Quo vadis, esthetic dentistry? Part II: Composite resin overtreatment and social media appeal.

OBJECTIVES: This article presents case reports highlighting over-treatments with resin composites, often misconceived as minimally invasive procedures. CLINICAL CONSIDERATIONS: Tooth-colored restorative materials, such as ceramics and composites, have found widespread application to correct problems related to tooth color, shape, and alignment. When composite resin is used, these procedures can be done in a very conservative, cost-effective, and timely fashion. However, it is noteworthy that contemporary dental esthetic expectations are based on standards propagated by social media and other marketing and communications platforms. The abuse of and addiction to social media impacts can lead to unrealistic esthetic expectations and standards for both patients and dentists. CONCLUSIONS: After a critical discussion on ceramic veneers published in part I of this 2-part series, this article directs attention towards what has become a trendy fashion, i.e., the use of direct composite resins as "non-prep" veneers in clinical situations that arguably required no restorative intervention at all. We further explore how social media influences the decision-making processes of both professionals and patients.

Quo vadis, esthetic dentistry? Ceramic veneers and overtreatment-A cautionary tale.

The increased emphasis on orofacial esthetics, experienced both by dental professionals and the lay public, results in an environment where overtreatment can easily occur. Patients on the one hand feel pressure from esthetic norms that are often unrealistic, while dental professionals are compelled to deliver immediate results many times without considering what is best for the ill-informed patient. This article is an illustrated cautionary tale against overtreatment disguised as esthetic dentistry. Representative clinical examples illustrate how porcelain veneers are used without following sound operatory principles, as well as how these cases have been resolved.

Surface treatments on CAD/CAM glass-ceramics: Influence on roughness, topography, and bond strength.

OBJECTIVE: To evaluate the influence of surface treatment on roughness (SA), topography, and shear bond strength (SBS) of computer-aided designer and manufacture (CAD/CAM) zirconia-reinforced lithium silicate (ZLS) and feldspathic (FEL) glass-ceramics. MATERIALS AND METHODS: FEL and ZLS specimens were submitted to 5% or 10% hydrofluoric acid (HF) or self-etching ceramic primer (MEP) and different application times (20, 40, and 60 s), or to sandblasting (Control, 20 s). Resin cement cylinders were bonded to the specimens and tested in shear (n = 10) after 24 h and 16-months of water storage. SA and topography were evaluated by atomic force (AFM, n = 10) and scanning electron microscopy. Data were analyzed by ANOVA and Bonferroni test (α = 0.05). RESULTS: Sandblasting promoted the highest SA for ZLS, but 10% HF (40, 60 s) promoted higher SBS at 16 months. 10% HF produced the highest SA for FEL, but sandblasting and 5% HF (20 s) maintained SBS after 16 months, without differences from 10% HF (20 s) (p > 0.05). Overall, MEP produced lower SA and SBS among groups (p < 0.05). HF displayed greater morphological changes on FEL. CONCLUSION: 10% HF (40 s) provided better results for ZLS, while 5% or 10% HF (20 s) was suitable for FEL. CLINICAL SIGNIFICANCE: Surface treatments influenced SA, topography, and SBS of materials. HF etching is the surface treatment of choice for both CAD/CAM glass-ceramics.

Seeing is believing? When scanning electron microscopy (SEM) meets clinical dentistry: The replica technique.

In restorative dentistry, the in situ replication of intra-oral situations, is based on a non-invasive and non-destructive scanning electron microscopy (SEM) evaluation method. The technique is suitable for investigation restorative materials and dental hard- and soft-tissues, and its interfaces. Surface characteristics, integrity of interfaces (margins), or fracture analysis (chipping, cracks, etc.) with reliable resolution and under high magnification (from ×50 to ×5,000). Overall the current study aims to share detailed and reproducible information about the replica technique. Specific goals are: (a) to describe detailed each step involved in producing a replica of an intra-oral situation, (b) to validate an integrated workflow based on a rational sequence from visual examination, to macrophotography and SEM analysis using the replica technique; (c) to present three clinical cases documented using the technique. A compilation of three clinical situations/cases were analyzed here by means the replica technique showing a wide range of possibilities that can be reached and explored with the described technique. This guidance document will contribute to a more accurate use of the replica technique and help researchers and clinicians to understand and identify issues related to restorative procedures under high magnification.

Adhesion, Mechanical Properties, and Microstructure of Resin-matrix CAD-CAM Ceramics.

PURPOSE: To investigate the effects of 1-year water storage and surface treatments on shear bond strength (SBS) of two composite cements bonded to resin matrix CAD-CAM ceramics (RMCs) and on the mechanical properties of RMCs. MATERIALS AND METHODS: Three types of RMCs were tested: 1. polymer-infiltrated hybrid ceramic (PIHC, Enamic, VITA Zahnfabrik); 2. resin nanoceramic (RNC, Lava Ultimate, 3M Oral Care); and 3. flexible hybrid ceramic (FHC, Cerasmart, GC). One indirect laboratory composite (ILC, Epricord, Kuraray Noritake) was used as control. For each material, 60 plates (14 x 7 x 1 mm) were prepared for the SBS test and submitted to three different surface treatments: following manufacturer's instructions, non-thermal atmospheric plasma application (30 s), and plasma + bonding agent. Two composite cements were tested: RelyX Ultimate (3M Oral Care) and Panavia V5 (Kurarary Noritake). Two resin cylinders (1.5 mm diameter x 1.5 mm height) were bonded to each plate (n = 10), with one tested after 24-h storage in distilled water and the other after 1 year of storage in distilled water. Twenty rectangular bars (12 x 2 x 1 mm) of each indirect material were prepared and submitted to the 3-point flexural test after 24-h or 1-year water storage to determine the elastic modulus (EM) and flexural strength (FS) (n = 10). Fractured samples were also examined with SEM and energy dispersive x-ray spectroscopy (EDS). SBS data were analyzed by four-way ANOVA, and EM and FS data by two-way ANOVA, followed by Tukey's post-hoc test (α = 0.05). RESULTS: Groups treated in accordance with manufacturer's instructions exhibited higher SBS than did plasma and plasma + bonding agent groups for all indirect materials, composite cements, and storage periods tested. In general, RelyX Ultimate displayed higher mean SBS than did Panavia V5, except for some groups of ILC where manufacturer's instructions were followed. After 1-year storage in water, all groups exhibited a significant reduction in SBS, except for some groups that following manufacturer's instructions. ILC showed the lowest values of EM and FS. Among the CAD-CAM materials, FHC exhibited the lowest EM and highest FS means, while PIHC possessed the highest EM and lowest FS means for both storage periods. CONCLUSIONS: In general, following the respective manufacturer's instructions yielded the best bond strength results. For most materials, 1-year water storage decreased bond strength of composite cements to RMCs, as well as their FS, while increasing their EM. Microstructure and composition influenced the mechanical properties studied.

Periodontal considerations for adhesive ceramic dental restorations: key points to avoid gingival problems.

The stability and health of the periodontal tissues should be a common goal for all dental care providers with regard to natural or restored teeth as well as implant-supported restorations or any other type of prosthesis. The objective of this study was to address the key aspects to be respected when executing adhesive oral rehabilitations involving ceramic restorations, regardless of their thickness, and to reinforce the importance of each step to ensure the success and longevity of the treatment from a periodontal standpoint. This article reviews the fundamentals of the periodontics that relate directly or indirectly to adhesive ceramic dental restorations, and also addresses their clinical relevance.

Bond Strength of Resin Cements to Zirconia Ceramic Using Adhesive Primers.

PURPOSE: To evaluate the influence of adhesive primers on the microshear bond strength of resin cements to zirconia ceramic. MATERIALS AND METHODS: Fifty zirconia plates (12 mm × 5 mm × 1.5 mm thick) of a commercially available zirconium oxide ceramic (ZirCad) were sintered, sandblasted with aluminum oxide particles, and cleaned ultrasonically before bonding. The plates were randomly divided into five groups of 10. Three resin cements were selected (RelyX ARC, Multilink Automix, Clearfil SA Cement self-adhesive resin cement), along with two primers (Metal-Zirconia Primer, Alloy Primer) and one control group. The primers and resin cements were used according to manufacturers' recommendations. The control group comprised the conventional resin cement (RelyX ARC) without adhesive primer. Test cylinders (0.75 mm diameter × 1 mm high) were formed on zirconia surfaces by filling cylindrical Tygon tube molds with resin cement. The specimens were stored in distilled water for 24 hours at 37°C, then tested for shear strength on a Shimadzu EZ Test testing machine at 0.5 mm/min. Bond strength data were analyzed statistically by two-way ANOVA and Dunnett's test (5%). RESULTS: The bond strength means in MPa (± s.d.) were: RelyX ARC: 28.1 (6.6); Multilink Automix: 37.6 (4.5); Multilink Automix + Metal-Zirconia Primer: 55.7 (4.0); Clearfil SA Cement: 46.2 (3.3); and Clearfil SA Cement + Alloy Primer: 47.0 (4.1). CONCLUSION: Metal-Zirconia Primer increased the bond strength of Multilink Automix resin cement to zirconia, but no effect was observed for Alloy Primer using Clearfil SA Cement. RelyX ARC showed the lowest bond strength to zirconia.

Bulk Fill Composites: An Anatomic Sculpting Technique.

UNLABELLED: Composite resins have been routinely used for posterior cavities due to a phasedown on amalgam as a restorative option. However, clinical problems related to polymerization shrinkage demands careful and specific techniques for placement of the composite layers. New low shrinkage composites are now marketed for bulk filling of cavities without the need of a traditional layering. With this new concept, the restoration can be built in one or two layers, depending on the classification of the bulk fill material. This article discusses and presents two alternative techniques using the low shrinkage composites, suggesting a called "amalgam-like sculpting technique," one using a flowable bulk fill and other a regular bulk fill material. Clinical cases illustrate these two alternatives compared with the layered technique. CLINICAL SIGNIFICANCE: New techniques using low shrinkage composites for bulk filling can provide a simpler technical approach for the clinician in sculpting and generating highly esthetic posterior composites.

Individualização em prótese dentogengival (IPD) em cerâmica: previsibilidade do projeto a realização das peças / Porcelain dentogingival prostheses customization (DPC): predictability from design to the manufacturing

A extração múltipla anterior causa consequências irreversíveis à anatomia do tecido gengival: o arco côncavo regular é perdido, as pontas das papilas passam a não mais existir, tornando a anatomia do rebordo remanescente retilínea. Podem-se realizar enxertos de tecidos ósseo e conjuntivo para aumento de volume, mas conseguir papilas pontiagudas, finas e longas é objetivo inalcançável, cuja consequência são próteses com dentes quadrados, em que se busca fechar os espaços negros formados pela ausência das papilas. O presente artigo revela aplicação da técnica de individualização em prótese dentogengival (IPD), para oferecer um tratamento personalizado com resultados esteticamente excelentes e melhor solução para casos estéticos com perda de tecido gengival...

Multiple teeth extraction in the anterior region causes irreversible consequences to gingival tissue anatomy: regular tissue architecture and papillae tips are lost, causing the tissue anatomy of the ridge to be flat. Bone or connective tissue graft may be performed for volume increase. However, achieving long and peaked papillae is nearly unreachable. The consequence is squared teeth, and the need to close the black holes formed from the absence of papillae. This article reveals the application of dentogingival prosthesis customization (DPC) technique, which the main goal is to offer a custom-made treatment with excellent aesthetic results which would be the best solution for aesthetic cases with loss of gingival tissue...

Tratamento multidisciplinar visando a excelência: apresentação de um caso clínico / Multidisciplinary treatment aiming at excellence: a clinical case report

Resumo / Atualmente, quando os pacientes vêm ao nosso consultório, sabem exatamente o que querem e já vislumbram um resultado final próximo à excelência. Alinhamento e nivelamento é pouco. Hoje os pacientes almejam uma aparência próxima aos artistas do “Jet Set”, com dentes brancos e reluzentes. Assim, ao final do tratamento ortodôntico, uma finalização estética deve ser envolvida. Portanto, hoje, para se alcançar os resultados esperados, o tratamento multidisciplinar é imprescindível. O presente artigo aborda um tratamento restaurador total em um paciente adulto, sendo iniciado pelo tratamento ortodôntico e finalizado por reabilitação bucal total com prótese sobre implante e restauração tipo full veneer (FV). Esse tipo de técnica é usada em casos onde é possível cobrir todas as faces de um dente com o um mínimo de desgaste ou até sem preparo algum, mantendo a maior área possível em esmalte e preservando a estrutura dentária. O artigo evidencia a importância do tratamento ortodôntico prévio ao tratamento reabilitador para se alcançar resultados excelentes.

Esthetic and functional rehabilitation of crowded mandibular anterior teeth using ceramic veneers: a case report.

The use of ceramic veneers to restore crowded teeth in the maxilla has been widely discussed in the literature. However, the use of this technique in the mandible has received little attention. Therefore, this case report describes the treatment of crowded mandibular anterior teeth using ceramic veneers. The primary treatment challenge in this region is the reduced tooth structure available for rehabilitation. Proper communication between the clinician and dental technician is required to achieve clinical success. This article presents a straightforward treatment plan and restorative technique that includes both the clinical and laboratory sequences necessary for predictable and stable postoperative outcomes.

Ultimate ceramic veneer: a laboratory-guided preparation technique for minimally invasive laminate veneers.

Clinical success of ceramic laminate veneers depends on material selection, bonding procedures, controlled laboratory steps, and enamel preservation. Enamel preservation is the most critical because excessive tooth preparation can expose dentin reducing bond strength, which is a factor that can cause a decrease in long-term clinical success. The proposed technique based on carefully treatment planning developed between clinician and dental technician helps to maximize enamel preservation, which is an important element for clinical success.

Laminados cerâmicos anteriores: relato de caso clínico / Anterior porcelain veneers: Case report

As facetas de resina composta podem ser utilizadas adequadamente para modifcações de cor, forma, posição e textura dos dentes anteriores. No entanto, esse material é suscetível à alteração de cor e ao desgaste, restringindo, assim, o resultado estético ao longo do tempo. Para compensar tais limitações, foram, então, propostos os laminados cerâmicos. A evolução na indicação dessa técnica ocorreu, principalmente, com a melhoria das propriedades físicas e mecânicas das cerâmicas, associada ao desenvolvimento dos sistemas adesivos e dos cimentos resinosos, permitindo, assim, uma adequada união da cerâmica à estrutura dentária e, dessa maneira, aumentando a longevidade e o desempenho clínico dessas restaurações.

Direct composite veneers can be appropriately used for modifying color, shape, position and texture of anterior teeth. Therefore, this material is liable to color changes and teeth abrasion, limiting the esthetic result in the long term. The laminate porcelain veneers were proposed to compensate those limitations. Its evolution occurred with the improvement on the physical and mechanical properties of porcelain, associated to adhesive systems development, allowing an accurate bonding to porcelain as well as to dental structure, increasing, this way, the longevity and clinical performance of laminate veneers.

Técnica all-on-four bimaxilar com função imediata / Bimaxillary all-on-four technique with immediate implant loading: a clinical report

A insuficiente quantidade óssea nos maxilares pode impossibilitar a instalação de implantes pelas técnicas convencionais, sem que sejam realizadas cirurgias alternativas. A instalação de quatro implantes, sendo os dois implantes distais com posição tridimensional modificada (técnica denominada all-on-four) permite a colocação de implantes em maxilas atróficas, sem a necessidade de técnicas cirúrgicas mais avançadas. O correto planejamento cirúrgico e protético é a chave do sucesso para estes casos, como o descrito neste artigo.

The lack of bone quantity does not permit implant placement in the maxillary arch, unless alternative surgical techniques are used. The installation of four implants, being the two distal ones installed with a modified technique, called All-on-four, allow implant placement in atrophic maxillae, without the need of any advanced surgical technique. Adequate surgical and prosthetic planning is the key for success on those cases, like the one described in this article.

Protocolo clínico para restaurações cerâmicas associadas a implantes em área estética / Clinical protocol for ceramic restorations combined with implants in aesthetic areas

A otimização dos resultados estéticos e funcionais em reabilitações implantos suportadas depende da sofisticação dos procedimentos técnicos, das condições teciduais adjacentes às restaurações, e da perfeita integração entre os elementos que compõem o sorriso. Para tanto, deve-se despender tempo e concentração durante a fase de planejamento do caso clínico, em caráter multidisciplinar. O presente artigo traz uma sequência de passos clínicos importantes para um diagnóstico correto, e para um plano e uma sequência de tratamento adequados, destacando a importância da instalação de implantes em um posicionamento tridimensional adequado, dentro do conceito de cirurgias guiadas pela restauração final - planejamento reverso. Além disso, o artigo aborda técnicas úteis para a preservação, o aumento e/ou a manipulação dos tecidos perimplantares, fundamentais ao alcance da estética e da estabilidade dos implantes no longo prazo.

Aesthetic and functional outcomes in dentistry depend on technical procedures, on the conditions of the tissues adjacent to restorations, and on the integration of ali the components of a smile. With this in mind, the dental team must invest time and focus during the planning phase of the clinical case, with a multidisciplinary approach. This article presents a sequence of clinical steps for a correct diagnosis, treatment plan and sequence, stressing the importance of installing implants in a correct three-dimensional position, within the concept of surgery guided by the final restoration - Restoration Driven. In addition, this article discusses useful techniques for the preservation, enhancement and/or manipulation of perimplantar tissues, which are essential to obtaining long term implant aesthetics and function.

Pastas de prova em laminados cerâmicos: aplicação clínica para alcançar o resultado estético / Try-in pastes for porcelain laminate veneers: an esthetic achievement for esthetic results

Na odontologia restauradora, o mimetismo das restaurações em cerâmica é alvo de interesse considerável entre os profissionais, na reconstrução de elementos dentais ou modificações de forma e cor. A seleção de cores é uma etapa crítica do tratamento restaurador, especialmente em dentes anteriores, sendo o conhecimento das propriedades ópticas dos materiais e da estrutura dental de extrema importância para o sucesso da restauração final. Esta descrição clínica mostra a importância da escolha da cor do cimento resinoso na confecção de restaurações cerâmicas em dentes anteriores, com uso de pastas de prova

Mimicking restorations are desireable in Restorative Dentistry when teeth are being reconstructed or when shade and contour are be changed by restorations. Shade selection is a critical step in restorative treatment, especially in anterior dentition, and expertise on optical properties and tooth substrate is extremely important for the success of the final restoration. The purpose of this clinical guide is showing the significance of shade selection of resin cement for anterior ceramic restorations, by using try-in pastes

Restauração transcirúrgica na junção cemento-esmalte / Transsurgical restoration of the cement-enamel junction

Restaurações ou próteses mal adaptadas são causas comuns de inflamação gengival e destruição do periodonto, devido à retenção do biofilme dental. Alterações morfológicas da junção cemento-esmalte, como defeitos no esmalte com projeção para a região radicular, podem ter o mesmo efeito de retenção de placa bacteriana, perpetuando o processo inflamatório nas áreas adjacentes ao defeito. O tratamento desses casos consiste em remover o fator de retenção do biofilme, com realização da restauração em procedimento transcirúrgico. Este artigo apresenta um caso clínico, no qual foi necessário intervir cirurgicamente para restabelecer a morfologia radicular, por meio da restauração do contorno da junção cemento-esmalte com resina composta.