August 2013 Esthetics

Minimally invasive and its impact on esthetic restorative dentistry Wynn H. Okuda, DMD, FICD, FICOI

ne of the goals of dentistry is to mottling to congenital defects, interfer- and remineralization techniques using develop new approaches in restor- ence in the formation of enamel and/or Recaldent CPP-ACP (such as MI Paste Oative dentistry that will reduce the demineralization of the enamel matrix and MI Paste Plus, GC America, Inc.) amount of tooth removal during treat- can result in an unaesthetic appearance of has proven to be a minimally invasive ment. With advances in material science the smile and dentition.1 approach to corrections.4-6 The develop- and restorative techniques, we are able Normal enamel has the appearance of a ments in micro-invasive technology allows to attain these ideals and recreate nature lustrous surface that reflects light from the for minimally invasive treatment of these with minimal removal of tooth structure. surface and subsurface. Along with that, lesions (Fig. 3 and 4). In addition, for The latest developments in minimally different aspects of tooth structure will treatment of enamel decalcification and invasive dentistry (MID) and its impact reflect, refract, and absorb wavelengths incipient decay—up to the first third of on esthetic restorative dentistry will be of light at different degrees. However the dentin—infiltration therapy can be used discussed (Fig. 1 and 2). reflection and scattering of light from the to reinforce demineralized areas through surface and the subsurface should be rela- the capillary action of resin (such as Icon, Current advances in minimal tively the same.2,3 When this is the case, DMG America).7-9 This modality of intervention esthetics the enamel and the dentition will have a treatment assists in restoring decalcified The most conservative of all esthetic natural appearance. The appearance of the enamel. The infiltration of resin impreg- restorative procedures is one that involves teeth is altered when there is a disturbance nates the voids left by the decalcification no tooth removal at all. Minor blemishes in the enamel matrix. and aids in restoring the optical nature on smooth surfaces of facial enamel can There are now several choices for cor- of the treated area resulting in a natural be an esthetic problem depending on the rection of decalcified enamel and unaes- esthetic result, without any tooth removal. severity. From decalcification and enamel thetic white spots. Enamel microabrasion For carious lesions that go beyond the

Fig. 1. Patient presents with missing restorations in central and lateral incisors. Fig. 2. Composite resin restorations can exhibit great chameleon effect, color blending, and improved esthetics. Fig. 3. Dentition affected by moderate decalcification of anterior teeth. Fig. 4. Natural recalcification of dentition achieved.

Fig. 5. A failing composite restoration along the central incisor (tooth No. 8). Fig. 6. Internal anatomy sculpted to create a natural characterization.

incipient stage, minimally invasive treat- America, Inc.; Renamel Universal, proper shade layering sequence. Several ments are available for correction as well. Cosmedent; and Esthelite Sigma, composite resin shades were directly placed Using the latest in composite resin technol- Tokuyama Dental America, Inc.) achieve on the tooth to determine colors that ogy, minimally invasive correction of Class great success because the physical proper- would best match the adjacent teeth. I, II, III, IV, and V lesions is now attain- ties mimic the properties exhibited by Total removal of the failing restoration able. In addition, with the latest generation natural dentition. and decay was performed. For minimally of nanohybrid composite resin, long-lasting invasive purposes, a caries detector (Caries composite resin restorations that Minimally invasive dentistry Detector, Kuraray America, Inc.) was mimic the strength and beauty of natural application used only to remove the infected caries. dentition can be attained.10 Case study Minimally invasive burs (Micro Prep Kit, One of the challenges of esthetic den- A 26-year-old male patient presented with Komet USA, LLC) were used, as they are tistry is the creation of predictable color a failing composite resin restoration on important to minimize tooth removal. A harmony between the restorative material the central incisor (tooth No. 8) (Fig. 5). slight chamfer margin was created along and natural tooth structure. In natural It was proposed to have a composite the free gingival margin, so that optimal dentition, different aspects of tooth struc- resin veneer restoration placed, using an blending could be attained. ture will reflect, refract and absorb wave- MID approach. Prior to bonding and to restoring the lengths of light at different degrees (such There are several factors necessary to tooth, the enamel was etched with 37% as enamel rods, dentinal tubules, dentin- attain a successful composite resin restora- phosphoric acid (Select HV Etch, Bisco, enamel junction, etc.) Therefore, for an tion. Proper understanding of composite Inc.). A dentinal adhesive (All Bond SE, esthetic material to be successful, it must resin shade selection, and preparation Bisco, Inc.) was placed, blown thin for reflect, refract, and absorb light similar to design and sequence of composite resin 10 seconds with compressed air, and light tooth structure.11,12 layering are important in attaining an cured for 20 seconds. Using one of the When the composite resin is able accurate blending of the composite resin latest generation of nanohybrid composite to match the optical properties of the to the existing tooth. A correct finishing resins (Kalore) a sequence of composite surrounding teeth, a chameleon effect and polishing technique is equally essential resin layering was done to create a natural is achieved that renders the restora- in obtaining optimal esthetic results.13,14 depth of shade that mimics the adjacent tion “invisible.” The latest nanohybrid Shade selection is always done prior central incisor. To eliminate the shine- composite resins (such as Kalore, GC to start of treatment. This allows for the through of light, an opacious dentin shade Fig. 7. Finishing with aluminum oxide discs and Fig. 8. Using the correct principles of color selection, prep design, color layering, finishing burs. characterization, finishing, and polishing, esthetic success can be achieved with composite resin veneer restorations.

(A-02, Kalore) was placed in areas where Author information 12. Terry DA. Direct reconstruction of the maxillary dentin was lost. Then, using a freehand Dr. Okuda is an international speaker on anterior dentition with composite resin: a case sculpt technique, universal shade A-1 was the topic of and the report. Pract Periodontics Aesthet Dent. 1999; carefully sculpted over the opacious dentin founder of the Okuda Educational Institute 11(3):361-367; quiz 368. 13. Duarte S Jr, Perdigao J, Lopes M. Composite resin shade, with an emphasis of placing inter- for Innovative Dentistry in Honolulu, restorations—natural aesthetic and dynamics of nal anatomy to simulate natural dentition Hawaii, where he also has a private practice. light. Pract Proced Aesthet Dent. 2003;15(9):657- (Fig. 6). After placement of subtle charac- 664; quiz 666. terizations with tints and color modifiers References 14. Fahl N Jr, Swift EJ Jr. The invisible Class IV restoration. (Kolor + Plus, Kerr Corporation), a neu- 1. Mount GJ, Ngo H. Minimal intervention: a new con- J Esthet Dent. 1989;1(4):111-113. cept for operative dentistry. Quintessence Int. 2000; 15. Fahl N Jr, Denehy GE, Jackson RD. Protocol for predict- tral translucency (Kalore NT) was used as 31(8):527-533. able restoration of anterior teeth with composite res- 15,16 the final layer. 2. Sieber C. Voyage: visions in color and form. Quintes- ins. Pract Perio Aesthet Dent. 1995;7(8):13-21. After final light curing, esthetic con- sence Int. 1991;22:775-782. 16. Crispin BJ, Hobo S, Hewlett ER, et al. Contemporary tours were refined using aluminum oxide 3. Ubassy G. Shape and Color: The Key to Successful Ce- Esthetic Dentistry: Practice Fundamentals. Hanover Park, IL: Quintessence Publishing Co., Inc.;1994. finishing discs (Sof-Lex, 3M ESPE) and ramic Restorations. Hanover Park, IL: Quintessence Publishing Co., Inc.;1993. composite finishing burs (Q-Finishers, 4. Muia PJ. The Four-Dimensional Tooth Color System. Ha- Komet USA, LLC) (Fig. 7). Finally, a nover Park, IL: Quintessence Publishing Co., Inc.;1985. Manufacturers micro-diamond polishing paste (Diamond 5. Reynolds EC. Remineralization of enamel subsurface le- Bisco, Inc., Schaumburg, IL Polish, Ultradent Products, Inc.) brought sions by casein phosphopeptide-stabilized calcium phos- 800.247.3368, www.bisco.inc.com out the surface luster of the nanohybrid phate solutions. J Dent Res. 1997;76(9):1587-1595. Cosmedent, Chicago, IL 6. Sato T, Yamanaka K, Yoshi E. The caries prevention po- 800.6216729, www.cosmedent.com composite resin veneer. By using proper tential of a tooth-coating material containing casein DMG America, Englewood, NJ technique and state-of-the-art dental mate- phosphopeptide–amorphous calcium phosphate (CPP- 800.662.6383, www.dmg-america.com ACP) [abstract]. IADR General Session, Goteborg, Swe- rials, natural color, contour, and finish GC America, Inc., Alsip, IL were achieved (Fig. 8). den. 2003:100. 7. Reynolds EC, Cain CJ. Webber FL, et al. Anticariogenic- 800.323.7063, www.gcamerica.com ity of calcium phosphate complexes of tryptic casein Kerr Corporation, Orange, CA Conclusion phosphopeptides in the rat. J Dent Res. 1995;74(6): 800.537.7123, www.kerrdental.com In the development of MID, it is impor- 1272-1279. Komet USA, LLC, Rock Hill, SC tant to explore progressive ideas in order 8. Meyer-Lueckel H, Paris S. Improved resin infiltration of natu- 888.566.3887, www.kometusa.com ral caries lesions. J Dent Res. 2008;87(12):1112-1116. Kuraray America, Inc., New York, NY to preserve the natural dentition. With 9. Garcia-Godoy F, Summitt JB, Donly KJ. Caries progres- 800.879.1676, www.kuraraydental.com advances in innovative materials, new sion of white spot lesions sealed with an unfilled res- and improved clinical techniques are in. J Clin Pediatr Dent. 1997;21(2):141-143. Tokuyama Dental America, Inc., Encinitas, CA developed to elevate patient care. These 10. Paris S, Meyer-Lueckel H, Kielbasa AM. Resin infiltra- 877.378.3548, www.tokuyama-us.com tooth-conserving methods could replace tion of natural caries lesions. J Dent Res. 2007;86(7): Ultradent Products, Inc., South Jordan, UT 662-666. 888.230.1420, www.ultradent.com traditional treatment as a new standard in 11. Mitra SB, Wu D, Holmes BN. An application of nano- 3M ESPE, St. Paul, MN restorative care. Using a creative approach technology in advanced dental materials. J Am Dent 888.364.3577, solutions.3m.com to dentistry helps us provide our patients Assoc. 2003;134(10):1382-1390. with new levels of excellence.

Eprinted and posted with permission to GC America Inc. from General Dentistry August © 2013 Academy of General Dentistry.