The Dentist's Network #103

Cosmetic Composites - Rewarding for Patients and Dentists

When we think about cosmetic dentistry, we usually think about procedures like porcelain veneers, short term ortho, deep bleaching and aligner treatment. These procedures can be highly effective and can yield a tremendous change for our patients. However, over the last few years I’ve continued to see how well-performed anterior cosmetic composites can dramatically improve a smile and add to a dental practice.

Many of our patients have worn, chipped, ill-proportioned and asymmetrical anterior teeth. Furthermore, many smiles demonstrate other unattractive features such as black triangles (unfilled gingival embrasures), diastemas, fluorosis spots etc. Most of us are well aware that a nice looking smile must contain a certain amount of symmetry. All of the features I’ve listed here detract from the symmetry of a smile and cause the smile to look less appealing.

With some operator skill and the right knowledge/materials, we can greatly serve our patients by providing improvements in these areas with the use of composite resin. In my experience, in order to yield great results, a dentist must:

1. Understand The Anatomy Of Anterior Teeth To A High Degree
When we are replacing missing tooth structure or adding dimension to misshapen teeth, it is vital that we can envision the desired result in our minds’ eyes. I’ve found that carefully studying models of teeth and perusing photos of teeth taken from various angles allows us to truly understand all of the anatomical characteristics of anterior teeth. This provides us with the ability to be intentional about what we are creating and to understand what is incorrect if something doesn’t look quite right.

2. Bevel And Scallop Appropriately
Particularly for upper central incisors, it is important to bevel and scallop appropriately. This allows us to blend the composite in a way that will prevent a distinct line from showing at the margin. For instance, when doing a class 4 restoration on an upper incisor, the margin should be beveled so that the bevel is as long as the restoration will be. This provides for a long and smooth gradation in the thickness of composite. The bevel should also be scalloped so that there is not a distinct edge on the bevel. This further helps to create a smooth transition from tooth to composite.

3. Use Bioclear Matrices For Diastema Closure And Black Triangle Closure
One of the best products to be released over the last few years is the Bioclear matrix from Bioclear. We all can finally throw our mylar strips out the window as Bioclear matrices provide for much more predictable, efficient and anatomically accurate composite restorations. The Bioclear matrices come in a variety of shapes and sizes and all of them are exquisitely crafted so that they match natural tooth anatomy. In my cosmetically focused practice I primarily use them to close diastemas, add width to teeth before short term ortho, and to close those unsightly black triangles that so many patients have. The shape of the Bioclear matrix allows us to accomplish these things in a controlled fashion. Bonding black triangles closed has traditionally been a nightmarish procedure that most dentists don’t even try to tackle. The Bioclear matrix system makes it simple.

4. Use Interface™-The “Super Silane”
Interface is a product that has changed dentistry forever. It allows us to bond composite to porcelain in a predictable manner. Whether bonding an orthodontic bracket to a PFM or repairing a chipped veneer, Interface (by Apex Dental) is a lifesaver! Have you ever bonded a set of veneers only to have the patient chip one of them months later? Typically, that situation has been very challenging. Do we replace the veneer? Do we just leave it “as is?” A few drops of Interface and then some bonding adhesive allows for us to repair veneer chips, fractured bridges or broken crowns with composite. It truly is a fantastic product that every dental practice can benefit from.

5. Work With A Composite That Has Good Blending Capabilities
I’ve used many composites that are difficult to work with. In my experience, some composites are just too transparent to be used for incisal edge repairs. If you’re like me, you don’t want to have to use five different shades and translucencies for one restoration. I prefer to use one or two different shades/translucencies per restoration. I also want to use a flowable composite that works in conjunction with the packable composite. For incisal edge repairs and diastema closures it is necessary to use a composite that blocks enough light. If the composite is too translucent, the area of the restoration will always have an inappropriate value and chroma.

Conservative and strategically placed cosmetic composites are not just a great service, but they can be a practice builder too. Whether it’s worn and “ditched out” incisal edges, black triangles due to periodontal disease or chipping from trauma, composite resin can yield fantastic results that patients see tremendous value in. In my practice, we offer what we call “the quick and easy smile rejuvenation.” We evaluate the smile and then use composite and cosmetic re-contouring to provide as much harmony to the smile as possible. Patients love this service because it is done in one visit, there is no anesthesia used and the results are immediate. This is dentistry that is tangibly rewarding for both patients and dentists.

Dr. Ryan Swain is a graduate of the University of Florida College of Dentistry. He practices in Rochester, NY and focuses on Short Term Ortho and other conservative cosmetic dental procedures. He is president and chief clinical instructor for Six Month Smiles. Dr. Swain is a pioneer in the field of Short Term Ortho and constantly on the forefront of GP orthodontics. He has trained dentists internationally and prides himself on de-mystifying orthodontics for GPs.

Dr. Swain can be reached at Drswain@thedentistsnetwork.net

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Chris J. Lampert, DMD
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Endodontic Questions and Answers

The following three questions represent a sample of questions I am often asked during continuing education courses. I think they are good to share because they cover a variety of endodontic topics and they demonstrate what other clinicians are thinking. Please feel free to e-mail me your own endodontic questions at DrLampert@thedentistsnetwork.net

Question: How do you determine if a vertical fractured tooth is non-restorable?

Answer: Determining the subgingival depth of the vertical fracture is the key to answering this question. This often requires the use of a surgical operating microscope. If the fracture extends apical to where a crown margin can be placed, for example into the biological width, then the fracture has a hopeless long-term prognosis. This is because the fracture will not be sealed by the cast restoration and the exposed fracture will be a portal of entry for bacteria.

A second clinical situation that has a poor prognosis is when two opposing fractures exist in the same plane. Even if the fractures are not particularly deep, this situation generally has a vertical and horizontal component. It is my experience that this situation is more common with maxillary pre-molars than with other teeth.

A third non-restorable clinical situation exists when a fracture involves the pulpal floor on multi-rooted teeth. If a fracture extends across or onto the pulpal floor then the tooth is not restorable regardless of how deep the fracture goes. With these guidelines in mind, it must also be said that not all fractures are visible, even under high magnification through the access opening. Some vertical fractures cannot be visualized until a periodontal flap has been reflected.

Question: How do you stop or control bleeding from a canal during treatment?

Answer: The main causes for a hemorrhaging canal are remaining vital tissue in the canal, strip perforation, and over instrumentation. Determining which of these three causes you are dealing with is necessary to enable you to select the correct treatment.

If vital pulp tissue in the canal is the cause, then confirming true working length with an apex locator and using larger file sizes to extirpate the remaining pulp tissue is the solution. his is more common in canals with large apical diameters and in young teeth with large underdeveloped apical foramen.

To determine if you have a strip perforation, an apex locator is a valuable instrument. The apex locator will read patency when you get to the level of the strip perforation. Paper points are another method for detecting a strip perforation. If a paper point has a consistent bleeding spot that is not on the tip of the paper point then a strip perforation should be suspected. If you consistently reproduce these findings then you are likely dealing with a strip perforation. This requires a techniquely challenging repair with MTA.This procedure should be handled by an endodontist.

Canal bleeding can also occur if shaping instruments are taken past the canal terminus (over instrumentation). Large hand files sizes .15 and larger and all rotary instruments can damage the periradicular tissues and produce bleeding. If bleeding occurs because of over instrumentation, the best remedy is to close the tooth and complete the procedure on a different day. It should be mentioned that using small hand files, sizes .08 and .10, to determine working length and maintain patency, do not produce bleeding.

Question: Do you reduce the occlusion on the treated tooth following the completion of endodontic treatment?

Answer: If the treated tooth has acute percussion or periodontal ligament symptoms prior to treatment then I usually reduce the occlusion. Post-operative inflammation is generally easier to manage and the patient will be more comfortable if the occlusion is reduced in these cases. I do not reduce the occlusion on asymptomatic necrotic teeth or on teeth with irreversible pulpitis that only have thermal symptoms.

Another clinical situation requiring occlusion reduction includes fractured teeth. For posterior teeth without crowns, the tooth is structurally compromised following access, especially if the tooth has a fracture. Reducing the occlusion will help protect the tooth from further breakdown.

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University.

Dr. Lampert can be reached at drlampert@thedentistsnetwork.net

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Louis Malcmacher
DDS MAGD
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It's About Time

It’s really interesting to me now, looking back with 30 years of dentistry under my belt, to see certain situations come around over and over again. What is even more interesting is how dentists and the dental market sway to one kind of thinking by a plethora of opinions that then become accepted as fact to dentists. This certainly is true of the whole arena of veneers and what we have just gone through in the last 15 to 20 years.

This is not at all a discussion of should we prep for veneers or should we not prep for veneers - I think we are well beyond that and there are many instances where preparation is absolutely necessary and many more instances where some kind of minimal preparation or enameloplasty is all that is required with a percentage that really do require no preparation at all. Dentistry has gone through the phase of no preparation and then to full preparation of veneers and now it really seems like the pendulum has swung back to a more reasonable tone where each case individually requires the careful teeth-by-teeth analysis as to what that tooth requires in terms of preparation or no preparation to what the final case will look like.

I have been an advocate in teaching the no/minimal approach to veneers for close to 25 years. A few years ago, when DenMat “introduced” the concept of a no-prep veneer called Lumineers and advertised it straight to the consumer market, there was a terrible backlash by dentists and most dental laboratories. I clearly remember the advertisements that were placed that said: “No prep - No good.” It was just inconceivable to most of the key opinion leaders in esthetic dentistry that a no-prep approach had any validity. In terms of consumer marketing, DenMat was breaking new ground that is still being argued within the dental community as to whether it is right or wrong. We will leave that aside for now, but one thing is crystal clear - the consumer, your patient, certainly responded quite strongly in favor of a minimally invasive approach, especially when it came to esthetics. Given the choice, and that choice really came with training dentist in the no/minimal preparation veneer procedure more than anything else, patients overwhelmingly want to save and retain tooth structure whenever possible and certainly require a great esthetic result.

Now, especially in the last few months, it seems to me that you almost can’t open a dental journal without finding an article about no preparation veneers, many of them written by the same key opinion leaders who derided them not so long ago. One key opinion leader (and good friend of mine) just wrote an article on no preparation veneers and in the article states that while this is his first case of no preparation veneers “done on a family member,” goes on to say the advantages and disadvantages of this technique based on one case! There is a lengthy dissertation on the pros and cons of minimally invasive veneers just based on his experience on just this one case. He has hundreds of cases of prep veneers and still leans toward that approach, but begrudgingly says that this technique may have some applications in dentistry for just the perfect case.

All I can say is that it’s about time that some key opinion leaders have caught on to what dentists have known responsible esthetic dentistry should be. It is also about time that we don’t publish a case study and give our opinion based on one case as to what the advantages and disadvantages of any technique. As someone who has literally done hundreds of these cases over the last 30 years, I can tell you that it makes up the bulk of my aesthetic practice and you really have to show me in many instances why you would do any kind of heavier preparation when a no/minimal preparation approach can give you the same, if not better, result. Once you understand the concept behind these techniques, using the especially made porcelain developed for very thin veneers and done by a laboratory who also understands these concepts, the results can be incredible.

There is no question that we are into the next generation of minimally invasive veneers with the advent of Cristal Veneers by Aurum Ceramics Laboratories. The two biggest complaints about these veneers in the past are that they were too opaque and too bulky. This is now solved with the right kind of porcelain and the right kind of laboratory partner. Everyone will agree that LVI has some of the highest level of esthetics in dentistry and only two laboratories get them there - one being Aurum Ceramics. They have brought the highest level of esthetics possible to the no/minimal prep technique which now rivals any other kind of veneer out there.

New concepts are entering dentistry every single day. In the case of esthetic dentistry and veneers, this was the original concept that has come around to us in a new and improved form. Quite frankly, it was abandoned for a while. It’s about time that we have partners that develop ways to take minimally invasive dentistry to the next level and accomplish what both we and our patients want - great esthetics while maintaining healthy tooth structure.

If you want to learn more about the best way to do no/minimal prep veneers, click HERE to order the definitive live over the shoulder treatment DVD of no prep veneers and learn how to do these correctly and make them a part of your practice.

Dr. Louis Malcmacher is a practicing general dentist in Bay Village, Ohio, an internationally known lecturer, dental consultant and author, and is President of the American Academy of Facial Esthetics. Interested in knowing more about how to truly enjoy dentistry? Click here.

Interested in having Dr. Malcmacher speak to your dental society or study club? Click here. To reach Dr. Malcmacher, email him at DrMalcmacher@thedentistsnetwork.net or call 1.800.952.0521.

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