Additional conservative and esthetic procedures

ADDITIONAL CONSERVATIVE
AND ESTHETIC CONSIDERATIONS
LRM 3 BDS IV YEAR CURRICULUM DEPARTMENT OF CONSERVATIVE
DENTISTRY AND ENDODONTICS MANAV RACHNA DENTAL COLLEGE

CONTENTS
1. Artistic elements
2. Conservative alterations of tooth contours
and contacts
3. Conservative treatments for discolored teeth
4. Bleaching treatments
5. Microabrasion and macroabrasion
6. Veneers

SHAPE
SYMMETRY AND
PROPORTIONALITY
SURFACE
TEXTURE
COLOR
TRANSLUCENC
Y
POSITION
AND
ALIGNMENT
ARTISTIC
ELEMENTS

SHAPE OR FORM
• Determines the esthetic appearance of teeth.
• FEMININE SMILE:
• Rounded incisal angles,
• Open incisal and facial
embrasures,
• Softened facial line
angles.

• MASCULINE SMILE:
• Less rounded incisal angles.
• Closed embrasures
• COSMETIC RECONTOURING:
Minor modifications of existing tooth
contours can effect a significant esthetic
change .

• Reshaping enamel by rounding incisal angles,
opening incisal embrasures, and reducing
prominent facial line angles can produce a more
feminine, youthful appearance.
• Restoring an individual tooth rather than all
anterior teeth simultaneously may require
greater artistic ability.

• ILLUSIONS OF SHAPE:
• Border outline of an anterior tooth is primarily
two dimensional (i.e, Length and Width)
• Third dimension of Depth becomes crucial
when creating illusions.
• By controlling the areas of light reflection and
shadowing a natural appearance can be given
to restorations.

SYMMETRY AND PROPORTIONALITY
• Dental symmetry can be maintained if the sizes of
the contralateral teeth are equivalent.
• In addition to being symmetric, anterior teeth must
be in proper proportion to one another to achieve
maximum esthetics.

The concept of the Golden proportion:
• Based on this formula, a smile, when viewed
from the front, is considered to be esthetically
pleasing if each tooth in thatsmile (starting from
the midline) is approximately 60% of the size of
the tooth immediately mesial to it.
• The exact proportion of the smaller tooth to the
larger tooth is 0.618.
• In a typical esthetically pleasing smile, the
maxillary anterior teeth are generally in golden
proportion to one another

POSITION AND ALIGNMENT
• The overall harmony and balance of a smile
depend largely on proper position of teeth
and their alignment in the arch.
• Malposed or rotated teeth disrupt the arch
form and may interfere with the apparent
relative proportions of the teeth.

SURFACE TEXTURE
• The character and individuality of teeth are
determined largely by the surface texture and
characteristics that exist.
• E.g. Teeth in young individuals
characteristically exhibit significant surface
characterization, whereas teeth in older
individuals tend to possess a smoother surface
texture caused by abrasional wear.

COLOR
• Color is the most complex artistic element. It
is an area in which numerous interdependent
factors exist, all of which contribute to the
final esthetic outcome of the restoration.
• Teeth typically are composed of a multitude
of colors. A gradation of color usually occurs
from gingival to incisal, with the gingival
region being typically darker because of
thinner enamel.

• An understanding of normal tooth coloration
enhances the dentist’s ability to create a
restoration that appears natural.
• Accurate shade selection is best attained by
applying and curing a small amount of the
composite restorative material in the area of
the tooth anticipated for restoration.
• Shade selection should be determined before
isolating the teeth to avoid color variations
that can occur as a result of drying and
dehydration of the teeth.

TRANSLUCENCY
• Translucency affects the esthetic quality of the
restoration.
• The degree of translucency is related to how
deeply light penetrates into the tooth or
restoration before it is reflected outward.

CONSERVATIVE TREATMENT FOR
DISCOLOURED TEETH
• It includes:
1.Removal of surface stains.
2.Bleaching
3.Macroabrasion
4.Microabrasion
5.Veneering
6.Placement of porcelain crowns

Discolorations
• Types:
1.Extrinsic discolorations
2.Intrinsic discolorations

Extrinsic Discolorations:
• Etiology:
1. Remnants of nasmyth’s membrane
2. Poor oral hygiene
3. Existing restorations
4. Gingival bleeding
5. Plaque accumulation
6. Eating habits
7. Chromogenic bacteria
8. Stains due to tobacco coffee and tea.

• Treatment:
1.Prophylactic procedures
2.Mild microabrasion

• Intrinsic Discolorations:
• it can affect vital or non vital teeth and also
root canal treated teeth.
• It can be either localised or generalised.
• Etiology:
1.Hereditary disorders
2.Medications
3.Excess flourides
4.High fever associated with early childhood
illnesses
5.Other types of trauma

• Treatment:
1. Bleaching
2. Microabrasion
3. Macroabrasion
4. Veneering

BLEACHING TREATMENTS
• The lightening of the color of a tooth through the
application of a chemical agent to oxidize the organic
pigmentation in the tooth is referred to as bleaching.
Bleaching techniques may be classified:
• whether they involve vital or nonvital teeth, and
• whether the procedure is performed in the office or
outside the office.
• The mechanism of action of bleaching teeth with
hydrogen peroxide is considered to be oxidation of
organic pigments

NON VITAL BLEACHING PROCEDURES
Causes:
1.Bleeding into dentin as a result of trauma
before RCT.
2.Degradation of pulp tissue left in chamber
after such therapy
3.Staining from restorative materials and
cements placed in the tooth as a part of RCT.

• Nonvital bleaching techniques include an in-
office technique and an out of the office
procedure referred to as walking bleach.
• In Office Non Vital Bleaching Technique:
• Historically comprised of A thermocatalytic
technique consisting of the placement of 35%
hydrogen peroxide liquid into the debrided pulp
chamber and acceleration of the oxidation
process by placement of A heating instrument
into the pulp chamber.
• A more contemporary technique uses 30% to
35% hydrogen peroxide pastes or gels that
require no heat.

• In both techniques, it is imperative that a
sealing cement placed over the exposed root
canal filling before application of the
bleaching agent to prevent leakage and
penetration of the bleaching material in an
apical direction.
• The bleaching agent should be placed in the
coronal portion of the pulp chamber to
prevent unwanted leakage of the bleaching
agent through lateral canals or canaliculi to
the periodontal ligament.

• Walking Bleach
• isolate the discolored tooth and remove all
materials in the coronal portion of the tooth.
• Remove gutta-percha (to approximately 1-2
mm apical of the clinical crown)
• enlarge the endodontic access opening
sufficiently to ensure complete debridement
of the pulp chamber.
• place a resin-modified glass-ionomer liner to
seal the gutta-percha of the root canal filling
from the coronal portion of the pulp chamber.

• After the seal hardens, trim any excess material
from the seal so that the discolored dentin is
exposed peripherally.
• Sodium perborate is used with this technique.
• Using a cement spatula with heavy pressure on a
glass slab, one drop of saline or sterile anesthetic
solution is blended with enough sodium
perborate to form a creamy paste.
• A spoon excavator or similar instrument is used
to fill the pulp chamber (with the bleaching
mixture) to within 2 mm of the cavosurface
margin, avoiding contact with the enamel
cavosurface margins of the access opening.

• a cotton pellet is used to blot the mixture and a
temporary sealing material is used(e.g.,
Intermediate Restorative Material or Cavit) to
seal the access opening.
• Sodium perborate should be changed weekly
until desired result is achieved.
• The chamber is rinsed and filled to within 2 mm
of the cavosurface margin with a paste consisting
of calcium hydroxide powder in sterile saline.
• Allow calcium hydroxide to remain in the pulp
chamber for 2 weeks and then clean the cavity by
removing all the temporary restoration seal the
cavity with composite.

VITAL BLEACHING PROCEDURES
• INDICATIONS:
• intrinsically discolored teeth from aging,
trauma, or drug ingestion.
• before and after restorative treatments to
harmonize shades of the restorative materials
with the natural teeth.
• Teeth exhibiting yellow or orange intrinsic
discoloration

• Vital bleaching techniques include an in-office
technique referred to as power bleaching
• and an outside the office alternative that is a
“dentist-prescribed, homeapplied”technique
(i.e., nightguard vital bleaching, or simply “at-
home bleaching”)

• In-Office Vital Bleaching Technique.
• requires excellent rubber dam technique and
careful patient management.
• Vaseline or cocoa butter may be placed on
the patient’s lips and gingival tissues
• application of the rubber dam to help
protect these soft tissues from any
inadvertent exposure to the bleaching agent.
• Bleaching agent: Most consist of paste or gel
compositions that most commonly contain
30% to 35% hydrogen peroxide.

• The dentist places the hydrogen peroxide–
containing paste or gel on the teeth.
• On completion of the treatment, the dentist
rinses the teeth,
• removes the rubber dam or isolation medium,
and cautions the patient about postoperative
sensitivity.
• Bleaching treatments generally are rendered
weekly for two to six treatments, with each
treatment lasting 30 to 45 minutes.

Dentist-Prescribed, Home-Applied
Technique
• Also known as night guard vital bleaching
• Less labour intensive and requires less in office
time
• An alginate impression of the arch to be treated
is made and poured in cast stone.
• The dentist trims the cast around the periphery
to eliminate the vestibule and thin the base of
the cast palatally.
• The dentist allows the cast to dry and blocks out
any significant undercuts using a block-out
material.

• The nightguard is formed on the cast using a heated
vacuum-forming machine.
• After the machine has warmed up for 10 minutes, a
sheet of 0.020 to 0.040 inch (0.75-1.5 mm) soft vinyl
nightguard material is inserted and allowed to soften
by heat until it sags approx. 1 inch.
• The top portion of the machine is closed slowly and
gently, and the vacuum is allowed to form the heat-
softened material around the cast.
• After sufficient time for adaptation of the material,
the dentist turns off the machine and allows the
material to cool.

• the dentist uses scissors or a No. 11 surgical
blade in a Bard-Parker handle to trim in a
smooth,straight cut about 3 to 5 mm from the
most apical portion of the gingival crest of the
teeth.
• Excess material is removed.

• Scalloped design is preferred as it allows the
tray to cover only the teeth and prevents
entrapment of the bleaching material
between the gingival tissue and the
nightguard.
• The dentist inserts the nightguard into the
patient’s mouth and evaluates it for
adaptation, rough edges, or blanching of
tissue.
• A 10% to 15% carbamide peroxide bleaching
material generally is recommended for this
bleaching technique.

• Carbamide peroxide degrades into 3%
hydrogen peroxide (active ingredient) and 7%
urea.
• The patient is instructed in the application of
the bleaching gel or paste into the nightguard.
• If the nightguard is worn at night, a single
application of bleaching material at bedtime is
indicated.
• In the morning, the patient should remove the
nightguard, clean it under running water with
a toothbrush, and store it in the container
provided.

• Total treatment time using an overnight
approach is usually 1 to 2 weeks.
• It is recommended that only one arch be
bleached at a time, beginning with the
maxillary arch.
• Tetracycline-stained teeth typically are much
more resistant to bleaching.

MICROABRASION
• Conservative alternative for the removal of
superficial discolorations.
• Microabrasion involves the surface dissolution
of the enamel by the acid along with the
abrasiveness of the pumice to remove
superficial stains or defects.
• Acid used is 11% HCl.
• Usually indicated for non hereditary
dysmineralization defects

MACROABRASION
• An alternative technique for the removal of
localized, superficial white spots and other
surface stains or defects is called
macroabrasion.
• uses a 12-fluted composite finishing bur or a
fine grit finishing diamond in a high-speed
handpiece to remove the defect.

VENEERS
• A veneer is a layer of tooth-colored material that
is applied to a tooth to restore localized or
generalized defects and intrinsic discolorations.
• Veneers can be either direct or indirect veneers.
• Indirect veneers include processed
composite,porcelain or pressed ceramic
materials.
• Two types of esthetic veneers exist:
1.Partial veneers
2.Full veneers

• Partial veneers are indicated for the
restoration of localized defects or areas of
intrinsic discoloration.
• Full veneers are indicated for the restoration
of generalized defects or areas of intrinsic
staining involving most of the facial surface of
the tooth.

• INDICATIONS:
1.Malformed facial surfaces
2.Dicolored teeth
3.Abraded or eroded teeth
4. Teeth with faulty restorations

• When only a few teeth are involved, or when the
entire facial surface is not faulty (i.e., partial
veneers), directly applied composite veneers can be
completed chairside for the patient in one
appointment.
• Indirect veneers require two appointments, but
typically offer three advantages over directly placed
full veneers, as follows:
1. Indirectly fabricated veneers are much less sensitive
to operator technique. Considerable artistic
expertise and attention to detail are required to
achieve esthetic and physiologically sound direct
veneers consistently

Indirect veneers are made by a laboratory
technician and are typically more esthetic.
2. If multiple teeth are to be veneered, indirect
veneers usually can be placed much more
expeditiously.
3. Indirect veneers typically last much longer
than direct veneers, especially if they are
made of porcelain or pressed ceramic.

• Two basic preparation designs exists for full
veneers:
1.Window preparation:
• it is recommended for most direct and
indirect composite veneers.
• This intraenamel design preserves the
functional lingual and incisal surfaces of the
maxillary anterior teeth, protecting the
veneers from significant occlusal stress.
• By using a window preparation,the functional
surfaces are better preserved in enamel.

2.Incisal,lapping preparation:
• It is indicated when the tooth being veneered
needs lengthening or when an incisal defect
warrants restoration.
• This design is used frequently with porcelain
veneers because it not only facilitates
accurate seating of the veneer on
cementation,but it also allows for improved
esthetics along the incisal edge.

Additional conservative and esthetic procedures

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