Minimally Invasive Dentistry: A Conservative Approach to Smile Makeover

The concept of minimally invasive dentistry is based on preserving tooth structure, especially enamel. A conservative method to treat discolored teeth that have diastemas is a freehand additive technique using composite resin. While selecting the correct shade of resin can be challenging, newer composite resin formulations are being developed with optical properties that enable the material to more effectively blend into the dentition. This case report describes the use of conservative approaches and materials to treat discolored, unevenly spaced teeth and restore harmony and balance to a patient's smile.

[Preliminary clinical evaluation of the esthetic effect of deep discolored anterior teeth restored with zirconia veneers]

OBJECTIVE

To observe the esthetic effect of deep discolored anterior teeth restored by zirconia veneers.

METHODS

Small defected deep discolored anterior teeth with complete root canal therapy were restored by zirconia veneers (n=15). The same name teeth on the other side of the same dental arch were chosen as control teeth. The color difference values ΔE of the neck 1/3, the middle 1/3 and the incisor 1/3 between the deep discolored tooth and the normal control tooth before and after therapy were measured to evaluate the esthetic effect of zirconia veneer restoration. At the same time, the marginal fit of zirconia veneers was checked by the standard of United States Public Health Service (USPHS). The integrity of the veneers was also examined.

RESULTS

On the labial side, fibers color difference values ΔE of the neck 1/3, the middle 1/3 and the incisor 1/3 between deep discolored teeth and normal control teeth were measured by the electronic colorimeter, which were 24.92±3.00,26.64±4.00 and 21.94±3.31 respectively. All the values were above 4.0, which were considered unacceptable in clinic. After restoration by zirconia veneers, the color difference values ΔE of the middle 1/3 and the incisor 1/3 between the restored and control teeth were 1.82±0.17 and 1.84±0.21. Both values were less than 2.0, which indicated both good color matching. The color difference value ΔE of the neck 1/3 was 3.92±0.48, which was less than 4.0 and could be accepted in clinic. The statistical analysis of the colors of the teeth before and after restoration compared with the control teeth was done by Paired t test. The t values in the neck 1/3, the middle 1/3 and the incisor 1/3 were 30.37, 21.56, 23.37 respectively. In the three group, all the P<0.001. There were obvious statistical differences. According to the standard of USPHS, the marginal fit of all the restored teeth was perfect (grade A). No zirconia veneers were broken or detached in the period of observation.

CONCLUSION

Zirconia veneers can be a good method to restore deep discolored anterior teeth. However, it should be used cautiously when the patient's esthetic expectation was too high.

A Randomized Controlled Clinical Trial to Evaluate Extrinsic Stain Removal of a Whitening Dentifrice

OBJECTIVES

To evaluate the extrinsic stain removal efficacy of a new whitening dentifrice containing sodium hexametaphosphate (SHMP) over a two-week period.

METHODS

This study used a controlled and randomized, examiner-blind, single-center, two-treatment, parallel group design. Subjects with visible extrinsic dental stain on facial surfaces of their anterior teeth, and meeting all study criteria, were entered into the trial. The test group received the whitening dentifrice with sodium fluoride and SHMP and an ADA reference soft manual toothbrush. Subjects in the control group received a dental prophylaxis after the initial examination at Baseline and were instructed to use their usual oral hygiene products at home. Subjects returned at Day 3 and Week 2 for re-evaluation of extrinsic dental stain. Extrinsic stain was measured using the Interproximal Modified Lobene (IML) Stain Index; safety was assessed based on clinical examination.

RESULTS

Fifty subjects (mean age 32.0 years) completed the study, with 25 in each group. Statistically significant reductions in composite stain for whole tooth, as well as interproximal, gingival, and body surfaces were observed for both groups at Day 3 and Week 2 (p < 0.0001) with no significant differences between the two groups (p > 0.3). At Day 3, median percent reductions in composite IML stain from Baseline were 98% for the prophylaxis group and 100% for the test dentifrice group. At Week 2, median percent reductions in composite IML stain were 100% compared to Baseline for both groups. No adverse events were reported for either group.

CONCLUSIONS

The whitening dentifrice demonstrated a statistically significant reduction in IML stain after three days and two weeks of use relative to baseline. Stain reduction with the toothpaste was comparable to a dental prophylaxis.

Clinical Study to Determine the Stain Removal Effectiveness of a New Dentifrice Formulation

OBJECTIVES

This randomized, prospective clinical trial was conducted to determine the safety and effectiveness of a new whitening dentifrice formulation in comparison to that of both a negative and a positive control dentifrice.

METHODS

Seventy-nine qualifying subjects were randomly assigned to either the new whitening dentifrice (Arm & Hammer® Truly Radiant™ Clean & Fresh Toothpaste), a positive control whitening dentifrice (Crest® 3-D White® Radiant Mint Toothpaste), or a negative control regular dentifrice (Colgate® Cavity Protection Toothpaste). The subjects brushed with their assigned dentifrice for two minutes, twice daily, for five days. Extrinsic tooth stain was assessed using a Modified Lobene Stain Index (MLSI) at baseline and after five days of product use.

RESULTS

All entering subjects completed the study. There were no significant differences (p > 0.05) in stain among the three groups at baseline. The Arm & Hammer Truly Radiant and positive control groups had statistically significant (p < 0.001) mean composite MLSI reduction scores of 13.2% and 7.8%, respectively, from baseline to day five. The negative control dentifrice group was virtually unchanged during this period. Intergroup comparisons showed the Truly Radiant group to have significantly greater stain removal (p < 0.0001) scores than the negative control. The Truly Radiant group also had greater stain removal than the positive control, though the differences were not statistically significant.

CONCLUSIONS

This study demonstrates that five-days' use of Arm & Hammer Truly Radiant Clean & Fresh dentifrice was significantly more effective in stain removal than a regular (non-whitening) dentifrice and comparable in effectiveness to a whitening dentifrice positive control.

Efficacy of E-Learning via the Website of Tehran University of Medical Sciences for Diagnosing Tooth Discolorations and Treatment Planning by Senior Dental Students

The efficacy of methods like e-learning as a supplement to traditional face-to-face instruction needs to be evaluated in dental courses. This study aimed to assess the efficacy of posting case presentations on one of the educational websites of  the virtual school of Tehran University of Medical Sciences called "SARMAD" to enhance the ability of senior dental students to diagnose tooth discolorations and offer treatment plans. This experimental study had a pre-test/post-test control group design and was conducted on 63 senior dental students. After filling out the primary questionnaire and obtaining a written informed consent, students participated in a pre-test and were then randomly divided into two groups of intervention and control. Fifteen case presentations were posted on the university website (SARMAD) during 6 weeks and discussed. Then, students participated in a post-test. Students' perspectives and their satisfaction with the website were assessed by a questionnaire. For ethical purposes, the same program was also offered to the controls. The post-test score was significantly higher than the pre-test score in the intervention group (P<0.001); but in the control group, the post-test score was only slightly higher than the pre-test score (P=0.128). In the intervention group, 70% stated that they would suggest this method as an efficient educational modality; 93.3% stated that this method would be beneficial as a supplement to conventional education; 16.7% ranked the SARMAD website excellent, 30% ranked it good, 33.3% acceptable, 16.7% moderate and 3.3 poor. It appears that this instructional modality may be efficiently used as a supplement to traditional instruction in undergraduate dental curricula.

Effect of Light-Activated Tooth Whitening on Color Change Relative to Color of Artificially Stained Teeth

PURPOSE

There is still controversy as to the efficacy of light activation used in tooth whitening. The purpose of this study was to evaluate the effect of light activation on tooth color change relative to the artificial dye color.

MATERIALS AND METHODS

Extracted human third molars (160) were randomly distributed into eight groups of 20 specimens each based on artificial staining and use of light activation. All groups received three 45-minute sessions of in-office whitening at 3-day intervals. Color measurements were performed with an intraoral spectrophotometer at baseline prior to staining (T0), after artificial staining (T1), 1-day--(T2), and 1-week--(T3) post-whitening. Color differences were calculated relative to after artificial staining color parameters (L*1, a*1, b*1) with the use of a software analysis program enabling synchronization of two images.

RESULTS

Within the same staining groups, the light-activated samples exhibited a greater color change than their nonlight-activated counterparts. However, only in the case of the yellow-stained samples at 1-day post-whitening was there a significant difference between the nonlight-activated and light-activated groups (Tukey's post hoc multiple comparison test for pairwise comparisons, p < 0.05).

CONCLUSIONS

Light activation is a valid method for enhancing the efficacy of tooth whitening with respect to overall color change and works best with yellow stains.

CLINICAL SIGNIFICANCE

Light activation is a valid method for enhancing the efficacy of tooth whitening with respect to overall color change and works best with yellow stains.

Direct Composite Restorations to Mask Intrinsic Staining: An Eighteen-Year Follow-Up

In this case example, the use of direct composite resin allowed for a relatively simple, conservative treatment that provided excellent function and aesthetics, while preserving healthy dental tissue. The importance of continued follow-up and a periodic maintenance and minor repair process will ensure longevity of the restorations, as aesthetics, and the occlusion.

Esthetic rehabilitation with tooth bleaching, enamel microabrasion, and direct adhesive restorations

The aim of this case report is to report esthetic rehabilitation with combined tooth bleaching, enamel microabrasion, and anterior restoration replacement in a 26-year-old man. Clinical examination showed deficient restorations in the maxillary anterior teeth, significant discoloration of the maxillary left central incisor, and hypoplastic stains affecting the maxillary right lateral incisor. A radiograph of the left central incisor showed satisfactory endodontic treatment, allowing preparation for the walking bleach technique. For 3 weeks, 37% carbamide peroxide in the pulp chamber was renewed every week. In-office bleaching with 35% hydrogen peroxide was also performed on the maxillary teeth. After 21 days, all teeth had been bleached to shade A1. After bleaching was completed, enamel microabrasion of the maxillary right lateral incisor was conducted with 6% hydrochloric acid. In later sessions, microhybrid composite resin restorations were placed in all 4 maxillary incisors. A combination of dental bleaching techniques, enamel microabrasion, and resin restorations was a successful and conservative choice for reestablishing the natural appearance of discolored teeth, improving the self-esteem of the patient.

Stain removal efficacy of two manual toothbrushes

PURPOSE

To evaluate the dental stain removal efficacy of two commercially-available manual toothbrushes.

METHODS

This was a randomized, examiner-blind, parallel-group, two treatment clinical trial of 2 weeks duration. Subjects qualifying for the study had a mean Modified Lobene Stain Index of ≥ 1.5 on at least two anterior teeth. Subjects were randomly allocated to one of two groups, receiving a test manual toothbrush (Oral-B 3D White Radiant) or a positive control (PC) manual brush to be used for 1 minute, twice daily for 2 weeks with a standard, anti-cavity fluoride dentifrice. Subjects were given written and verbal instructions, and the first use was supervised at the baseline visit. Stain was measured at baseline and after 2 weeks of product use. Stain measurements were conducted using the Modified Lobene Stain Index (MLSI) and the Interproximal Modified Lobene Stain Index (IMLSI).

RESULTS

Use of the two manual brushes resulted in statistically significant reductions of surface stain relative to baseline after 2 weeks of use. The mean MLSI composite stain reductions versus baseline were 1.37 for White Radiant and 0.87 for PC (P < 0.001 for both). Using the IMLSI, the mean stain reductions for composite, gingival and interproximal regions were 1.68, 1.20 and 1.68 for White Radiant (P < 0.001) and 1.25, 0.97 and 1.43 for PC (P ≤ 0.002). ANCOVA yielded statistically significant between group differences, with greater composite stain removal observed for White Radiant using both indices (P ≤ 0.025).

Resin Infiltration for Aesthetic Improvement of Mild to Moderate Fluorosis: A Six-month Follow-up Case Report

PURPOSE

To determine whether fluorosed areas of teeth can be successfully treated with resin infiltration and whether the results are long lasting.

MATERIALS AND METHODS

For the present case of mild to moderate dental fluorosis, the microinvasive resin infiltration technique was chosen, following suboptimal results of in-office vital tooth bleaching to improve the aesthetic appearance of the affected teeth.

RESULTS

Six months after treatment, the white opaque and brown discolourations remain masked.

CONCLUSION

This case report demonstrates that resin infiltration is an agreeable option for this type of tooth discolouration, rather than choosing more invasive, conventional procedures. More studies need to be completed to determine longer-term outcomes of the technique.

Effect of Melamine Sponge on Tooth Stain Removal

OBJECTIVES

To investigate the stain removal ability of melamine sponge before aesthetic tooth whitening in extracted teeth.

METHODS

Melamine sponge of thickness 40 mm was compressed and the destruction of the partition wall structure during the compression process was examined under a stereoscopic microscope. An extracted human tooth was cleaned by normal polishing or with melamine sponge for 90 s. To evaluate the stain level, the tooth surfaces were photographed under a stereoscopic microscope at 0, 30, 60 and 90 s. The residual stained region was traced in a high-magnification photograph, and the stain intensity was presented as a change, relative to the intensity before the experiment (0 s).

RESULTS

Mechanical cleaning by toothbrushing produced polishing scratches on the tooth surface, whereas use of the melamine sponge resulted in only minimal scratches. As the compression level increased, the stain-removing effect tended to become stronger.

CONCLUSION

Melamine sponge can remove stains from the tooth surface more effectively and less invasively compared to a conventional toothbrush. As no new scratches are made on the tooth surface when using a melamine sponge brush, the risk of re-staining is reduced. Cleaning using a melamine sponge brush can be easily and effectively performed at home and in a dental office.

Splinted Porcelain Laminate Veneers With a Natural Tooth Pontic: A Provisional Approach for Conservative and Esthetic Treatment of a Challenging Case

Esthetic rehabilitation of discolored anterior teeth is always a great challenge, especially in the presence of pathology. Fortunately, conservative management in the esthetic zone has become more feasible in compromised cases because of the development of restorative materials and advances in dental adhesives. This report presents a complicated case of a patient with tetracycline-related discoloration, multiple root resorption, and a periapical lesion. Treatment was conservative and used a natural tooth pontic and splinted porcelain laminate veneers.

Comprehensive Risk-Based Diagnostically Driven Treatment Planning: Developing Sequentially Generated Treatment

The clinical example presented in this article demonstrates a risk-based, diagnostically driven treatment planning approach by focusing on 4 key categories: periodontal, biomechanical, functional, dentofacial. In addition, our unique approach allowed the comprehensive clinical management of a patient with complex restorative needs. A full-mouth rehabilitation was completed sequentially without sacrificing the amount of dentistry necessary to restore health, comfort, function, and esthetics. The result exceeded the patient's expectation and was made financially possible by extending treatment over numerous years.

Using functional analysis to determine if esthetically driven treatment requires comprehensive care for long-term success

This article reviews the case of a male patient with esthetic concerns about a large diastema between teeth Nos. 8 and 9. Through functional analysis, the clinician determined that the patient had a mild temporomandibular disorder, as well as a constriction in his anterior envelope of function. These issues will affect the prognosis of treatment if only orthodontics is used to close the diastema. The clinician determined that implementing a systematic treatment planning approach was critical in achieving a successful outcome, which was accomplished with a combination of orthodontics, occlusal deprogramming, and complex prosthodontics restorations.

The non-vital discolored central incisor dilemma

The restoration of anterior teeth is frequently a demanding mission. Patients generally have high expectations for the anterior region, which makes the emotional side of treatment especially important. When this involves discolored endodontically treated teeth, consensus can hardly ever be found as to the chosen approach. Bleaching with direct composites is undoubtedly the most conservative choice for these cases. However, this may require more maintenance (touch-up bleaching and repairs) in the long term, which is an important issue for adult patients. On the other hand, bonded porcelain veneers represent a more 'high-end' option, as they recover the original biomechanics of the intact tooth, allow an optimal masking of the substrate, remain stable, and have a reasonable biological cost when compared to full-coverage crowns. This strategy is explained in this article and documented with a clinical case. We describe treatment planning based on the biomimetic concept, taking into consideration what is possible with current materials and techniques when combined with the patient's particular needs, including the introduction of an innovative step during dentin sealing--the microsuction. The laboratory work was totally accomplished by 'teledentistry', with no direct contact between the dental technologist and the patient.

Stain Removal Assessment of Two Manual Toothbrushes with an Interproximal Tooth Stain Index

OBJECTIVE

To assess a newly developed index to measure interproximal stain and evaluate the stain removal efficacy of two commercially available manual toothbrushes.

METHODS

This was a randomized, examiner-blind, parallel-group, two-treatment clinical trial of two weeks' duration. Subjects qualified for the study if they had an average Modified Lobene Stain Index of ≥ 1.5 from two anterior teeth. At baseline, subjects brushed in front of a mirror for one minute under supervision. All subjects were provided with a standard 0.243% sodium fluoride dentifrice and were randomly assigned either an Oral-B Pulsar manual brush (OBP) or a Colgate Whitening manual brush (CW) to use for two weeks. Stain was reassessed after two weeks of product use. Stain measurements were conducted using the Modified Lobene Stain Index and the new Interproximal Modified Lobene Stain Index, which allows for assessment of stain in hard-to-reach areas using the same area and intensity scales as the Modified Lobene Stain Index.

RESULTS

Use of the two manual brushes resulted in statistically significant reductions in surface stain relative to baseline after two weeks of use. Median stain reductions were 78% and 60% for the OBP and CW, respectively, as measured by the Modified Lobene Stain Index. The mean changes in the composite scores from baseline to week two were 1.85 and 1.57 for the two treatment groups, respectively. Statistically significant reductions from baseline were also found for the intensity and extent of stain measures (p < 0.001). Similar trends were found using the new Interproximal Modified Lobene Index. Composite median stain removal percentages versus baseline were 88% and 73% for the OBP and CW groups, respectively (p < 0.001). For the interproximal sites, a median stain removal of 92% was observed with the OBP brush and 83% reduction with the CW brush. For the gingival sites, the median stain removal percentages were 83% and 50%, respectively For the body region, a median stain removal of 100% was found for both treatment groups. No statistically significant differences were found between the two groups for the mean composite scores for either index.

CONCLUSION

Both manual brushes showed effective stain removal, including interproximal hard-to-reach sites. The Interproximal Modified Lobene Stain Index gave clinically relevant results consistent with the traditional Modified Lobene Stain Index, while allowing assessment of interproximal regions.

Esthetic non-invasive IPS e.max CAD veneers using the Cerec system: Two case reports

Incisors can sometimes become discolored due to trauma. In most cases, the trauma involves complicated fractures of dentin and enamel that necessitates immediate restorative treatment. In some cases, the trauma is minor and does not involve any structural damage to the tooth. In these cases, the pulp tissue reacts to the trauma, causing discoloration. In the following two cases involving anterior teeth, there were no changes visible at the apex of the incisor. We assumed that the pulp tissue remained vital to some degree and was able to react in several ways to the trauma. In both cases, we saw a change in color of a central incisor, combined with an irregularity in the position of the anterior teeth. The patients involved both explicitly wished to alter the color of the darker incisor in order to restore the harmony of their smiles.

Color masking of developmental enamel defects: a case series

Developmental defects involving color alteration of enamel frequently compromise the esthetic appearance of the tooth. The resin infiltration technique represents an alternative treatment for color masking of these lesions and uniformization of tooth color. This technique is considered relatively simple and microinvasive, since only a minimal portion of enamel is removed. This article illustrates the color-masking effect with resin infiltration of fluorosis and traumatic hypomineralization lesions with a case series. The final esthetic outcomes demonstrated the ability of the resin infiltrant to mask the color of white developmental defect lesions, resulting in satisfactory clinical esthetic improvements. However, in more severe cases, the color-masking effect was not complete.

Management of the single discoloured tooth. Part 2: Restorative options

This is the second article of a two part series covering the aetiology, prevention and broad range of management options for the single discoloured tooth. The article covers situations where masking and simulation techniques with direct composite are required. Direct composite, indirect composite and ceramic veneers are then considered, as well as full coverage crowns. The option of extraction of the affected tooth and its prosthodontic replacement will also be considered. Clinical cases are used to illustrate various scenarios.

CLINICAL RELEVANCE

The single discoloured tooth is a commonly encountered clinical problem in general dental practice. A wide variety of management options exist and it is recommended that general dental practitioners consider adopting minimally invasive techniques in the first instance before moving on to more invasive therapies.