Advanced

restorative dentistry

Prepared by: Dr. Sok Kunthy

Outline
1. The hydrochloric acid- pumice
microabrasion technique.
2. Non Vital bleaching
3. Vital bleaching-chairside and nightguard
4. Composite veneers
5. Porcelain veneers
6. Adhesive metal castings
Advanced Restorative Dentistry

● The aim of ARD (advanced restorative

dentistry is to manage of more complicated
clinical problems associated with children
and adolescents, this problem are :
☞ Tooth discoloration
☞ Inherited enamel and dentine defects
☞ Hypodontia and tooth surface loss
1. The hydrochloric acid-pumice
microabrasion technique

Use: to remove the enamel surface in order to

improve discolorations that are limited to
the outer enamel layer.

Indication
a. Fluorosis
b. Idiopathic speckling
c. Postorthodontic treatment deminealization
d. Prior to veneer placement for
well-demarcated stains
e. White/brown surface staining
Armamentarium
● Bicarbonate of soda/water
● Copalite varnish or vaseline
● Fluoridated toothpaste
● Non-acidulated fluoride
● Pumice
● Rubber dam
● Rubber prophylaxis cup
● Soflex discs(3M)
● 18% hydrochloric acid
 Technique
● Vitality test preoperative, Rx and Photograph
● Clean the teeth with pumice and water, wash,
dry
● Rubber dam
● Place a mixture of Sodium bicabonate and
water on the dam
● Mix 18% hydrochloric acid with pumice into a
slurry and a small amount to the labial surface
on either a rubber cup rotating slowly for 5s or
a wooden stick rubbed over the surface for 5s
Technique (cont.)
• Apply the fluoride drop to the teeth for 3min
• Remove the rubber dam
• Polish the teeth with the finest Soflex disc
• Polish the teeth with fluoridated toothpaste for
1mn
• Review 1month for vitality tests and clinical
photograph
• review biannually checking pulpal status
2. Non-vital bleaching

What is the cause of

Non-vital bleaching?

Before non vital bleaching After non vital bleaching

Indication
● discolored non vital teeth
● well condensed gutta-percha root filling
● no clinical or radiological signs of periapical
disease
Contre-indication
● heavily restored teeth
● staining due to amalgam
Armamentarium
● rubber dam
● zinc phosphate or IRM cement
● 37%phosphate acid
● bleaching agent, for example hydrogen peroxide,
carbamide peroxide, or sodium perborate
● cotton wool
● glass Ionomer cement
● white gutta-percha temporary restorative
● composite resin
● non-setting calcium hydroxide
Technique (cont.)
● Take periapical Rx preoperative
● Clean the teeth with pumice and make a note of the
shade of the discolored tooth
● Isolating the tooth with Rubber dam
● Remove palatal restoration and pulp chamber
restoration
● Remove root filling to the level of the dentogingival
junction
● Place 1mm of cement over the GP
Technique (cont.)
● Freshen dentine with a round bur. Do not
remove excessively
● Etch the pulp chamber with 37% phosphoric
acid for 30-60s,wash and dry
● Place the bleaching agent, either alone or on
a cotton wool pledget into the pulp chamber.
● Place a dry piece of cotton wool over the
mixture
Technique (cont.)
● Seal the cavity with glass ionomer cement
● Repeat the process at weekly intervals until
the tooth is slightly overbleached
● Place non-setting calcium hydroxide into the
pulp chamber for 2weeks. Seal with glass
ionomer cement
● Finally, restore the tooth with white GP and
composite resin
Advantages
● Easy for operator and patient
● Conservation of tooth tissue and
maintenance of the original crown
morphology
● No irritation to gingival tissues
● No problem with changing gingival level in
young patient
3. Vital bleaching- chairside

This technique involves the external application

of hydrogen peroxide to the surface of the
tooth followed by its activation with a heat
source.

Note: time consuming and patient must be

highly motivated.
Indication

● Very mild tetracycline staining without

obvious banding
● Mild fluorosis
● Yellowing due to ageing
● Single teeth with sclerosed pulp chambers
and canals
Armamentarium
● Rubber dam with clamps floss ligatures
● Orabase gel
● Topical anaesthetic
● Gauze
● 37% phosphoric acid
● Heating light with rheostat
● 30-volume hydrogen peroxide
● Polishing stones
● Fluoride drops( 0-2ys)
Technique
● Take periapical Rx & Vitality test
● Clean the tooth with pumice in order to remove
extrinsic staining
● Apply topical anaesthetic to gingival margins
● Coat the buccal and palatal gingivae with Orabase
gel
● Using individual ligature to isolate the tooth
● Etch the tooth with phosphoric acid for 60s, wash &
dry
Technique( cont.)

● Soak a strip of gauze in the 35% hydrogen peroxide

and cover the teeth to be bleached
● Position the heat lamp 13-15 inches from the
patient’s teeth. Set the rheostat to a mid temperature
range and increase it until the patient can just feel
the warmth in their teeth, and then reduce it slightly
until no sensation is felt.
● Keep the gauze damp by reapplying the hydrogen
peroxide every 3-5min using a cotton bud.
Technique(cont.)

● Remove the rubber dam after 30min, clean

and polish the tooth. Apply Fluoride drops for
2-3min
● Postoperative sensitivity will occurred, use
paracetamol
● Access the change
Vital bleaching- nightguards

🏵 Using of carbamide peroxide gel into a

custom fitted tray of either upper or the lower
arch.

🏵 Usually carried out by patient at home and

is initially done on a daily basis
Indication

● Mild fluorosis
● Moderate fluorosis as an adjunct to
hydrochloric acid
● Yellowing of ageing
Armamentarium

● Study model
● Soft mouthguard-avoiding the gingivae
● 10% carbamide peroxide gel
Technique
● Study model
● Relieve the labial surfaces of the teeth about 0.5mm
and make a vacuum-formed splint as a mouthguard
● The splint 2mm in thickness& not cover the gingivae
● Instruct the patient how to use it
● The length of time depending on the product used
● Review 2ws later to check that patient is not
experiencing any sensitivity, then at 6ws by which
time 80% of any color change should have occurred
4. Composite resin veneers

● Type: Direct or Indirect

Most placed in children and adolescents are
the ‘Direct type”, as the durability of indirect
composite veneer is yet unknown.

Note: porcelain jacket crown is not appropriate

for children for 2 reasons:
- large pulp
- immature gingival contour
● Factors to be considered:

1. Oral hygiene if increased labiopalatal

2. Bond strength to enamel when surface of layer
2-3 mm is removed
3. Whether the tooth is very discolored
thicker reduction is required
4. Whether the tooth rotated thicker labial
veneer.
Indications

1. Discoloration
2. Enamel defects
3. Diastema
4. Malpositioned teeth
5. Large restoration
Contraindications
1. Insufficient available enamel for bonding
2. Oral habits e.g. woodwind musicians

Armamentarium
1. Rubber dam / contoured matrix strip
2. Preparation and finishing burs
3. Hybrid composite
4. Soflex discs and interproximal polishing
strips
Technique
1. Reduce labial enamel about 0.3-0.5 mm
using tapered diamond bur

2. Clean the tooth with pumice in water. Wash

and dry ,then select shade
3. Isolated the tooth either with rubber dam or
contoured matrix strip
4. Etch enamel for 60s, wash and dry
5. Apply bonding + light cure for 15s. If the
discoloration is intense, opaquer may be
needed
Technique (cont.)
● Apply composite of desired shade + light
cure 60s gingivally , 60s mesioincisally, 60s

distoincisally, and 60s from palatal aspect if

incisal coverage is used.
7. Remove matrix strip
8. Finishing and polishing

Note: if dentine is exposed while preparation, it

should be covered by GIC prior to
placement of composite.
Design of composite veneer
It can be one of the four types
5. Porcelain veneer
● Advantages over composite veneer
1. Superior appearance
2. Better resistance to abrasion
3. Well tolerated with gingival tissues
4. Minimal luting cement need, resulting long
term acceptable aesthetic
6. Metal casting

● Indications
1. Amelogenesis imperfecta
2. Dentinogenesis imperfecta
3. Dental erosion, attrition, abrasion
4. Enamel hypoplasia

Hypoplasia
Armamentarium
1. Gingival retraction cord
2. Elastomeric impression material
3. Facebow system
4. Semi-adjustable articulator
5. Rubber dam
6. Luting cement (Panavia Ex)
Technique
1. Study model and photograph if possible
2. Perform full mouth prophylaxis
3. Moisture isolation
4. Place retraction cord and prepare
5. Take impression using elastomeric material
impression ( Silicone)
6. Take biting record
7. Mount the cast on articulator
 Technique (cont.)
8. Construct cast onlay, a max. 1.5 mm thick
occlusally ( either nickle/chrome or gold)

9. Grit-blast the fitting surface of the occlusal

onlay
10. Return to mouth and check the fit
11. Polish the tooth and isolate under rubber
dam
12. Cement onlay using Panavia Ex
13. Check occlusion
14. Review in 1 week for problems and
regularly thereafter.
5. Metal casting
● Some challenges:
- high-level of patient co-operation
- LA always need
- moisture control can be difficult
- aesthetic problem ( shine through) when
place on the palatal aspect of upper anterior
teeth.
Thanks
for
your
listening