Lec12

OPERATIVE DENTISTRY 2 | DOD2 41

Conservative Aesthetic Resin

Ture Dr Kathrene Faye Lampa
First Semester – Midterms

1
Artistic Elements
• Shape or form
• Symmetry and proportionality
• Position and alignment
• Surface texture
• Color
• Translucency

(1) Shape or Form

 The shape of teeth largely determines their esthetic appearance.

 To achieve optimal dental esthetics, natural anatomic forms must be

achieved. Creating illusions of length.
A, Normal length. B, A tooth can be made to appear shorter by emphasizing
 A basic knowledge of normal tooth anatomy is fundamental to the horizontal elements and by positioning the gingival height of contour
success of any conservative esthetic dental procedure. farther incisally. C, The illusion of length is achieved by moving the gingival
height of contour gingivally and by emphasizing vertical elements, such as
 Subtle variations in shape and contour produce very different
developmental depressions.
appearances

 Youthful: Rounded incisal angles, open incisal and facial

embrasures, and softened facial line angles.
(2) Symmetry and Proportionality
 The overall esthetic appearance of a human smile is governed largely
 Older: Incisal embrasures that are more closed and incisal
by the symmetry and proportionality of the teeth.
angles that are more prominent (i.e., less rounded).
 Asymmetric teeth or teeth that are out of proportion to the
**Usually you would only need minor modification of existing tooth contours
surrounding teeth disrupt the sense of balance and harmony essential
otherwise known cosmetic contouring to give effect a significant esthetic
for optimal esthetics.
change on the appearance of a tooth.
 Dental symmetry can be maintained if the sizes of contralateral teeth
are equivalent.

 Anterior teeth must be in proper proportion to one another to achieve

maximum esthetics. The quality of proportionality is relative and
varies greatly, depending on other factors (e.g., tooth position, tooth
alignment, arch form, configuration of the smile)

 Theorem: The relative proportionality of maxillary anterior teeth

typically visible in a smile involves the concept of the “golden
proportion” by Euclid.
Creating illusions of width.
A, Normal width. B, A tooth can be made to appear narrower by positioning  On the basis of this formula, a smile, when viewed from the front, is
mesial and distal line angles closer together and by more closely considered to be esthetically pleasing if each tooth in that smile
approximating developmental depressions. C, Greater apparent width is (starting from the midline) is approximately 60% of the size of the
achieved by positioning line angles and developmental depressions farther tooth immediately mesial to it. The exact proportion of the distal
apart. tooth to the mesial tooth is 0.618.

Principles of Line

 Where in you create line in a tooth to make it appear either wider or

narrower , and longer or shorter

 Tooth have transitional line angles wherein its facial translation to the
proximal or incisal Tooth proportions.
A, The rule of the golden proportion. The exact ratios of proportionality.
B, The anterior teeth of this patient are in golden proportion to one another.

(3) Position and Alignment

 The overall harmony and balance of a smile depend largely on proper  The degree of translucency is related to how deeply light penetrates
position of teeth and their alignment in the arch. into the tooth or restoration before it is reflected outward.

 Malposed or rotated teeth disrupt the arch form and may interfere  Normally, light penetrates through enamel into dentin before being
with the apparent relative proportions of teeth. reflected outward

 Orthodontic treatment of such defects always should be considered,  **Shallow penetration of light often results in loss of esthetic vitality.
especially if other positional or malocclusion problems exist in the
 Common problem encountered when treating severely or
mouth. Minor positional defects often can be treated with composite intrinsictly stained teeth, Ex. tetracycline stain)
augmentation or full facial veneers indirectly made from composite or
porcelain.  Indirect veneers of processed composite or porcelain fabricated to
include inherent opacity also may have this problem.
 Minor rotations can be corrected by reducing the enamel in the area
of prominence and augmenting the deficient area with composite  Illusions of translucency also can be created to enhance the realism of
resin. a restoration.

 Color modifiers (also referred to as tints) can be used to achieve

apparent translucency and tone down bright stains or to characterize
a restoration.

Position and alignment. A, A minor rotation is first treated by reducing

enamel in the area of prominence. B, The deficient area is restored to
proper contour with composite. C, Maxillary lateral incisor is in slight
linguoversion. D, Restorative augmentation of facial surface corrects
malposition.

(4) Surface Texture Translucency and light penetration. A, Light normally penetrates deeply
 The character and individuality of teeth are determined by their through enamel and into dentin before being relected outward. This affords
surface texture and existing characteristics. realistic esthetic vitality. B, Light penetration is limited by opaquing resin
media under veneers. Esthetic vitality is compromised.
 Realistic restorations closely mimic the subtle areas of stippling,
concavity, and convexity that are typically present on natural teeth.

 Young: exhibit significant surface characterization

 Older: smoother surface texture NOTES:

 The surfaces of natural teeth typically break up light and reflect it in

many directions.

 Anatomic features (developmental depressions, prominences, facets,

perikymata) should be examined and reproduced if present on the
surrounding surfaces.

 Restored areas of teeth should reflect light as in the unrestored

adjacent surfaces.

(5) Color
 Color is the most complex and least understood artistic element. It is
an area in which numerous interdependent factors exist, all of which
contribute to the final esthetic outcome of the restoration.

 Three(3) fundamental elements of color:

 Hue is the intrinsic quality or shade of the color.

 Value refers to the relative lightness or darkness of a hue. It is

determined by the amount of white or black in a hue.

 Chroma is the intensity of any particular hue. Some current

shade guides are based first on value because of the
importance of this element of color.

Treatment
(6) Translucency  Enamel Recontouring
 Microabrasion  It is commonly used to smoothen the roughened enamel margins,
fractured tooth surfaces and to soften interproximal angles
 Macroabrasion
 Tooth is polished after so as to have fine scratch-proof appearance.
 Bleaching treatments

 Veneers

Restorations with Composite Resins

REVIEW  Composite resins are indicated for treatment of minor defects present
on incisal edges or labial surfaces of teeth like caries, fracture of teeth
• There are number of problems which can alter the esthetics of anterior and for the modification of anatomy and morphology of teeth like
teeth. Many treatment options are available which can be employed to correction of diastema, peg shaped laterals, etc.
improve the esthetics of affected tooth/teeth. Though not all of these
treatment options give perfect effects, but alternatives can be explained to  Composite resins have advantages of being esthetic, noninvasive,
the patient for better results. inexpensive, simple to use but they tend to discolor and wear with
time.

 Commonly seen problems with anterior teeth which affect

esthetics of these teeth are Veneers
 Veneer can be described as a layer of tooth colored material which is
 Caries applied on the tooth surface for esthetic purpose. They are used to
mask the localized, generalized defects and intrinsic discolorations .
 Tooth discoloration because of trauma, hypoplasia and other
factors  Indications:

 Tooth malformations  Damaged, defective and malformed facial surface

 Diastema between teeth  Discolored facial surface

 Mal-alignment of teeth  Discolored restorations

 Fracture of tooth

 Cervical lesions like erosion, abrasion and abfraction Types of Veneers

 Based on method of fabrication
 Attrition of teeth
 Direct technique
 Ectopic eruptions - tooth is erupted in wrong position
 Indirect technique.

 Based on extent of coverage

 Partial veneers are used for the localized damage, defect and
 Following treatment options are available for correction of these discoloration of the tooth, i.e. they involve only a portion of the
conditions. More than one option can be advocated in some cases so tooth crown
as to achieve optimal results
 Full veneers are used when majority of facial surface or whole
 Ameloplasty/enameloplasty of the crown of a tooth is discolored.
 Bleaching of teeth  Types of Full Veneers - cavity prep design to use
 Restorations with composite resins  Full veneer with incisal overlapping
 Orthodontic treatment  Full veneer with window preparation.
 Veneering

 Composite

 Porcelain

 Metal ceramic.

 Full coverage crown

(1) Direct Partial Veneer

Enamel Recontouring / Enameloplasty
 It helps in improving minor changes in contour of tooth by removal of
enamel
 Direct partial veneers are
placed on localized
discolorations or defects
which are surrounded by
sound enamel.

 Indications:

 Localized Discoloration
**diastema closure by full veneer
 When the entire facial
surface is not defective

Direct Partial Veneer Procedure

1. Cleaning of teeth to be veneered

2. Shade Selection

3. Isolate the teeth

4. Removal of defect and tooth preparation **Treatment of a tetracycline stains by full veneers

5. Application of composite as usual.

Advantages and disadvantages of Direct Technique

Advantages Disadvantages

• Single appointment • More chair side time

• Useful for young patients • Require more labor

• Useful for localized defects **treatment of stained teeth by full veneers

• Economical

(2) Direct Full Veneers

 Indications:

 Diastema closure

 Tetracycline stains

 Grossly stained and pitted teeth

 Gross enamel hypoplasia of anterior teeth

Direct Full Veneers Procedure

 Cleaning of the teeth

 Selection of the shade

**case of amelogenesis imperfecta
 Tooth isolation and retraction of gingiva using retraction cords

 Reduction of tooth using coarse round end diamond bur. At the

proximal side, the preparation should be facial to the contact point. Advantages and Disadvantages
Heavy chamfer at the gingival margin is preferable
Advantages Disadvantages
 Acid etching, washing and drying followed by application of bonding
agent • Less technique sensitive • Expensive

 Placement of composite in increments. When adding composites, • Last longer • Require special tooth preparation.
care should be taken to create proper physiological contour, contact
point, and smooth surfaces. • Effective for multiple veneers
 Tooth preparation:
Window Preparation
 Indications: Variations in Veneer Preparations
 To preserve functional lingual and incisal surfaces of anterior
teeth

 To prepare maxillary canines in patients with canine guided

occlusion

 In patients with high occlusal stresses.

FACIAL ONLY INCISAL BUTT

 Advantages • Color or slight shape change • Color or shape change
• No lengthening • May lengthen
 Saves the functional lingual and incisal surfaces of anterior • Improve incisal translucency
teeth.

 It does not extend subgingivally or involve incisal edge.

 Decreases the chances of wear of opposing teeth.

**Tooth preparation should be facial to contact area **(LEFT) Facial veneer, (RIGHT) Incisal butt
-it gives more lifelike appearance, light travel more naturally

Lingual Wrap Veneer

 Preparation - extend into esthetically visible areas

**Window preparation

Tooth Preparation Type:

Incisal Lapping Preparation
 Indications

 When crown length

is to be increased

 When incisal defect

is severe and
restoration is
necessary.

 Advantages

 As tooth preparation is within the enamel, hence no temporary

restoration is given
Lingual wrap
 Improved esthetics along incisal edge

 Preparation - for diastemas, extend to lingual line angle

Incisal Butt Veneers
  Indirect veneers are commonly made-up of following:

 Processed composite

 Etched porcelain

 Castable ceramic.

 It has following advantages:

 Less technique sensitive than direct veneers

 Multiple teeth can be done in less time

Variations in Veneer Preparations  Chair time required for indirect veneer is less

 Indirect veneers produce better contour, contacts and shade

 These veneers have longer life than direct veneers.

Processed Composite Veneers

 Superior physical and mechanical properties as compared to direct Co
LINGUAL WRAP LINGUAL WRAP
 Can be bonded to the teeth with a bonding agent

 Easy to finish and polish

 Indications for Lingual Wrap  Can be easily repaired

 Existing restorations (Existing composites)  Processed veneers are made in the cases which show attrition of
anterior teeth due to occlusal stress.
 Wear or defects on lingual

 Diastema
Steps of veneer placement
 Less than ideal enamel remaining  Processed composites have less potential to form chemical bond with
bonding medium, thus additional micromechanical features are added
 Previous veneers were wrapped
by surface conditioning or sandblasting,

 And the Etch the enamel

 After this, bonding agent is applied to the tooth enamel

 Veneer is placed by using fluid resin bonding medium

 After placement, finishing and polishing is done.

Etched Porcelain Veneers

 In these porcelain veneers, internal surface is acid etched which forms
stronger bond with etched surfaces of tooth.

 Advantages

 Better retention

 Less prone to stains

 Good esthetics

 Less prone to fractures than other types of veneers.

Steps
 After cleaning and shade selection, the isolation of teeth is done
Indirect Veneer Technique
 It is done in two appointments.  Tooth surfaces are prepared with round end diamond bur.
Preparation should be incisal capping veneer type
 Impression is taken with rubber base impression material and sent to  Tetracycline stains and other antibiotic use, Fluorosis stain.
laboratory for veneer formation
 Posteruptive causes of discoloration
 A completely finished veneer should be seated on clean, dry and
isolated prepared tooth  Pulpal changes

 Internal surfaces of porcelain veneers are conditioned with silane  Trauma

primer
 Dentin hypercalcification
 After setting, excess cured resin is carefully removed by knife or
scalpel  Dental caries

 Recontouring and trimming is done, if required.  Restorative materials and operative procedures

 Aging

 Functional and parafunctional changes.

Different Extrinsic Stains

 Daily acquired stains

 Plaque

 Food and beverages

 Tobacco use

 Poor oral hygiene

 Swimmer’s calculus - chemical in the pool

 Gingival hemorrhage.
Castable Ceramic Veneers
 Commonly used castable ceramic is ‘Dicor’.  Chemicals

 A newer material which is commonly used today is a pressable  Chlorhexidine

ceramic (Empress).
 Metallic stains.
 These are fabricated for only light to moderate discolorations because
it is very translucent material.

 Formed by lost wax technique.

 Preparation of tooth and bonding are like etched porcelain veneers.

 These veneers are not finished with rotary instruments as rotary

instruments cause loss of surface coloration

Bleaching
Different Intrinsic Stains  Bleaching is a procedure which involves lightening of the color of a
 Disease tooth through the application of a chemical agent to oxidize the
organic pigmentation in the tooth.
 Alkaptonuria, Hematological disorders, Disease of enamel and
dentin, Liver diseases.  Conservative option
  Hydrogen peroxide and sodium hydroxide: breaks down to water and
nascent oxygen
Contraindications for Bleaching
 Poor Case Selection  Sodium perborate

 Patient having emotional or psychological problems are not  Thickening agent-carbopol or carboxy polymethylene: Increased
right choice for bleaching. viscosity of bleaching material

 In case selection, if clinician has opinion that bleaching is not in  Urea: anti-acriogenic - It makes the gel acidic
patient’s best interest, he should decline doing that.
 Surfactant and pigment dispersants: Surfactant acts as surface
 Dentin Hypersensitivity wetting agent which allows the hydrogen peroxide to pass across gel
tooth boundary.
 Hypersensitive teeth need extra protection before going for
bleaching  Preservatives

 Extensively Restored Teeth  Vehicle

 These teeth are not good candidate for bleaching because:  Glycerine: It is used to increase viscosity of preparation and
ease of manipulation
 They do not have enough enamel to respond properly to
bleaching.  Dentifrice - whitening tooth paste

 Teeth heavily restored with visible, tooth colored

restorations are poor candidates as composite
restorations do not lighten, in fact they become more Bleaching Techniques for Vital Teeth
evident after bleaching.  Home bleaching technique/Night guard vital bleaching.

 Teeth with Hypoplastic Marks and Cracks  In-office bleaching

 Application of bleaching agents increase the contrast between  i. Thermocatalytic

white opaque spots and normal tooth structure:
 ii. Nonthermocatalytic
 In these cases, bleaching can be done in conjunction with:
 iii. Microbrasion.
 Microabrasion

 Selected ameloplasty
Bleaching Technique for NonVital Teeth
 Composite resin bonding.  Thermocatalytic in-office bleaching - one you put heat source on the
tooth, blue light that is used
 Defective and Leaky Restoration
 Walking bleach/lntracoronal bleaching - undergone RCT, put the
 Defective and leaky restorations are not good candidates for bleaching agent in the chamber to lighten the color of tooth
bleaching. Because they would just be obvious
 Inside/outside bleaching - depends where the stain is
 Discoloration from metallic salts particularly silver amalgam:
The dentinal tubules of the tooth become virtually saturated  Closed chamber bleaching/Extracoronal bleaching - outside the tooth
with alloys and no amount of bleaching with available products
 Laser assisted bleaching.
will significantly improve the shade.

 Defective obturation: If root canal is not well obturated, then

refilling must be done before attempting bleaching.

Ideal agents of a bleaching agent

 Be easy to apply on the teeth

 Have a neutral pH

 Lighten the teeth efficiently

 Remain in contact with oral soft tissues for short periods

 Be required in minimum quantity to achieve desired results

Home Bleaching Technique/Night Guard Bleaching
 Not irritate or dehydrate the oral tissues
 Indications for Use
 Not cause damage to the teeth
 Mild generalized staining
 Be well-controlled by the dentist to customize the treatment to the
 Age related discolorations
patient’s need.
 Mild tetracycline staining

Constituents of Bleaching Gel  Mild fluorosis

 Carbamide peroxide: 35 percent solution or gel of carbamide peroxide
  Acquired superficial staining  Severe discolorations

 Stains from smoking tobacco  Extensive caries

 Color changes related to pulpal trauma or necrosis.  Patient sensitive to bleaching agents.

 Contraindications  Advantages of In-office Bleaching

 Teeth with insufficient enamel for bleaching  Patient preference

 Teeth with deep and surface cracks and fracture lines  Less time than overall time needed for home bleaching

 Teeth with inadequate or defective restorations  Patient motivation

 Discolorations in the adolescent patients with large pulp  Protection of soft tissues.
chamber
 Disadvantages of In-office Bleaching
 Severe fluorosis and pitting hypoplasia
 More chair time
 Noncompliant patients
 More expensive
 Pregnant or lactating patients
 Unpredictable and deterioration of color is quicker
 Teeth with large anterior restorations
 More frequent and longer appointment
 Severe tetracycline staining
 Dehydration of teeth
 Fractured or mal-aligned teeth
 Serious safety considerations
 Teeth exhibiting extreme sensitivity to heat, cold or
sweets  Not much research to support its use

 Teeth with opaque white spots  Discomfort of rubber dam.

 Suspected or confirmed bulimia nervosa.

 Advantages of Home Bleaching Technique

 Simple method for patients to use

 Simple for dentists to monitor

 Less chair time and cost effective

 Patient can bleach their teeth at their convenience.

 Disadvantages of Home Bleaching Technique

 Patient compliance is mandatory

 Color change is dependent on amount of time the trays are

worn

 Chances of abuse by using excessive amount of bleach for too

many hours per day.

Microabrasion
 It is a procedure in which a microscopic layer of enamel is
In-Office Bleaching simultaneously eroded and abraded with a special compound
(usually contains 18 percent of hydrochloric acid) leaving a perfectly
 Indications of In-office Bleaching
intact enamel surface behind.
 Superficial stains
 Indications
 Moderate to mild stains.
 Developmental intrinsic stains and discolorations limited to
 Contraindications of In-office Bleaching superficial enamel only

 Tetracycline stains  Enamel discolorations as a result of hypomineralization or

hypermineralization
 Extensive restorations
  Decalcification lesions from stasis of plaque and from  Minimally invasive treatment via micro-invasive technology
orthodontic bands
 Treats decalcification and incipient decay in up to 1/3 of outer dentin
 Areas of enamel fluorosis

 Multicolored superficial stains and some irregular surface

texture.

 Contraindications

 Age related staining

 Deep enamel hypoplastic lesions

 Areas of deep enamel and dentin stains

 Amelogenesis imperfecta and dentinogenesis imperfecta cases

 Tetracycline staining

 Carious lesions underlying regions of decalcification.

 Advantages

 Minimum discomfort to patient

 Can be easily done in less time by operator

 Useful in removing superficial stains

 The surface of treated tooth is shiny and smooth in nature.

 Disadvantages

 Not effective for deeper stains

 Removes enamel layer

 Yellow discoloration of teeth has been reported in some cases

after treatment

Microabrasion Protocol
 Clinically evaluate the teeth

 Clean teeth with rubber cup and prophylaxis paste

 Apply petroleum jelly to the tissues and isolate the area with rubber
dam

 Apply microabrasion compound to areas in 60 seconds intervals with

appropriate rinsing

 Repeat the procedure if necessary. Check the teeth when wet

 Rinse teeth for 30 seconds and dry

 Apply topical fluoride to the teeth for four minutes

 Re-evaluate the color of the teeth. More than one visit may be
necessary sometimes.

**Topical fluoride white in color

Resin Infiltration

 "Infiltration CONcept"