Tag Archives: dental

Ceramic restorations on Discoloured stumps around the gingival tissues

A tooth can discolour for a lot of reasons. If you ask a Sydney dentist about this, you will be advised that teeth could discolour due to age, food, beverage, medications, trauma, dental caries or exposure to highly staining compounds.

A tooth fitted with a porcelain fused to metal crown may stain after prolonged exposure to the metal. This results in an unsightly discoloured stump that often reflects and affects the gum tissue. Teeth with discoloured stumps are very unattractive. It gives the patient a smile that looks dirty, old and diseased, especially since the stained appearance reflects on the soft tissue or gums too.

It is a frustrating problem because even if you place the margins at a subgingival level, the problem still remains. When we encounter a problem like this in the clinic, we suggest a few things to the patient:

1. Internal bleaching. An initial remedy for the discoloured stump that has spread to the gingival tissues is to perform an internal bleaching procedure. This is most appropriate for root canal treated teeth, with effectiveness that is quite unreliable.

2. Opaque restoration. A more definite solution that we provide involves masking or covering the discoloured stump with an opaque restorative material or composite resin. Using Kolor +- Kerr Dental we overlay the darkened area to mask the unappealing area so that it does not reflect on the crowns and on the gum tissues.

This kind of remedy is applicable for root canal treated teeth, teeth receiving dental crowns, bridges and veneers. It may be performed on porcelain-fused-to-metal crowns, all-porcelain crowns or even zirconium crowns. The result you receive is a natural-looking teeth restoration, the appears good as new. The teeth will appear beautiful, healthy and clean.

Discoloured stumpsDiscoloured stumpsCeramic restorationsCeramic restorations

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Sonic activated composite in a full arch build-up for extensive tooth wear

Extensive multi-surface tooth wear is common in several people and your Sydney dentist will explain how it may easily be caused by a different things:

  • Chemical erosion. When there is acid regurgitation or the presence of a naturally acidic oral environment, the teeth may be severely worn away so that the bite collapses as teeth height is reduced on the maxillary and mandibular jaw.

  • Bruxism. Night grinding or bruxism is a paroxysmal habit observed during night slumber, but may also be experienced in the day. It is an involuntary problem that involves the over-clenching of the teeth that often leads to wear facets and damage.

  • Malocclusion. When the patient’s bite is wrong or is misaligned, this disharmony can cause damage to the teeth. This is common with people with cross-bite, deep bite and edge-to-edge bite. The upper and the lower teeth contact each other, in damaging fashion so that teeth become excessively worn away.

  • Ideally, this issue is resolved by installing dental crowns and bridges on all the teeth to restore the bite and the appearance of the teeth. This would be acceptable when not much damage has been incurred but when very little tooth surface is left to work with, retention for the prosthetics is highly compromised.

    Dr. Chris Ho follows a different approach and it is explained in detail in the attached post. In lieu of invasive and expensive crowns, composite resin is provided to restore the worn teeth. Utilizing a template, a specialized bonding adhesive and reinforced composite resin, the patient is given a better reason to smile.

    Advantages of getting a sonic-activated composite full-arch build-up:

Class II: Wedge doesn’t do anything!

Dental caries or defects on the teeth may occur on different areas. Pit and fissure caries affect the occlusal table and decay of this nature is limited to just one surface, but when caries extend to the proximal areas, a different approach is required. When the sides are involved, a barrier or matrix band is utilised to keep saliva and blood away from the area and properly restore the proximal and contact points. Ideally, a matrix barrier should be enough. It is inserted in between the teeth, is held in place with the help of wedge and the restoration is given to the tooth without any problem.

Unfortunately, sometimes you will come across those frustrating cases when you stick a wedge into a matrix and the bloody gum still bleeds as you work. This can be quite frustrating because it makes it hopeless to restore the tooth. The blood and saliva will disrupt your work, so you will take longer. Either that or the restorative work you complete will be poor.

One way of adapting the matrix more intimately is the use of another wedge (two wedges) or another neat trick is to use Teflon tape (aka plumbers tape) to adapt the matrix to ensure a clean field to place your composite. Using a Teflon tape is unusual but it offers a few benefits:

  • Teflon tape will isolate the and provide visual enhancement for results achieved. With its help, the dentist is able to shape the composite up to the proximal third of the crown.
  • The Teflon tape is very flexible and thin. It is kind of the tissues and it inserts easily through the area between the gum and tooth. It provides better barrier and protection to the tooth and gums.
  • This offers proper manipulation of the composite material, so that you can avoid creating dark triangles in between the anterior teeth you are trying to restore.

  • WedgeWedge

    wedge

     

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What is Biomimetic Dentistry?

The days of invasive dentistry that involves having to remove vital parts of teeth or cut down teeth for crowns are drawing to a close with the latest in Biomimetic technology. Biomimetic Dentistry allows a Sydney dentist to conserve teeth by treating weakened teeth that may be fractured or decayed and protecting them from bacterial invasion by sealing them with an adhesive restoration.

Better than traditional methods, Biomimetic Dentistry does not require a dentist to destroy healthy tooth structure in order to build a new restoration. Using the latest in technology, we can bond and adhere teeth together and build missing components of teeth without destroying vital tissue. Modern Dentistry believes in conservativeness of treatments and so nowadays we seek to undertake as little prep or even no prep when it comes to applying veneers or offer onlay, partial crown Biomimetic solutions in preference to a traditional crown thus conserving teeth. This means that restorative treatments are achieved without compromising health.


Indirect Restorations


The advances in adhesives and bonding materials have improved dramatically over the last 40 years, in so much that dentists can restore many cases that would have required crowns with minimally invasive conservative restorations. Although relatively successful and producing increased likelihood for success, understand that carrying out conventional crowns can lead to non-vitality of teeth due to the aggressive preparation required. By utilising the philosophy behind Biomimetics, the preparation needed is often reduced, thus minimising the biological impact to the tooth. Additionally, when this route is opted, many times the preparations can be kept at a supragingival level, leading to the preservation of healthier tissues that allow easier impressions and simpler adhesion procedures.

The Biomimetic technology involves the use of innovative materials. These new materials mimic tooth dentin so well that it even fuses to the existing tooth, offering reliable stabilisation and strength to the restoration. Biomimetic means to copy or mimic nature. For any restorative or cosmetic job done, a patient should appreciate any effort to get their smiles back in the healthiest and most aesthetically appealing manner.

Bio MimeticImage Courtesy of  https://biomimeticdentistryce.com/what-is-biomimetic-dentistry/

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USEFUL APPS FOR DENTISTS AND PATIENTS

The world as we knew it has changed. We are in the digital age and to better survive, one has to fully integrate the changes into their lives. The same could be said with dentists. These days, we have multiple technologies in our grasp, and one of the easiest for patients to understand is using a tablet like an iPad. Being able to demonstrate images on a tablet is just so much more high tech for a patient. This sets you apart from another Sydney dentist and helps educate your patients in a more effective manner.

Here are just some apps for dentists and patients:

DDS GP

DDS GP

DDS GP is an app for dental professionals that allow them to show dental conditions and treatments to their patients using an iPad. It is probably the most comprehensive of all the applications that I have seen.

  • You can TAP and DRAG items on the screen, to easily show severity of decay, periodontal disease, cracks, and numerous other conditions and procedures.
  • You can DRAW right on the screen with your finger and you can save your drawings for future use.
  • You can also ADD your own images or photos from your photo library, then draw on and save them.
  • Finally, you are allowed to SEND or PRINT custom treatment plans to your patients using this app.
  • Check here for details & download
  • Dental Navigator

    DENTAL NAVIGATOR

    Dental Navigator is an interactive application, which can be used by dentists to explain different methods of treatment to patients. If you have the new Apple iPad, you can use an HDMI adapter to project the whole application onto a large screen for better viewing.

    Check here for details & download.

    Dental Expert

    DENTAL EXPERT

    This application is an excellent app for patients as it explains the different treatments available in dentistry, and the best thing is it is FREE! Check here for details & download.

    Pediatric Dental Expert

    PEDIATRIC DENTAL EXPERT

    This application is a food guide that parents could use to be able to understand the proper dental care that their children need. It is FREE and it is easy to use, so you can download it today. Check here for details & download.

    Dentistry ProConsult

    Dentistry ProConsult

    Dentistry ProConsult is designed to provide dental students with a quick and easy way to review procedures they may have to perform in clinic. It is Free!

    Check here for details & download.

Geistlich Mucograft ® Seal

Depending on the case presented to the Sydney dentist, there will be instances when the needs of the patient will go beyond what is usually done, just so health, function and aesthetics could be restored.

Mucograft seal is collagen membrane matrix that may be applied to the patient’s mouth. It is a synthetically fabricated material made from purified type 1 collagen so that it can guide, promote and hasten tissue healing for the following cases:

  • Difficult tooth extraction that involved extreme bone loss, such as in the case of impacted teeth removal.
  • Dental implant placement procedures on areas with insufficient bone. When diagnostic evidence reveals poor bone level and quality, it could be improved with bone grafts and matrices.
  • Immediate loading of dental implants following a tooth extraction to gain proper stability.
  • Tissue replacement after removal of bony defect or pathology, when gum tissue has been lost from the surgery.
  • Ridge augmentation procedures for cosmetic or treatment purposes, either for removal dentures or dental implant placement.
  • Soft tissue grafting procedures as a result of gum recession or disease, to successfully cover exposed tooth or bone.
  • Sinus lifting procedure for treatment purposes.
  • After the procedure, after the grafting material is placed the tissue soft tissue is brought back and to enhance healing and success. Behaving as a soft tissue covering or dressing, the collagen material is placed, sometimes to hold the bone graft.

    The people at Geistlich have produced a new collagen matrix named Mucograft ® Seal. It comes in a convenient circular shape and is indicated for the sealing of extraction sockets with preserved buccal walls in combination with Geistlich Bio-Oss ® Collagen in Ridge Preservation procedures. The collagen matrix allows predictable soft tissue dimensions and provides an alternative to soft-tissue grafts. In other words, treatment procedures provided with the collagen are given a higher success rate; and the provision of the material bring forth a more aesthetically appealing surgical site.

    Geistlich Mucograft

Complex Aesthetic and Functional Rehabilitation with an Additive Minimally Invasive Restorative Approach

The treatment of a patient with extensive tooth wear presents with particularly complex challenges, however experience the Sydney dentist may be. This arises primarily due to determining the source of often a multi-factorial etiology, to the diagnosis of tooth wear and the definitive management of the patient. Because of this, Complex Aesthetic and Functional Rehabilitation will be needed.

Historically the management of patients presenting with extensive tooth wear was with conventional fixed prosthodontics. This would involve preparation with crowns on the teeth where tooth structures were already compromised. This would increase the biomechanical risk to the dentition due to the reduction of tooth structures, which negatively impact the structural rigidity of the teeth.

Additionally a conventional approach could result in a loss of pulpal vitality of the teeth. Teeth requiring fixed prostheses have a 6-11% requirement for endodontic treatment. This approach is more invasive and is irreversible.

With the development of adhesive bonding, we have the means of restoring the dentition in a much more conservative manner with an additive approach and this case will describe the concepts involved in a complex rehabilitation using both direct and indirect restorations with minimal biological risk to the patient.

Table 1: Advantages of adhesive restorations 

ADHESIVE RESTORATION

                        Retention form and resistance form not relevantEnamel bonded – predictableConservative and minimally invasiveDecreased endodontic riskMaximizing remaining tooth structures

 

Clinical Case Overview

Gender: Female

Age: 41 year old

Chief complaint: Short nature of her teeth causing poor quality and esthetics, as well as the occasional bilateral masseter muscle tenderness.

Oral examination: Intra-orally the tooth surface loss was generalized, involving all the teeth in both arches and extended into dentine. Anteriorly, there was also thinning and chipping of the incisal edge resulting in reduced clinical crown height.

 

Diagnosis

The diagnosis requires a need to identify the factor(s) contributing to tooth wear, which may be difficult due to often a multi-factorial etiology. This is important to identify to preserve the remaining dentition and to improve the long-term prognosis of any restorative treatment completed.

The patient was diagnosed to have tooth wear due to tooth erosion that had occurred when she was bulimic, with a secondary etiology of bruxism. Chronic exposure to acidic substrates had led to exposure of the dentine, chipping of the teeth, and was complicated with the parafunctional habits of the patient.

Patients that present with generalized tooth wear often do not display a loss of OVD due to the loss of tooth surfaces occurring at a slow rate, which allows time for alveolar compensation. In cases where the surface loss is active and rapidly progressing this may lead to loss of occlusal vertical dimension as alveolar compensation may not be keeping up to the same rate. In occlusion, the patient appeared to have a decreased lower face height due to a loss in occlusal vertical dimension, which had not fully been compensated for by alveolar compensation (Figure 2).

loss in occlusal vertical dimension

Figure 2


The objectives of  treatment are to:

  1. Improve dentofacial aesthetics.
  2. Restore occlusal vertical dimension and improve occlusal function establishing a stable position of maximum intercuspation with bilateral simultaneous occlusal contacts.
  3. Restoring and protecting structural compromised and exposed dentinal teeth structures with minimally or no preparation designs.
  4. Prevent further tooth erosion.

 

Treatment

The extra-oral examination allows
 assessment of the amount of incisal display while the upper lip is relaxed (Figure 3) and while the patient is talking and smiling (Figure 4). This reveals that there was insufficient display of the teeth, and that there was the potential to lengthen the incisal edges of the maxillary teeth.

extra-oral examination

Figure 3

extra-oral examination

Figure 4

Following a comprehensive intra-oral clinical assessment including diagnostic photographs, study casts were taken and mounted on a semi-adjustable articulator.

diagnostic wax up

Figure 5

diagnostic wax up

Figure 6

A diagnostic wax up (Figure 5, 6) was undertaken, with the requested esthetic changes communicated to the dental ceramist. The occlusal prescription included contouring the wax build-ups to provide bilateral even contacts in retruded contact position.

Upon completing the work-up the treatment plan decided upon in consultation with the patient included:

  • Mandibular – direct resin composite build-ups on teeth Nos 22-28 and coverage of dentinal exposed areas on teeth Nos. 19, 30, 31
  • Maxillary
  • No-preparation restorations on teeth Nos. 2, 5-12
  • Minimal invasive onlay preparations on previously restored teeth Nos. 3, 14, 15

 

Mandibular Direct Composite Resin Build-ups

Each tooth was prepared by abrading with 27 micron Aluminum Oxide and a total etch adhesive technique (Optibond Solo Plus, Kerr Dental) was utilized. Placement of resin composite (Herculite Ultra, Kerr Dental) was accomplished with the aid of a silicone matrix formed from the palatal anatomy established from the diagnostic wax up (Figure 7). Resin composite was carefully adapted in layered increments, no greater than 1.5 mm per increment. The use of the matrix allows the placement of composite to form the palatal contour and incisal length of the teeth as planned from the diagnostic waxup (Figure 8). This will allow minimal adjustment at completion of the restrations.

27 micron Aluminum Oxide

Figure 7

27 micron Aluminum Oxide

Figure 8



Maxillary Indirect Restorations

Prep-less or additive restorations were planned for the majority of the maxillary teeth as these were in a lingualized axial position and furthermore needed to be lengthened for ideal esthetics. Hence there would be no need to prepare the teeth to achieve the desired outcome. Additionally by not preparing the teeth the restorations would be bonded to mainly enamel apart from areas that had dentine exposure on the incisal/occlusal surfaces. The success and predictability of bonding to enamel are major factors in terms of longevity and durability of the restorations.

In a 12-year study of 583 veneers 7.2% or 42 veneers failed. With those veneers bonded to dentin and teeth with preparation margins in dentin were approximately 10 times more likely to fail than those bonded to enamel.

putty indexes

Figure 9

 

putty indexes

Figure 10

Teeth that were previously restored had the restorations removed and the preparations completed to allow a path of insertion for onlays to be inserted (Figure 9). In this case a bonded functional esthetic prototype (BFEP) was spot-etched and bonded into position utilising putty indexes made from the diagnostic wax-ups (Figure 10). This allows the patient to assess the “trial smile” prior to completing the final restorations (Figure 11). This transitional stage allows time for the patient to accept the proposed new smile but also to be able to assess the occlusal changes from the increase in occlusal vertical dimension and occlusal stability over a period of weeks or even months.

trial smile

Figure 11

The provisional restorations were removed with careful attention to remove areas that had been spot-etched and bonded with a bur. The remaining tooth structures were air abraded with 27 micron aluminum oxide.

The final restorations were fabricated with pressed lithium disilicate (e.max – Ivoclar Vivadent) materials using a B1 LT ingot (Figure 12).

lithium disilicate

Figure 12

The lithium disilicate restorations were individually placed to assess marginal fit and contact points. The restorations were then placed with a clear try in gel to display to the patient prior to permanent cementation, who then gave approval for the final cementation.

Each restoration was etched with 4.5% hydrofluoric acid for 20 seconds, followed by cleaning of the chemical salts by rinsing and insertion into an ultrasonic bath with distilled water. After air drying each restoration was then silanated for more than 60 seconds.

As the ceramic restorations are thin, and have minimal retention due to minimal or no preparation, cementation requires the restorations to be adhesively bonded with resin cement. A strong, durable resin bond provides high retention, improves marginal adaptation reducing microleakage, and increases fracture resistance of the restored tooth and the restoration.

The teeth were adhesively bonded with a total etch technique (Optibond Solo Plus, Kerr Dental) and restorations bonded with a light cure resin cement (NX3 Nexus, Kerr Dental) for the anterior teeth, and dual cure resin cement (NX3 Nexus, Kerr Dental) for the posterior onlays which were thicker in cross-section.

The restorations were then adjusted and finished with ceramic polishing and finishing techniques. The margins were finished into an “infinity margin” (Figure 13). Once the margins were no longer detectable with an explorer, they were polished with rubbers and diamond polishing pastes. The occlusion was evaluated and adjusted in centric occlusion, lateral and protrusive movements and finally in the chewing envelope.

infinity margin

Figure 13

Due to the nocturnal bruxism habit a full maxillary occlusal splint was fabricated with careful instructions on it use.

 

Conclusion

The aim of managing the worn dentition should be to determine the etiological factors and institute an appropriate preventive program to protect the remaining tooth structures whilst restoring function, occlusal stability and esthetics. Treatment planning involves understanding the etiological factors involved, to the planning of the steps involved with the reconstruction of the dentition for both functional and esthetic requirements. A minimally invasive or prep-less approach is preferred and the use of
direct and/or indirect restorations can be utilized in reconstructing the lost tooth structures in an additive approach.

 

Acknowledgements

The author thanks Mr. Brad Grobler (dental ceramist) for the technical and artistic expertise of restorations included in this article.

 

Figure Descriptions

 

  1. Extensive wear of tooth structures
  2. Facial view of patient with reduced occlusal vertical dimension
  3. Repose position of patient – lips at rest
  4. Full smile with minimal display of teeth
  5. Maxillary Diagnostic Waxup
  6. Mandibular Diagnostic Waxup
  7. Silicone matrix of diagnostic waxup allowing a template to allow buildup of resin composite
  8. Composite resin buildups carried out individually to template
  9. Occlusal view of maxiallary teeth demonstrating no preparation on majority of teeth and the removal of old restorations
  10. Bis-Acryl Resin Provisional restorations
  11. Trial smile with provisional restorations
  12. Lithium disilicate restorations on model and demonstration of incisal length increase
  13. Completed restorations on maxillary teeth
  14. Retracted frontal view of maxillary lithium disilicate restorations and mandibular direct resin composite
  15. Smile view of completed restorations.

Katana Zirconia (Noritake) translucent multi-layered zirconia

 

 

When a Sydney dentist is faced with an important cosmetic problem on a patient, one of the things he makes sure to do right is to pick the right shade. This is determined, by matching the existing teeth and making certain that the shade is appropriate to the complexion.

 

Matching the color and choosing the right shade for the restoration is important because the results and the overall satisfaction of the patient depends on this. A patient comes into a Sydney dentist’s office to get better smile and if the smile does not look natural and even, he will not be happy. The success of every case will rely on how happy the patient is with the results and sometimes it will all be about choosing the right restorative material.

Katana Zirconia

There has always been the concern with veneering porcelain chipping from a traditional zirconia crown, and the use of monotlithic full contour zirconia has recently become extremely popular to a Sydney dentist due to the high physical properties of these materials.

Historically it has always been the veneering (fedspathic) porcelain failing with fracturing or chipping. The trade off was always the poor aesthetics that followed due to the dense polycrystalline structures.

Recently, Noritake has released a full contour zirconia restoration using the new Katana Zirconia ML, a gradational multilayered zirconia disc with four layers of color–35% enamel, 15% of the first gradation layer, 15% of the second gradation layer and 35% dentin–that offers the look of layered porcelain. The pre-colored multilayered shades provide esthetic results without manual dipping or staining and eliminate additional material costs. KATANA Zirconia ML discs are available in three shades: A-Light, A-Dark and B-Light (KATANA HT–a high translucent mono-colored zirconia–is also available in three shades: HT10, HT12 and HT13). So far this material exceeds the aesthetics of other full contour zirconias, so look out for this material.