communication in, 108111
removal in, 291, 293f Esthetic resin composites, direct placement of, 112
embrasure contour in, 294, 295f Esthetic zone, tooth loss in, 194195
bre placement in, 286, 287f Esthetics
nishing in, 291, 293f of all-ceramic bridges, 274275, 275f
owable composite in, 286, 287f direct, clinical cases on, 120144
gingival contour in, 291, 292f direct anterior, 111115, 113f114f
increasing bre volume in, 286, 288f direct posterior
isolation in, 283, 283b, 284f clinical case on, 160162
light curing in, 291, 292f severe tooth wear treatment, 146159, 157b
framework in, 288, 289f lost teeth replacement and, 195
measuring the bre in, 283284, 285f RBBs and, 207, 208f
occlusal adjustment in, 294, 295f resin-bonded bridgework and, 209, 210f
pontic construction in, 288, 291f Etch and rinse adhesive procedure, 173f
restoration assessment in, 294, 296f Etching
review of, 294, 296f of abutment teeth, 313f
rubber dam removal in, 294, 294f acid, 23
shade test in, 282b, 282f Eugenol-containing endodontic materials, 3t5t, 9
technique tips in, 282, 283f EVA lamineer tip, 182f
tooth surface preparation in, 284, 285f Excessive uoride intake, 3t5t
Direct posterior esthetics Extra-coronal retainer, 269
clinical case on, 160162, 162f Extraction
severe tooth wear treatment, 146159, 157b early, 200
Direct resin composite of tooth, 239, 239f
mock-up, 108109, 109f110f tooth movement following
reconstruction, 162 evidence for, 198b
restorations negative consequences of, 198b
for severe tooth wear, 149150, 157b Extrinsic colourants, 96t
for uneven distribution of front upper teeth, 122f Extrinsic discolouration, 3t5t, 11
veneers, placement of, 124f
Direct shaping by occlusion (DSO) technique, 150157, F
151f152f, 175f Fibre placement, in direct bre-reinforced composite
adhesive procedure, 153 resin-bonded bridge, 286, 287f
advantages and disadvantages of, 156b Fibre-reinforced composite resin-bonded bridges (FRC-RBBs),
for building up of maxillary anterior teeth, 181f 259f, 261272, 262b
evidence for, 156157 advantages and disadvantages of, 264b
for lower premolars restoration, 154f bonding of bres to matrix, 265, 266f
for mandibular premolar restoration, 186f contraindications for, 262263
for maxillary second premolars and molar restoration, functional, 262263
187f moisture control as, 262
restorative procedure, 153 technique sensitivity as, 263
for upper posterior teeth restoration, 154, 155f designing, 268270
Direct stains, 3t5t framework design in, 269
Discolouration, of teeth, 6, 6f, 3233, 32b, 33f, retainer design in, 269270
93b95b tooth preparation in, 268
causes of, 3t5t, 96t direct
combined aetiology of, 90 adhesive application on, 285, 286f
extrinsic, 3t5t, 11 bridge design in, 281282
intrinsic, 3t5t, 810, 8f care plan in, 280281, 281f
non-vital anterior teeth, management of, 7689, 92t case history on, 280, 280f
pink spot, 38f clinical case on, 280294
Dual curing, of resin-bonded bridgework, 247, 247f composite placement in, 288, 289f
Dye, dental bleaching, 32, 34f crown form preparation for, 288, 290f
crown form removal in, 291, 293f
E embrasure contour of, 294, 295f
Edentulous areas, routine restoration of, 196 bre placement in, 286, 287f
Edentulous spaces, assessment of, 199f nishing of, 291, 293f
EhlersDanlos syndrome, 3t5t owable composite on, 286, 287f
Embrasure contour, in direct bre-reinforced composite gingival contour of, 291, 292f
resin-bonded bridge, 294, 295f increasing bre volume in, 286, 288f

325
i n d e x

isolation in, 283, 283b, 284f H


light curing in, 291, 292f Haemorrhage, pulpal, 9
light-cure framework in, 288, 289f Hardness of teeth, effects on, 39
measuring the bre in, 283284, 285f Hereditary defects, 3t5t, 7, 8f
occlusal adjustment in, 294, 295f Hybrid designs, of retainer, 214, 215f, 270, 282b
pontic construction in, 288, 291f Hydrogen peroxide, 3336
restoration assessment in, 294, 296f in bleaching, 86
review of, 294, 296f vs. carbamide peroxide, in bleaching, 36b
rubber dam removal in, 294, 294f chemical formulae of, 34b
shade test in, 282b, 282f concentrations of, from different bleaching agent
technique tips in, 282, 283f formulations, 86t
tooth surface preparation in, 284, 285f mechanism of action, 33f
factors in uencing reinforcement of, 265b in pulp, 39
failure of, 270272, 271f swallowing of, 93b95b
bre systemic defence mechanisms against, 37
orientation of, 265 Hydrophilic vinyl polysiloxane registration material, 165f
type of, 263 Hyperbilirubinaemia, congenital, 3t5t
volume of, 265 Hypodontia, 7
indications for, 261262, 261f minimally invasive management of, 200, 201f
indirect Hypoplasia, 10f11f
cementation of, 302303, 303f of lateral incisors, 107f
clinical case on, 297303 Hypoplastic upper central incisors, 24f
nishing of, 303, 304f
t surface preparation in, 301, 302f I
framework construction in, 299, 300f IARC. see International Association for Research on Cancer
indications for, 297 (IARC)
minimally invasive preparation for, 297, 298f Imbrication, 13
model construction in, 299, 300f see also Crowding
preparation complete in, 297299, 299f Implant-retained restorations, 203, 203f
restoration check of, 303, 304f Implants, 203, 203f
review of, 303, 304f placement and restoration of, 14, 19, 19f
tooth surface preparation in, 301302, 302f Impressions, 217, 218f
veneering composite placement in, 300, 301f for all-ceramic resin-bonded bridge, 308, 308f
longevity of, 270272 and minimally invasive simple cantilever bridge, 224, 225f
position of bres in framework in, 266, 267f of resin-bonded bridgework, 235, 235f
veneering resin composite in, 266268, 268f Incisors
Fibre-reinforcement, 263268, 265b central
Filtek Supreme XTE layered resin composite system, 112 adjacent, building up of, 180f
First permanent molars, as candidates for premature loss, in tight-lipped smile, 139f
200 chipping of, 2425, 25f
First premolar, ectopic, orthodontics for, 200 dislocated, remodelling of, 106f
Fit surface preparation, in indirect bre-reinforced composite lateral
resin-bonded bridge, 301, 302f hypoplasia of, 107f
Fixed bridge, 14 missing, clinical case on, 136f138f
Fixed bridgework, 203 removal of, 122f
provision of, 1819 maxillary central
Fixed prosthodontics, 203, 203f arch length discrepancy in, 122f
Fixed/ xed designs, bridge, 213, 214f retroclination of, 128f
Fixed/ xed resin-bonded bridge, with Rochette design, 207f right, restoration of, 180f
Fixed/ movable designs, bridge, 213214 rotated position of, 128f
Flexural strength, of bridge, 273 missing, 106f
Flowable resin composite, 174f, 235 upper central
in direct bre-reinforced composite resin-bonded bridge, hypoplastic, 24f
286, 287f treatment of, 25
Fluoride ion, excessive administration and intake of, 910, upper lateral, as congenitally missing teeth, 200
10f upper right central, 1720
Fracture resistance, of all-ceramic bridges, 273 missing, 16, 17f
FRC-RBBs. see Fibre-reinforced composite resin-bonded replacement of missing, 1720
bridges (FRC-RBBs) upper right lateral, 22, 22f
Free radicals, 35 peg-shaped, 2122
Incomplete dental arches, 197f, 198199
G Indirect bre-reinforced composite resin-bonded bridge
Gag re ex, in bleaching, 59 cementation of, 302303, 303f
Gastro-oesophageal re ux disease (GORD), tooth wear and, clinical case on, 297303
162f nishing of, 303, 304f
Gel formulation, viscous, within mouthguard, use of, 53 t surface preparation for, 301, 302f
Gingival contour, in direct bre-reinforced composite framework construction for, 299, 300f
resin-bonded bridge, 291, 292f indications for, 297
Gingival epithelium burn, white, 45f minimally invasive preparation for, 297, 298f
Gingival recession, masking, 105f model construction in, 299, 300f
Gingival retraction cord, 23 preparation complete in, 297299, 299f
Gingival surface, 214 restoration check of, 303, 304f
Gingival tissue, 1617 review of, 303, 304f
Glucose-6-phosphate dehydrogenase (G6PD) de ciency, 47 tooth surface preparation for, 301302, 302f
GORD. see Gastro-oesophageal re ux disease (GORD) veneering composite placement in, 300, 301f
Gums, unevenness of, 128f Indirect resin composite restorations, for severe tooth wear,
Gypsum casts, 165f 149
326
i n d e x

Indirect stains, 3t5t Metabolic disorders, 7


Infection, localized, dental discolouration and, 3t5t dental discolouration and, 3t5t
Inlay-retainer, 270 Metal compounds, 32
In-of ce bleaching, 44, 45f Metal display, in partial coverage bridge retainers, 205,
vs. nightguard vital bleaching, 44b 206f
Inside/ outside bleaching, 8085, 80f84f, 92t Metal matrix band, 153, 171f172f, 183f
protocol for, 8789 Metal sectional matrix, 232, 233f
In-surgery bleaching, 91 Metalceramic resin-bonded bridges, 205210, 207f
Internal resorption, 3t5t advantages of, 206208
International Association for Research on Cancer (IARC), 37 conservative, 206207, 208f
Intrinsic colourants, 96t esthetics, 207, 208f
Intrinsic discolouration, 3t5t, 810, 8f, 10f11f minimum long-term damage, 207
Isolation patient popularity, 208
in direct bre-reinforced composite resin-bonded bridge, versatility, 207
283, 283b, 284f Micro-abrasion technique, minimally invasive, 24, 25f
in resin-bonded bridgework, 240, 240b, 240f Microdontia, 21, 22f
rubber dam, 123f, 132f, 240b, 240f MIH. see Molar incisor hypomineralization (MIH)
Minimal enamel re-contouring, 200
J Minimal interprismatic proteinaceous matrix, 32
Jaw, upper, widening of, 103f Minimally invasive (MI), concept of, 2
Minimally invasive (MI) dentistry, contemporary, aim of,
L 195
Lateral incisors Minimally invasive (MI) esthetic intervention
hypoplasia of, 107f biological approach, 13
missing, clinical case on, 136f138f common clinical conditions requiring, 128, 26b
removal of, 122f dental caries, 3t5t, 1113, 12f
upper dental crowding (imbrication), 13
as congenitally missing teeth, 200 developmental defects, 68, 7f8f
left, discoloured mesial resin composite restoration in, discolouration, 6, 6f
41f extrinsic discolouration, 3t5t, 11
Leverage forces, 204 intrinsic discolouration, 3t5t, 810, 8f, 10f11f
Light curing missing teeth, 1315
in direct bre-reinforced composite resin-bonded bridge, tooth wear, 1516, 15f
291, 292f Minimally invasive (MI) replacement, of missing teeth,
of resin-bonded bridgework, 247, 248f, 249b 192321
Light-cure framework, in direct bre-reinforced composite with all-ceramic materials, 272278
resin-bonded bridge, 288, 289f clinical case on, 222251
Lightening, 36 with resin composite materials, 258272, 259f260f
Lingual resin-bonded bridge retainers, 208f bre-reinforced composite resin-bonded bridges in, 259f,
Localized infection, dental discolouration and, 3t5t 261272, 262b
Longevity Minimally invasive (MI) simple cantilever bridge, 222226
of all-ceramic bridges, 278 assessment of, 222, 222f
of bre-reinforced composite resin-bonded bridges, cementation of, 226, 226f
270272 impression and temporization for, 224, 225f
Lower left third molar, transplantation of, 200201, 201f materials for, 224, 225f
Luting cement, in all-ceramic resin-bonded bridge, 314315, preparation of, 223, 224f
315f treatment opinions for, 222, 223f
Luting resin, for resin-bonded bridgework, 244245, 245b, Minimum intervention dentistry, 2
245f false perception in, 16
Missing teeth, 1315
M minimally invasive replacement of, 192321
Malocclusions, crowded, orthodontics for, 200 with all-ceramic materials, 272278
Mandibular anterior teeth clinical case on, 222251
bleaching in, 34f with resin composite materials, 258272,
extruded, 164f 259f260f
restorative process in, 169f170f options for management of, 196205, 199b
Mandibular premolars, restoration of, 186f early extractions, 200
Marginal t, of all-ceramic bridges, 275, 277f xed prosthodontics, 203, 203f
Masticatory ef ciency, 196 implants, 203, 203f
Masticatory function, tooth replacement and, 196 non-operative management, 198199, 199f
Maxillary incisor orthodontics, 200, 201f
central partial coverage bridge retainers, 205, 205f206f
arch length discrepancy in, 122f re-implantation, 199200
retroclination of, 128f removable prosthodontics, 201203, 202f
right, restoration of, 180f simple cantilever bridgework, 203204, 204f
rotated position of, 128f transplantation, 200201, 201f
diminutive lateral, 22f replacement of, 107f
Maxillary premolars, restoration of, 183f185f Model construction, in indirect bre-reinforced composite
Maxillary teeth resin-bonded bridge, 299, 300f
anterior Molar incisor hypomineralization (MIH), 3t5t
building up of, DSO technique for, 181f Molars
metal matrix band for restoration of, 171f rst permanent, as candidates for premature loss, 200
unesthetic appearance of, 103f restoration of, using DSO technique, 187f
erosive wear of palatal surfaces of, 164f Mouthguard
front, arch length discrepancy of, 128f bleaching, 61
Melanoidins, 32 in position, sleeping and, 93b95b
Mesial drift, 196, 198b Mouthrinses, 48
327
i n d e x

N Porcelain laminate veneers, restoration with, 8f


Nightguard vital bleaching (NgVB), 52, 52f Porphyria, congenital erythropoietic, 3t5t
clinical protocol for, 5474, 55f60f Post crowns, 93
colour regression after, 43b Premolars
effect on soft tissues, 40, 40f dislocated, remodelling of, 106f
in-of ce bleaching vs., 44b ectopic rst, orthodontics for, 200, 201f
tray-applied, advantages/ disadvantages, 58b lower, restoration of, DSO technique for, 154f
Non-vital anterior teeth, discoloured, management of, 7689, mandibular, restoration of, 186f
92t maxillary
aetiology, 78, 79f restoration of, 183f185f
aims of, 7689 second, restoration of, using DSO technique,
assessment in, 76, 77f 187f
inside/ outside bleaching, 8085, 80f84f, 92t Primary canine, fractured
mechanisms of discolouration, 7879 extraction of, 239, 239f
outcomes, 76 painful, retained, 227f
review, 7980 Prosthodontics
Non-vital bleaching, 107f contemporary, 194
No-prep technique, 215 xed, 203, 203f
removable, 201203, 202f
O restorations, unesthetic xed, 105f
Occlusal adjustment, in direct bre-reinforced composite Provisional crown, 224
resin-bonded bridge, 294, 295f Proximal grooves, 234, 234f
Occlusal registration, 228 Pseudo-hypoparathyroidism, 3t5t
Occlusal surface, resin-bonded bridgework and, 214215, Pulp considerations, in dental bleaching, 39
234, 234f Pulp test, 227f
Occlusal vertical dimension (OVD), 152153 Pulpal haemorrhage, 9
new, replication of, 166f
Opalustre (Ultradent), 25 Q
Opposing alginate impressions, 224 Quality moisture, control of, 240
OptraGate dam, 169f
Oral hygiene, resin-bonded bridgework and, 251, 252f R
Orthodontic dividers, 180f Radiographic examination, loss of bone support, 17,
Orthodontic movement, 196, 197f 18f
Orthodontic retainer style, 72 Radiographs
Orthodontic treatment, 111 bitewing, in severe tooth wear, 164f
Orthodontics, 200, 201f bleaching and, 56, 57f
Osseointegration, period of, 2021, 20f21f of complete obliteration of pulp canals, 59f
Osteoclasts, increased activity of, 111 periapical, of teeth, 226, 227f
OVD. see Occlusal vertical dimension (OVD) Radiopacity, of all-ceramic bridges, 274
Over-eruption, 196, 198b Re-bleaching, 74
Over-the-counter products, and bleaching, 93b95b see also Dental bleaching
Oxidation/ reduction (redox) reaction, 34 Re-contouring, minimal enamel, 200
Oxidative bleaching process, 33 Redox reaction. see Oxidation/ reduction (redox) reaction
Re ex replacement, tooth loss followed by, 196
P Re-implantation, 199200
Palatal contour, shaping of, 176f Relapse, dental bleaching and, 43b
Palatal surfaces Removable bridge, 14
construction of, 140f Removable partial dentures (RPDs), 201203, 202f
extreme wear of, 140f Removable prosthodontics, 201203, 202f
shaping of, 174f Reservoir
Panavia F 2.0 dual cure adhesive system, 244 sizes of, 65
Parallel resistance grooves, 234 trays, in bleaching, 6365
Partial coverage bridge retainers, 205, 205f206f Resin composite materials, minimally invasive tooth
advantages of, 205 replacement with, 258272, 260f
disadvantages of, 205 bre-reinforced composite resin-bonded bridges in, 259f,
Partial denture, removable, 14 261272, 262b
Patient-centred care plan, in direct shaping by occlusion advantages and disadvantages of, 264b
(DSO) technique, 150152 bonding of bres to matrix, 265, 266f
Perhydroxyl ion, 34 contraindications for, 262263
Periapical radiography, of teeth, 226, 227f designing, 268270
Periodontal surgery, 105f factors in uencing reinforcement of, 265b
Periodontitis failure of, 270272, 271f
prevalence of, 194 bre orientation in, 265
resulting in tooth loss, 194f bre type in, 263
Permanent restorations, 105f bre volume in, 265
Peroxide gel, 93b95b indications for, 261262, 261f
Phenol-containing endodontic materials, 3t5t, 9 longevity of, 270272
Phonetics, 196 position of bres in framework in, 266, 267f
Phosphoric acid veneering resin composite in, 266268, 268f
etch, 243f Resin composite restorations
etchant, 302f poor quality, 140f
Photographs, dental bleaching and, 46 for severe tooth wear
Pontic construction, in direct bre-reinforced composite direct, 149150
resin-bonded bridge, 288, 291f indirect, 149
Porcelain, 114, 238 Resin composites
veneering, for all-ceramic resin-bonded bridge, 310, 312f direct, for black triangle disease, 40f

328
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direct anterior esthetic dentistry with, 115b crown cementation of, 247, 248f
colour determination in, 109110, 110f111f dual curing of, 247, 247f
communication ladder in, 104105 esthetic assessment in, 249, 250f
decision making in, 102111 extraction in, 239, 239f
digital imaging in, 108, 108f history, examination and diagnosis for, 226, 227f
direct resin composite mock-up in, 108109, impression of, 235, 235f
109f110f isolation in, 240, 240b, 240f
resin composite wax-up in, 110111 light curing of, 247, 248f, 249b
verbal communication in, 102105 luting resin for, 244245, 245b, 245f
visual communication in, 108111 materials for, 237238
drawback of, 115 model check of, 236, 236f
ejection of, 125f occlusal assessment in, 249250, 250f
owable, 174f, 235, 286, 287f occlusal examination for, 228, 228f
materials, direct bonding of, 23, 23f occlusal preparation for, 234, 234f
mock-ups, 152f oral hygiene and, 251, 252f
nano-hybrid, 25f proximal grooves of, 234, 234f
photocuring of, 174f reason for attendance, 226, 227f
placement of, 133f restoration design and manufacture in, 237, 237f238f
direct, 112 restoration surface preparation in, 241, 242f
for severe tooth wear, 114 review of, 251, 253f
technique, minimally invasive, 21, 22f rubber dam removal in, 249, 249f
wax-up, 110111 shade and form selection of, 231, 231b, 231f
Resin-bonded bridges (RBBs), 206, 207f shade test in, 239, 239f
advantages of, 206208 study models of, 228229, 229f
conservative, 206207, 208f temporization of, 235, 236b, 236f
esthetics, 207, 208f tooth preparation (opposing teeth) for, 232, 232b, 232f
minimum long-term damage, 207 tooth surface preparation for, 242, 242b, 243f
patient popularity, 208 treatment options for, 229230, 230f
versatility, 207 try-in for, 241, 241b, 241f
all-ceramic washing and drying in, 242, 243b, 243f
adhesive application in, 314, 314f clinical factors of, 211212
care plan in, 305, 306f abutment teeth, 211
case history on, 305, 305f maintenance, 212
cementation of, 315, 316b, 316f occlusal factors, 212
clinical case on, 305317 pontic space, 212
computer aided design of, 308310, 309f span length, 211
connector design in, 307, 307f, 308b disadvantages of, 209210
nishing and polishing of, 315, 316f esthetics, 209, 210f
framework manufacture for, 310, 311f longevity, 210
impression for, 308, 308f technique sensitivity, 209, 209f
luting cement in, 314315, 315f trial cementation and temporization, 210
preparation in, 306, 307f guidelines for success with, 210220, 216b, 216f217f
provisional restoration in, 308, 309f laboratory factors for success with, 219220
restoration assessment of, 316, 317f communication, 219, 219f
review of, 317, 317f materials, 219220, 219b
surface preparation for, 310, 312f management of failure in, 220221
tooth surface preparation for, 313, 313b, 313f operator factors for success with, 212217
try-in of, 310, 313f abutment preparation design, 215
veneering porcelain for, 310, 312f bridge design, 212214
disadvantages of, 209210 cementation, 217, 218f
esthetics, 209, 210f impressions, 217, 218f
longevity, 210 pontic design, 214215
technique sensitivity, 209, 209f patient factors for success with, 211
trial cementation and temporization, 210 Resins
bre-reinforced composite, 259f, 261272, 262b application of, 125f
advantages and disadvantages of, 264b conventional owable, relatively high volumetric shrinkage
bonding of bres to matrix, 265, 266f of, 235
contraindications for, 262263 luting, for resin-bonded bridgework, 244245, 245b, 245f
designing, 268270 Resorption, 3839, 38f
factors in uencing reinforcement of, 265b internal, 3t5t
failure of, 270272, 271f Restoration fracture, in failure of FRC-RBBs, 270, 271f
bre orientation in, 265 Restorations
bre type in, 263 amalgam, 40, 41f
bre volume in, 265 esthetic tooth-coloured, 195
indications for, 261262, 261f nishing using EVA lamineer tip, 182f
longevity of, 270272 implant-retained, 203, 203f
position of bres in framework in, 266, 267f of mandibular premolars, 186f
veneering resin composite in, 266268, 268f of maxillary premolars, 183f185f
metalceramic, 205210, 207f of maxillary right central incisor, 180f
re-cementing, 220221 of maxillary second premolars and molar, DSO technique
Resin-bonded bridgework for, 187f
clinical case on, 226251 of missing tooth, 195
adhesive for, 244, 244b, 244f photocuring from buccal and palatal aspects, 177f
axial preparation of, 232233, 233b, 233f resin composite
care plan of, 230, 231f direct, 122f, 149150
cementation of, 245246, 246b, 246f indirect, 149

329
i n d e x

shaping and nishing using diamond burs and Sof-Lex extrinsic, 3t5t, 11
discs, 178f intrinsic, 3t5t, 810, 8f
Sof-Lex discs for, 179f masking of, 107f
surface-retained, 269270, 269f non-vital anterior teeth, management of, 7689, 92t
Restorative materials pink spot, 38f
teeth discolouration and, 9 extraction of, bleaching and, 5960
tooth-coloured, 4041, 41f42f in intercuspal position (ICP), 151f
Retainer design, 269270 internal surfaces of, bleaching of, 8284
Retroclination, of maxillary central incisor, 128f missing. see Missing teeth
Rickets, vitamin D dependent, 3t5t mottled appearance of, 24, 24f
Rigid occlusal splint, 168f palatal aspect, bleaching of, 56
Rigidity, of all-ceramic bridges, 273 reshaping of
Rochette design, xed/ xed resin-bonded bridge with, 207f to camou age crowding, 104f
RPDs. see Removable partial dentures (RPDs) with developmental disorders, 107f
Rubber dam, 23, 240 resorption, 3839, 38f
isolation of, 123f, 132f staining, 26b
in RBB preparations, 240b, 240f substance, replacement of, 104f
for moisture control, 283, 283b tetracycline-stained, 47f
removal of, 249, 249f, 294, 294f upper posterior, restoration of, DSO technique for, 154,
155f
S wear of. see Tooth wear
Scalloped tray, 52f, 6466, 65f66f whitening, 26b, 32
Self-correction, 200 yellow, in bleaching, 55b
Sensitivity, in bleaching, 3738, 74, 93b95b Temporary dental hypersensitivity, 3738
Sequential dental study casts, 148149 Temporary owable composite, removal of, 239
Shade Temporization, 210
nightguard vital bleaching and, 55b, 56f for minimally invasive simple cantilever bridge, 224, 225f
selection of, 231, 231f of resin-bonded bridgework, 235, 236b, 236f
Shade test, 239, 239f Temporomandibular dysfunction (TMD), nightguard vital
in direct bre-reinforced composite resin-bonded bridge, bleaching and, 54
282b, 282f Tetracycline
Silane primer, 241 administration of, as cause of dental discolouration, 3t5t
Silicone, 224 deposition of, 9
Silicone index, 232, 233f effect on teeth, 9
Silicone stops, 170f -stained teeth, 47f
occlusal, 153 Textbook designs, abutment preparation design, 215
Simple cantilever bridge, minimally invasive, 222226 Thermal conductivity, of all-ceramic bridges, 274
assessment of, 222, 222f Tipping, 196, 198b
cementation of, 226, 226f TMD. see Temporomandibular dysfunction (TMD)
impression and temporization for, 224, 225f Tof emire matrices, 171f, 183f
materials for, 224, 225f Tonsillectomy, bleaching and, 5960
preparation of, 223, 224f Tooth loss
treatment opinions for, 222, 223f aetiology of, 195
Simple cantilever bridgework, 203204, 204f in esthetic zone, 194195
Simple cantilever design, for RBBs, 213 prevalence of, 194, 194f
Single-tooth tray, 58f, 67, 68f69f reasons for replacing, 195196
Snow-plough technique, 153, 174f esthetics, 195
Sof-Lex discs, 178f179f function, 196
Soft tissues, effects of bleaching on, 3940, 40f phonetics, 196
Speech patterns, short-term impact on, 196 prevention of tooth movement, 196
Splint, rigid occlusal, 168f psychological factors, 196
Split-pontic design, 237, 237f Tooth movement, prevention of, 196, 197f, 198b
Staining, 26b Tooth surface
external, 11 loss of, 15
Stains preparation of, in direct bre-reinforced composite
direct, 3t5t resin-bonded bridge, 284, 285f
indirect, 3t5t Tooth wear, 1516, 15f, 148
Stops, for replication of new occlusal vertical dimension anamnesis for, 148149
(OVD) position, 166f attrition and, 148
Straight-line tray, 66, 67f esthetic management of, 1516
Supra-gingival margins, 235 nightguard vital bleaching and, 55
Surface-retained restorations, 269270, 269f severe, 114, 162, 162f164f
Systemic infectious disease, 3t5t direct resin composite restorations for, 149150, 157b
direct shaping by occlusion (DSO) technique for,
T 150157, 151f152f, 154f155f, 156b, 175f
Teeth (tooth) gastro-oesophageal re ux disease (GORD) and, 162f
abutment, 195, 211 indirect resin composite restorations for, 149
etching of, 313f materials use for treatment of, 190b
altered contours of, 142f results of direct minimally invasive treatment in,
blue/ grey, 55b 188f189f
complete displacement of, 200 treatment options for, 148150
direct mock-up on, 167f Tooth-coloured materials
discolouration of, 6, 6f, 2425, 25f, 3233, 32b, 33f, in minimally invasive replacement of missing teeth,
93b95b, 107f 256321
causes of, 3t5t, 96t restorative, 4041, 41f42f
combined aetiology of, 90 Tooth-coloured restorations, esthetic, 195

330
i n d e x

Toothpaste Upper teeth


bleaching and, 48, 93b95b appearance of, after periodontal surgery, clinical case on,
whitening, ef cacy of, 93b95b 128f135f
Torpedo-shaped diamond bur, 232 uneven distribution of front, clinical case on,
Transformation toughening, of all-ceramic bridges, 122f127f
273274 wearing of, clinical case on, 139f144f
Transplantation, in management of missing teeth, 200201, Urea, 3637
201f
Trauma V
as cause of dental discolouration, 3t5t Veneering resin composite, 266268, 268f
lost teeth due to, 195 placement of, in indirect bre-reinforced composite
Trays resin-bonded bridge, 300, 301f
combination, 67 Veneers, 2223, 9192
design, 6167, 61b, 62f63f bleaching and, 64
tting of, 7074, 72f direct composite, 170f
making of, 8788 resin, placement of, 124f
purpose of, 6162 restoration, for severe tooth wear, 153
reservoirs, with or without, 6365 Vitamin D dependent rickets, 3t5t
scalloped, 52f, 6466, 65f66f
single-tooth, 58f, 67, 68f69f W
straight-line, 66, 67f Walking bleach technique, 86, 91, 92t
Trial cementation, 210 Whitening, 36
TWI (tooth wear index), 148149
Type IV gold alloy, 237238 Y
Yttrium tetragonal zirconia polycrystal (Y-TZP), 272
U frameworks, 273, 275f
Ultra-violet light, resin composite mock-ups, 110f Y-TZP. see Yttrium tetragonal zirconia polycrystal
Unilateral de-cementation, management of, 221, 221b, (Y-TZP)
221f
Upper jaw, widening of, 103f Z
Upper lateral incisors, as congenitally missing teeth, Zirconia, 272
200 Zirconia-yttria bridges, 272273

331
This pa ge inte ntiona lly le ft bla nk