OPERATIVE

DENTISTRY

Clinical Course For

Fifth Year Students
second term

Edited by:

Prof. Mohamed Atef

Dr. Wael Gamal

2022-2023

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 :‫الرؤية‬
‫تتطلع الكلية إلى أن تكون من أكثر الكليات تميزا ً على المستوى المحلي و اإلقليمي في مجال‬
‫طب الفم و األسنان من خالل وضع برامج و أساليب أكاديمية متطورة في تعليم طب األسنان و‬
‫دعم البحث العلمي في هذا الميدان و أن تقدم مستوى متميز من خدمات المهنة للمجتمع المحيط‬
.‫من خالل كوادر الكلية من الخريجين والقائمين علي النشاط العلمي‬

:‫الرسالة‬
‫تلتزم الكلية بإعداد أطباء أسنان يتميزون بالجدارة المهنية من خالل برامج تعليمية متطورة‬
‫قادرين على التوافق مع متطلبات سوق العمل و مواكبة التطور العلمي و اإلسهام فيه باألنشطة‬
.‫البحثية مع تلبية إحتياجات المجتمع من خدمات طب األسنان‬

Vision:
The college aspires to be one of the most distinguished colleges at the
local and regional levels in the field of oral and dental medicine through
the development of advanced academic programs and methods in
dental education and support for scientific research in this field, and to
provide an outstanding level of professional services to the surrounding
community through the college cadres Alumni and associates of the
activity

Mission:
The college is committed to preparing dentists of professional merit
through advanced educational programs who are able to comply with
the requirements of the labor market, keep pace with scientific
development and contribute to it through research activities while
meeting the community’s needs of dental services.

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 Chapter one
Esthetic Consideration in Restorative Dentistry

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Esthetic Consideration in Restorative Dentistry
The most attractive of all our facial features is the smile, as it is an expression of
the person as a whole. The beauty of a person’s face is enhanced and maintained
by a pleasant smile and reflects the qualities of that person’s character.
WHAT IS ESTHETICS?
Webster’s Third New International Dictionary defines “esthetic” as
appreciative of, responsive to, or zealous about the beautiful; having a sense …of
beauty or fine culture.” Each of us has a general sense of beauty.

Everything has beauty, but not everyone sees it!’Confucius . The most
important aspect of the clinical assessment is for the clinician to know what to look
for. Leonardo da Vinci called this ‘saper vedere’, or ‘Knowing how to see’.
Esthetics is not absolute, but extremely subjective.
SMILE COMPONENTS
A smile is something that bridges a large gap between any two individuals.
There are two facial features that do play a major role in the smile design.
1. The interpupillary line
2. Lips
Dental Composition
The vital elements of smile designing include the
following:
• Tooth components
– Dental midline
– Incisal lengths
– Tooth dimensions
– Zenith points
– Axial inclinations

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– Interdental contact area (ICA) and interdental
-contact point (ICP)
– Incisal embrasure
– Sex, personality, and age
– Symmetry and balance
• Soft tissue components
– Gingival health
– Gingival levels and harmony
Natural head position
In order to assess facial proportions patients must be examined in natural head
position (NHP). NHP is a standardized and reproducible position of the head in
space when the subject is focusing on a distant point at eye level. In NHP, the
visual axis is horizontal. The patient must be examined for facial proportions and
symmetry in full face and in profile view.
Frontal facial analysis Facial type
The facial height to width ratio (Facial index) gives the overall facial type, such as
‘long’ or ‘short’ or ‘square’ face .The proportionate facial height to width ratio is
1.35:1 for males and 1.3:1 for females.

Facial Analysis
The facial morphology is important factor for determination of the tooth
morphology.
The basic shape of the face when viewed from the frontal aspect can be one of
the following :
1. long 2. Round 3. Oval
4. Square 5. Heart 6. Diamond

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An individual lateral profile:
1. Straight 2. Convex 3. Concave

Straight convex concave

Vertical proportions :
• Rule of fifth: the width of the face should be the width of five “eyes”.

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Horizontal proportions :
The facial height is divided into three equal parts from the fore head to the
eyebrow line, from the eyebrow line to the base of the nose and from the base of
the nose to the base of the chin.
The lower one third of the face from the base of the nose to the chin is divided into
two parts, the upper lip forms one-third of it and the lower lip and the chin two-
thirds of it.

Facial Midline
A line is drawn between the nasion and the base of the philtrum.
• Whenever possible the midline between the maxillary central incisors should be
coincidental with the facial midline. In cases in which this is not possible, the
midline between the central incisors should be parallel to the facial midline.
Naso-Labial Angle:
• Formed by intersection of two lines (one tangent to the base of the nose and one
to the upper vermillion border of the lip) at subnasale.
• The angle ranges generally from 85° to 105°.

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Ricketts* E-plane:
• A line that extends from the tip of the nose to the chin
• The maxillary and mandibular lip positions are away by 4 and 2 mm, respectively
from this plane (an important reference for esthetic lip position).

Labial Analysis
Lip morphology (Figure 10-13):
1. Medium lips
2. Flat lips
3. Thin lips
4- Thick or Full lips
Lip Line:
Lip line should not be confused with the smile line.
• Refers to the position of the inferior border of the upper lip during smiling

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• Determines the display of tooth or gingiva at this hard and soft tissue interface.
• Under ideal conditions, the gingival margin and the lip line should be congruent
or there can be a 1-2 mm display of the gingival tissue.
It may be either:
1. Low lip line: showing only the edges of upper front teeth.
2. High lip line: showing part of their labial gingival tissues.
3. Reversed: showing the lower teeth.
N.B: “Gummy smile” resulted from High lip line (Figure 15) together with short
clinical crowns may cause exposure of excessive amounts (3-4 mm or more) of
gingiva on smiling or during conversation. It often requires cosmetic periodontal
recontouring to achieve an ideal result.
Lip aesthetics
Aesthetic assessment of the lips must also be undertaken. The acronym ‘LAMP’
may be used to assess the length, activity, morphology and posture of the lips.
Upper lip to maxillary incisor relationship
The vertical exposure of the maxillary incisors in relation to the upper lip at rest
should be 2−4 mm, and on smiling the entire crown of the maxillary incisors
should be exposed, with up to 1−2 mm of associated gingiva. The starting point of
a smile is the lip line at rest, with an average maxillary incisor display of 1.91mm
in men and nearly twice that amount, 3.40mm, in women. With aging, there is a
gradual decrease in exposure of the maxillary incisors at rest and, to a much lesser
degree, in smiling. This steady decline in maxillary tooth exposure at rest is
accompanied by an increase in mandibular incisor display.
The lip incisor relationship depends on a number of factors, including:
1. Upper lip length. A long upper lip will tend to decrease maxillary incisor show
and vice versa.
2. The ‘smile curtain’, defined as the muscular capacity to raise the upper lip.
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3. The vertical position of the anterior maxilla and incisor teeth. The more inferior
the position of the anterior maxilla, the greater the exposure of the maxillary
incisors, and vice versa.
4. The anteroposterior position of the anterior maxilla and incisor teeth. The more
anterior the position of the maxillary incisors, the greater the exposure of the
maxillary incisors, and vice versa.
5. The inclination of the maxillary incisor teeth.
6. Maxillary incisor crown length, including the presence of incisal wear.
7. The vertical level of the gingival margins on the labial surface of the maxillary
incisor crowns.
Gingival Analysis
The gingival components of the smile are the color, contour, texture, and height of
the gingivae. Inflammation, blunted papillae, open gingival embrasures, and
uneven gingival margins detract from the esthetic quality of the smile. The space
created by a missing papilla above the central incisor contact point, referred to as a
“black triangle”, may be caused by root divergence, triangular teeth, or advanced
periodontal disease.
Gingival level and harmony
- Establishing the correct gingival levels for each individual tooth is the key in the
creation of harmonious smile.
- The cervical gingival height (position or level) of the centrals should be
symmetrical. It can also match that of the canines. It is acceptable for the laterals to
display the same gingival level.
- The gingival margin of the lateral incisor is 0.5-2.0 mm below that of the central
incisors. The least desirable gingival placement over the laterals is for it to be
apical to that of the centrals and or the canines.

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Gingival Zenith :
• It is highest point of the gingival margin
• Zenith of the laterals -* on midline
• Zenith of centrals and canines distal to midline

Gingival symmetry:
For maximum esthetic it is preferable for the gingiva to be symmetrical
Dental Analysis
Teeth size, proportions and position
Central dominance :
The centrals are the key to the smile. They must be the dominant teeth in the smile
and they must display pleasing proportions.
The width to length ratio of the centrals should be approximately of 75-80%,
which is considered the most acceptable.

Dental Proportion Guidelines

1. Golden proportion (Lombardi),
2. Recurring esthetic dental proportions “RED” (Ward),

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These proportions are based on when viewed from the facial aspect. The distance
between proximal line angles of the teeth (the perceived size) and not the actual
size.
Principle of Golden Ratio (Golden proportion, Lombardi):
• When viewed from the facial, the width of each anterior tooth is 60% of the width
of the adjacent tooth (mathematical ratio being 1.6:1:0.6).

Dental Components
A pleasant smile also depends on the quality and beauty of the dental elements it
contain and their harmonious integration. Dental components of the smile include
the size, shape, color, alignment, and crown angulation (tip) of the teeth; the
midline; and arch symmetry.
Shape or Form
The shape of teeth largely determines their esthetic appearance. When viewing the
clinical crown of an incisor from a facial (or lingual) position, the crown outline is
trapezoidal.
For instance, rounded incisal angles, open incisal and facial embrasures and
softened facial line angles typically characterize a youthful, feminine smile.
A more masculine smile, or a smile characteristic of an older individual having
experienced attrition due to aging, typically exhibits incisal embrasures with more
closed and prominent (i.e., less rounded) incisal angles.

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Illusions of shape also play a significant role in dental esthetics. The border outline
of an anterior tooth (i.e., facial view) is primarily two-dimensional (i.e., length and
width). However, the third dimension of depth is critical in creating illusions,
especially those of apparent width and length..
Symmetry and proportionality
The overall esthetic appearance of a human smile is largely governed by the
symmetry and proportionality of the teeth that constitute the smile. Assuming the
teeth are of normal alignment, dental symmetry can be maintained if the sizes of
the contralateral teeth are equivalent. When dealing with restorations involving the
midline, particular attention also must be afforded to incisal and gingival
embrasure form; the mesial contours of both central incisors must be mirror images
of one another to ensure an optimally symmetric and esthetic result.
Translucency
The degree of translucency is related to how deeply light penetrates into the tooth
or restoration before it is reflected outward. The number of rays that are reflected
from the enamel and those reflected from dentin are responsible of the life like
esthetic vitality characteristics of normal unrestored teeth.
Fluorescence
It is defined as the ability to absorb radiant energy and emit it in the form of a
different wavelength. Because it makes teeth brighter and whiter in daylight,
fluorescence is an additional parameter to be considered
Surface texture
Surface texture determines how light is reflected from tooth.
Young teeth exhibit significant surface characterization, whereas teeth in older
teeth tend to possess a smoother surface texture caused by abrasional wear. The
surfaces of the natural teeth typically break up light and reflect it in many
directions. Consequently, anatomic features e.g. developmental depressions,
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prominence, should be closely examined and reproduced.
Surface texture
• The character and individuality of teeth are largely determined by the surface
texture and characteristics that exist.
• Realistic restorations closely mimic the subtle areas of stippling, concavity, and
convexity that are typically present on natural teeth.
• Young teeth characteristically exhibit significant surface characterization,
whereas teeth in older individuals tend to possess a smoother surface texture
caused by abrasional wear.
• The surfaces of natural teeth typically break up light and reflect it in many
directions.
• The restored areas of teeth should reflect light in a similar manner to unrestored
adjacent surfaces.
ESTHETIC CONSIDERATIONS
Smile Arc (Line):
• An imaginary line along the incisal edges of the maxillary anterior teeth that
mimic the curvature of the superior border of the lower lip while smiling. When
the centrals appear shorter than the canines along the incisal plane (Reverse smile
line or inverse smile line)

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• The smile arc is the relationship between a hypothetical curve drawn along the
edges of the maxillary anterior teeth and the inner contour of the lower lip in the
posed smile.
• The curvature of the incisal edges appears to be more pronounced for women
than for men, and tends to flatten with age.
• The curvature of the lower lip is usually more pronounced in younger smiles.
• In an optimal smile arc—described as “consonant”—the curvature of the
maxillary incisal edges coincides with or parallels the border of the lower lip in
smiling.
• The lower lip can either touch, not touch, or slightly cover the upper incisal
edges.
Dental midline
• It should be:
1. Parallel to the long axis of the face
2. Perpendicular to the incisal plane
3. Over the papilla (drop straight down from the papilla).
• Minor discrepancies between facial and dental midlines are acceptable and, in
many instances, not noticeable.
• The maximum allowed discrepancy :
2 mm and sometimes greater than 2 mm discrepancy is esthetically acceptable as
long as the dental midline is perpendicular to the interpupillary line.
Buccal Corridor
• A dark space (negative space) that is visible between the corners of the mouth
and the buccal surfaces of the maxillary teeth during smiling.
• Its appearance is influenced by
1. The width of the smile and the maxillary arch
2. The tone of the facial muscles,
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3. The positioning of the labial surface of the upper premolars,
• The buccal corridor is directly influenced by the arch form.
• A narrow arch is generally unattractive. The unattractive, negative space should
be kept to a minimum. To solve or minimize this problem, the premolars can be
restored.
Axial Inclination:
• There should be natural, progressive increase in the mesial inclination of each
subsequent anterior tooth (from the central to the canine) (Least noticeable with
the centrals and more pronounced with the laterals and slightly more so with the
canines).
• The evaluation of axial inclination can be done on a photograph of the anterior
teeth in a frontal view.

Display Zone and Teeth Visibility

• In a young individual (when the mouth is relaxed and slightly open): 3.5mm of
the incisal third of the maxillary central incisor should be visible.
• As age increases:
Less tooth display due to the decline in the muscle tonus showing tooth display at
rest.

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Interproximal contact point (ICP) :
• It is the most incisal aspect if the Interproximal contact area (ICA).
• As a general rule, the ICP moves apically, the further posterior one moves from
the midline.

Incisal edge positioning: is determined by:

• Vermillion border of the lower lip
• Phonetics
• Parallel to interpupillary line
Incisal Embrasures;
The incisal embrasures should display a natural, progressive increase in size or
depth from the central to the canine.
As a rule, a tooth distal to incisal corner is more rounded than its mesio incisal
corner.

Surface Texture and Luster:

It refers to the degree of smoothness vs. roughness that occurs on the tooth's
surface.
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Sex, age and personality:
Minor differences in the length, shape and positioning of the maxillary teeth allow
for dramatic characterization.
• Age;
Maxillary central incisor
Youthful teeth: unworn incisal edge, defined incisal embrasure, low chroma and
high value
Aged teeth: shorter; so less smile display, minimal incisal embrasure, high chroma
and low value
• Sex:
Maxillary incisors
Female form: round smooth, soft delicate Male form: cuboidal, hard vigorous
• Personality:
Maxillary canine
Aggressive, hostile angry: pointed long “fangy” cusp form Passive, soft: blunt,
rounded, short cusp form
• Younger patients may show between 2-4 mm of maxillary incisal edge in this
position.
• As people age, the maxillary incisal edge reveal shrinks and even disappears.

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Position and alignment:
Teeth should be aligned in harmony.
The smile can be analyzed at rest (M-position) or smile (E-position).
In the M-position, the following references are measured and analysed:
commissure height; philtrum height; and visibility of the maxillary incisors.
• By having the patient says the letter “M” repetitively and then allow her/ his lips
to part gently, the dentist can be able to assess minimum tooth reveal.
In E-position the following references should be analysed:
smile arc (line); dental midline; smile symmetry; buccal corridor; display zone and
teeth visibility; smile index; and lip line. • When patients say the letter “E” in an
uninhibited and exaggerated way, the dentist can ascertain the maximum extension
of the lips.
Teeth shade
Color perception:
When the light bands reflected from the tooth, strike the eye, energy -> stimulates
the photoreceptor{rods and cones} in the retina -> photo-chemical reaction ->
neural impulses^ brain-* excite the perception of a given color. The rod cells are
responsible for brightness of color (value) while the cone cells are responsible for
hue and Chroma.
Factors affecting optical qualities of an object as seen by an observer's eye:
1. Spectral characteristics of the light source
2. The spectral characteristics of the object
3. Sensitivity of the observer eye
1. Spectral characteristics of the light source:
■ These are: the angle between the observing eyes and the object, interface of the
object and incident light rays, intensity of light and type of light.

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■ Metamerism: Color, transluncy and surface texture of the same object appear
different under different light sources therefore; color determination of teeth must
be done under neutral illumination i.e. light having no dominance of a specific
color.
2. The spectral characteristics of the object:
■ These are: surface reflectivity, refractive index, homogeneity, light absorption
and light scattering.
3. Sensitivity of the observer eye:
■ Including: the eye sensitivity lo light, color vision and blindness, optical illusion
and color fatigue.
Requirements for correct color determination
■ The illuminant should be neutral.
■ The background should be neutral orgray to eliminate dominance of particular
colors.
■ The background involves wetness of the tooth, office curtains, walls, and we
should remove any lipstick and make-up before color determination.
■ Patient position: color selection is preferably made with patient seated at the
same level relative to the observer's eye.
Measurement of color Methods of shade selection in dentistry
Color determination in dentistry can be divided into two categories:
• Subjective technique (Visual technique)
- Shade guide
• Objective technique (Instrumental technique)
A. Spectrophotometer
B. Colorimeter
C. Digital cameras and imaging systems

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Type of measurements used in digital shade selection
Digital shade selection is based on two types of measurements namely spot
measurement and complete tooth measurements.
CAUSES OF ESTHETICS DEFECTS
1. Caries: loss of tooth substance and if the pulp is involved, the translucency
of the tooth will be changed.
2. Occlusal disharmony of teeth e.g. drifting, crowding or diastema.
3. Loss of tooth substance due to traumatic fracture, erosion, attrition or
abrasion.
4. Discoloration (intrinsic or extrinsic) that may be a result of drug therapy
(tetracycline), congenital anomalies (fluorosis), loss of pulp vitality, caries,
discolored restorations.
5. Minor abnormalities in size and shape of teeth e.g. (pig-shaped teeth).
6. Missing teeth due to extraction, trauma, or congenital anomalies.
LIMITING PROBLEMS IN RESTORING ESTHETICS:
1. Exact color match.
2. Gingival and periodontal health.
3. Establishment of adequate retention.
4. Abnormal occlusion or biting habits.
5. Intrinsic deficiencies of available restoratives.
1. Exact color match:
Exact duplication of a tooth color is very difficult because it requires duplicating
the combined color of two optically different tissues, enamel and dentin, in one
synthetic restorative material. Color determination is done by comparison with
buttons of different thickness to both the tooth and restoration which may cause
variation from the exact color. Background and the observer’s eye are variable
factors, which affect color selection. The color determined by the operator is sent
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to the laboratory technician in a prescription sheet, this will add another human
variable. The restoration in the mouth will be subjected to discoloration
influences, which may affect its color on aging.
2. Gingival and periodontal health:
The position of the gingival finish line constitutes a major problem especially with
veneers and crown preparations. Supra-gingival finish line leads to appearance of
restoration margins, increased solubility of luting cement, but it’s less damaging
for the gingival while Sub-gingival finish line is better for esthetic, but it’s more
damaging for the gingiva. It is better to place the finish line in the gingival sulcus
at the level of the gingival crest or slightly sub-gingival but before reaching the
sulcus base.
3. Establishment of adequate retention:
If the involved tooth is grossly mutilated the remaining tooth substance becomes
inadequate to provide enough mechanical retention. Bondodontics may solve
this problem. Full coverage or radicular retention may be essential in some cases
and other cases may require using the adjacent tooth for retention and support.
4. Abnormal occlusion or biting habits:
Edge- to- edge biting causes excessive wear of the incisal edge and may
contraindicate the use of laminate veneers. Abnormal occlusal habits such as
bruxism may cause excessive wear or fracture of esthetic restoratives.
5. Intrinsic deficiencies of available restoratives:
None of the currently available restorative materials satisfy the required
characteristics
SOLVING SOME ESTHETIC PROBLEMS
I. Esthetic cavity design.
II. Restorative materials and techniques:
a. Bonded composite
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b. Glass ionomer cement.
c. Ceramic material systems including:
1. All porcelain (inlay / onlays, crowns)
2. Porcelain-fused-to metal (crowns)
3. Castable ceramics (inlays/onlays, veneers, and crowns)
4. Machine-milled ceramics (inlays/onlays, veneers, and crowns)
d. Veneers
III. Non-restorative esthetic treatment:
a. Bleaching.
b. Micro and Macro abrasion.
c. Selective grinding
I. Esthetic cavity design
The outline form of prepared cavities should be conservative as no restorative
material can adequately replace natural tooth structure.
The following guidelines should be taken into consideration during preparation of
cavities for bonded resin composite restorations:
a. In class III cavities:
A lingual approach is recommended. The labial margin should be parallel with the
labial surface of the tooth as possible so that the restoration blends with the general
contours of the tooth.
b. In class V cavities
The occlusal margin should be parallel to the occlusal plane. If the rest of margins
are kept under the free gingiva they will look better. Cavity margins should always
be with no irregularities or insensible extensions.

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II. Restorative materials and techniques:
a. Bonded composite
Indications:
1. Restoration of carious defects of all classes, discoloration or hypoplastic
defects in labial surfaces of anterior teeth
2. As a veneer for a glass-ionomer in class V restoration {Sandwich technique}
to combine its superior esthetics and form stability to the superior retention and
biocompatibility of the glass ionomer cement.
3. It may be used to veneer a full metal crown.
4. To recontour anterior teeth for filling-up diastema or correcting malformed
teeth as pig-shaped cuspids.
5. As a tooth-colored bonding material:
• To splint mobile anterior teeth as a part of an.
• To bond laminate veneers.
• To bond brackets of orthodontic appliances.
6. It is also used to bond resin bonded bridge retainers e.g., Maryland Bridge
retainers.
Advantages:
1. The procedure is shorter.
2. Less costly.
3. Maximum conservation: minimum tooth reduction is required on the
proximal or lingual surfaces while facial enamel is never touched.
4. Better esthetics.
5. No possibility of pulp irritation.
6. No gingival irritation since the restoration is always supragingival.

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Basic principles for reproduction of esthetic anterior restorations:
In natural tooth, the color comes from within, not from the surface. The light
penetrates the enamel layer and is then dispersed in the dentin; therefore the tooth
color comes from dentin than from enamel. It is therefore necessary to replace
dentin with an opaque dentin composite and enamel with a more
transparent/translucent “enamel-composite”.
Layering technique:
Dentin shades should provide very intense colors (high chroma) and relatively low
translucency while Enamel shades should provide enhanced translucency together
with relatively low intensity of color. Staining or discoloration of the underlying
dentin may be masked using opaque shades or compensated for the application of
lighter dentinal shades of the composite.
Color Modifiers:
The most frequently used color modifiers are white, gray, yellow, yellow-brown,
blue, and red.
Yellow-orange: create illusion of narrowness
Yellow brown: Masking blue gray tetracycline stains.
Blue, Gray, or Violet: These shades are used on the incisal one third of the tooth to
simulate translucency.
White: is used to increase the value of any color modifier. It can be used to
simulate craze lines, enamel hypocalcification and used to mask yellow stains.
Red or Pink: Red or pink simulates gingival tones, enhances vitality, and can
neutralize blue tetracycline stains.
Color stability:
Curing; composites become darker and less chromatic.
Aging: Composite becomes darker, more chromatic, more opaque and has higher
scattering and absorption coefficients.
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Staining: Some fluoride varnishes produce perceptible color changes.
b. Glass ionomer cement
Indications:
1. Class V caries.
2. Erosive lesions.
3. In moderately deep cavities and when pulp insulation is necessary.
Advantages:
1. Its biologic superiority is attributed to: weak acid content high molecular weight
2. It has a good adhesive potential and emits fluorides.
CLINICAL CONSIDERATIONS
Although an understanding of basic artistic elements is imperative to esthetic
restorations, certain clinical considerations must be addressed concomitantly to
ensure the overall quality of the restoration. In addition to being esthetic,
restorations also must be functional.
CONSERVATIVE ALTERATIONS OF TOOTH CONTOURS AND
CONTACTS ALTERATIONS OF SHAPE OF NATURAL TEETH
Some esthetic problems can be corrected very conservatively without the need for
tooth preparation and restoration. Consideration always should be given to
reshaping and polishing the natural teeth to improve their appearance and function.
In addition, the rounding of sharp angles also can be considered a prophylactic
measure to reduce stress and to help prevent chipping and fractures of the incisal
edges.
Etiology. Attrition of the incisal edges often results in closed incisal embrasures
and very angular incisal edges.
Treatment.
As noted earlier, cosmetic contouring to achieve youthful, feminine characteristics
often includes rounding incisal angles, reducing facial line angles, and opening
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incisal embrasures. The opposite characteristics are typically considered more
masculine features. However, cosmetic reshaping to smooth rough incisal edges
and improve symmetry is equally beneficial to both women and men. Because all
reshaping is restricted to enamel, anesthesia is not required.
ALTERATIONS OF EMBRASURES
Etiology. Anterior teeth can have embrasures that are too open as a result of the
shape or position of the teeth in the arch. For example, permanent lateral incisors
are congenitally missing,
Treatment. Composite can be added to establish an esthetic contour and correct
the open embrasures. Evaluation of the occlusion before restoration determines if
the addition will be compatible with functional movements.
CORRECTION OF DIASTEMAS
by routine procedures. The occlusion should be evaluated to assess centric contacts
and functional movements, and any adjustments or corrections should be made if
indicated.
Etiology. The presence of diastemas between the anterior teeth is an esthetic
problem for some patients
Treatment. Traditionally diastemas have been treated by surgical, periodontal,
orthodontic, and prosthetic procedures. These types of corrections can be
impractical or unaffordable and often do not result in permanent closure of the
diastema.
CONSERVATIVE TREATMENTS FOR DISCOLORED TEETH
Discolorations are classified as extrinsic or intrinsic. Extrinsic stains are located on
the outer surfaces of the teeth, whereas intrinsic stains are internal. The etiology
and treatment of extrinsic and intrinsic stains are discussed in the following
sections.

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EXTRINSIC DISCOLORATIONS
Etiology. Stains on the external surfaces of teeth (referred to as extrinsic
discolorations) are quite common and may be the result of a number of causes.
Treatment.
Microabrasion:
In 1984 McCloskey reported the use of 18% hydrochloric acid swabbed on teeth
for the removal of superficial fluorosis stains.

Macroabrasion:
Macroabrasion simply uses a 12-fluted composite finishing bur or a fine grit
finishing diamond in a high-speed hand piece to remove the defect. A 30fluted
composite-finishing bur is used to remove any facets or striations created by the
previous instruments.
INTRINSIC DISCOLORATIONS
Etiology. Intrinsic discolorations are caused by deeper internal stains or enamel
defects; these stains are more complicated to treat than external types.
BLEACHING TREATMENTS
OTC Home Bleaching
Dentist - Assisted Home Bleaching
Dentist - Assisted In - Office Bleaching
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 Typically, veneers are
made of chairside composite, processed composite, porcelain, or pressed ceramic
materials. Common indications for veneers include teeth with facial surfaces that
are malformed, discolored, abraded, eroded, or have faulty restorations.
Two types of esthetic veneers exist:

28
(1) Partial veneers are indicated for the restoration of localized defects or areas of
intrinsic discoloration.
(2) Full veneers are indicated for the restoration of generalized defects or areas of
intrinsic staining involving the majority of the facial surface of the tooth.
Indications:
1. Gross esthetic derangement as gross discoloration (brown intrinsic stain,
due to dentinogenesis imperfecta or gray stain of tetracycline).
2. Loss of translucency (mottled enamel in fluorosis).
3. Imperfections in contour or surface texture of upper anterior teeth.
Contraindications:
1. Bruxism.
2. Occlusal interference.
3. Excessive incisal wears.
4. Class III malocclusion because of the great possibility for dislodgment.
Types:
1. Direct Veneers
Direct application of visible light cured resin composite of a suitable shade.
It is completed in a single chair-side visit.
Sufficient thickness of enamel should be available to provide retention
that relies on micro-mechanical bonding.
Technique:
• Grinding of a part-thickness of enamel.
• The incisal reduction should stop just short of the incisal edge to avoid sub
jecting the veneer to displacement by functional forces.
• The enamel at the periphery of the preparation is beveled for 1mm all round
in order to expose fresh and clean enamel of higher surface energy.
• The enamel is acid-etched, washed and dried.
29
• Bonding agent is applied and cured and then the composite is pressed gently
to the preparation, carved, cured, finished and polished.
DIRECT VENEER TECHNIQUES
Direct Partial Veneers. Small localized intrinsic discolorations or defects that are
surrounded by healthy enamel are ideally treated with direct partial veneers. All
too often, practitioners place full veneers when only partial veneers are indicated.
These defects can be restored in one appointment with a light cured composite.
Usually it is not necessary to remove all of the discolored enamel in a pulpal
direction. However, the preparation must be extended peripherally to sound,
unaffected enamel. Use of an opaquing agent for masking dark stains. If the entire
defect or stain is removed, then a microfilled composite is recommended for
restoring the preparation.
Direct Full Veneers. Extensive enamel hypoplasia involving all of the maxillary
anterior teeth was treated by direct full veneers. A direct technique was used with a
light-cured microfill composite. Although all six teeth can be restored at the same
appointment, it may be less traumatic for the patient and the dentist if the veneers
are accomplished in two appointments.
The preparation for a direct veneer normally is terminated just facial to the
proximal contact, except in the area of a diastema. To correct the diastema, the
preparations are extended from the facial onto the mesial surfaces, terminating at
the mesiolingual line angles.
2. Indirect Veneers
• It involves the use of either prefabricated or custom- made resin or ceramic
laminate veneers that are bonded to the surface of the tooth by resin luting cement.
• Custom-made ceramic or resin composite laminate veneers are constructed in
the laboratory on dies made out of precise rubber base impressions.

30
Intraenamel preparation (or the roughening of the surface in undercontoured areas)
before placing a veneer is strongly recommended for the following reasons:
1. To provide space for opaque, bonding, or veneering materials for maximal
esthetics without overcontouring.
2. To remove the outer, fluoride-rich layer of enamel that may be more
resistant to acid-etching
3. To create a rough surface for improved bonding
4. To establish a definite finish line.
5. If the defect or discoloration does not extend subgingivally, then the margin
of the veneer should not extend subgingivally.
Two basic preparation designs exist for full veneers:
(1) a window preparation
(2) incisal, lapping preparation.
INDIRECT VENEER TECHNIQUES
Many dentists find that the preparation, placement, and finishing of several direct
veneers at one time is too difficult, fatiguing, and time-consuming. Some patients
become uncomfortable and restless during long appointments. In addition, veneer
shades and contours can be better controlled when made outside of the mouth on a
cast. For these reasons, indirect veneer techniques are usually preferable. Indirect
veneers include those made of: (1) processed composite, (2) feldspathic porcelain,
and (3) cast or pressed ceramic.
Although two appointments are required for indirect veneers, chair time is
saved because much of the work is done in the laboratory. Excellent results can be
obtained when proper clinical evaluation and careful operating procedures are
followed. Indirect veneers are attached to the enamel by acid-etching and bonding
with either a light-cured, or dual-cured resin-bonding material.

31
VENEERS FOR METAL RESTORATIONS
Esthetic inserts (i.e., partial or full veneers) of a toothcolored material can be
placed on the facial surface of a tooth previously restored with a metal restoration.
Veneers for Existing Metal Restorations. Occasionally the facial portion of an
existing metal restoration (amalgam or gold) is judged to be distracting.
REPAIRS OF VENEERS
Failures of esthetic veneers occur because of breakage, discoloration, or wear.
Consideration should be given to conservative repairs of veneers if examination
reveals that the remaining tooth and restoration are sound. It is not always
necessary to remove all of the old restoration. The material most commonly used
for making repairs is light-cured composite.
Digital smile design
-DSD is a unique dental treatment planning tool that strengthens a dental
provider’s diagnostic vision, enhances predictability, and improves communication
between dental providers and their patients.
Advantages of DSD
• Patient’s Visualization
Digital designing, and imaging paints a final image of the results to the patient,
thus helps him be more accepting of the final treatment’s outcomes.
• Patient’s Motivation toward the treatment
DSD is advantageous with skeptical and hesitant patients because it allows for an
easier education about the benefits of the treatment plan.
• Aesthetically improved treatment plan
DSD provides a standardized analysis manner of the patient’s dental, gingival, and
facial parameters.

32
 This allows the clinician to further identify the patient’s problem and draw more
customized treatment plan.

• Smile design customization

Through the patient’s participation in the design of his own smile, a more
satisfying smile is obtained, in terms of aesthetics, emotions, and confidence.
The final smile design is modified by the patient’s expectations and the
clinician’s views before the start of the procedure.

 It also helps to evaluate and compare pre and post treatment changes.

 Patients can view their rehabilitations even before they start, and this can also
have important medico-legal functions.

 Helps in communication between not only the clinician and the patient, but also
between the interdisciplinary team members.

33
Limitations of DSD

 As the diagnosis and treatment plan depends on photographic and video

documentation, inadequacy in them may distort the reference image and may
result in an incorrect diagnosis and planning.

 For complete 3D digital work flow, 3D softwares with updates, intraoral

scanner, 3D printer and CAD/CAM are required which makes it economically
expensive.

 Training and handling for certain software are necessary which further
increases time and cost.
Requirement For DSD
Photography Protocol
• At first we should follow a photography protocol to get a correct DSD.
• Photographs should be accurate with correct posture, as facial reference lines
like the commissural lines, lip line and inter-pupillary line which forms the
basis of smile designing are established on them.
• Poor photography misrepresents the reference image and may lead to an
improper diagnosis and planning.
The following photographic views in fixed head position are necessary:
Three frontal views:
• Full face with a wide smile and the teeth apart

34
 • Full face at rest

• Retracted view of the full maxillary and mandibular arch with teeth apart.

Two profile views:

• Side Profile at Rest

35
• Side Profile with a full Smile

A 12 O, clock view with a wide smile and incisal edge of maxillary teeth visible
and resting on lower lip.

An intra occlusal view of maxillary arch from second premolar to second

premolar.

36
VIDEOGRAPHY PROTOCOL:

8 VIDEOS for the FULL DSD Documentation

4 basic:

• A facial frontal video with retractor and without retractor smiling

• A facial profile video with lips at rest and wide-E smile.

• A 12 O'clock video above the head at the most coronal angle that still allows
visualization of the incisal edge
• An anterior occlusal video to record maxillary teeth from second premolar to
second premolar with the palatine raphe as a straight line.

4 additional:

• Face casual interview.

• Close up Counting, smiling and phonetics.
• Intra oral Functional movements.
• Structural Oclusal view.

37
TYPES OF DSD SOFTWARE

• Photoshop CS6 (Adobe Systems Incorporated)

• Microsoft PowerPoint (Microsoft Office, Microsoft, Redmond, Washington,
USA)
• Smile Designer Pro (SDP) (Tasty Tech Ltd)
• Aaesthetic Digital Smile Design (ADSD - Dr. Valerio Bini)
• Cerec SW 4.2 (Sirona Dental Systems Inc.)
• Planmeca Romexis Smile Design (PRSD) (Planmeca Romexis®)
• VisagiSMile (Web Motion LTD)
• DSD App by Coachman (DSDApp LLC)
• Keynote (iWork, Apple, Cupertino, California, USA)
• Guided Positioning System (GPS)
• DSS (EGSolution)
• NemoDSD (3D)
• Exocad DentalCAD 2.3

What is the process?

1. Preliminary Consultation

The dentist and the patient discuss what exactly the patient wants to achieve from
this treatment. This preliminary consultation is very necessary as the dentist gets to
know about the patient’s requirements and the patients are made aware of all the
aspects of the Digital Smile Design process.

2. Gathering information
The next step is to gather aesthetic and structural information of the teeth of the
patient. High-quality digital photographs and short videos of the patient, while

38
speaking and smiling, are recorded from various angles. These details are needed
by the Smile Design software.

3. Smile Design / Simulation

The information gathered in the second step is input into the software for analysis.
The software then depicts feasible solutions as per the patient’s requirements.
These possible outcomes are represented graphically in 3D form.

4. Patient Review
The 3D representations are demonstrated to the patient for review. And the patient
can approve or ask for revisions in the design. The dentist will only carry on with
the process if the design is approved by the patient.

5. Cosmetic Procedure

The final step is to perform dental restoration or alignment. The length of the
treatment and costs vary for each patient. Thorough care is taken during the
procedure. Later, the patient is guided about post-operative care needed.

Conclusion

Esthetics is a very huge term, it is not easy to achieve or maintain, every

dentist should be well acquainted with the recent advances in the field of the
material science and the new equipment to reach his ultimate goal of satisfying the
patient’s needs .

39
 Chapter 2
Bleaching systems and whitening agents

40
 Bleaching systems and whitening agents
Tooth discoloration is one of the most popular problems facing
esthetic dentistry nowadays.

Teeth bleaching (Teeth lightening) is the process that

lightens the color of a teeth. It may be accomplished by chemical
reaction to lighten the teeth color.

 Types of stains:

Causes of tooth staining must be carefully assessed for

better prediction of the rate and the degree to which
bleaching will improve tooth color, since some stains are more
responsive to the process than others.

- Teeth with Yellowish stains respond quickly to

bleaching in most cases.

- Teeth with brown fluorescence are moderately

responsive.

- Blue–gray tetracycline stains are the slowest to respond

to bleaching.

41
 1) Extrinsic stains:

- Accumulation of chromatogenic substances on the external tooth

surface.

- Occur due to poor oral hygiene, ingestion of chromatogenic

food and drinks, and tobacco use.

- Can be removed by routine prophylactic procedures. With

time, these stains will darken and become more persistent, but
they are still highly responsive to bleaching

2) Intrinsic stains:

- Incorporated during tooth formation or after eruption /

presence of stain molecules within the enamel and dentin

- Pre-eruptive stains arise due to dental fluorosis, tetracycline

staining, hematologic disorders, and inherited developmental
defects of enamel or dentin without systemic features.

- Cannot be removed by regular prophylactic procedures.

However, they can be reduced by bleaching with agents

penetrating enamel and dentin to oxidize the chromogens.

3) Internalized: Arise from dental caries and discolurations of

restorations.
 Chemical composition of bleaching agents:

42
 Bleaching agents contain both active and inactive ingredients.
Active ingredients include:

a) Hydrogen peroxide: an effective bleaching agent.

b) Carbamide peroxide: an organic compound contains

hydrogen peroxide and urea.

c) Sodium perborate compounds: used in combination

with hydrogen peroxide or water.

Inactieve gredients include:

a) Thickening agents

b) Carrier

c) Surfactant

d) Preservative

e) Flavoring

recently, amorphous calcium phosphate (ACP), to reduce

sensitivity, reduce the demineralization of enamel through a
remineralization process after whitening treatments, and add a
lustrous shine to teeth.

Mechanism of Action:

-The active ingredient in most lightening products are hydrogen

peroxide or carbamide peroxide. Carbamide peroxide
decomposes into hydrogen peroxide and urea thus the
43
chemistry of most tooth lightening is hydrogen peroxide.

-It oxidizes a wide variety of organic and inorganic compounds

due to its reactive properties. It can form a number of different
active oxygen species depending on reaction conditions
including temperature, pH, light and presence of transition
metals.

-Basically, mechanism of bleaching is oxidation and reduction

reaction, with the release of free radicals.

-The free radicals are unstable oxidants, which have unpaired

electrons. That react with organic molecules of chromogens.
When reaction occurs between the free radicals and
chromogens, the carbon chains bonds are broken, generating
compounds with simpler molecular, resulting in tooth
whitening.

 Types of activation of different bleaching systems:

I.Chemically Activated Bleaching:

It is hydrogen peroxide two part gel system. It consists of one

syringe, containing hydrogen peroxide, which is mixed with the
second syringe that contains an activator. When mixed together,
the bleaching agent is supercharged and does not require light

44
or laser activation.

II .light activated Bleaching:

light sources is that they heat the HP, thereby increasing the
rate of decomposition of oxygen into free radicals and
increasing its bleaching effect

III.Laser activated bleaching:

- Available Laser units include Carbon dioxide, Nd:YAG improve

the inflammatory response of the pulpal tissue, reducing
pulp damage and relieving pain after the bleaching process.
 Techniques of teeth bleaching:

According to the ADA specifications, the tooth whitening market

has evolved into four categories:

1) Professionally applied (in- office vital and in- office non-vital)

2) Dentist-prescribed (patient home-use)

3) Consumer-purchased/over the counter (OTC) (applied by

patients)

4) Do it yourself (Natural Ingredients).

N.B. Dentist-prescribed bleaching materials are sometimes used

at home after dental office bleaching to maintain or improve
whitening results.
45
1) In-Office dental bleaching:

2 types: vital and non-vital.

A) Vital:

In-office vital bleaching utilizes a high concentration of tooth-

whitening agents (25–40% hydrogen peroxide).

In this procedure, the whitening gel is applied to the teeth after

protection of the soft tissues by rubber dam, and the peroxide
will further be chemical or physical activated for around one
hour in the dental office.

The in-office treatment can result in significant whitening after

only one treatment, but more visits may be needed to achieve an
optimum result.
B) Non vital:

There are numerous non-vital bleaching techniques used:

a- Walking bleach technique: involves sealing a mixture of

sodium perborate with water into the pulp chamber of the

affected tooth, a procedure that is repeated at intervals until the
desired bleaching result is achieved.

b- Modified walking bleach: This technique is modified with a

combination of 30% hydrogen peroxide and sodium perborate

46
sealed into the pulp chamber for one week.

c- Non-vital power bleaching, hydrogen peroxide gel (30–

35%) is placed in the pulp chamber and activated either by light

or heat, and the temperature is usually between 50 and 60 C°
maintained for five minutes before the tooth is allowed to cool
for a further 5 min. Then, the gel is removed, the tooth is dried,
and the ‘walking bleach technique’ is used between visits until
the tooth is reviewed 2 weeks later to assess if further
treatment is needed.

d- Inside/outside bleaching technique is a combination of

internal bleaching of non-vital teeth with the home bleaching
technique (Setien et al., 2008).

2) Dentist-prescribed (patient home-use):

- Involves the use of a low concentration of whitening agent

(10–20% carbamide peroxide, which equals 3.5–6.5% hydrogen

peroxide).
In general, it is recommended that the 10% carbamide peroxide
be used 8 h per day, and the 15–20% carbamide peroxide 3–4
hours per day. This treatment is carried out by the patients
themselves, but it should be supervised by dentists during recall
visits. The bleaching gel is applied to the teeth through a

47
custom-fabricated mouth guard worn at night for at least 2
weeks.

The at-home technique offers many advantages: self-

administration by the patient, less chair-side time, high degree
of safety, fewer adverse effects, and low cost. Disadvantages:

1) Active patient compliance is mandatory

2) Color change is dependent on patient use, and the results are

sometimes less than ideal, since some patients do not remember

to wear the trays every day.

3) Excessive use may cause teeth sensitivity

3) OTC:

Consumer whitening products available today for home use

include gels, rinses, chewing gums, toothpastes, paint-on films
and strips with low levels of hydrogen peroxide have some
whitening effect, but without clinical relevance.

OTC products are considered to be the fastest growing sector of

the dental market (Kugel, 2003). However, these bleaching
agents may be of highly questionable safety, because some are
not regulated by the Food and Drug Administration.

4) Do it yourself: through natural ingredients (e.g. .banana peel,

charcoal, baking soda, or strawberries etc...)

48
 Systemic effects:

- Occasionally, patients report gastrointestinal mucosal

irritation, e.g., a burning palate and throat, and minor upsets in
the stomach or intestines. However, most reports in the
literature have concluded that the use of low concentrations of
hydrogen peroxide in tooth bleaching is still safe.

 Effects on soft tissues:

In-office bleaching can easily produce soft-tissue burns,

turning the tissue white. These burns are reversible with no
long-term consequences if the exposure to the bleaching
material is limited in time and quantity. These negative effects
can be prevented in the in-office technique by carefully applying
a gingival barrier, which effectively precludes the contact of the
whitening gel with gingival tissue and periodontal ligament.
Rehydration and application of antioxidant vitamin C quickly
returns the color to the tissue.

Soft-tissue irritation has been reported with at-home

bleaching due to an ill- fitting tray rather than to the bleaching
agent itself

 Effects on hard tissues:

49
I. Tooth sensitivity:

Tooth sensitivity is a common side-effect of vital tooth

bleaching. Data from various studies of 10% carbamide
peroxide indicate that from 15 to 65% of the patients reported
increased tooth sensitivity.

Higher incidence of tooth sensitivity from 67 to 78% was

reported after in -office bleaching with hydrogen peroxide and
heat.

Tooth sensitivity normally persists for up to 4 days after

cessation of the bleaching procedures, but a longer period up
to 39 days has also been reported.

II. Tooth resorption:

Cervical tooth resorption may be seen with non- vital bleaching

technique when high concentration of HP (30-38%) is applied in
conjugation to heat.

III. Effects on Enamel surface:

1) Effects on Enamel surface morphology and texture:

changes in the enamel surface after 28 h of bleaching with 10%

carbamide peroxide and 30% hydrogen peroxide, and found that

50
the sample’s surface became more irregular and surface grooves
became deeper after bleaching treatment.

2) Effects on Enamel surface hardness and wear resistance:

3) Effects on enamel chemical composition:

Regarding the effect of dental bleaching on enamel chemical

composition, many studies examined it by measuring the
changes in constituent enamel elements found
Increasing hydrogen peroxide concentrations, ion release from
both enamel and dentin increased, and that microhardness of
enamel decreased significantly with bleaching. cause
demineralization of the enamel extending to a depth of 50 ųm
below the enamel surface. Therefore, they recommended that
the application of bleaching agents should be carefully
considered in patients susceptible to caries. In addition, the
amount of calcium lost from teeth after 12 h of bleaching
treatment was similar to that lost from teeth exposed to a soft
drink or juice for a few minutes
 Effect of bleaching on different restorative materials:

I. Composite resin restorations:

Decrease in the surface hardness of bleached composite
resins, not only on superficial surfaces, but also in the deeper
51
 layers of the filling materials. These results were related to the
high oxidation and degradation of the resinous matrix in the
composites.

1. Color changes

Changes in the color of nanohybrid and packable

composite resins after bleaching with 15% carbamide
peroxide.
- Generally alterations in the color of restorative materials have
been attributed to:
a. Oxidation of surface pigments and amine compounds.

b. Differences in color change between and among different

materials might be a result of different amounts of resin and
different degrees of conversion of the resin matrix.

2. Effects on marginal quality and microleakage

3. Effects on the bonding of composite resin restorations to
tooth structure

Can be divided to the effects of pre- and post- operative

bleaching:

a- The effects of pre-operative dental bleaching on the

bonding potential of composite resin restorations to
tooth structure.

52
- Reduction in bond strength of adhesive restorations to tooth

structure after dental bleaching due to:

1. Presence of residual peroxide on the tooth surface, which

interferes with the resin bonding and prevents its complete

polymerization.

2. Alter the protein and mineral content of the superficial layers

of enamel, which may be responsible for reduced bond strength.

- 10% sodium ascorbate in reversing the compromised bond

strength of enamel previously bleached with 10% carbamide
peroxide when bonded to resin composite

Best method, is to postpone the bonding procedure for a period

of time after tooth bleaching, which varies in many studies from
24 h to one week, 2 weeks, or even up to 4 weeks

b- The effects of post-operative dental bleaching on the

bonding potential of composite resin restorations to
tooth structure.

- These peroxide radicals are supposed to damage the dental

53
 substrate bond to resin tags (hybrid layer) which is mainly
responsible for the mechanisms of adhesion between teeth and
resin composites.
II. Ceramic Restorations:

1. Colour Change: No effect on the color

2. Changes in Surface Texture & Hardness: the micro hardness

of ceramic restorations was not affected.

III. Amalgam Restoration

1. Mercury Release:
- Bleaching teeth with amalgam restorations release of mercury,

silver, copper and tin from the dental amalgams.

- Level of release did not exceed the limits defined by the World

Health Organization and don’t pose a risk to patient.

2. Change in surface texture and hardness:

- Surface roughness and the microhardness of dental amalgams

after bleaching procedures no significant changes.

3. Colour change:
- Greening of tooth –amalgam interface after bleaching treatment
54
 in areas of chipped cavosurface margins (defective) amalgam
restorations.
- Clinician should examine properly the restorations before

proceeding with bleaching.

IV. Glass Ionomer Cement and Resin-Modified Glass Ionomer
Cement:
1. Increase in solubility: bleaching increase the soloubility of GI
and RMGI.
2. Change in surface texture and hardness:
- Found alterations, such as cracks and pits, in the surface of the
glass ionomer cement, which were explained by the ability of the
bleaching agent to alter the surface properties of the material.
- When using 15% CP and 35% HP on resin modified glass

ionomer cement restorations found a softening effect and a

significant decrease in their surface hardness.
- Glass ionomer and resin modified glass ionomer cement

restorations are changed when bleached, they may need to be

replaced.

3. Change in Colour:
-Bleached glass ionomer restorations were more susceptible to
different staining solutions with a pH from 3.73 to 6.25, such as
red wine, herbal tea, Coca Cola and coffee.
V. Temporary restorations:

55
1. Change in surface texture & colour:
- The macroscopic changes results into cracking and swelling.
- Polycarbonate crowns and bis-acryl composite temporary

restorations do not discolor upon bleaching.

56
 Chapter 3

INDIRECT ESTHETIC RESTORATIONS

57
 INDIRECT ESTHETIC RESTORATIONS

INDICATIONS FOR INDIRECT RESTORATIONS:

1. Extensively damaged teeth: where the direct restorations can not solve solely the
problems of restoring proper contour, contact and occlusion.

2. Uncooperative patient: wise management of such patients require minimizing

chair- side time by taking an accurate impression and completing most of the
restorative steps outside the patient's mouth.

3. Deeply seated subgingival cavities, where proper finishing and polishing of

direct restorations is difficult if not impossible.

4. Solving of occlusal problems such as severe attrition with decreased vertical

dimension

5. Correction of esthetic derangement, such as excessive discoloration caused by

fluorosis, peg lateral incisors, and tetracycline stains when it is difficult to be
removed by other esthetic alternatives. Also indirect tooth-colored restorations are
indicated for Class I or Class II restorations located in areas of esthetic importance
for the patient.

6. Lack of accessibility.

Contraindications for indirect tooth-colored restoration:

1- Heavy occlusal forces: Ceramic restorations may fracture when they lack
sufficient bulk or are subject to excessive occlusal stress, as in patients who have
bruxing or clenching habits. Heavy wear facets or a lack of occlusal enamel are
good indicators of bruxing and clenching habits.

58
2- Inability to maintain a dry field: Despite that modem dental adhesives can
counteract certain types of contamination; adhesive techniques require near-perfect
moisture control to ensure successful long-term clinical results.

3- Deep subgingival preparations: although this is not an absolute contraindication,

preparation with deep subgingival margins should be avoided. These margins are
difficult to record with an impression and are difficult to finish. Additionally,
bonding to enamel margins is greatly preferred, especially along gingival margins
of proximal boxes.

Advantages:

The advantages of indirect tooth-colored restorations are similar to those of

direct composite restorations (excluding cost and time). Indirect tooth colored
restorations have the following additional advantages:

1- Improved physical properties: A wide variety of high strength tooth colored

restorative materials, including laboratory-processed and computer milled
composites and ceramics, can be used with indirect techniques. Indirect
restorations have better physical properties than direct composite
restorations because they are fabricated under relatively ideal laboratory
conditions. Also, while CAD/CAM restorations are generally fabricated
chair-side, the materials themselves are manufactured under very nearly
ideal industrial conditions.
2- Variety of materials and techniques: Indirect tooth-colored restorations can
be fabricated with either composites or ceramics using various laboratory
processes or CAD/CAM methods.
3- Wear resistance: Ceramic restorations are more wear resistant than direct
composite restorations, an especially critical factor when restoring large

59
 occlusal areas of posterior teeth. Laboratory-processed composite
restorations wear more than ceramics, but less than direct composites.
4- Reduced polymerization shrinkage: Polymerization shrinkage and
itsconsequential stresses are still a major shortcoming of direct composite
restorations. With indirect techniques, the bulk of the preparation is filled
with the indirect tooth-colored restoration, and stresses are reduced because
very little composite cement is used during cementation. Although shrinkage
of composite in thin bonded layers can produce relatively high stress,
indirect composite restorations have fewer marginal voids, less micro
leakage, and less postoperative sensitivity than direct composites.
5- Ability to strengthen remaining tooth structure: Tooth structure weakened by
caries, trauma, and/or preparation can be strengthened by adhesively
bonding indirect inlays and onlays. The reduced polymerization shrinkage
stress obtained with the indirect technique is also desirable when restoring
such weakened teeth.
6- More precise control of contours and contacts: Indirect techniques usually
provide better contours (especially proximal contours) and occlusal contacts
than direct restorations because of the improved access and visibility outside
the mouth.
7- Biocompatibility and good tissue response: Ceramic materials are
considered the most chemically inert of all materials. They are
biocompatible and generally are associated with a good soft tissue response.
The pulpal biocompatibility of the indirect techniques is related more to the
adhesive composite cements rather than the ceramic materials used.
8- Increased auxiliary support Most indirect techniques allow the fabrication of
the restoration to be totally or partially delegated to dental laboratory

60
 technicians. Such delegation allows for more efficient use of the dentist's
time.

Disadvantages:

1- Increased cost and time: Most indirect techniques require two patient
appointments, plus fabrication of a temporary restoration. These factors,
along with laboratory fees. contribute to the greater cost of indirect
restorations as compared to direct restorations. However, while indirect
tooth-colored inlays and onlays are more expensive than direct restorations
(amalgams or composites), they are usually less costly than more invasive
esthetic alternatives, such as all-ceramic or porcelain-fused-to-metal crowns.
2- Technique sensitivity: Restorations made using indirect techniques require a
high level of operator skill. A devotion to excellence is necessary during
preparation, impression, try-in, cementation, and finishing the restoration
3- Brittleness of ceramics: A ceramic restoration can fracture if the preparation
does not provide adequate thickness to resist occlusal forces and/or if the
restoration is not appropriately supported by the cement medium and the
preparation. Fractures can occur either during try-in or after cementation,
especially in patients who generate unusually high occlusal forces.
4- Wear of Opposing dentition and restorations: Ceramic materials can cause
excessive wear of opposing enamel and/or restorations. Recent
improvements in ceramics have reduced this problem, but ceramics,
particularly if rough and unpolished, can wear opposing teeth and
restorations.
5- Resin-to-resin bonding difficulty: The bond between the indirect composite
restoration and the composite cement is the weak link in the system.

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 However, bonding of composite cements to properly treated ceramic
restorations is not a problem.
6- Low potential for repair Indirect restorations, particularly ceramic
inlays/onlays, are difficult to repair in the event of a partial fracture. If the
fracture occurs in the restoration, an indirect composite inlay or onlay can be
repaired using an adhesive system and a light cured restorative composite.
7- Difficult intraoral polishing: Indirect composite restorations can be polished
intraorally with the same instruments/materials used to polish direct
composites. Ceramics, on the other hand, are more difficult to polish after
they have been cemented because of either (1) limited access or (2) lack of
appropriate instrumentation

Cavity preparation for esthetic inlays:

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 1. Occlusal reduction 1:2mm

2. minimal depth for porcelain is 1.5 mm-2.0 mm

3. Isthmus width should be 1/4-1/3 the intercuspal dimension (ICD) and

inceaseased in porcelain 1/3 (2 mm)

4. Gingival seat flat(90 degree) and 1:1.5mm width

5. Minimum thickness of cusps to be covered with onlay at the base (pulpal

floor) is 2 mm to prevent enamel fracture

6. Wall divergence 8:15 degree

7. pulpal/axil line angles must me smooth and rounded

8. single path of insertion. Multiple paths of insertion lead to rocking of the

ceramic)

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Cavity lining for indirect esthetic restorations:

The reason for cavity lining of esthetic inlay preparations is not the same for
amalgam and gold preparations.

The objectives for lining are:

1. Removal of all cavities undercuts. It is not necessary to cut away all undercuts
providing that they can be removed by blocking them by suitable liner.

2. The liner should provide pulp protection.

3. For non-vital teeth, the liner or core should be adequately retained

4. The lining material adjacent to outer tooth walls should not block light
transmission.

5. It must be compatible with the resin material and the luting cement.

The best lining materials are:

1. Resin modified glass ionomer.

2. 2. Visible light cured composite resin.

Classification of indirect restorations:

1) According to material:
a. Metallic: e.g. gold –silver palladium-non precious.
b. Non- metallic: i.e, esthetic.
2) According to technique:
a. Direct technique, some of the steps are done in the patient’s mouth.
b. Indirect technique requires impression taking and detailed laboratory
steps.

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 c. Indirect-direct technique, initial fabrication is done on a model.

Indirect resin composite restoration fabrication:

Techniques for fabrication of composite resin inlays:

1. Indirect technique on stone die.

a. Impression Making
b. Cast Preparation
c. Inlay Fabrication
d. Heat Treatment
e. Finishing and polishing
f. Characterization

2. Indirect flexible model technique.

a. Impression Making

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 b. Flexible die Preparation
c. Inlay Fabrication
d. Heat Treatment
e. Finishing and polishing
f. Characterization

Indirect ceramic restoration fabrication:

Types of ceramic inlays:

Man-made ceramic inlays:

1. Ceramic inlays produced on refractory die material.
2. Castable and pressed ceramic inlays.
3. Ceromers inlays.
Machined restorations:

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 1. CAD/CAM (Computer Aided Designed / Computer Aided Manufacturing)
restorations.

 Techniques for fabrication of CAD/CAM inlays:

a) Optical impression: The miniature intra-oral camera maps the cavity contours.
It is essential to position the camera over the long axis so that the computer can
read all internal walls and cavosurface equally.

b) Computer generated restoration design: The restoration is designed from the

image shown on the computer screen by using a series of icons or symbols.
Once the restoration has been designed, the computer develops a three-
dimensional image of the inlay or onlay.

c) Milling procedure: The milling is accomplished by a five- axis of rotation

cutting machine which mills the restoration from prefabricated ceramic blocks
with different shades, which generally takes 4 to7 minutes to complete the
procedure.

d) Final occlusal adjustments are done in the patient’s mouth.

2. Celay type inlays.

3. Prefabricated size-matching restorations (Sonicsys).

Cementation of indirect esthetic restoration

A. Tooth

The adhesive protocol must be performed with extreme care, according to

the indications of the materials used and the manufacturers' considerations

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 Acid conditioning of the tooth structure, a low suction cannula was used to
remove the existing acid, being the best way to protect the adjacent teeth
after washing.

B. restoration

The adhesive protocol must be performed with extreme care, according to

the indications of the materials used and the manufacturers' considerations

Acid conditioning with hydrofluoric acid

silane coupling was applied in the internal surface of the onlay restorations
and dried for 5 seconds. The silane acted as a coupling agent between the
filler particles on the ceramic surface and the resin cement. After silane
application.

C. Tooth restoration interface

1. dual-cured cement was placed simultaneously in the preparation and in the

internal surface of the onlay.

2. the restoration was seated firmly in place

3. the gross excesses of cement were removed with a microbrush and in the
proximal areas with Super-floss

4. Glycerin was applied to all the margins in order to prevent the formation of
an oxygen-inhibition layer on the resin cement.

5. The restoration was polymerized from all aspects for 60 seconds.

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 Chapter 4
Restorative Management of Endodontically
treated teeth

69
 Restorative Management of Endodontically
treated teeth
Effect of Endodnotic Treatment Procedures on Mechanical Properties and
canal shape:

1- Compositional Changes in Nonvital Teeth and the Influence of Endodontic

Therapy ( Tooth moisture, mineral alteration and collagen structure):
The loss of pulpal vitality is accompanied by a slight change in tooth moisture
content. This loss of moisture (9%) is attributed to a change in free water but not in
water bonded to the organic and inorganic components. Nonvital teeth undergo
rather minor changes in physical characteristics. The reduction in water content
after endodontic treatment could result in dentin tissue shrinkage, inducing stresses
leading to crack formation, and these cracks could initiate tooth fracture.
-Sodium hypochlorite and chelators such as ethylenediamine tetra-acetic acid
(EDTA), or calcium hydroxide (Ca[OH]2) commonly used for canal irrigation and
disinfection interact with root dentin, with either mineral content or organic
substrate.
- Chelators mainly deplete calcium by complex formation and also affect
noncollagenous proteins (NCPs), leading to dentin erosion and surface softening.
- Sodium hypochlorite can demonstrate a proteolytic action on collagen.

2- Dentin Structure and Properties in Nonvital and Endodontically Treated

Teeth: (Elasticity modulus, Tensile, shear Strength and Microhardness):
The chemicals used for canal irrigation and disinfection, as already mentioned,
interact with mineral and organic contents and then reduce dentin elasticity and
flexural strength to a significant extent as well as microhardness. On the contrary,

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disinfectants like eugenol and formocresol increase dentin tensile strength by way
of protein coagulation and chelation with hydroxyapatite
3- Fracture Resistance and Tooth Stiffness of Nonvital and Endodontically
Treated Teeth:
The major changes in tooth biomechanics appear to be due to the loss of hard
tissue following decay, fracture, or cavity preparation (including the access cavity
prior to endodontic therapy)
a- Immature teeth with incomplete root formation:
After endodontic treatment, they are severely weakened because of wide, flared
canal spaces and thin dentin walls. Apexification and root rehabilitation with a
relined glass fiber post is the best solution for such cases.
b- Endo access preparation:
The loss of hard tooth structure following a conservative access cavity preparation
affects tooth stiffness by only 5%. In fact, the largest reduction in tooth stiffness
results from excessive access preparation, especially the loss of marginal ridges.
The literature reports a 20% to 63% and a 14% to 44% reduction in tooth stiffness
following occlusal and MOD cavity preparations, respectively. It was shown that
an endodontic access cavity combined with an MOD preparation results in
maximum tooth.
c- Root canal Preparation:
The most common reasons for catastrophic failure of endodontically treated teeth
[vertical root fracture (VRF)] are weakening of the residual tooth structure by
caries and overpreparation and the post system used during the rehabilitation.
VRF of endodontically treated teeth is a clinical problem of increasing
significance that may lead to tooth extraction.

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d- Loss of Dentin: The removal of the inner dentin negatively influences the stress
distribution. The resulting flared root canals have thin root dentin walls, which
may be too weak to resist physiologic occlusal loading, thus becoming more
susceptible to fatigue and fracture.
4- Esthetic changes in Nonvital and Endodontically Treated Teeth:
Color change or darkening of nonvital teeth where organic substances present in
dentin (e.g., hemoglobin) is a common clinical observation or incomplete
endodontic treatment root canal filling materials (gutta-percha and root canal sealer
cements, MTA-like materials) retained in the coronal aspect of anterior teeth can
detract from the aesthetic appearance.
Tooth survival after root canal treatment:

- In the absence of preoperative apical periodontitis, primary root canal therapy has
shown success rates above 90 % . However, when preoperative apical periodontitis
was present, this number dropped to approximately 80 %.
- In -adequate coronal seal allow for ingress of microbes and recontamination and
ultimate failure for both endo and restorative treatment. Poorer clinical outcomes
may be expected with adequate root filling-inadequate coronal restoration and
inadequate root filling-adequate coronal restoration.
Pretreatment Evaluation (Diagnosis)

Before any therapy is initiated, the tooth must be thoroughly evaluated to ensure
treatment success. Each tooth must be examined individually and in the context of
its contribution to the overall treatment plan and rehabilitation. This assessment
includes endodontic, periodontal, biomechanical, and aesthetic evaluations.

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 Endodontic Evaluation
 Assessing the Pulpal Status: inspection of the quality of existing endodontic
treatment. New restorations, particularly complex restorations, should not be
placed on abutment teeth with a questionable endodontic prognosis.
 Endo/Perio Lesions: proper diagnosis must be done to determine whether the
problem is of an endodontic origin, a periodontal origin, or a real
combination of both.
 Resorption: The clinician must keep in mind that resorption could be trauma
induced or idiopathic, and could also be in conjunction with a root fracture.
It is important to assess the type of resorption as some do require root canal
treatment and some do not.
Periodontal Evaluation
 There are many factors to be evaluated when assessing the periodontal
condition. The age of the patient, the initial bone loss, the probing depths,
the clinical attachment loss, the mobility, the root form, the furcation
involvement, and whether or not the patient is a smoker are to be considered
when determining the prognosis of a tooth.
 Maintenance of periodontal health is also critical to the longterm success of
endodontically treated teeth. The periodontal condition of the tooth must
therefore be determined before the start of endodontic therapy and
restorative phase. The following conditions are to be considered as critical
for treatment success: -*Healthy gingival tissue -*Normal bone architecture
and attachment levels to favor periodontal health - *Maintenance of biologic
width and ferrule effect before and after endodontic and restorative phases.
 Periodontal health has to be achieved and maintained before any treatment is
to be initiated, when it comes to mechanical forces, a tooth is subjected to
stresses that come from all directions. The weaker the support it has from its
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 periodontium, the more likely the horizontal stresses on the entire system are
to increase and the more strain the restoration and the periodontium have to
absorb.

Biomechanical Evaluation (Tooth Restorability)

From initial decay or trauma to final root canal therapy, influence the
biomechanical status of the tooth and the selection of restorative materials and
procedures. The biomechanical status can even justify the decision to extract
extremely mutilated teeth that do not deserve extensive treatments that carry a
limited probability of success.

Evaluation of the Remaining Tooth Structure

- Removal of all carious tooth structure and/or defective restorations in order

to properly assess the overall condition of the tooth.
- If the remaining sound tooth structure is sufficient in order to provide a
strong support that will confer the restoration longevity and function. It is
also at this stage that we assess the crown-to-root ratio and the occlusal
forces the tooth is subject to in the dentition and determine the necessity of
crown lengthening.
- Teeth with minimal remaining tooth structure are at increased risk for the
following clinical complications such as: *Root fracture,*Coronal-apical
leakage, Recurrent caries,* Dislodgment or loss of the
core/prosthesis,*Periodontal injury from biologic width invasion.
- The amount and quality of remaining tooth substrate are far more
important to the long-term prognosis of the restored tooth than any
restorative material properties.

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  When and Why Do Endodontically Treated Teeth Require Full
Coverage?
The need for a full-coverage restoration after endodontic therapy is largely
determined by tooth type, amount of tooth structure loss, and the amount of
occlusal stress on the tooth.
Anterior Teeth: it was found that long-term prognosis for anterior teeth,
both maxillary and mandibular, was not increased with full-coverage
restoration with or without a metal post versus simple restoration of the
endodontic access.
Some current research may indicate that bonded fiber posts may offer some
reinforcement.

In anterior teeth, full coverage may only be necessary when there has been
significant loss of tooth structure prior to endodontic therapy or for esthetic
reasons.

Posterior Teeth: it was found that full coronal coverage did significantly
improve the long-term success rate for endodontically treated maxillary and
mandibular premolars and molars. The reasoning behind why endodontically
treated molars without cuspal coverage have a decreased long-term prognosis can
be explained by cuspal deflection. When molar teeth with MO or MOD
preparations and endodontic accesses are subjected to occlusal-type forces, the
cusps actually move more than intact teeth.

Even when the marginal ridges are preserved, the adjacent cusps are still
significantly weakened. This type of cuspal deflection creates stress within the
tooth and can lead to catastrophic coronal fractures. Based on these findings, it is
suggested that all posterior teeth receive full-coverage restorations following

75
endodontic treatment. The only exception to this rule may be the mandibular first
premolar. In some cases, when the lingual cusp of this tooth is underdeveloped, it
may not be subject to the wedging forces of opposing cusps when restored with an
occlusal repair of the endodontic access.

 Ferrule

a crown is deemed necessary after root canal therapy, it is also imperative that the
dentist considers the amount of tooth structure remaining coronal to the alveolar
crest in order to respect biologic width and provide space for a crown margin on
tooth structure. The preservation of intact coronal and radicular tooth structure is
crucial in optimizing the biomechanical behavior of the restored tooth, by allowing
for incorporation of a “ferrule” feature during crown preparation.

A ferrule effect is created by incorporating a 360° collar of the crown surrounding

the parallel walls of the dentin extending coronal to the shoulder of the preparation.
The result is an increased resistance form of the crown from the extension of dental
tooth structure.

If the condition of the tooth is such that even adjunct surgical and/or orthodontic
procedures cannot provide at least a 2 mm-high and 1 mm thick ferrule, without
compromising significantly the prognosis of the tooth, extraction might be the
solution.

Dentin and Enamel Integrity

Careful attention must be taken when instrumenting the canal during

endodontic therapy as well as when preparing a post space. Over- instrumentation
will contribute to over-enlargement of the root canal and unnecessary dentin
removal. It is well accepted that a minimum of 1 mm of dentinal thickness wall is

76
necessary to prevent its fracture and properly support the core foundation, if any is
planned.

The integrity of the enamel seems to play a more important role in bonding of the
restorations quality and survival.

Tooth Position, Occlusal Forces, and Parafunctions

Teeth are subjected to cyclic axial and nonaxial forces. The teeth and
associated restorations must resist these forces to limit potential damages such as
wear or fracture. The degree and direction of forces depend on the location of the
tooth in the arch, the occlusal scheme, and the patient’s functional status.

In most occlusal schemes, anterior teeth protect posterior teeth from lateral forces
through anterolateral guidance.

In very steep anterior guidance and deep vertical overbite, maxillary anterior teeth
are sustaining higher protrusive and lateral forces from the mandibular anterior
teeth. Restorative components should be stronger than would be required for teeth
with an edge-to-edge relationship and therefore vertical forces,

Posterior teeth normally carry more vertical forces, and restorations must be
planned to protect posterior teeth against fracture.

The literature reports that average biting forces vary between 25 and 75 N in the
anterior region and between 40 and 125 N for the posterior region of the mouth,
depending on food type, dental status (dentate or edentulous), and patient anatomy
and functional habits. Those forces can easily reach 1000 N or above in case of
parafunctions, showing how potentially destructive they can be for intact teeth and
even more so for nonvital, fragilized teeth. Parafunctional habits (clenching and
bruxism) are major causes of fatigue or traumatic injury to teeth, including wear,

77
cracks, and fractures. Teeth that show extensive wear or sequelae from
parafunctions, especially heavy lateral function, require components with the
highest physical properties to protect restored teeth against fracture.

Aesthetic Evaluation and Requirements

Anterior teeth, premolars, and often the maxillary first molar, along with the
surrounding gingiva, compose the aesthetic zone of the mouth. Changes in the
color or translucency of the visible tooth structure, along with thin soft tissues or
biotype, diminish the chance for a successful aesthetic treatment outcome.

All teeth located in the aesthetic zone also require critical control of endodontic
filling materials in the coronal third of the canal and the pulp chamber to avoid or
reduce the risk of discoloration. Careful selection of restorative materials, careful
handling of tissues, and timely endodontic intervention are important for
preserving the natural appearance of nonvital teeth and gingiva.

Treatment Strategy

The foundation restorations (the post, the core, and their luting or bonding agents)
which support the coronal restoration and its different constituents are then aimed
at providing the best protection against leakage-related caries, fracture, or
restoration dislodgment. Therefore, all aforementioned local and general
parameters are to be systematically analyzed in order to select the best treatment
approach and restorative materials. Prosthetic requirements are also to be taken
into consideration to complete each case analysis. In general, abutments for fixed
or removable partial dentures clearly dictate more extensive protective and
retentive features than do single crowns, owing to greater transverse and torquing
forces.

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Structurally Sound Teeth

Anterior teeth: generally do not require a crown, core, or post; restorative

treatment is limited to sealing the access cavity and direct composite fillings.
Discoloration, whenever present, is addressed by nonvital bleaching, or, for
untreatable or relapsing ones, with conservative restorative approaches such as
direct or indirect veneers.

Posterior Teeth: Occlusal cavities or mesio/disto-occlusal cavities can be restored

with either direct- or indirect-adhesive intracoronal restorations, providing residual
walls are thick enough (proximal ridges and buccolingual walls more than 1.5-mm
thickness).

Conservative options must, however, always be analyzed under the light of

functional and occlusal environment. They can only be considered in the absence
of parafunctions and with anterior guidance, which limits overall functional
loading and lateral or flexural forces

In less favorable biomechanical conditions (e.g.,) group guidance, steep occlusal

anatomy, bruxism, clenching a protective approach with full occlusal coverage
(onlay or overlay) is mandated to minimize the risk of fatigue failures.

Structurally Compromised Teeth

The decision for placing a post as well as the selection of a post system (rigid or
nonrigid) depends once again on the amount and quality of remaining tooth
structure and the anticipated forces sustained by this tooth.

In structurally sound teeth, nonrigid posts flex with the tooth under functional
forces, reducing the transfer of force to the root and reducing the risk of root
fracture. In structurally compromised teeth, which lack cervical stiffness from

79
dentin and ferrule effect, excessive post flexion can be detrimental to the marginal
seal and prosthesis longevity, so fiber posts are generally contraindicated.

Teeth with minimal tooth structure and limited ferrule effect need additional
cervical stiffness from a more rigid post to resist distortion. In this situation,
adhesive cementation is preferred to conventional cementation.

Structurally Compromised Anterior Teeth : Restoration of endodontically

treated teeth becomes more complex as teeth or supporting structures become
increasingly affected. A nonvital anterior tooth that has lost significant tooth
structure requires restoration with a crown, supported and retained by a core and
possibly a post as well. When less than half the core height is present, or when
remaining walls are extremely thin (less than 1 mm on more than three fourths of
the tooth circumference), a post is needed to increase retention and stabilize and
reinforce the foundation. Many post options are available nowadays, including
titanium, fiber-reinforced resin, and ceramics. Adhesion is now the preferred mode
of post cementation.

In the aesthetic zone, the post should not detract from the aesthetics of the coronal
tooth structure, ceramic crown, or gingiva. Current restorative procedures allow
fabrication of highly aesthetic ceramic coronal restorations that have no metal
substructure. When such restorations with remarkably lifelike color and vitality are
selected, it usually implies the use of nonmetal aesthetic posts, either ceramic or
resin fiber reinforced ones.

Structurally Compromised Posterior Teeth: Slightly decayed posterior teeth in

the context of parafunctions or significantly fragilized premolars and molars
require cuspal protection afforded by onlay restoration, endocrown, or a full
crown. The need for a post and core depends on the amount of remaining tooth

80
structure. When remaining walls (buccal and lingual) provide more than 3 to 4 mm
height (from the pulpal chamber floor) and 1.5 to 2 mm thickness, core and
restoration stability are granted through macromechanical retention or adhesion;
then, posts are not needed. With current treatment strategy, the post has become
the exception rather than the rule for the restoration of nonvital posterior teeth.

Additional Procedures

Periodontal crown lengthening surgery or orthodontic extrusion can

expose additional root structure to allow restoration of a severely damaged tooth.

In the smile frame, crown lengthening might, however, be limited by aesthetically

adverse consequences (proximal attachment reduction); basically, buccal crown
lengthening only can be considered as a potential indication for this procedure. In
the posterior region, crown lengthening is limited by tooth and furcation anatomy
or by loss of bone structure, which complicates future implant placement. As
regards to orthodontic extrusion, root length and anatomy are the limiting factors
of this procedure; short roots or conical anatomy are contraindications to
orthodontic extrusion.

Prognosis of Endodontically Treated Teeth

All aspect of the treatment, from the periodontal condition to the root canal
therapy to the restoration, have an impact on the overall outcome. When coronal
restorations are inadequate, the odds of maintaining the healed status of an
apical periodontitis decrease as microbes ingress through the defective margins of
the restorations

81