TOP 25IMPLANT

PRODUCTS

2014 READERS’ CHOICE AWARDpg. 50

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ENDODONTICS

Clifford J. Ruddle, DDS, MSDpg. 104

PROSTHODONTICS

George Priest, DMDpg. 98

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MATERIALS

Jack Griffi n Jr, DMDpg. 90

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ROBERT C. MARGEAS, DDSDes Moines, Iowa

Douglas A. Terry, DDSpg. 80

RESTORATIVE

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VOLUME 33 NO. 6 THE NATION’S LEADING CLINICAL NEWS MAGAZINE FOR DENTISTS JUNE 2014

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MAXIMUM SUCCESS With

DentistryMinimally Invasive

4th Annual

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INTRODUCTIONMinimally invasive dentistry is a buzz phrasethat means different things to many clini-cians. One dentist may think a three quarterporcelain veneer is conservative, whereanother believes it is too destructive of toothstructure. During the last several years, tech-nological developments have allowed clini-cians to be more respectful of tooth structure.G. V. Black’s classification of cavity prepara-tion was based on the restorative needs of thematerials used at a particular time in our den-tal history. It was necessary to create resist-ance and retention form so the restorationwould not fall out. This required removingmore tooth structure to produce convergingwalls and to create retention grooves.1,2When Black proposed his preparation princi-ples and his classification system of cavitydesign, dentists were more focused on con-trolling caries and not on the scientificknowledge of the disease.3,4 At the time, nei-ther the fluoride ion nor the process of re min -er alization was known.5 Today, research isgeared toward materials that are bioactive oranticarious. An example would be a product

like CariFree, developed by V. Kim Kutsch,DMD, who has dedicated his career to devel-op new ideas, technologies, and treatmentmethods to help eradicate caries.

The term extension for prevention, intro-duced by Black, referred to a preparation thatwas extended to the proximal line angles sothe margins of the restoration would be self-cleansing by way of food excursion. It alsoincluded extending preparations through allthe enamel fissures, whether carious or not,to allow cavosurface margins to be placed onnonfissured enamel.6 This phrase could nowbe changed to extension for destruction since weno longer need to remove healthy tooth struc-ture in order to retain our restoration. Theseconcepts of the “Mechanical Era in Dentistry”sanctioned the removal of healthy toothstructure with the sole purpose of retainingthe restorative material.7

Composite Versus AmalgamPreparations

The requirement of a composite resin prepara-tion versus an amalgam is different. With theability to bond to tooth structure, we are able

to be much more conservative with our prepa-ration design. The problem remains that sever-al of the restorative concepts and principles ofthe past are still being performed with the cur-rent adhesive technique. The effect of this mis-direction could be one of the reasons for the rel-atively short longevity of adhesive restorationsin the general dental practice.8,9 Advances inmaterial science and adhesive technology re -quire the clinician to modify nonadhesive res -torative techniques for application to restora-tive adhesive concepts when considering diag-nosis, material selection, preparation design,restorative placement techniques, pulp protec-tion, restorative finishing, and maintenance ofthe restoration.10 There have been numerousnew classification systems designed since theoriginal principles of cavity classification werefirst viewed as outdated.

PREVENTIONToday, dentists should have as their clinicalobjectives: prevention, preservation, andintegrity in order to make the right deci-sions for their patients. The primary objec-tive for the clinician is to prevent the place-ment of the initial restoration.11 The mostminimally invasive procedures includeremineralization, sealants, and preventiveresin restorations that require the leastamount of tooth removal. The patient’sdiet, oral hygiene, fluoride use, and regularrecare help reduce dental caries. This pre-ventive approach provides the patient andclinician an opportunity to re-evaluate theoutcome of the preventative measures andpossibly reduce the potential for invasiveintervention. Furthermore, this processinvolves educating the patient and involv-ing him or her in the treatment decisions,which may result in acceptance of appro-priate preventive and restorative strategiesin caries management and improved pa -tient compliance and oral health.12

When Restorative Work Is Necessary With the ability to bond to tooth structure,adhesive preparation designs should be basedupon the conservation of tooth structure andutilizing adhesive re storative materials.13 The

Robert C.Margeas,DDS

Augmentation VersusAmputation

continued on page 70

Figure 1. Pre-op smile. Figure 2. Pre-op close-up.

Figure 3. Pre-op left lateral view. Figure 4. Pre-op right lateral view.

AESTHETICS

Implementing Noninvasive and Minimally Invasive Protocols for Maximum Success

CASE 1

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conservative concept of the adhesivetooth prep aration requires a biologicap proach,14 which represents a keycom ponent to adhesive dentistry.15 Theadhesive res toration does not re quire asmuch volume to resist clinical fracture,which enables a more conservativepreparation design.16 This conservativeap proach hopefully minimizes the res -toration and re placement cycle for thepatient throughout his or her lifetime.It has been demonstrated that smallerres torations can have an increased clin-ical performance and lifespan.17

Being able to bond to tooth struc-ture has changed the playing field ofdentistry. Adhesive dentistry has al -lowed more conservation of tooth asstated earlier, but materials are beingimproved with more physical, mechan-ical, and optical properties similar totooth structure.18 Restoring the naturaldentition with bonded composite orporcelain reinforces the natural toothand restorations almost as if nothingwere done to the tooth if the prepara-tions are conservative and bonded, asshown by Magne and Belser.19

The cavity preparation for a directcomposite restoration is usually limit-ed to the carious enamel and dentin.For porcelain, the preparations are notas conservative due to the removal ofundercuts for proper path of insertionand adaption to the cavity walls. Thedirect composite can be used with min-imal preparation because it uses theundercuts and surface irregularities toincrease the surface area for bonding.

This really conserves the dentin andreinforces the tooth to help reduce thechances of fracture during function orhelps prevent a catastrophic failure ofthe tooth. I would rather replace arestoration than have the whole toothfracture due to a rigid restoration.

When it comes to porcelain ve -neers, I feel it is one of the strongestrestorations we have in dentistry,when done properly. Having morethan 28 years of experience preparingand placing veneers, the most impor-tant thing in predicting long-term suc-cess is enamel preservation. Whenveneers are prepared minimally inenamel, they will not debond. Theymay chip, stain, or have recession, butin my clinical experience, they do notpop off. Even as conservative as porce-lain veneers are, they are not a lifetimerestoration. Calamia20 first describedthe technique in 1983. Since veneersare usually an elective procedure,patients need to understand that theyare not 100% successful. The patientsare placing themselves on the cycle ofrestorative dentistry that needs to bereplaced from time to time. No studyshows that they are infallible.

The following 2 cases will serve asexamples that demonstrate the mini-mally invasive philosophy that weem ploy in our practice on a dailybasis. The procedures are conserva-tive in nature, done in a responsiblemanner with long-term solutions inmind that are designed to keep anyfuture treatments to a minimum.

CASE REPORTSCase One

Diagnosis and Treatment Planning—A59-year-old female presented to ouroffice because she was not happy withher smile. She wanted a quick fix be -cause she and her husband were goingto be on the cover of a tae kwon domagazine in a few weeks, highlightingtheir business. I talked to the patientabout orthodontic treatment and in -formed her that it would be the besttreatment option. She was not inter-ested in orthodontics and wanted toknow what other options she mighthave. I explained to her that the onlyway I would treat her was if there wereno preparation of the teeth, permit-ting her to have orthodontics in thefuture if she so desired. There would

not even be any enameloplasty done.The only removal of tooth structurewould be by acid-etching. This is trulyan augmentation versus amputationcase. There would be a small aestheticcompromise due to no preparation.

Her full smile is in Figure 1, and aclose-up view is in Figure 2. From thelateral views (Figures 3 and 4), you cansee the rotation of the central incisorsand the poorly done diaste ma closure.The objective was to see if we could cor-rect the rotation of her centrals and giveher the appearance of a straight smile. Clinical Protocol—An alginate im -

pression was made of her upper teethto see if a mock-up could accomplishwhat I wanted. The occlusal view is inFigure 5. To achieve the desired resultwithout preparing the teeth, the distalof the left central would be the lineangle to which I would build out myfinal contour. The patient would nothave a problem with the materialbeing too thick, as this was the areathat was already touching her lip.

A microfilled composite resin (Re -namel [Cosmedent]) would be mymaterial of choice, due to its translu-

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Figure 5. Pre-op occlusal view. Figure 6. Etching gel (Ultra-Etch [UltradentProducts]) placed on left lateral incisor (No. 10).

Figure 7. Microfilled composite resin(Renamel [Cosmedent]) was then placed andsculpted.

Figure 8. Etch placed on left central incisor(No. 9).

Figure 9. Polished interproximal of left central.

Figure 10. Post-op restorations (teeth Nos.7 to 10) prior to polish.

Figure 11. Post-op restorations after polish. Figure 12. Post-op smile showing the com-pleted aesthetic and noninvasive compositeresin restorations on teeth Nos. 7 to 10.

Figure 13. Post-op right lateral view. Figure 14. Post-op left lateral view.

continued on page 72

Augmentation Versus Amputation...

CASE 1

Figure 15. Post-op occlusal view.

AESTHETICS72

cency and polishability. I did not needstrength in this area because we wouldhave the natural tooth as the lingualbacking. Due to the financial con-straints the patient had, I only used oneshade of composite to expedite the pro-cedure. This was done in 2 hours ofchair time. Matrix strips were placed toprotect the adjacent teeth, and the leftlateral incisor was etched with phos-phoric acid (Ultra-Etch [UltradentProducts]) (Figure 6) for 20 seconds.This allows the material to be placednext to the adjacent tooth and not bondto it. A universal adhesive (ScotchbondUniversal [3M ESPE]) was applied onthe tooth and then light cured for 20seconds. Next, the composite wasplaced in one increment onto the facialsurface of the lateral and sculpted toshape (Figure 7). The matrix bandswere used as instruments and pulled tothe lingual to form a tight contact.

The next tooth was then etched(Figure 8) and adhesive and compositewere placed, then sculpted to shape.The tooth was built out on the mesialto correct the rotation. It is very impor-tant to polish the interproximal of therestoration (Figure 9), because oncedone, the next restoration would beallowed to stick to the polished surfacebut would not adhere to it. An instru-ment was placed between the teeth andslightly twisted to torque the restora-tions apart (a technique first describedby Dr. K. William “Buddy” Mopper).The polish was accomplished usingdiscs (Flexi-Discs [Cosmedent]).

The right central and lateral inci-sors were then completed in the samemanner (Figure 10). To polish the inter-proximal and provide a smooth surface,EPITEX Strips (GC America) were used.The final polish was achieved withenamelize and a FlexiBuff (Cosmedent)(Figure 11). The patient was happy withthe final result (Figures 12 to 15), as wasI. This case would not have been appro-priate for preparation due to theamount of enamel that would haveneeded to be removed.

An innovative product out ofAustralia, Uveneer, has recently hit themarket. It allows you to build a fullcomposite veneer by utilizing a clearplastic form of a central, lateral, cuspid,or bicuspid built on a handle similar toa VITA shade tab. It comes in mediumand large sizes, and the user can choosethe size that best fits the tooth, thenplace composite on the tooth followingacid-etching and adhesive placement.While the composite is soft, the form isplaced on the tooth and excess material

around the margins is removed. Thecomposite is then light cured throughthe form and the former is removed.The tooth formers are autoclavable, sothey can be used many times. Thisleaves a very high shine of composite,due to no air-inhibited layer being pres-

ent. You then finish and polish the mar-gins. This product is an aid for practi-tioners who don’t have the time to layeror charge enough due to the time ittakes to create an ideal restoration.There is a learning curve, and it is rec-ommended to start with a single tooth

prior to trying multiple teeth.

Case 2Diagnosis and Treatment Planning—A17-year-old male presented with trau-matically fractured left central and lat-eral incisors (teeth Nos. 9 and 10)

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Augmentation Versus Amputation...

Figure 16. Pre-op of fractured teeth. Figure 18. Etch placed on fragment (leftcentral incisor).

Figure 20. A 4th generation adhesive (ALL-BOND 3 [BISCO Dental Products])primer was placed on tooth.

Figure 22. Adhesive placed on fragment. Figure 24. Fragment placed.

Figure 17. Fractured pieces.

Figure 19. Etching gel placed on tooth No. 9. Figure 21. ALL-BOND 3 adhesive placed ontooth.

Figure 23. Insure resin cement placed onfragment.

Figure 25. Fragment bonded to place (No. 9). Figure 26. Post-op smile after fragmentsteeth Nos. 9 and 10 were bonded to place.

Figure 27. Close-up of teeth following bonding of fragments.

Figure 28. Preparation of teeth for porcelainveneers in enamel.

Figure 30. Note the frosty appearance ofthe etched enamel.

Figure 29. Etch placed on No. 9.

CASE 2

AESTHETICS

(Figure 16). There was pulpal involve-ment of both teeth and the patient wasin quite a bit of discomfort. The piecesof the teeth were salvaged by his par-ents and brought to the office (Figure17). It may have been possible to try adirect pulp cap (using a material such asTheraCal [BISCO Dental Products]), butbecause the parents were concernedabout possible future problems withthe teeth and related insurance issues,they wanted to have the root canalsdone. In order to provisionalize thecase, the pieces would be bonded backin place prior to root canal therapy. Clinical Protocol—The avulsed

pieces were acid-etched (Ultra-Etch)along with the teeth (Figures 18 and19). A 4th generation bonding system(ALL-BOND 3 [BISCO Dental Prod ucts])was used due to its long track record of

success. The ALL-BOND 3 primer wasplaced on the left central incisor (No. 9)intraorally (Figure 20) and the avulsedpiece scrubbed for 20 seconds. This wasair-thinned and light cured for 20 sec-onds. Care was taken to prevent anybleeding of the pulp. The ALL-BOND 3adhesive was placed on the tooth andthe fractured piece and air-thinned(Figures 21 and 22). This was not lightcured, as it might not have gone toplace due to the film thickness of theadhesive. A light-cure resin ce ment(Insure [Cosmedent]) was placed on thefractured piece (Figure 23) and taken tothe mouth. The piece was lined up withthe fracture (Figure 24) and the resincement was cleaned with a brush priorto light curing. No preparation of thetooth was done so that it would line upas a butt margin. Figure 25 shows the

avulsed piece attached to the naturalleft central incisor.

Next, the same protocol was fol-lowed for the lateral incisor (No. 10).Figure 26 shows the patient’s aesthet-ics prior to endodontic treatment.

Once the pieces were attached, theendodontist saw the patient that samemorning and performed endodontictherapy on both teeth. Compositeresin was placed in the endo accessopenings. The patient was thenappointed back with us a few weekslater to begin the definitive restorativephase (Figure 27). The sequencing ofthe treatment, as described, allowedthe patient to have a pleasing appear-ance prior to finalizing the treatment.

For the veneers, feldspathic por -celain was to be used. The teeth wereprepared with diamond burs (Bras -seler USA), maintaining as muchenamel as possible for maximumstrength. A temporary made fromcomposite was placed on the teethprior to final veneer placement.

When the patient returned forseating of the restorations, cord wasplaced to displace the tissue and tocontrol sulcular fluid (Figure 28). Theveneers were placed individually. Theleft central was isolated with inter-proximal strips, and acid-etching gelwas placed on the tooth for 20 seconds(Figure 29). There was ample enamelavailable for bonding (Figure 30).ALL-BOND 3 primer was placed onthe tooth for 20 seconds (Figure 31),air-thinned, and light cured for 20 sec-onds. Next, All-BOND 3 adhesive wasthen placed on the tooth, air-thinned,but not light cured (Figure 32). Adhe -sive was placed in the veneer, alongwith the resin cement (Insure), thenplaced on the tooth (Figure 33). Theexcess resin cement was removedprior to light curing for easy cleanup.

Next, the lateral, with the prepthat had been contained in enamel,was etched for 20 seconds (Figures 34and 35). The primer was placed for 20seconds, thinned with air, and lightcured. The adhesive was once againplaced on the tooth and inside theveneer along with resin cement. Thiswas placed on the tooth, and theexcess resin cement was removedprior to light curing the restoration.

The completed restorations areshown on the day after removingexcess cement in Figure 36. The finalrestorations are shown at one-yearpostoperatively in Figures 37 and 38.

This case demonstrates a very con-servative approach to treating a youngpatient who had many years to keephis teeth. If these teeth were preparedfor crowns, I feel they would not have

the longevity that these conservativeveneers have to offer. The case is now 8years old and maintaining very well.

CLOSING COMMENTSWhile prevention is always the ulti-mate goal, noninvasive/minimally in -vasive dentistry is an obligation that wemust always consider and offer to ourpatients when restorative work isrequired. Once the decision is made thata restoration is necessary, the clinicalobjective should always be to preserveas much tooth structure as possible.�

References1. Mount GJ. Minimal intervention dentistry: ration-

ale of cavity design. Oper Dent. 2003;28:92-99.2. Mount GJ, Ngo H. Minimal intervention: ad vanced

lesions. Quintessence Int. 2000;31:621-629.3. Mount GJ, Hume WR. A new cavity classification.

Aust Dent J. 1998;43:153-159.4. Welk DA, Laswell HR. Rationale for designing cavity

preparations in light of current knowledge and tech-nology. Dent Clin North Am. 1976;20:231-239.

5. Mount GJ, Ngo H. Minimal intervention: earlylesions. Quintessence Int. 2000;31:535-546.

6. Black GV. A Work on Operative Dentistry. Volume1. Chicago, IL: Medico-Dental Publishing; 1917.

7. Simonsen RJ. Conservation of tooth structure inrestorative dentistry. Quintessence Int.1985;16:15-24.

8. Moffa JP. Comparative performance of amalgamand composite resin restorations and criteria fortheir use. In: Anusavice KJ, ed. Quality Evalu -ation of Dental Restorations: Criteria for Place -ment and Replacement. Chicago, IL: Quin -tessence Publishing; 1989.

9. Qvist V, Qvist J, Mjör IA. Placement and longevityof tooth-colored restorations in Denmark. ActaOdontol Scand. 1990;48:305-311.

10.Leinfelder KF. Using composite resin as a pos-terior restorative material. J Am Dent Assoc.1991;122:65-70.

11.Peters MC, McLean ME. Minimally invasive oper-ative care. I. Minimal intervention and conceptsfor minimally invasive cavity preparations. JAdhes Dent. 2001;3:7-16.

12.Tam LE, McComb D. Diagnosis of occlusalcaries: Part II. Recent diagnostic technologies. JCan Dent Assoc. 2001;67:459-463.

13.Mount GJ, Hume WR. Preservation and Restorationof Tooth Structure. London, England: Mosby; 1998.

14.Hosoda H, Fusayama T. A tooth substance savingrestorative technique. Int Dent J. 1984;34:1-12.

15.Lutz F. State of the art of tooth-colored restora-tives. Oper Dent. 1996;21:237-248.

16.Leinfelder KF. A conservative approach to plac-ing posterior composite resin restorations. J AmDent Assoc. 1996;127:743-748.

17.Almquist TC, Cowan RD, Lambert RL. Conser -vative amalgam restorations. J Prosthet Dent.1973;29:524-528.

18.Terry DA, Leinfelder KF, James A. A nonmechani-cal etiology: The adhesive design concept. PractProced Aesthet Dent. 2006;18:385-391.

19.Magne P, Belser U, eds. Bonded PorcelainRestorations In The Anterior Dentition: A Bio -mimetic Approach. Quintessence Publishing Co,Inc: Chicago, IL: 2002.

20.Calamia JR. Etched porcelain facial veneers: anew treatment modality based on scientific andclinical evidence. NY J Dent. 1983;53:255-259.

Dr. Margeas received his DDS from the Uni-versity of Iowa College of Dentistry in 1986and completed an advanced education in gen-eral dentistry residency in 1987. He is an ad-junct professor in the department of operativedentistry at the University of Iowa. He isboard-certified by the American Board of Oper-ative Dentistry and a Fellow of the AGD. Hehas authored numerous articles on implantand restorative dentistry, and he lectures onthose subjects. He is the director of theCenter for Advanced Dental Education andmaintains a private practice in Des Moines,Iowa. He can be reached at (515) 277-6358or at rcmarge@aol.com.

Disclosure: Dr. Margeas reports no disclosures.

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Figure 32. ALL-BOND 3 adhesive placed ontooth.

Figure 34. Etch placed on left lateral.

Figure 31. ALL-BOND 3 primer placed ontooth.

Figure 33. Veneer placed on tooth.

Figure 35. Notice enamel etch. Figure 36. Immediately post-op.

Figure 37. One year post-op. Figure 38. Lingual view, one year post-op.