Cosmetic Tribune U.S. No. 6, 2011
Alternative treatment options with nanohybrid composites / Wanted: whiter - brighter teeth
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Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition
June 2011
www.dental-tribune.com
Vol. 4, No. 6
Alternative treatment options
with nanohybrid composites
By Bruce J. LeBlanc, DDS
In the past few years, the economic condition of many of our patients has changed, thus
limiting their options when making dental
treatment choices.
In situations where lab-processed restorations may be the optimal long-term option,
patients may be forced to choose dentistry
that will transition them, not only spreading out treatment over a longer period of
time, but choosing restorations that require
less immediate cost. For many of us practicing dentists, this can include our family and
friends.
In my practice, I have always developed
patient-friendly choices both for financing as
well as the treatment offered. We use digital
X-rays and photographs to triage and explain
treatment needs and solutions, encouraging
our patients to be involved with treatment
decisions.
There is little doubt that today’s porcelain
crowns offer maximized esthetics for the longest period of time. However, these types of
restorations, especially when multiple teeth
are involved, may be beyond a patient’s ability to pay.
Recognizing that a current financial limitation can be temporary should be considered
when charting a path that hopefully assists a
patient in keeping his or her teeth for a lifetime in comfort.
Our ability to offer different treatment
options to solve the same clinical condition
can be a tremendous service to our patients
and creates some of our most satisfying success stories.
In that regard, I am sharing in this article
two situations that I encountered where the
need for restorations was immediate and yet
the patients were financially limited as to how
much they could afford.
In my practice, nanohybrid composites are
my preferred restorative materials of choice
when creating alternatives to lab-processed
porcelain. These restorations can be sculpted
in a way that minimizes the amount of tooth
structure removed while providing durable
long-term success when done with bonding
agents and techniques that maximize adhesion.
The following cases offer insight into how
we use these materials to offer treatment
Fig. 1
Fig. 2
g CT page 2B
Wanted: whiter, brighter teeth
Teeth whitening seems to be
on everyone’s wish list — and this
momentum is likely to continue
through 2011, according to a quick
poll of members at the American
Academy of Cosmetic Dentistry
(AACD).
AACD members performed an
average of 77 whitening treatments
last year, and 57 percent said they
expect this number to rise.
“We are doing more whitening
than ever before in our practice,”
says Shannon Pace Brinker, certified
dental assistant and clinical editor
for CPS magazine.
Pace Brinker performed more
than 400 whitening treatments in
the past year, and gives credit for
the treatment acceptance due to
the ability to offer a high-quality
whitening system with options to
treat her patients based on bleaching
strength, time, finances and patient
compliance systems within her prac-
tice at Greenbrier Dental in Chesapeake, Va.
Pace Brinker says that her practice has reduced its whitening fees,
which has not only brought in more
patients seeking whitening — but
it’s also opened their eyes to other
cosmetic dental treatments.
“Our existing patients are saying
‘yes’ to other procedures after the
whitening, such as bonding, replacing amalgam fillings and replacing
porcelain restorations to match the
whitening they have achieved,” she
said.
While the number of patients
seeking whitening treatments will
likely increase this year, Pace Brinker expects that the fees for whitening will actually decrease, due to
specials offered by dental practices
through deal-a-day sites such as
Groupon and LivingSocial.
The average price for a whitening
treatment is about $150 for take-
home whitening and $350 for inoffice, Pace Brinker says. Since her
practice adjusted the fees for treatment, she sees up to 12 to 14 patients
per day on Mondays and Tuesdays
just for whitening.
“Our case acceptance has exceeded our expectations with these
adjusted fees,” Pace Brinker said.
AACD members said their practices generated about $19,100 on
average from whitening last year.
The majority of AACD members
polled said they provide in-office and
take-home whitening treatments.
Twenty-two percent said their
patients have told them they use
over-the-counter or commercially
available whitening treatments.
Gender-wise, it seems that
women are more concerned with a
white smile. Roughly 65 percent of
dental patients seeking whitening
treatment last year were female,
according to the poll.
(Photo/Scott Rubenstein,
www.dreamstime.com)
AACD members expect the demand for teeth whitening to increase this year
“I think women are used to paying
higher fees for services to make us
look and feel better,” Pace Brinker
says. “Currently, men are more concerned about costs; however, as the
market continues to be concerned
with whiter teeth, I think you will
see a trend from our male patients
that is more equal to our female clients’ philosophy.”
g CT page 3B
[2] =>
2B
Clinical
Fig. 3
Cosmetic Tribune | June 2011
COSMETIC TRIBUNE
Fig. 4
The World’s Dental Newspaper · US Edition
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t.oemus@dental-tribune.com
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Fig. 5
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Fig. 6
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Implant, Endo & Lab Tribunes
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Managing Editor/Designer
Ortho Tribune & Show Dailies
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Fig. 8
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Fig. 7
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f CT page 1B
alternatives that patients enthusiastically accept in that they minimize tooth removal and reduce
immediate costs.
Case No. 1
Often in orthodontics, tooth shapes
can present challenges in achieving optimal results. Some conditions may require restorative as
well as orthodontic treatment to
complete.
In this case, we were presented
with a challenge that many of us
encounter routinely in practice:
peg-shaped lateral incisors with
very pointed cuspids.
Figure 1 shows the patient in
mid treatment for orthodontics
with the upper cuspid rotated past
90 degrees.
The orthodontist corrected the
rotation and created appropriate
spacing on each side of the peg
laterals to facilitate optimal tooth
shapes during reconstruction.
When dealing with peg laterals, it is my preference that 60
percent of the space be orthodontically positioned on the mesial of
the lateral incisor and 40 percent
on the distal.
This allows the shaping of the
lateral incisor to have proper mesial canting in appearance. Figure
2 shows the final condition after
braces were removed.
At this point, I would ask you to
consider what options you would
offer for a similar case in your
practice. In my opinion, it was necessary to address not only the peg
laterals and spacing, but the shape
of the cuspids.
Prescribing multiple porcelain
restorations was not only financially unrealistic for the patient,
but also required considerable
removal of sound tooth structure.
Our initial treatment was to use
take-home bleaching to lighten the
tooth color to a “realistic to maintain” B1 range.
It is my belief, based on what
I see clinically at recalls of treatment we have previously provided,
that nanohybrid direct composite
restorations offer durable outcomes while removing minimal
tooth structure.
In my practice, Kerr Premise,
Herculite Ultra and Cosmedent
Nano are materials of choice that
sculpt nicely, blend easily and
maintain a gloss polish at recall
that maximizes appearance while
minimizing plaque retention
I am convinced that it is crucial to use bonding agents that
maximize etching and sealing of
enamel. For that reason, I continue
to use etch/rinse multi-bottle systems that allow proper application
and drying of primers to eliminate
solvents and minimize sensitivity.
I believe proper enamel sealing
and adhesion is a critical component of durable adhesive restorations and an important barrier in
protecting the underlying dentin.
This case required no tooth
removal. For many patients, conserving tooth structure makes
direct composite dentistry very
appealing. Treatment was completed with one shade of nanohybrid.
The relaxed posture of the smile,
shown at completion of treatment
in Figure 3, indicates the patient
was comfortable with her appearance. For this patient, the outcome
was life changing.
Follow-up photos taken at one
year postop shown in Figures 4
and 5 show close-up views of the
completed restorations exhibiting
a retained polish and esthetics that
can be typical and predictable with
nanohybrid composites.
Dental Tribune America, LLC
116 West 23rd Street, Suite 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
Published by Dental Tribune America
© 2011 Dental Tribune America, LLC
All rights reserved.
Cosmetic Tribune strives to maintain
utmost accuracy in its news and clinical reports. If you find a factual error or
content that requires clarification, please
contact Group Editor Robin Goodman at
r.goodman@dental-tribune.com.
Cosmetic Tribune cannot assume responsibility for the validity of product claims
or for typographical errors. The publisher also does not assume responsibility
for product names or statements made
by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune America.
Tell us what
you think!
Do you have general comments or criticism you would like to share? Is there
a particular topic you would like to see
articles about in Cosmetic Tribune?
Let us know by e-mailing feedback@
dental-tribune.com. We look forward to
hearing from you!
[3] =>
Clinical
Cosmetic Tribune | June 2011
Case No. 2
In my practice, I am seeing more
patients with decay that I believe
to be related to taking or abusing
medications that dry the mouth
in combination with high sugar
intake.
We as dentists have recognized
for a long time the implications of
reduced salivary flow in increasing caries as related to radiation
treatment and have become more
aware in recent years of similar
clinical conditions related to medications that cause decreased salivary output.
Figure 6 shows our patient with
decay that was limited to facial
areas yet quite severe. Her history indicated using medications
that decrease salivary output while
drinking an excessive amount of
sugary drinks.
Although the preparation to
remove decay was extensive, as
shown in Figure 7, much more
tooth structure was retained by
doing direct nanohybrid restorations as compared with preparations for lab-processed restorations.
Gingival hemorrhaging from tissue contouring was quickly arrested with Ultradent Astringedent X,
followed by cleaning the remaining
residue with Ultradent Consepsis.
I have found no matrix system to
compare to the Greater Curve band
About the author
Dr. Bruce J. LeBlanc provides
seminars nationally on adhesive
dental techniques. His practice
offers adhesive and cosmetic
solutions that minimize tooth
removal. He is a product consultant to dental manufacturers
and has published internationally on his adhesive technique.
LeBlanc is course director and presenter for “Mastering Posterior Esthetics” at LSU
School of Dentistry as well as
presenter for the LSU Cosmetic
Continuum.
He is also the president of
the F. Harold Wirth Foundation
established at LSU School of
Dentistry to enhance the dentist patient relationship and the
enjoyment of practicing dentistry.
LeBlanc may be reached via
e-mail at bjleb@cox.net.
for doing these types of whole tooth
composites. Figure 8 shows how
we positioned the matrix in a way
that a gingival seal was achieved
and a perimeter created to mold
the composite.
The case was completed with
a rinse/etch multi bottle bonding
system and a single shade A3.5 of
nanohybrid composite. The final
picture in Figure 9 shows restorations that blend seamlessly with
the teeth and are natural in appearance.
With this treatment, the patient
was offered a final chance to save
her teeth. We discussed at length
the dietary changes and maintenance requirements that would
offer the best long-term clinical
outcome.
Conclusion
Direct bonding with nanohybrid
composites create exciting opportunities in our practices to offer
multiple treatment options that are
extremely predictable when done
with products and techniques that
maximize adhesion and prevent
microleakage.
Patients appreciate the cost
savings, conservation of tooth
structure and immediate esthetic
improvements.
Helping patients through challenging financial times with multiple treatment options that match
their financial condition can create
the kind of trust that creates
patients for life. For me, this adds
to the enjoyment of practicing dentistry. Happy bonding! CT
3B
f CT page 1B
About the AACD
The AACD is the world’s largest
non-profit member organization
dedicated to advancing excellence
in comprehensive oral care that
combines art and science to optimally improve dental health, esthetics and function. Composed of more
than 6,300 cosmetic dental professionals in 70 countries worldwide,
the AACD fulfills its mission by offering superior educational opportunities, promoting and supporting a
respected accreditation credential,
serving as a user-friendly and inviting forum for the creative exchange
of knowledge and ideas, and providing accurate and useful information
to the public and the profession. CT
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