Advancements in Restorative Dentistry
Advancements in Restorative Dentistry
Advancements in Restorative Dentistry
POWERED BY
ADVANCEMENTS IN
RESTORATIVE
DENTISTRY
AUGUST 2020
2 C E C R E D I T S
P R O D U C T S I N P R A C T I C E
SUPPORTED BY AN UNRESTRICTED GRANT FROM BISCO, INC. • Published by AEGIS Publications, LLC © 2020
Is Extraction
Overrated?
A
AUGUST 2020 | www.compendiumlive.com
PUBLISHER
Matthew T. Ingram
dvancements continue to be made in the SPECIAL PROJECTS DIRECTOR
field of restorative dentistry. This special C. Justin Romano
problems that may arise and explaining that there is a full MANAGING EDITOR
Bill Noone
range of alternatives. The second article is a Products in
CREATIVE
Practice case review on durable, contemporary cementa- Claire Novo
tion of lithium-disilicate crowns and veneers. EBOOK DESIGN
As the CE article explains, patients are often presented Jennifer Barlow
tive, longer-lasting restoration through calcium and fluoride Vice Chairman & Co-Founder
Anthony A. Angelini
release. This case review shows that a calcium silicate-based
Chief Executive Officer
dual-cure resin cement with optimal clinical characteristics, Karen A. Auiler
including easy cleanup, was an effective choice for full-cov- Corporate Associate
erage lithium-disilicate anterior restorations. Jeffrey E. Gordon
Media Consultant, East
At Compendium, we strive to provide you with informa- Scott MacDonald
tion on the latest advancements in restorative dentistry and Subscription & CE information
other topics, whether for CE credit or overall knowledge Hilary Noden
877-423-4471, ext. 207
acquisition. For more on restorative dentistry, please visit us [email protected]
at https://www.aegisdentalnetwork.com/cced/restorative/.
Sincerely,
LEARNING OBJECTIVES
•D
iscuss the risk factors •D
escribe reasonable •E
xplain how clinicians may
associated with tooth treatment alternatives to assist patients in making
extraction extraction of teeth informed decisions about
T
treatment options
the radiographs where shown again, with when indicating extraction is that, in some
the question: “If this was your tooth, what cases, this treatment must be followed by
would you do?” Comparing the responses, proper rehabilitation. For example, extrac-
the authors concluded that dentists were tion by itself is less costly than endodontic
more conservative regarding their own teeth, treatment plus a full crown, which perhaps
opting for endorestorative treatment or re- may sway patients toward the extraction
ferral to specialists.11 option. However, failure to rehabilitate the
Hypothetical scenarios do not reproduce missing tooth could cause further harm to
feelings such as pain and fatigue, dental care oral health, negatively impacting adjacent
phobia, patient personality, oral health his- teeth stability and periodontal status.4 An
tory, and financial issues that influence de- adequate treatment plan involving extrac-
cision-making. However, the Re et al study tion should include a bridge or implants
shows that dentists chose challenging but to restore the missing teeth. This would
more conservative procedures to save their level the cost of the treatment alternatives,
own teeth, indicating that they value tooth perhaps making patients less inclined to
retention over tooth extraction. Extraction is choose extraction only for financial reasons.
left as a last resource for when the prognosis Therefore, it could be argued that treatment
is hopeless and there are no other alterna- plans that do not include rehabilitation after
tives to save the tooth.11 This strengthens the extraction when rehabilitation is needed are
argument that extraction is not seen as a gold not in compliance to the ADA principle of
standard of care by providers. nonmaleficence, because harm to oral health
If dentists, with all of their background is bound to happen.
knowledge, do not choose this option for With advances in implant dentistry, there
themselves, patients should not be choos- is a trend to extract teeth with good or fair
ing it either. Considering that dentists, to the prognoses to save bone for placement of im-
best of their abilities, are fully communicating plants, which are being considered equal or
risks and benefits of each treatment plan to even superior to natural teeth in regard to
obtain informed consent, patients must not survival.12-14 Moshaverinia et al challenged
be fully comprehending the implications of this school of thought as they summarized
their decision. There appears to be a discon- 10-year follow-up studies that have shown
nection between the dentist’s and patient’s that the longevity of periodontally compro-
understanding of the treatment plans and mised teeth surpasses implants, especially
their outcomes that the dental community in well-maintained patients.15 They demon-
must address. This could be done via train- strated that teeth with good or fair prognoses
ing for predoctoral students and continuing should not be extracted, because there is a
education for practicing professionals. lack of evidence supporting this aggressive
Another factor that should be considered approach. They also stated that traditional
dental practice should consider extraction standard of care may dentists legally and
as a last resource. ethically refuse to offer such extraction as a
Chandki and Kala also believe that ad- reasonable alternative.
equate consideration should be given to
treatments focusing on preserving and re- Conclusion
storing compromised teeth instead of ex- Patients’ autonomy must be respected in their
traction and replacement.12 Considering decision-making process, even though they
the expenses necessary for implant place- might be inclined to choose extraction as a
ment, Parirokh et al pointed out that this treatment option instead of more conserva-
approach might not be a reasonable option tive approaches. However, indicating extrac-
for many patients, and this must be taken tion alongside other treatment plans may lead
into account when presenting the treatment patients to believe it to be as good an alter-
plan. Extraction without implant placement native as any other, and not a last resource.
would cause greater bone resorption and at- Patients’ perception of extraction is not the
rophy of the alveolar ridge than if the tooth same as dentists’, which is to value teeth re-
was kept, further compromising the possi- tention and proper oral rehabilitation. Dental
bility of future implant placement.16 As such, healthcare providers need to be aware of and
although implants have a high success rate, address this situation.
the cost of implant placement is high, and
there is a lack of evidence showing they have ACKNOWLEDGMENT
better survival rates than teeth with good or The University of Pittsburgh Dental Regis-
fair prognoses. try and DNA Repository, which is supported
Overall, it is important that the dental by the School of Dental Medicine, provided
community effectively communicates to data for this report. The authors sincerely
patients that tooth extraction is an aggres- thank Joseph D. Myers for proofreading and
sive, last-resource approach. The difference editing the article.
between patients’ and dentists’ perceptions
of the optimal treatment alternative shows ABOUT THE AUTHORS
that this message may not be properly under- Vicente Telles, DDS
stood, jeopardizing informed consent. The Research Assistant, Department of Oral
Biology, School of Dental Medicine, University
present authors suggest that to start chang- of Pittsburgh, Pittsburgh, Pennsylvania
ing patients’ perceptions, the extraction al-
ternative should not be presented as a final Mariana Bezamat, DDS
treatment goal, but accompanied by reha- Graduate Student Researcher, Department of Oral
bilitation when appropriate. This would help Biology, School of Dental Medicine, University
of Pittsburgh, Pittsburgh, Pennsylvania
level treatment costs and thereby eliminate
financial bias. The hope is that this approach Alexandre R. Vieira, DDS, PhD
will eventually change patients’ misconcep- Professor, Department of Oral Biology, School of
tions and enable them to stop considering Dental Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania
extraction as a complete treatment option
without proper rehabilitation. Nevertheless, Queries to the author regarding this course may be
submitted to [email protected].
patients’ autonomy protects their right to
choose less-than-optimal treatment plans. REFERENCES
Thus, only when the removal of a restorable 1. Iovino RP. Revising the American Dental Associa-
tooth would cause injury or be below the tion Principles of Ethics and Code of Professional
Conduct: Adding “Respect for Human Dignity” as BMC Oral Health. 2018;18(1):72.
the sixth principle of dental ethics to accommo- 9. Vieira AR, Silva MB, Souza KKA, et al. A pragmatic
date advances in genetic science. J Am Dent Assoc. study shows failure of dental composite fillings is
2016;147(12):918-922. genetically determined: a contribution to the dis-
2. Broers DL, Brands WG, Welie JV, de Jongh A. cussion on dental amalgams. Front Med (Lausanne).
Deciding about patients’ requests for extraction: 2017;4:186.
ethical and legal guidelines. J Am Dent Assoc. 10. Vieira AR, Hilands KM, Braun TW. Saving more teeth-
2010;141(2):195-203. a case for personalized care. J Pers Med. 2015;5(1):
3. De Marchi RJ, Leal AF, Padilha DM, Brondani MA. 30-35.
Vulnerability and the psychosocial aspects of tooth 11. Re D, Cerutti F, Consonni D, Gorni FG. Treatment
loss in old age: A southern Brazilian study. J Cross planning of damaged teeth: to recover or to extract?
Cult Gerontol. 2012;27(3):239-258. Minerva Stomatol. 2017;66(5):201-211.
4. Aquilino SA, Shugars DA, Bader JD, White BA. Ten- 12. Chandki R, Kala M. Natural tooth versus im-
year survival rates of teeth adjacent to treated and plant: a key to treatment planning. J Oral Implantol.
untreated posterior bounded edentulous spaces. J 2012;38(1):95-100.
Prosthet Dent. 2001;85(5):455-460. 13. Mordohai N, Reshad M, Jivraj SA. To extract or
5. Gupta A, Felton DA, Jemt T, Koka S. Rehabilitation not to extract? Factors that affect individual tooth
of edentulism and mortality: a systematic review. J prognosis. J Calif Dent Assoc. 2005;33(4):319-328.
Prosthodont. 2018. doi: 10.1111/jopr.12792. 14. Anson D. The changing treatment planning para-
6. Seymour B, Yang H, Getman R, et al. Patient-cen- digm: save the tooth or place an implant. Compend
tered communication: exploring the dentist’s role Contin Educ Dent. 2009;30(8):506-517.
in the era of e-patients and health 2.0. J Dent Educ. 15. Moshaverinia A, Kar K, Chee WW. Treatment plan-
2016;80(6):697-704. ning decisions: implant placement versus preserving
7. Ravindramurthy S, Vieira AR. Depression and its natural teeth. J Calif Dent Assoc. 2014;42(12):859-868.
effects on the success of resin-based restorations. 16. Parirokh M, Zarifian A, Ghoddusi J. Choice of
Spec Care Dentist. 2018;38(4):266-268. treatment plan based on root canal therapy versus
8. Amoo-Achampong F, Vitunac DE, Deeley K, et al. extraction and implant placement: a mini review. Iran
Complex patterns of response to oral hygiene instruc- Endod J. 2015;10(3):152-155.
tions: longitudinal evaluation of periodontal patients.
1. Which ADA Code principle states that 6. In the case presented, the patient’s decision-
dentists must respect the patient’s right to making process was impacted by:
confidentiality and self-determination? A. the dentist persuading him to choose
A. patient autonomy extractions.
B. nonmaleficence B. h
is dental phobia.
C. beneficence C. f inancial limitations.
D. veracity D. his desire to comply with ADA principles.
2. Which ADA Code principle means that dentists 7. Among common reasons why patients
have an obligation to communicate truthfully choose extraction is:
and be honest and trustworthy? A. fear of new technology.
A. patient self-governance B. mistrust of their dentist.
B. nonmaleficence C. desire for a “quick fix.”
C. justice D. lack of knowledge about dental implants.
D. veracity
8. In a study, Re et al concluded that compared
3. Meaning that there should be no bias in to treatments suggested for their patients,
driving the patient to choose any of the dentists were:
treatment alternatives presented, dentists A. more conservative regarding their own
must not be: teeth.
A. transparent. B. more aggressive regarding their own teeth.
B. paternalistic. C. m ore apt to choose extraction over
C. beneficent. endorestorative treatment for themselves.
D. empathetic. D. more conservative regarding their patients’
teeth.
4. Gupta et al have shown that there is an
association between tooth loss without 9. Moshaverinia et al demonstrated that teeth
rehabilitation and: with good or fair prognoses:
A. improved periodontal status. A. are better off being extracted and replaced
B. reduced bone resorption. with implants.
C. increased self-esteem. B. a
re usually incapable of being extracted.
D. higher mortality. C. always benefit from aggressive treatment.
D. should not be extracted.
5. The case presented demonstrates a situation
where extractions were not the ideal 10. T
he dental community must effectively
treatment plan but were carried out: communicate to patients that tooth extraction:
A. in respect to the patient’s autonomy. A. is the safest alternative in any situation.
B. due to time constraints. B. is an aggressive, last-resource approach.
C. based on the patient’s age. C. is never a suitable solution.
D. because this was considered the least D. must always be accompanied by
aggressive option. subsequent rehabilitation.
Durable, Contemporary
Cementation of Lithium-
Disilicate Crowns and Veneers
Jack D. Griffin, Jr., DMD
ABSTRACT: Clinicians have many restorative options from which to choose. For indirect
restorations, the selection of cementation technique is critical to a successful outcome. One
emerging trend in dentistry today is the development of materials that have bio-interactive
or regenerative qualities. This case presentation reports on the use of a calcium silicate-
based dual-cure resin cement that has shown to be effective for use with full-coverage
lithium-disilicate restorations due to not only its excellent clinical characteristics but also
calcium and fluoride release capabilities. The case also includes conservative lithium-disili-
M
cate veneer restorations.
any viable material choices used for restorations ranging from conser-
are available in restorative vatively prepared veneers to full-coverage
dentistry today. Despite crowns to full-arch prostheses.2 Factors such
the ever-growing arsenal as occlusion, parafunctional habits, esthetics,
of newer materials and and biological effects influence a clinician’s
techniques, clinicians are often reluctant to choice of indirect materials.3,4
change from using those materials and meth- The success of lithium disilicate, specifi-
ods with which they are most familiar and cally IPS e.max® (Ivoclar Vivadent, ivoclar-
have had success. Above all else, clinicians vivadent.com), has been well documented,
want predictable, repeatable results. and it has become one of the most versatile
Restorative dental materials have advanced esthetic materials in dentistry.5 The dental
to meet the increasingly bio-friendly and profession has had more than 15 years of
metal-free esthetic demands of the public clinical performance and numerous stud-
today. Contemporary materials are expected ies to fairly evaluate this material, its clini-
to have, not a negative, but a positive effect on cal properties, and durability.6,7 Success has
living tissues. An aversion to metal, the avoid- been observed in both full-coverage and
ance of potential allergies, and the systemic conservative restorations as well as in an-
effect of dental materials all drive the dental terior and posterior situations.8
profession to be more biologically tolerant. High translucency imparts vitality to a res-
toration and is important to its esthetic suc-
Versatile Predictability cess.9 The esthetic predictability of lithium
When working with indirect restorative disilicate, particularly when used in conser-
materials, clinicians require consistency in vative anterior preparations, makes it a popu-
esthetics, functionality, durability, and pa- lar cosmetic material choice. Lithium disili-
tient comfort. Zirconia and lithium disilicate cate is available in several different levels of
have become dominant materials in modern opacities. The opacity should be chosen on a
metal-free dentistry.1 They are commonly case-by-case basis depending on preparation
DISCLOSURE: This article was commercially supported by BISCO.
would be a “lighter color” and to bleach her a mock-up was done, and a temporary impres-
other teeth (Figure 2). sion matrix was made. The patient chose a final
A full series of photographs was taken and VITA 3D shade of .5M1 (VITA, vitanorthamer-
reviewed with the patient. Occasionally, in ica.com). Preparations were done using a
the author’s experience, patients might want course diamond (NeoDiamond®, Microcopy,
to choose a “lighter color” for their restora- microcopydental.com), with 1.5 mm occlusal
tions and attempt to bleach their other teeth clearance and chamfer margins. On teeth Nos.
until they match. After some discussion and 5 through 7 and 10 through 12, 0.5 mm veneer
patient education, the patient accepted a plan preparations were executed with a finishing
calling for lithium-disilicate porcelain res- diamond, staying in enamel in all places ex-
torations on teeth Nos. 5 through 12, which cept abfraction areas at the gingival margins.
included full coverage on the central incisors Preparation corners were rounded to reduce
and conservative veneer preparations on the internal stresses on the restorations.
other teeth. A full-coverage restoration for Shade photographs were taken on moist
tooth No. 8 was chosen because the existing teeth with shade tabs on the same plane as
preparation was primarily in dentin, there the teeth (Figure 3). Because of the dark gray
was a history of veneer failure, and doing so color of the endodontically treated tooth No.
would provide the laboratory with symmetri- 9, the silver point was removed from the coro-
cal consistency in restoration thickness. nal portion of the tooth and replaced with
Another full series of photographs was taken, a dual-cure build-up material (Core-Flo™
Fig 1. Fig 2.
Fig 3. Fig 4.
Fig 1. Patient with failed veneer No. 8 and dislodged crown No. 9. Fig 2. Treatment goals were to replace res-
torations on the central incisors and lighten color throughout the dentition. Fig 3. After restoration removal
and veneer preparation, shade photographs were taken. Fig 4. Silver point was removed from coronal por-
tion of tooth No. 9, and build-up was done with dual-cure material resulting in less darkness on the tooth.
Cementation for Veneers while being held securely in place. Along with
The intaglio surfaces of the veneers after long-term color stability, the light-cure-only
re-silanation were thoroughly dried, and a material allowed for thorough clean-up and
universal dentin bonding agent (All-Bond an efficient cementation process.
Universal®, BISCO) was applied and air- With each veneer being held in place, the res-
thinned. The teeth were isolated with retrac- torations were cured with an LED light. Minor
tors, etched with 37% phosphoric acid (Etch- adjustments were made with a finish diamond,
37™ with BAC, BISCO) for 15 seconds, and and the restorations were polished.
rinsed (Figure 6). The universal adhesive was The patient was scheduled for a follow-
applied in several applications, allowed to sit up appointment for adjustments as needed,
for 20 seconds, air-dried with an air syringe cement clean-up, final photographs, and to
for 10 seconds, and then light-cured for 10 place direct composite on the facial surfaces
seconds (Figure 7). of the second bicuspids for enhanced blend-
After material was extruded from the tip ing. The soft-tissue response at 6 months was
onto a napkin, the translucent light-cure resin excellent for both the full-coverage restora-
cement (Choice™ 2, BISCO) was applied to tions and the veneers (Figure 9). The blend-
each tooth, and the veneers were placed en- ing of materials, despite varied restoration
suring that excess material extruded from all thicknesses, was acceptable, and the patient
margins (Figure 8). The excess material was enthusiastically approved of the final color
brushed away and all restorations were flossed shade (Figure 10).
Fig 7. Fig 8.
Fig 7. Several coats of universal bonding agent were applied, air-dried, and light-cured. Fig 8.
Light-cure-only cement was applied to the teeth, veneers were placed, clean-up was completed,
and light-curing was done. Fig 9. Soft-tissue response was excellent, as was long-term prognosis.
Fig 10. Good opacity of the selected lithium disilicate resulted in a consistent final shade.
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