Advancements in Restorative Dentistry

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CLINICAL EBOOK SERIES

POWERED BY

ADVANCEMENTS IN
RESTORATIVE
DENTISTRY
AUGUST 2020

2 C E C R E D I T S

THE EXTRACTION QUESTION

An Argument Against Extraction as a Treatment


Alternative for Restorable Teeth
Vicente Telles, DDS; Mariana Bezamat, DDS; and Alexandre R. Vieira, DDS, PhD

P R O D U C T S I N P R A C T I C E

CALCIUM-SILICATE RESIN CEMENT

Durable, Contemporary Cementation of Lithium-


Disilicate Crowns and Veneers
Jack D. Griffin, Jr., DMD

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

Compendium eBook consists of two articles SPECIAL PROJECTS EDITOR


Cindy Spielvogel
on restorative advancements. The first is
SPECIAL PROJECTS COORDINATOR
a continuing education (CE) article that June Portnoy
presents an argument against extraction as a treatment BRAND COORDINATOR
alternative for restorable teeth, discussing the potential Perri Lerner

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

with extraction as an alternative treatment for restorable


Copyright © 2020 by AEGIS Publications, LLC. All
teeth without being fully educated on the issues that can rights reserved under United States, International and
potentially transpire. This article discusses risk factors Pan-American Copyright Conventions. No part of this
publication may be reproduced, stored in a retrieval
associated with extraction of teeth that are restorable and system or transmitted in any form or by any means
without prior written permission from the publisher.
highlights the need for dental care providers to clearly PHOTOCOPY PERMISSIONS POLICY:
communicate to patients the possible negative outcomes This publication is registered with Copyright
Clearance Cen­ter (CCC), Inc., 222 Rosewood
that could occur as a result of extraction. Although some Drive, Danvers, MA 01923. Per­mission is granted
schools of thought, particularly in this day and age where for photocopying of specified articles provided
the base fee is paid directly to CCC.
implant dentistry is thriving, advocate extraction, espe- Printed in the U.S.A.
cially when it may benefit bone preservation, the authors
argue that extraction usually should be considered a last
resort, that patients should understand the finality of it,
and that it should be indicated primarily only when res-
toration is not an option.
This eBook also presents a Products in Practice article on
a calcium-silicate resin cement. The author explains that
as materials for indirect restorations continue to advance, Chairman & Founder
biologically friendly cements can help generate a less sensi- Daniel W. Perkins

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,

Louis F. Rose, DDS, MD


Editor-in-Chief
[email protected] AEGIS Publications, LLC
140 Terry Drive, Suite 103
Newtown, PA 18940

2 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

An Argument Against Extraction


as a Treatment Alternative for
Restorable Teeth
Vicente Telles, DDS; Mariana Bezamat, DDS; and Alexandre R. Vieira, DDS, PhD

ABSTRACT: Extraction is commonly presented as a treatment alternative for restorable


teeth, and patients are biased to choose it for a variety of reasons. However, without subse-
quent rehabilitation, patients’ health, function, and esthetics could be compromised. This
article explores problematic outcomes where extraction was offered as a treatment option
when teeth were restorable; a case report example demonstrates this issue. The case in-
volved a patient who was diagnosed with moderate to severe periodontitis and had severe
attrition and lingual erosion on his maxillary teeth. Despite being given the option of full-
mouth rehabilitation, ie, periodontal and restorative treatment, due to financial reasons
the patient chose to have all maxillary teeth extracted and receive a maxillary denture.
Respecting the patient’s autonomy, the dental team performed surgical extraction of the
maxillary teeth and an alveoloplasty and delivered an interim denture. The patient did
not adapt well to the denture, and several postoperative issues transpired, which required
unanticipated surgical procedures. Dissatisfied with the treatment, the patient continued to
need dental appointments more than a year after the extractions, and his oral health, func-
tion, and esthetics have still not been restored. The dental community must educate patients
regarding extraction being an irreversible, last-resource procedure, and mainly indicated
only when teeth restoration is not possible. Presenting extraction together with more con-
servative options for restorable teeth may contribute to patients’ misconceptions that it is a
treatment alternative as good as any other.

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

he American Dental Association justice, and veracity.1 The principle of pa-


Principles of Ethics and Code tient autonomy (“self-governance”) states
of Professional Conduct (ADA that dentists have to respect a patient’s right
Code) lists five fundamental to confidentiality and self-determination.
principles that are aspiration- It means that patients must be treated ac-
al goals for the dental profession: patient cording to their desires, needs, and abili-
autonomy, nonmaleficence, beneficence, ties, within the boundaries of accepted
DISCLOSURE: The authors had no disclosures to report.

3 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

The development of new techniques and materials


makes it possible for dentists to rehabilitate
challenging oral health conditions
with great success rates.
treatment. Also, they should be actively in- behavioral and historical factors might also
volved in treatment decisions. The principle play a role in this process. Take, for example,
of nonmaleficence expresses that dentists the association between dental care and tooth
must “do no harm.” The principle of benef- extraction. It is not uncommon for patients
icence says that dentists have the duty to to express a desire to have an extraction, be-
promote patients’ welfare, delivering com- lieving it to be the best and most definitive
petent dental care and taking into consid- solution to their dental problems.3
eration patients’ needs, desires, and values. Although extractions are still indicated,
The principle of justice means that dentists such as in cases of severely compromised
must treat people fairly, while the princi- teeth due to periodontal disease, caries, im-
ple of veracity means that dentists have an paction, or as an orthodontic treatment op-
obligation to communicate truthfully and tion, to name just a few, they should be seen
be honest and trustworthy. Although each as a last resource and not as a first option
principle is considered a guidepost, the ADA when tooth restoration is achievable.2 The
Code recognizes that these principles might development of new techniques and materi-
overlap and compete for priority, sometimes als makes it possible for dentists to rehabili-
needing to be balanced against each other.1 tate challenging oral health conditions with
In regard to patient autonomy, dentists are great success rates. While extraction might
required to obtain informed consent before solve the pain and restore health temporar-
providing any kind of treatment. Adequate ily, it fails to restore function and esthetics.
consent can only be obtained if the patient is Without posterior rehabilitation, removal of
introduced to all reasonable treatment alter- a tooth will further compromise patients’ oral
natives, including no treatment, with explana- health, having a negative impact on the stabil-
tion of risks and benefits. The dentist must not ity of adjacent teeth and periodontal status.4
be paternalistic, meaning that there should be Moreover, Gupta et al have shown that there
no bias in driving the patient to choose any of is an association between tooth loss without
the alternatives.1 Thus, it is not uncommon for rehabilitation and higher mortality.5
a patient to choose a different plan than the When dentists offer extraction as a treat-
one the dentist deems best. ment alternative among more conservative
To obtain better insight into a patient’s options, presenting it as a conclusive treat-
decision-making process, it is important for ment without consideration for rehabilitation,
clinicians to try to evaluate the conditions this may reinforce patients’ misconception
that might guide the patient, such as finan- that it is a treatment plan as good as any other.
cial issues, dental care phobia, and expectan- Even though health communication skills are
cy of tooth longevity.2 However, underlying developed in dental school, dentists may still

4 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

find it hard to fully convey to a layperson the


advantages and disadvantages of each treat-
ment plan, even when thoroughly explaining
it to obtain informed consent.6
In their Dental Registry and DNA Repository
(DRDR) project,7-10 the present authors ob-
served that there was a high number of pa-
tients who chose teeth extraction instead of
Fig 1.
rehabilitation or restoration as a solution to
their chief complaint. The factors described in
the health records affecting patients’ decisions
ranged from financial concerns and the desire
to expedite and rapidly complete care. In the
present report, a case is described of a patient
who chose an extraction alternative as a treat-
ment for his oral conditions, but many com-
plications developed that resulted in poorer
quality of life. This case, found in the DRDR Fig 2.
database, is reported for the purpose of exem-
plifying a situation where extractions were not Fig 1. Upper occlusal view, showing severe attri-
the ideal treatment plan, but the treatment tion and lingual erosion on maxillary teeth. Fig 2.
Frontal intraoral view, showing severe attrition on
was nonetheless carried out in respect to the maxillary teeth.
patient’s autonomy.
thodontics department, the patient was
Case Report presented with possible treatment options.
A 53-year-old man sought care at the Alternatives ranged from full-mouth rehabili-
University of Pittsburgh School of Dental tation, ie, periodontal and restorative treat-
Medicine for a routine oral evaluation and ment that included scaling, root planing, com-
prophylaxis on August 12, 2016. After a full posite restoration, and/or crown placement,
periodontal examination, the patient was re- to no treatment at all. Due to financial reasons,
ported having moderate to severe periodonti- the patient selected the least expensive treat-
tis. Probing depths ranged from 1 mm to 7 mm ment, which was extraction of all maxillary
and several teeth had class I mobility. Severe teeth and fabrication of a maxillary complete
attrition and lingual erosion were found on denture. The patient made this decision de-
all maxillary teeth, except the molars (Figure spite being informed that at his age these pro-
1 and Figure 2). cedures could be considered overly aggressive
The patient’s medical history was positive in light of his oral health conditions.
for tobacco use (half to one pack per day), sea- Respecting the patient’s autonomy, surgical
sonal allergies, and hepatitis C. He reported extraction of the maxillary teeth and an alveo-
the use of ibuprofen (Advil®) for hip pain and loplasty were performed on May 11, 2017, with
recreational marijuana. The blood pressure no complications, and oral and written post-
was documented as 155/98 millimeters of operative instructions were provided. The
mercury, pulse of 72, unlabored respiration, interim denture was delivered on the same
and body mass index of 23.0. day. The patient complained of ill fit, gagging,
After consultation at the School’s Pros- and pain, so, even though the prosthodontist

5 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

verified that the denture fit well, adjustments


were made for the patient’s comfort.
In the following months, besides complaints
of fit and sore spots, the patient had several
postoperative issues, including right canine
space infection with swelling of the maxilla
and numerous bony spicules. Each complaint
was properly addressed, but the resolution
Fig 3.
involved several surgical procedures that the
patient did not anticipate. Fig 3. Frontal intraoral view, after placement of
On January 11, 2018, the patient appeared maxillary denture in January 2018.
without the maxillary denture in mouth, com-
plaining that it was loose. He stated that he rehabilitation alternative, which he discard-
was “very unhappy with the dental proce- ed due to financial concerns but that would
dures.” The interim denture was causing dis- have been a more adequate treatment for
comfort to the point that he could not breathe his conditions.
properly. He suffered with pain, poor func- A more common and relatable situation in
tion, and subpar esthetics, which were not daily dental practice is when a patient chooses
restored because the patient avoided using extraction instead of endodontic therapy of a
the denture. Eleven days later, at the patient’s tooth with a good or fair prognosis. As men-
request the acrylic part of the denture was tioned earlier, the reasons for the choice of
significantly thinned down (Figure 3), even extraction vary among financial situation,
though he was informed that doing so would dental care phobia, desire for a “quick fix,”
cause the denture to be more prone to break- and expectancy of tooth longevity, as well as
age. Since then the patient had numerous sub- others. In challenging situations like these, a
sequent appointments for adjustment of the conflict arises between the ethical principles
denture, including several visits to remake it. of patient autonomy and nonmaleficence.
Eventually, he received a remade denture and However, as long as patients are adequately
has been satisfied with the current resolution. informed of the risks and benefits of all treat-
At the time of this writing, nearly 2 years af- ment alternatives, they have the right to de-
ter the extraction appointment, the patient is termine what shall be done to their body, and
assessing the option of having dental implants dentists must respect their decision, as was
for an overdenture to be built. done in this case. Because dentists must not
be paternalistic, a patient cannot be guided to
Discussion choose the treatment alternative the dentist
Although this case is an extreme example of deems best.
extractions not working out favorably, all of Interestingly enough, Re et al published a
these risks were properly conveyed to the pa- study in which they aimed to observe, in a
tient when treatment alternatives were pre- hypothetical scenario, if dentists chose for
sented. The patient’s decision-making pro- themselves the same treatment they sug-
cess was impacted by financial limitations, gested for their patients. First, 100 volunteer
but he was optimistic for favorable results dentists were shown 15 radiographs of com-
due to having sought care in a top-ranked promised teeth and had to decide between
dental teaching facility. Nevertheless, he is extraction, endorestorative recovery, or re-
now facing a cost as high as the full-mouth ferral to a specialist to save the tooth. Then,

6 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

If dentists, with all of their background knowledge,


do not choose this option for themselves,
patients should not be choosing it either.

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

7 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

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

8 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 THE EXTRACTION QUESTION

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.

9 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


CONTINUING EDUCATION 1 QUIZ 2 Hours CE Credit

An Argument Against Extraction as a Treatment


Alternative for Restorable Teeth
Vicente Telles, DDS; Mariana Bezamat, DDS; and Alexandre R. Vieira, DDS, PhD

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/ADVANCERESTOR


ENTER PROMO CODE: ADRESTDENT

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.

Course is valid from 6/1/2019-6/30/2022. Participants must


attain a score of 70% on each quiz to receive credit. Partici- Approved PACE Program Provider
AEGIS Publications, LLC, is an ADA CERP Recognized FAGD/MAGD Credit
pants receiving a failing grade on any exam will be notified
Provider. ADA CERP is a service of the American Dental Approval does not imply acceptance
and permitted to take one re-examination. Participants will Association to assist dental professionals in identifying quality by a state or provisional board of
receive an annual report documenting their accumulated
providers of continuing dental education. ADA CERP does not dentistry or AGD endorsement. The
approve or endorse individual courses or instructors, nor does current term of approval extends from
credits, and are urged to contact their own state registry it imply acceptance of credit hours by boards of dentistry. 1/1/2017 to 12/31/2022.
Concerns or complaints about a CE provider may be directed Provider #: 209722.
boards for special CE requirements. to the provider or to ADA CERP at www.ada.org/cerp.

10 COMPENDIUM EBOOK SERIES August 2020 || Volume


Volume 41
41 Number
Number 17
17 www.compendiumlive.com
PRODUCTS IN PRACTICE CALCIUM-SILICATE RESIN CEMENT

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.

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PRODUCTS IN PRACTICE CALCIUM-SILICATE RESIN CEMENT

Bioavailable ions generate an alkaline


pH environment, neutralize acid, and ultimately
promote healing, which may result in a less sensitive,
longer-lasting restoration.
shade, thickness of the restoration, and de- They provide a moderate bond to dentin and
sired final shade.10 good esthetics.
A newer emphasis has been placed on ce-
Modern Cementation ments that are bio-interactive or regenera-
Cementation technique is critical to restora- tive in nature.16 Bioavailable ions generate
tion success,8 and clinicians have many ma- an alkaline pH environment, neutralize acid,
terials and methods from which to choose: and ultimately promote healing, which may
cement or bond, light cure or chemical result in a less sensitive, longer-lasting res-
cure, acid-etch or no etch, bonding agent toration. The cement responds to the oral
or self-adhesive, silane or sandblasting, etc. environment to provide therapeutic ions.17
Retention is but one of many factors influ- Calcium silicate-based dual-cure resin ce-
encing cement choice. Other factors include ments have shown to be an effective choice
long-term physical properties, color predict- for full-coverage lithium disilicate because of
ability, ease of clean-up, and the luting mate- excellent clinical characteristics along with
rial’s compatibility with the restoration mate- calcium and fluoride release.18
rial.11 Self-adhesive resin cements work well The following case report demonstrates
with retentive preparations, but light-cure the use of an ion-releasing self-etch, self-
resin cements with separate steps for phos- adhesive calcium-silicate resin cement with
phoric acid-etching and adhesion provide layered lithium-disilicate crowns and a trans-
better long-term results with preparations lucent light-cure resin cement for placement
that have less-than-ideal retention.12,13 of lithium-disilicate veneers.
Light-cure-only resin cements are often
used with conservative anterior restorations Crown and Veneer Case
because of their longer working time, predict- A 61-year-old patient presented with her
able clean-up, excellent esthetics and color tooth No. 9 crown loose, and she could actu-
stability, and high strength.14 Transparent ally remove it (Figure 1). Many years earlier
light-cure resins have been demonstrated to the patient had had endodontic surgery, an
yield superior color stability when compared apicoectomy and retrograde filling to repair
to luting materials with more color or that a failing silver-point obturation, and was now
are dual cure.15 symptom free. The silver point remained in
Full-coverage restorations allow for great- the tooth and showed no lesions on radio-
er diversity in cementation choices. Self- graph. Tooth No. 8 had an unbonded porce-
adhesive dual-cure resin cements are popu- lain veneer that had come off “several times”
lar with full-coverage restorations because before. She wanted to replace the restora-
of their simplicity and predictable results. tions on the central incisors with ones that

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PRODUCTS IN PRACTICE CALCIUM-SILICATE RESIN CEMENT

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.

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PRODUCTS IN PRACTICE CALCIUM-SILICATE RESIN CEMENT

DC, BISCO, bisco.com), shade Natural/A1


(Figure 4). Communicating the final prepa-
ration shades accurately to the laboratory
was critical in enabling the lab to choose the
most translucent shade of lithium disilicate
that would mask the preparation and achieve
the final color desired.
Conventional impressions were taken
with a polyvinyl siloxane material (Panasil®, Fig 5.
Kettenbach, kettenbach-dental.us) in a stock
tray and sent to the laboratory with all photo-
graphs, the bite registration, and a dentofacial
analyzer index (Kois Dentofacial Analyzer,
Panodent, panodent.com). Temporary resto-
rations were made for the central incisors, 2%
chlorhexidine (Cavity Cleanser™, BISCO) was
painted on the teeth, and the restorations were
placed with a temporary cement (ZONEfree™,
Pentron, pentron.com). The veneer prepara-
tions were temporized via spot-etching and Fig 6.
lock-on technique without the use of a bond-
ing agent. Fig 5. Central incisors were cemented with a cal-
All records were sent to the laboratory and cium-silicate dual-cure resin cement. Fig 6. Teeth
all case photographs were uploaded to the with veneers were totally etched for 20 seconds
and rinsed.
lab portal. After 5 days, the patient returned
for evaluation of color, length, and function were cemented with a self-etch, self-adhesive
with the temporaries. Slight adjustments were calcium-silicate resin cement (TheraCem®,
made, polishing was done, photographs were BISCO) and held in place for about 1 minute;
taken, and desired changes were communi- excess cement was easily removed (Figure 5).
cated with the lab. After complete clean-up light-curing was done
at the margins. In the author’s experience, the
Cementation for Crowns calcium and fluoride release, easy clean-up,
The layered lithium-disilicate restorations and physical properties make this cement an
were returned from the laboratory having excellent choice for routine lithium-disilicate
been hydrofluoric acid-etched and silanated. full-coverage placement.
With a frosty appearance the intaglio surfaces This self-etch, self-adhesive cement is
were ready for cementation. The temporaries available in a “natural” shade and provides
were removed, the teeth were cleaned with firm bond to dentin and most modern dental
flour pumice, and the restorations were in- materials such as etched lithium disilicate
spected in place. No adjustments were needed and zirconia. The high calcium content in
in this case. this calcium and fluoride ion-releasing ce-
All restorations were rinsed, cleaned with ment gives the material a slightly opaque,
a restoration cleaner (ZirClean™, BISCO) to white appearance but does not seem to in-
remove contaminants, rinsed again, and re-si- fluence the final restoration shade in routine
lanated (Bis-Silane™, BISCO). The two crowns indirect restorations.

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PRODUCTS IN PRACTICE CALCIUM-SILICATE RESIN CEMENT

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 9. Fig 10.

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.

15 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


PRODUCTS IN PRACTICE CALCIUM-SILICATE RESIN CEMENT

Conclusion 6. Silva NR, Thompson VP, Valverde GB, et al. Com-


As materials for indirect restorations continue parative reliability analyses of zirconium oxide and
to advance, biologically friendly cements can lithium disilicate restorations in vitro and in vivo. J Am
Dent Assoc. 2011;142(suppl 2):4s-9s.
help generate a less sensitive, longer-lasting res- 7. Fasbinder DJ, Dennison JB, Heys D, Neiva G. A
toration through calcium and fluoride release. clinical evaluation of chairside lithium disilicate CAD/
As demonstrated in this case report, a calcium CAM crowns: a two-year report.J Am Dent Assoc.
silicate-based dual-cure resin cement, offering 2010;141(suppl 2):10s-14s.
8. Rojpaibool T, Leevailoj C. Fracture resistance of
excellent clinical characteristics, including easy lithium disilicate ceramics bonded to enamel or den-
clean-up, was an effective choice for full-cov- tin using different resin cement types and film thick-
erage lithium-disilicate anterior restorations. nesses. J Prosthodont. 2017;26(2):141-149.
9. Kelly JR, Nishimura I, Campbell SD. Ceramics in
ACKNOWLEDGMENT dentistry: historical roots and current perspectives. J
Prosthet Dent. 1996;75(1):18-32.
The author thanks Pacific Aesthetic Dental 10. Turgut S, Bagis BJ. Effect of resin cement and
Studio (ThePAC.org) for providing the indi- ceramic thickness on final color of laminate veneers:
rect restorations in this case. an in vitro study. J Prosthet Dent. 2013;109(3):179-186.
11. Krummel A, Garling A, Sasse M, Kern M. Influence of
bonding surface and bonding methods on the fracture
ABOUT THE AUTHOR resistance and survival rate of full-coverage occlusal
Jack D. Griffin, Jr., DMD veneers made from lithium disilicate ceramic after
Accredited Member, American Academy of Cosmetic Dentist- cyclic loading. Dent Mater. 2019;35(10):1351-1359.
ry; Diplomate, American Board of Aesthetic Dentistry; 12. Taskonak B, Sertgöz A. Two-year clinical evaluation
Master, Academy of General Dentistry; Private Practice, of lithia-disilicate-based all-ceramic crowns and fixed
Lake St. Louis, Missouri partial dentures. Dent Mater. 2006;22(11):1008-1013.
13. Jensen ME, Sheth JJ, Tolliver D. Etched-porcelain
REFERENCES resin-bonded full-veneer crowns: in vitro fracture re-
1. Zarone F, Di Mauro MI, Ausiello P, et al. Current status sistance. Compendium. 1989;10(6):336-347.
on lithium disilicate and zirconia: a narrative review. 14. Lee HY, Han GJ, Chang J, Son HH. Bonding of
BMC Oral Health. 2019;19(1):134. the silane containing multi-mode universal adhesive
2. Tysowsky GW. The science behind lithium disilicate: for lithium disilicate ceramics. Restor Dent Endod.
a metal-free alternative. Dent Today. 2009;28(3):112-113. 2017;42(2):95-104.
3. Rauch A, Reich S, Dalchau L, Schierz O. Clini- 15. Lee SM, Choi YS. Effect of ceramic material and
cal survival of chair-side generated monolithic di- resin cement systems on the color stability of lami-
silicate crowns: 10-year results. Clin Oral Investig. nate veneers after accelerated aging. J Prosthet Dent.
2012;22(4):1763-1769. 2018;120(1):99-106.
4. Pathan MS, Kheur MG, Patankar AH, Kheur SM. As- 16. Dworkin O, Kugel G, Loo C. What is bioactive den-
sessment of antagonist enamel wear and clinical per- tistry? A review. Dentistry Today. 2018;37(1):44-46.
formance of full-contour monolithic zirconia crowns: 17. Chan DC, Hu W, Chung KH, et al. Reactions: an-
one-year results of a prospective study. J Prosthodont. tibacterial and bioactive dental restorative materi-
2019;28(1):e411-e416. als: do they really work? Am J Dent. 2018;31(spec iss
5. Malament KA, Natto ZS, Thompson V, et al. Ten- B):32B-36B.
year survival of pressed, acid-etched e.max lithium 18. Chen L, Yang J, Wang JR, Suh BI. Physical and
disilicate monolithic and bilayered complete-coverage biological properties of a newly developed calcium
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tion of tooth position and age. J Prosthet Dent. 2019; 2018;31(2):86-90.
21(5):782-790.

16 COMPENDIUM EBOOK SERIES August 2020 | Volume 41 Number 17 www.compendiumlive.com


U

UNIVERSATILITY
/yoo-nuh-ver-suh-til-ah-tee/ noun

1. ability to be used with direct and indirect


restorations and formulated to be compatible
with light-, dual- and self-cured materials.

2. because universal versatility is a mouthful.

Ex. The universatility of All-Bond Universal gave


Dr. Moreno the feeling that he had the power
of the entire universe in one single bottle.

Scan to re
o
Learn M

Call us! We’re here to help:


1-800-247-3368 • www.bisco.com Rx Only MC-10164AB

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