A novel approach to treat gingival recession and non-caries cervical lesion combined defects: Restoration guided creeping attachment (RGCA) technique. A case report

Gingival recessions have multifactorial etiology and are often associated with non-caries cervical lesions. Different surgical techniques have been proposed over the years for their treatment, according to the severity of the recession. A novel technique, called restoration guided creeping attachment (RGCA), for the treatment of combined gingival recession and non-caries cervical lesion is presented. RGCA aims at treating Miller class I and II recessions using a specifically designed composite restoration and a minimally invasive approach. A clinical case describing the technique and forming the basis for further studies is presented. Although the results obtained are encouraging, a wider number of patients and longer follow-ups are needed to assess the reliability of this technique.

[Clinical observation on different kinds of laser on 60 molars with abrasion]

PURPOSE

To evaluate the clinical effect of different kinds of laser on 60 molars with abrasion.

METHODS

Thirty patients with 60 abrasive molars were selected according to the inclusion criteria. Molars and premolars were divided into 2 groups randomly. Teeth in the experimental group were treated with Er,Cr:YSGG laser combined with AdperTM Easy One, while teeth in the control group were treated with Nd:YAG laser combined with AdperTM Easy One, composite resin Z350 was selected to restore the defect. The modified USPHS criteria was used to evaluate the treatment effects at recall periods.The data were analyzed using SPSS 13.0 software package.

RESULTS

On retention, the B level rate of the experimental group was significantly lower than that of the control group(P<0.05) 12 months later. For success rate at 18 months，the difference between the experimental group and the control group was significant（P<0.05）. At the same time, sensitivity of tooth and overall response in the two groups had no significant difference (P>0.05).

CONCLUSIONS

Although the overall response between the two groups had no significant difference,Er,Cr:YSGG laser shows better effect of retention, which is the preferred option for treatment of abrasive molars.

Abrasion: A Common Dental Problem Revisited

Dental abrasion is most commonly seen at the cervical necks of teeth, but can occur in any area, even inter-dentally from vigorous and incorrect use of dental floss. Acid erosion has been implicated in the initiation and progress of the cervical lesion, while tooth-brush abrasion has long been held as the prime cause of cervical abrasion. Identification of the risk factors is clearly important in order to modify any habits and provide appropriate advice.

Ceramic laminate veneers: clinical procedures with a multidisciplinary approach

Complex cases with high esthetic needs represent a challenge for clinicians. A multidisciplinary approach is vital to achieve the planned result. New technological devices are needed to facilitate the collaboration between the clinical team members and to develop a fluent and effective diagnostic and therapeutic pathway. This article describes a well-defined protocol for the treatment of complex esthetic cases with the use of ceramic laminate veneers. The protocol involves different branches of dentistry: periodontal therapy, mucogingival surgery, restorative dentistry, orthodontics, and prosthodontics. Each step of the protocol should be executed in a very strict order: intra- and extraoral esthetic analysis of the patient, with photographs; digital previsualization by means of Digital Smile Design (DSD); clinical previsualization by means of a mock-up; orthodontic, mucogingival, and endodontic treatments, if needed; minimally invasive tooth preparation, driven by a mock-up and silicone indices; manufacture of ceramic laminate veneers; try-in and adhesive cementation. In this article, this protocol is illustrated by a clinical case report in which all the above-mentioned steps were carried out. The finalization was obtained by means of state-of-the-art adhesive techniques and ceramic laminate veneers. The correct use of modern materials, in combination with rigorous adhesive procedures, allows for a minimally invasive and highly esthetic treatment, with adequate function and a perfect integration that is in harmony with the patient's face.

[Teeth wedge-shaped defects in adults of different age groups: remark to prevention and treatment]

The aim of the study was to assess the treatment of teeth wedge defects in different age groups. Records of 383 patients (125 males and 258 females aged 22-85 years) treated in outpatient dental facilities with different ownership forms. It is shown that the medical care of patients with wedge-shaped teeth defects routinely consists of remineralization therapy and restoration of anatomical teeth shape regardless of the form of ownership. The extensiveness of dental rehabilitation as well as the use of more modern technologies are typical for private clinics and 96-100% of patients finished their treatment there. In the state and departmental institutions complete rehabilitation of wedge-shaped defects was provided in 45.5-58.0% and 54.3-83.9, respectively. The paper also highlights the drawbacks of primary medical documentation identified in medical institutions of all forms of ownership.

Treatment of a case of serious occlusal instability associated with TMDs through a modern mini-invasive approach

BACKGROUND

The latest trends in restorative dentistry are guided both by esthetic and mini-invasive procedures. New ceramic materials, such as lithium disilicate, allow the clinician to obtain invisible restorations with a minimum preparation thickness.

SUMMARY

A young female patient presented at our practice with left temporomandibular closed locking and uncomfortable occlusal instability. After manual reduction, medical therapy, and reversible treatment with a stabilization splint, a mini-invasive lithium disilicate occlusal inferior posterior rehabilitation was conceived and performed. The esthetic integration of the onlay restorations was excellent, no fractures had occurred by the time of the 1-year follow-up, and the patient perceived the dental occlusion as comfortable.

CONCLUSION

We strongly believe that a careful approach to esthetics is mandatory nowadays, including in the case of posterior teeth. New ceramic materials and the latest adhesive techniques make it possible to resort to mini-invasive and esthetic approaches, even in cases of restorations that are difficult in terms of functionality.

Interactive treatment planning in toothwear: are we doing it right?

Toothwear is now common, especially in younger patients, with high demand for the restoration of the damaged teeth which is likely to increase further over time. Fixed prosthodontic options range from direct composite resin to conventional tooth preparation and cemented indirect restorations. This paper summarizes the views of a variety of clinicians on a plan delivered to a patient with toothwear in secondary care and explores the possible reasons for the variation in decision-making in the treatment of toothwear.

CLINICAL RELEVANCE

With levels of toothwear increasing, the clinician needs to be aware of the different treatment modalities which are appropriate.

A survey of management strategies for noncarious cervical lesions

Both causation and management of noncarious cervical lesions (NCCLs) (abfractions, wedge-shaped defects, stress-induced cervical lesions, and cervical erosion) remain debatable. A survey of clinicians' perceptions was therefore conducted at a recent professional meeting to determine optimal approaches to NCCL management. Examples of lesions differing in depth (1, 2, and 3 mm) were presented as being either sensitive or nonsensitive, and participants recorded their responses to the presented individual scenarios. This report provides information regarding correlations between increases in lesion depth, lesion sensitivity, and professionals' willingness to restore them. It was also noted that decisions to ensure mechanical retention positively influenced estimates for restoration longevity.

[Optimization of treatment of wedge-shaped tooth defects with hyperesthesia]

Development of tooth wedge-shaped defect leads to a gradual loss of hard tissue and is characterized by pain. Most often patients complain of pain and aesthetic defect that adversely affects the emotional status and quality of life. Search for adequate means and methods of treatment providing increased resistance of dental hard tissues and reducing hyperesthesia is challenging for dentists. Wedge-shaped defect and hyperesthesia as concomitant symptom was found in the city of Ufa in the 5.65 and 63.0% of dental patients, respectively. Analysis of the questionnaires revealed a relationship between the sociological parameters (gender, age, profession) and the patient's quality of life. Improvement of all clinical manifestations was observed in the result of complex treatment.

Transitional bonding with the Kois deprogrammer: a conservative treatment approach

Restoration of a worn dentition has many challenges and considerations for the restorative dentist. Decisions on how to reconstruct the tooth structure that was lost as well as eliminating the risk factors that caused the problem must be addressed. Adding to the complexity is the ever-present demand for minimal dentistry that will satisfy the goals of the treatment while not increasing the long-term risks. A systematic approach to analyze periodontal, biomechanial, functional, and dentofactial risk must be considered before making treatment recommendations to the patient. The patient's esthetic concerns were addressed in this case using minimal- to no-preparation techniques. The placement of transitional bonding with the aid of a Kois deprogrammer allowed the restorative dentist and laboratory technician to meet the functional and esthetic requirements of the case.

Use of the connective tissue graft for the coverage of composite resin-restored root surfaces in maxillary central incisors

The purpose of this article is to report the use of the subepithelial connective tissue graft technique combined with the coronally positioned flap on a composite resin-restored root surface to treat Miller Class I gingival recessions associated with deep cervical abrasions in maxillary central incisors. Clinical measurements, including gingival recession height, probing depth, and bleeding on probing (BoP), were recorded during the preoperative clinical examination and at 2, 6, 12, and 24 months postoperatively. During the follow-up periods, no periodontal pockets or BoP were observed. The periodontal tissue of the teeth presented normal color, texture, and contouring. In addition, it was observed that creeping attachment had occurred on the restoration. This case report shows that this form of treatment can be highly effective and predictable in resolving gingival recession associated with a deep cervical abrasion.

Use of additive dentistry decreases risk by minimizing reduction

This case required enhancement of esthetics and reduction of long-term risk of pathologic tooth wear and decay, as well as minimizing erosion caused by innate and environmental influences. The author weighed patient expectations, diet, treatment of teeth, and age to create a treatment plan that would conserve tooth structure while accomplishing the goals of the case. The patient's dentition was restored utilizing intact enamel, adhesive dentistry, and etchable ceramic materials that require less than 1 mm of occlusal reduction without a significant loss of strength. In this case, opening the vertical dimension of occlusion--which was done to increase the height of both the maxillary and mandibular arches, in keeping with the patient's esthetic desires--eliminated the need to remove excessive amounts of healthy tooth structure and facilitated treatment of the occlusal dysfunction.

"The mother of all black triangles" case

Before the Bioclear matrix and a disciplined approach to composite treatment of black triangles, many treatments ended with significant compromise in periodontal health. Many cases debonded soon after placement. Others suffered problems with stain. Nonetheless, our patients are hopeful for a better solution. The interdental papilla serves as both a functional and aesthetic asset. Anatomically ideal interproximal composite shapes that are mirror smooth can serve as a predictable scaffold to regain this valuable gingival architecture. Clean enamel surfaces can be leveraged to permanently retain the restorations. However, the reader is cautioned that to attempt this elective procedure using no magnification, without a strict adherence to dentin detoxification with a blasting appliance, and using a flat matrix, nontreatment or referral is recommended. Our profession can change its thought processes, retrain its hands and expand its armamentarium to perform techniques that were previously impossible.

A comprehensive and conservative approach for the restoration of abrasion and erosion. Part I: concepts and clinical rationale for early intervention using adhesive techniques

Tooth wear represents a frequent pathology with multifactorial origins. Behavioral changes, unbalanced diet, various medical conditions and medications inducing acid regurgitation or influencing saliva composition and flow rate, trigger tooth erosion. Awake and sleep bruxism, which are widespread nowadays with functional disorders, induce attrition. It has become increasingly important to diagnose early signs of tooth wear so that proper preventive, and if needed, restorative measures are taken. Such disorders have biological, functional, and also esthetic consequences. Following a comprehensive clinical evaluation, treatment objectives, such as a proper occlusal and anatomical scheme as well as a pleasing smile line, are usually set on models with an anterior teeth full-mouth waxup, depending on the severity of tissue loss. Based on the new vertical dimension of occlusion (VDO), combinations of direct and indirect restorations can then help to reestablish anatomy and function. The use of adhesive techniques and resin composites has demonstrated its potential, in particular for the treatment of moderate tooth wear. Part I of this article reviews recent knowledge and clinical concepts dealing with the various forms of early restorative interventions and their potential to restrict ongoing tissue destruction.

A comprehensive and conservative approach for the restoration of abrasion and erosion. part II: clinical procedures and case report

This article proposes a comprehensive and conservative approach to the treatment of tooth wear, based on the application of minimally invasive composite restorations to treat both anterior and posterior decay. Three treatment options were considered, in relation to the severity of tissue loss and size of existing posterior restorations. Posterior tooth status actually will guide the clinician toward the most appropriate restorative option. In the presence of limited tissue loss and small fillings, only direct restorations are considered. With moderate tissue loss and medium size existing restorations, a mix of direct and indirect composite restorations is preferred, and with extensive tissue loss and large restorations, mainly indirect restorations will be chosen. The restoration of anterior guidance and a proper smile line are reestablished using adhesive restorations, including primarily direct composite buildups; in the presence of more severe tissue destruction, loss of facial morphology or discoloration, veneers and possibly crowns can be considered. The driving force behind the concept presented in this article is to intercept tissue destruction and restore proper tooth biomechanics, function, and esthetics using adhesive restorations which do not further invade hard tissues.

Reconstruction of the vertical jaw relation using CAD/CAM

There can be severe loss of the vertical dimension of occlusion due to chemical, mechanical and traumatic causes. This can give rise to both esthetic and functional problems for the patient. Restoration is possible usually only by redesigning the occlusal surfaces. The prosthetic readjustment of the vertical jaw relation represents a considerable intervention in the stomatognathic system, requiring predictable, minimally invasive methods. Long-term provisional solutions clearly superior to pure splint therapy can be produced by means of new CAD/CAM techniques. They are inserted permanently and only in this way can the patient test the new occlusal situation and the success of treating functional disorders be verified. A further major advantage then becomes apparent when the final restoration is produced. The previously adjusted and tested occlusion is retained and every tooth can be treated and restored individually. Long treatment sessions are thus a thing of the past.

Alternative restorative approach for treatment of patient with extremely worn dentition

Changes in tooth structure, missing teeth and decreased vertical dimension of occlusion severely deteriorate the stomatognathic system. This case report describes the treatment of a patient with loss of vertical dimension due to severe wear of maxillary and mandibular teeth. An occlusal splint was used to create an optimum maxillomandibular relationship and to provide restorative space prior to restoration of the remaining teeth. The restoration was accomplished with a hybrid composite material. This treatment has been a less-expensive alternative to full-mouth, fixed porcelain/metal-porcelain restoration while conserving the remaining tooth tissue.

A questionnaire based study to investigate the variations in the management of tooth wear by UK and prosthodontists from other countries

The aim of this research project was to compare how the management of toothwear differs between specialist prosthodontists in the United Kingdom and other countries' specialist prosthodontists. A questionnaire on the management of toothwear was sent to two groups of 100 specialist prosthodontists randomly selected in the United Kingdom and overseas. The response rate was 64% for UK and 54% for overseas respondents. Similarities existed in the management of bruxism and the prevention of erosion, but there were significant differences between the two groups regarding treatment of palatal erosion, short clinical crowns and wear on the lower incisors. UK prosthodontists more often use resin-based materials and a showed a more conservative approach to treatment of tooth wear compared to their overseas colleagues.

Restorations of endodontically treated teeth: new concepts, materials, and aesthetics

The care of endodontically treated teeth has been one of the greatest challenges in restorative dentistry. Left unrestored, endodontically treated teeth have complications that include coronal leakage and subsequent reinfection of the root canal system. These teeth are at risk for fracture, since they become predisposed to structural compromise when compared to their properly restored counterparts. As demonstrated herein, caries, previous restorations, fractures, wear, erosion, and endodontic procedures each require careful consideration and timely tooth reconstruction to ensure a favorable prognosis.

Identifying the aesthetic and functional determinants in the collapsed dentition

This patient's treatment involved a complex diagnostic challenge, as well as a challenging clinical sequence due to the utilization of immediate implant placement and restoration after extraction along with immediate prosthodontic restoration with sinus elevation with bone grafting. The inability to have diagnostic patient wax try-ins required a detailed and exacting diagnostic work-up which included significant laboratory diagnostic wax-ups. The utilization of the ACP Parameters of Care for Partial Edentulism for a PDI Class IV patient provided a framework in which care could be planned and executed with confidence. The availability of various reconstructive materials and techniques to create a seamless restorative result is essential to the success of this type of advanced treatment.

Clinical evaluation of a self-etch adhesive in non-carious cervical lesions

PURPOSE

To evaluate the clinical performance of a self-etching adhesive in Class V non-carious lesions with and without acid etching procedures.

METHODS

A total of 125 Class V non-carious cervical lesions (NCCL) with incisal or occlusal margins in enamel and gingival margins in dentin/cementum were selected and restored with Clearfil SE Bond self-etch adhesive and Clearfil APX resin composite. All cavities were restored using two techniques; after etching the whole cavity for 20 seconds and without acid etching (control). The restorations were evaluated at baseline, 1- and 2-year using modified USPHS criteria.

RESULTS

No loss of restorations was recorded after 1 and 2 years for the two restorative techniques. There was no significant difference between the baseline and 2-year results for any of the tested technique. However, restorations made after acid etching showed less marginal discoloration at the enamel margins.

Diagnosis and management of the worn dentition: conservative restorative options

A technique is presented for the use of a transparent polyvinyl siloxane template constructed from a diagnostic wax-up to rapidly reproduce the anatomical structure with direct restorative materials in the mouth. This technique is beneficial for a number of geriatric patients who would be unable to undertake long and complex dental treatment sessions and provides an alternative for those unable to meet the immediate costs of multiple indirect restorations. Consideration of increases in vertical dimension to create space for the new restorations and reconstruction utilizing a combination of direct and indirect procedures provides control and predictability over the final restorative result. In the short to medium term, the use of minimally invasive adhesive techniques enables tooth surface loss to be replaced with minimal destruction of the remaining sound tooth material, yet still enables the option for a more definitive restorative option at a later date.

Diagnosis and management of the worn dentition: risk management and pre-restorative strategies for the oral and dental environment

The incidence of tooth wear or non-carious tooth surface loss (NCTSL) is increasing and oral rehabilitation of patients with tooth tissue loss requires strategies that address all the factors relevant to the aetiology and pathogenesis of the disease. The multifactorial nature of the disease and the variability in its clinical presentation provides treatment challenges for the clinician. Management of tooth wear must be more than just restoration. Risk assessment, compliance and a commitment from both professional and patient underpin overall success of the treatment. Understanding that long term success is affected by the patient's oral environment and how diet, lifestyle and medical factors modify this environment. Improvements in the quantity and quality of saliva and remineralization strategies to enhance the remaining tooth structure are essential pre-restorative requirements. Successful management requires recognition of the problem, stabilization of the oral environment, remineralization of the tooth structure and when appropriate restoration.

Concepts and considerations of tooth wear: Part II--The mechanical component

Identification of etiological factors is essential for successful management of tooth wear. In many cases, the diagnosis may be complicated because of the multiple etiologic factors which may confound the clinical appearance of tooth wear. Comprehensively addressing all of these factors is paramount to the long-term success of patient management.

Creating the perfect smile: prosthetic considerations and procedures for optimal dentofacial esthetics

Creating the perfect smile and individual esthetics is a challenging procedure that requires a multidisciplinary approach and meticulous treatment planning. Since esthetics is subjective and depends upon the patient and the clinician perception, it is difficult to obtain specific guidelines or a systematic approach that will lead to consistent results. This article discusses several guidelines that have been proposed to help clinicians in the process of creating esthetic appearance and their applications in esthetic dentistry.

[Clinical evaluation of composite inlays in defective molars]

OBJECTIVE

To evaluate clinical effect of composite inlays in the defective molars.

METHODS

A total of 200 defective molars from 163 patients were divided into two groups, including 100 molars of each. One group was restored with the direct composite inlays and another group with the traditional composite fillings. All the restorations were evaluated in oral cavity after 6-month and 5-year filling or insertion with United States public health service criterions. The data were analyzed using SPSS 11.0 software with the chi-square test. The significance level was set at 5%.

RESULTS

In clinical service for 6 months, the successful rate of composite inlays was 91.8% (90/98) and the corresponding figure for traditional composite fillings was 91.8% (89/97), but there was no statistically significant difference (P > 0.05). In clinical service for 5 years, the successful rate of composite inlay was 87.9% (80/91), the corresponding figure for the traditional composite fillings being 67.4% (60/89) and the difference was statistically significant (P < 0.05).

CONCLUSIONS

In clinical, the defective molars can be well restored with the direct composite inlays. Especially in the long-term clinical service, the composite inlays show significant superiority over the traditional composite fillings.

Combining traditional and adhesive dentistry to reconstruct the excessively worn dentition

Adhesive dentistry has changed the face of traditional dentistry and has the potential to improve esthetics and reduce tooth preparation. However, the materials and techniques used in adhesive dentistry are generally more technique sensitive than those used in traditional dentistry. It is, therefore, important that strict guidelines and protocols are followed to ensure long-term success. Clinicians must be able to determine where adhesive techniques and materials can be used and where traditional, biomechanically sound techniques and materials should be used. There appears to be an increasing trend of young to middle-aged patients presenting with advanced generalized tooth surface loss. These dentitions are conducive to treatment that combines traditional and adhesive materials and techniques. This article discusses guidelines for treatment of these dentitions and outlines the clinical treatment involved in the full-mouth rehabilitation of a worn dentition using a combination of all-ceramic crowns, porcelain and gold onlays, and porcelain veneers.

Three-year clinical effectiveness of a two-step self-etch adhesive in cervical lesions

A 3-yr randomized, controlled prospective study evaluated the clinical effectiveness of a mild two-step self-etch adhesive, Clearfil SE, in Class-V non-carious lesions. The hypothesis tested was that prior selective etching of enamel with phosphoric acid does not affect the 3-yr clinical performance of this adhesive. A total of 100 lesions in 29 patients were randomly restored in one or two pairs, according to two experimental protocols: (i) application of Clearfil SE according to the instructions of the manufacturer (C-SE non-etch); and (ii) similar application of Clearfil SE with prior etching of enamel cavity margins with phosphoric acid (C-SE etch). Clearfil AP-X was used as a restorative material. At 3 yr, 90% of the restorations were examined for retention, marginal integrity, marginal discoloration, caries recurrence, postoperative sensitivity, and preservation of tooth vitality. An excellent retention rate (100%) was noted after 3 yr of clinical functioning. Only one restoration of the C-SE etch group was clinically unacceptable owing to the presence of a severe cervical marginal defect. A pairwise comparison between both groups showed a significant difference only in the number of small marginal defects at the enamel side, which was higher in the C-SE non-etch group. These incisal defects were small and clinically irrelevant. Superficial marginal discoloration increased slightly in the C-SE non-etch group and was related to the higher frequency of small incisal marginal defects. In this latter group, localized marginal discoloration was observed significantly more in smokers. In conclusion, the clinical performance of the mild two-step self-etch adhesive, Clearfil SE, remained excellent after 3 yr of clinical functioning. Additional etching of the enamel cavity margins was not critical for its clinical performance.

Restoration of non-carious cervical lesionsPart I. Modelling of restorative fracture

OBJECTIVE

As a typical non-carious cervical lesion, abfraction is a common clinical occurrence which requires restorative treatment in most patients. Nonetheless, the relatively poor clinical longevity of cervical dental used for restoring abfraction lesions has been a major concern of dentists and patients. The continuing loss of hard tissue and, in turn, the low retention of the restorative materials in situ motivates an in-depth exploration of the failure mechanism of the biomaterials involved. Despite considerable biomechanical relevance, conventional application of linear static finite element analysis (FEA) does not consider the fracture failure process, nor does it provide a quantitative predictive analysis for restorative design. This paper adopts a novel Rankine and rotating crack model to trace the fracture failure process of the cervical restorations.

METHODS

In contrast to the existing linear FEA, this study presents a nonlinear fracture analysis in an explicit finite element framework, which involves an automatic insertion of initial crack, mesh updating for crack propagation and self contact at the cracked interface.

RESULTS

The results are in good agreement with published clinical data, in terms of the location of the fracture failure of the simulated restoration and the inadequacy of the dental restoratives for abfraction lesions. The success of the proposed model also demonstrates the potential for the monitoring and prediction of mechanical failure in other brittle biomaterials in a clinical situation.

Restoration of non-carious cervical lesionsPart II. Restorative material selection to minimise fracture

OBJECTIVE

It is still largely unknown as to what material parameter requirements would be most suitable to minimise the fracture and maximising the retention rate of the restoration of cervical non-carious lesions (NCCL). The present paper, as a first of its kind, proposes a radical approach to address the problems of material improvement, namely: numerical-based, fracture and damage mechanics materials optimisation engineering. It investigates the influence of the elastic modulus (E) on the failure of cervical restorative materials and aims to identify an E value that will minimise mechanical failure under clinically realistic loading conditions.

METHOD

The present work relies on the principle that a more flexible restorative material would partially buffer the local stress concentration. We employ a "most favourable" parametric analysis of the restorative's elastic modulus using a fracture mechanics model embedded into finite element method. The advanced numerical modelling adopts a Rankine and rotating crack material fracture model coupled to a non-linear analysis in an explicit finite element framework.

RESULTS

The present study shows that the restorative materials currently used in non-carious cervical lesions are largely unsuitable in terms of resistance to fracture of the restoration and we suggest that the elastic modulus of such a material should be in the range of 1GPa. We anticipate that the presented methodology would provide more informative guidelines for the development of dental restorative materials, which could be tailored to specific clinical applications cognisant of the underlying mechanical environment.

Demolition Experts: Management of the Parafunctional Patient: 2. Restorative Management Strategies

The second part of this paper discusses strategies for providing restorative dental care for the parafunctional patient. These include direct composite resin restorations, cast metal resin-retained restorations and dentine-bonded crowns, design features for porcelain fused to metal crowns and denture design. Specific features can help enhance predictability in the hostile environment of increased occlusal loading and parafunction.

CLINICAL RELEVANCE

Appropriate planning, design and execution of restorative procedures can reduce the chance of failure. Patients may have to accept a compromise between appearance and restoration survival/maintenance.

Long-term survival of direct and indirect restorations placed for the treatment of advanced tooth wear

Advanced tooth wear was restored with direct resin-based composites (RBCs) in 17 patients, and with indirect ceramo-metal crowns (CMCs) and full gold crowns in 8 other patients. The mean patient age was 64.9 (8.6 SD) years, with each patient having a mean of 13.8 (5.4) restorations. In this retrospective case series study, the mean restoration age was 5.0 (3.0) years for the direct and 5.9 (2.6) years for the indirect restorations. Over 10 years, cumulative survival estimates were 62.0% for direct and 74.5% for indirect restorations (P = 0.23). Survival estimates were 58.9% for anterior RBCs and 70.3% for anterior CMCs (P = 0.06). RBCs usually failed from fractures, and CMCs from complete losses. RBC failures were usually replaced or repaired, while CMC failures often required root canal therapies or extractions. The findings from this relatively small study require confirmation by large long-term controlled clinical trials.

Adhesive restorations, centric relation, and the Dahl principle: minimally invasive approaches to localized anterior tooth erosion

The purpose of this article is to review biomechanical and occlusal principles that could help optimize the conservative treatment of severely eroded and worn anterior dentition using adhesive restorations. It appears that enamel and dentin bonding, through the combined use of resin composites (on the palatal surface) and indirect porcelain veneers (on the facial/incisal surfaces) can lead to an optimal result from both esthetic and functional/biomechanical aspects. Cases of deep bite combined with palatal erosion and wear can be particularly challenging. A simplified approach is proposed through the use of an occlusal therapy combining centric relation and the Dahl principle to create anterior interocclusal space to reduce the need for more invasive palatal reduction. This approach allows the ultraconservative treatment of localized anterior tooth erosion and wear.

Esthetic restorations: observations and insights gained over a 5-year period demonstrated with three case reports

This article presents two prosthodontically treated patient cases that were observed over a period of at least 5 years after treatment. The evaluation, diagnosis, treatment planning, and treatment stages were critically reviewed and reassessed from different perspectives. The conclusions drawn from this evaluation were subsequently implemented in a third clinical case. To ensure the long-term success of a restoration, certain biologic and mechanical principles must be observed, and the appropriate prosthodontic treatment must be chosen accordingly.

Clinical evaluation of self-etch adhesives in Class V non-carious lesions

PURPOSE

To evaluate the clinical performance of two self-etching and one total-etch adhesives in Class V non-carious cervical lesions (NCCL).

METHODS

Two self-etching primers, Clearfil SE Bond and Hybrid Bond, and one total etch adhesive, Admira Bond, were placed in 195 NCCL. Restorations were evaluated at baseline, 1 and 2 years using the USPHS criteria.

RESULTS

No restoration was lost after 1 and 2 years for all materials. There was no significant difference between the baseline and 2-year results for Admira Bond and Clearfil SE Bond restorations. In contrast, Hybrid Bond restorations showed significant deterioration in marginal adaptation and cavosurface marginal discoloration after 2 years. Also, there was no significant difference between Admira Bond and Clearfil SE Bond at each recall period.

[A maxillary premolar reconstruction with a glass fiber reinforced post]

This paper presents the case of a 37 years old female patient who needed a reconstruction of an endodontic treated' second maxillary premolar. The patient presented large areas of occlusal abrasion caused by bruxism, therefore the solution consisted of a reconstruction with a non-metallic post reinforced with glass fibers. In such cases, the excessive occlusal forces developed by bruxism can produce a radicular fracture if the tooth would be reconstructed with a rigid metallic post. The glass-fiber reinforced post has some important qualities, which render it more suitable in most clinical cases: it is easy to use; has the ability to bond with restorative resins; decreases the risk of tooth fracture and provides better esthetics.

[Micro-tensile bond strength to sclerotic dentin in non-carious cervical lesions]

OBJECTIVE

This in vitro study was to evaluate the micro-tensile bond strength (microTBS) of three adhesives to sclerotic dentin in non-carious cervical lesions.

METHODS

The maxillary premolars extracted due to periodontitis and with non-carious cervical lesions were collected. The non-carious, natural cervical sclerotic lesions were bonded with a total-etching adhesive Scotchbond Multi-Purpose, a two-step self-etching adhesive Contax, and an all-in-one self-etching adhesive Adper Prompt L-Pop. Artificially prepared wedge-shaped lesions were also made in sound premolars and bonded with the same adhesives as the controls. MicroTBS of these three adhesives was measured.

RESULTS

MicroTBS of Scotchbond and Contax to sclerotic dentin was significantly lower than to normal dentin. But microTBS of Adper Prompt L-Pop to normal dentin was significantly lower than to sclerotic dentin. MicroTBS to sclerotic dentin was Scotchbond 46.805 MPa, Adper Prompt L-Pop 39.045 MPa, and Contax 29.852 MPa.

CONCLUSIONS

In sclerotic dentin the microTBS was decreased because of the inferior micro-morphology of resin tags. Adhesives with low pH value might bond to sclerotic dentin effectively.

A 24-month Follow-up of Flowable Resin Composite as an Intermediate Layer in Non-carious Cervical Lesions

After 24 months of evaluation, the use of Filtek Flow as a liner under Filtek Z250 restorations did not improve the clinical performance of Class V restorations.

Clinical and anatomical factors limiting treatment outcomes of gingival recession: a new method to predetermine the line of root coverage

Complete root coverage is not always achievable, even in gingival recession with no loss of interproximal attachment and bone. The cemento-enamel junction is the most widely used referring parameter to evaluate root coverage results. The aim of the present study was to describe the most frequent diagnostic mistakes that may lead to incomplete root coverage in Miller Class I and II gingival recessions and to suggest a method to predetermine the level/line of root coverage in non-molar teeth. The line of root coverage (i.e., the level/line to which the soft tissue margin will be positioned after the healing process of a root coverage surgical technique) was predetermined by calculating the ideal vertical dimension of the interdental papilla of the tooth with the recession defect. This method was applied to 120 recession-type defects affecting non-molar teeth of 80 young healthy subjects that were treated with root coverage surgical procedures over the last 5 years. All recessions were Miller Class I or II and were associated with at least one of the following characteristics: 1) traumatic loss of the tip of the interdental papilla(e); 2) tooth rotation; 3) tooth extrusion with or without occlusal abrasion; and 4) a cervical abrasion defect with no evidence of the cemento-enamel junction. The line of root coverage may be considered the clinical cemento-enamel junction because it may substitute the anatomic cemento-enamel junction when this is no longer clinically visible on the tooth with recession or when the ideal conditions to obtain complete root coverage are not fully represented.

Use of additive waxup and direct intraoral mock-up for enamel preservation with porcelain laminate veneers

Erosion and surface wear result in the progressive thinning of enamel, ultimately generating increased crown flexibility and higher enamel surface strains. The restoration of tooth volume through the use of bonded porcelain veneers not only reestablishes the original and youthful appearance of the smile, but also allows biomimetic recovery of the crown. The driving force of this process should be the preservation of the remaining enamel. Traditional approaches to veneer preparation can lead to major dentin exposures. Enamel preservation can still be achieved with bonded porcelain veneer restorations, however, given a proper approach to tooth preparation. This article describes a treatment rationale that includes the use of a diagnostic template. This technique, presented here in a clinical case with moderate enamel loss, integrates an additive waxup and a direct intraoral acrylic mock-up. Using this strategy, clinicians should be able to perform tooth preparations that are both more accurate and also higher in quality in an extremely time-efficient fashion compared with traditional methods.