Expedient EDITORIAL STAFF
Friedrich Georg Mittelstädt Bianca Mittelstädt Ana Claudia Silveira Bruno Lippmann Douglas Guilherme Martins Lima Fernanda Marques Busarello Lais Mizuno Rafael Cury Cecato Rodrigo Vargas Stella Bousfield Thiago Alano Vanessa Cardoso Victor da Cunha Vieira
SPECIAL THANKS TO
EDITORIAL BOARD
Friedrich Georg Mittelstädt Bianca Mittelstädt Bruno Lippmann Rafael Cury Cecato
Alexandre Andrade Moreira Alex Santos Américo Mendes Carneiro Junior Ana Carolina P. de Freitas Aubrey Fernando Fabre Bruno Lippmann Carlos Eduardo Vieira Carlos Francci Cesar dos Reis Perez Cintia Aparecida Damo Simões Claudio Sato Daniel Gheur Tocolini Daniel Sundfeld Neto Edson Araujo Eduardo Galia Reston Eduardo Nassif Eduardo Vargas Ellena Ometto Antoniali Fernanda Signorelli Calazans Flavio Simões Gil Montenegro Guilherme M. Garone Hélio Rui Dutra Henrique de Castro e Souza Pires Humberto Carlos Pires Iduilton Grabowski Jr. José Vagner Ferreira Juan Carlos Pontons-Melo Juliana Kina
Larissa Cavalcanti Monteiro Laura Molinar Franco Leandro de Moura Martins Leopoldino Capelozza Filho Letícia de Souza Lopes Liliana Ávila Maltagliati Lucas Silveira Machado Luciana Mendonça da Silva Maciel Jr. Mara Ilka Holanda de Medeiros Marcus Vinicius Lucas Ferreira Mauricio de Almeida Cardoso Mauro Sayão de Miranda Mônica Kina Nagib Pezati Boer Narciso Garone Netto Ovídio César Lavesa Martins Rafael Cury Cecato Renato Herman Sundfeld Roberto Devólio Rogério Luiz Marcondes Sandra Kalil Bussadori Sanzio Marques Sônia Saeger Meireles Tays Almeida Alfaya Vanessa Eid da Silva Cardoso Vânia Amaro de Lacerda Vicente Saboia
ART DIRECTOR
JOURNALIST RESPONSIBLE
EF Design Gráfico
Stella Bousfield SC-01247-JP
Publishing Editor: FGM Produtos Odontológicos Ltda. Edition 6 - September 2014 Address: Av. Edgar Nelson Meister, 474 - Zip Code 89219-501, Joinville / SC / Brazil +55 47 3441 6100 www.fgm.ind.br/en fgm@fgm.ind.br
Consolidation and
Growth
2013 a year of great consolidation an planning for FGM. Challenges
emerged however, professionalism, high quality work and outstanding products led to a growth of 15%. As for the foreign market, reaching a general growth of 30%, 55% especially in the Middle East, and 44% in Europe. Such results are proof that FGM has remained prominent among dental professionals and researchers around the world. FGM is known to dictate the market due to its innovative products which always impress professionals and patients, nowadays the company is strengthening its brand as a synonym for safety since it is reference in research and new product development. The company also counts on a competitive advantage which is its distribution chain which means high liquidity, profitability and turnover. Part of the research and product details can be found on the following pages and clinical cases specially selected for the “FGM News”. As brand strength has been accomplished, product launches and challenges will definitively be part of 2014. Despite of four products that are already on schedule for launch soon, after four years and a half of intensive analysis and planning FGM is about to start manufacturing implants. The new products that will be part of the portfolio are products that are not available in the national market yet, therefore a great increase in the market share is expected. Nevertheless the company strengthens its operations to prepare for further growth, including biomaterials, implants, bleaching agents, composites, adhesives, dental cements, polishing and finishing accessories, while offering the usual high quality and professionalism as well as remaining true to its goal of expanding globally but keeping the local look. FGM is always making sure that society is aware that having a professional to take care of the oral health is a must, specially when more specific treatments are required. Our main goal is not only to live up to the slogan “FGM, a dentist-friendly company”, but encompass its scope and become of great support for society as well by providing the means to allow more and more people have beautiful smiles. In another attempt to integrate this mission, we have prepared with great effort one more edition of the FGM News in order to contribute to Dentistry enhance communication worldwide that is constantly evolving. We wish you all enjoy your reading. After all, sharing experiences is our greatest gift!
1
Friedrich Georg Mittelstädt Technical Director Bianca Mittelstädt Managing Director
Summary Day to day questions about cementation of veneers and “Dental Contact Lenses”: What do clinicians need to know? 10 Improving smiles with “Contact lens-thin Ceramic Veneers” 14 Indirect veneers for rehabilitation of anterior teeth 20
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Day to day questions about cementation of post and core build-up. What do clinicians need to know?34 Coronary reconstruction with glass fiber posts
37
Soccer World Cup host cities 48
37
Supervised at-home dental bleaching 62 Supervised at-home and in-office dental bleaching combined techniques68 In-office dental bleaching more aesthetic smiles 74 Dental and enamel microabrasion a conservative treatment for removal of superficial opacities78
68
Clinical protocol for application of pit and fissure sealant 82 P&D Column - a new idea 90 Indirect bonding of aesthetic self-ligating braces 96
84
Use of Top Comfort (FGM) resin as an alternative replacement for stainless steel “stop” in the mechanic with self-ligating brackets100 Shade and shapes: the goals of aesthetics108 Posterior tooth restoration techniques with composite resin Opallis (FGM)116 Aesthetic restorations on clinical day to day procedures. How is that possible?120
102
Aesthetic smiles with minimally invasive procedures132 Dental bleaching on composite resin restorations138 Schott: a consistent partner for the supply of glass load143 Aesthetic reconstruction of anterior tooth with composite resin144
114
The use of glass fiber posts as auxiliary in the retention of direct composite resin restorations 148 Chemical and mechanical removal of caries with Papacarie Duo and subsequent rehabilitation: case report 156 Dental hypersensitivity treatment160
138
FGM products research164 A guideline for clinical trials disclosure168
156 edition 6
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Cementation of veneers and dental
“contact lenses” As the oral health of the population has improved progressively, patients have increasingly looked for esthetic procedures to address dental problems that were so far difficult to solve. Ceramic veneers and “dental contact lenses” are conservative and esthetic procedures that solve many dental problems, as long as well planned and performed. FGM News asked for some questions for experts in the field to help the professionals to understand a little bit more about the cementation of ceramic veneers:
FGM News: DENTISTRY HAS BEEN DEVELOPING GREATLY OVER TIME OWED TO THE APPLICATION OF NEW MATERIALS AND TECHNIQUES. CERAMIC VENEERS, WHEN WELL INDICATED, ARE CURRENTLY A CHOICE FOR ESTHETIC RE-ANATOMIZATION OF SEVERAL ASPECTS OF THE PATIENT’S SMILE. WHAT ARE THE INDICATIONS, CONTRAINDICATIONS, AND BENEFITS OF CERAMIC VENEERS COMPARED WITH FULL CERAMIC CROWNS? Dr. Carlos Francci: We should differentiate between
and previous bleaching protocols did not solve that
veneers and ceramic crowns. We use the latter for cases
condition. Other indications of ceramic veneers are for
where we need to restore dental form and function such
cosmetic changes, such as diastema closure in sound
as clinical cases where the dental structures are severely
or misaligned teeth. In summary, veneers are used when
destroyed and associated with Class III and/or Class IV
there is an esthetic problem or for teeth with good enamel
restorations, with palatal or lingual access for endodontic
and dentin structure but with non-esthetic restorations.
treatment with or without esthetic compromise. On the
Albeit veneers and full ceramic crowns provide esthetic
other hand, veneers are specifically used when the chief
results, they aim to reproduce dental structure and
complaint is the esthetics. For instance in clinical cases,
esthetics while veneers are solely indicated for the
where the patients are not satisfied with their teeth color
restoration of esthetics.
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FGM News: AS VENEERS ARE VERY DELICATE PROSTETHIC PIECES, CLINICIANS USUALLY RAISE SOME DOUBTS ABOUT THEIR LONGEVITY. WHAT DOES THE LITERATURE REPORT ABOUT THE LONGEVITY OF THIS TREATMENT OPTION, CONSIDERING A CLINICAL CASE THAT WAS ADEQUATELY PLANNED AND PERFORMED? Dr. Carlos Francci: Studies of literature review
Therefore, it is recommended to make more conservative
are the most relevant to obtain a more realistic scenario
preparations, ideally on enamel only. As regards to the
of any subject. By searching the international literature,
incisal coverage, Shetty et al. [Survival rates of porcelain
we found very promising results for ceramic veneers. For
laminate restoration based on different incisal preparation
instance, the literature review by Land and Hopp [Survival
designs: An analysis. J Conserv Dent. 2011 Jan;14(1):10-
rates of all-ceramic systems differ by clinical indication
5] from Bangalore (India) showed that preparations without
and fabrication method. J Evid Based Dent Pract. 2010
incisal reduction and coverage presents higher longevity
Mar; 10(1):37-8] from the University of Southern (USA)
than those with incisal reduction and coverage. Therefore,
reviewed a total of 50 scientific articles and concluded
we may summarize that the longevity of veneers depends
that the failure risk of ceramic veneers was lower than
on the preparation design. The 5-year success rate is
5% after 5 years of clinical service, and lower than 10%
on average 95% for conservative preparations, without
after 10 years. Another literature review published by
incisal reduction.
Burke [Survival rates for porcelain laminate veneers with special reference to the effect of preparation in dentin: a
Dr. Carlos Francci
literature review. J Esthet Restor
Undergraduate, MS, and PhD degrees at School of
Dent.
Dentistry, University of São Paulo (USP, SP, Brazil).
2012
Aug;24(4):257-
65], from the University of
Coordinator of the Specialization and Update Courses in
Birmingham (United Kingdom)
Restorative Dentistry at EAP – APCD Central, São Paulo,
revealed that we rarely have a
Brazil, and EAP at Brazilian Association of Dentistry
success rate of 100% when
(ABO, Pouso Alegre, MG). Coordinator of the Update
more aggressive preparations
Course in Restorative Dentistry at FUNDECTO – USP
are performed and when the
and Coordinator of the GFree (Group Francci of Studies
veneer is bonded to dentin.
in Esthetics).
11
FGM News: THE DENTAL PREPARATION FOR VENEERS IS MORE CONSERVATIVE THAN OTHER TYPES OF PROSTHETIC PREPARATIONS. COULD YOU COMMENT ON DENTAL PREPARATIONS FOR CERAMIC VENEERS? ARE THERE OCCASIONS THAT DO NOT REQUIRE ANY DENTAL PREPARATION? Dr. Maciel Jr.: The dental preparation for veneers
This conservative treatment also depends on the
depends on several factors: amount of remaining tooth
technician’s skill in fabricating the veneer and on the
structure, amount of dental structure to be protected
dentist’s skill in veneer positioning and cementation.
and degree of dental discoloration. These factors will be
Suitable resin cement with proper color should be used
in line with the treatment planning and materials that will
for cementation, and no cement excess can be left, as it
be used. The choice for no preparation also depends on
may significantly change the emergency profile. Generally,
many factors, but this option is more restrictive. With the
veneers cemented in teeth without preparations are
advent of the “dental contact lenses” and ultra-thin ceramic
restricted to the buccal and proximal areas of sound teeth
fragments we can opt for very conservative preparations.
without dental discoloration or misalignment.
However, there are some features that cannot be ignored as the adaptation passivity and dental discoloration
Dr. Maciel Jr.
of the underlying dental structure, as we are dealing with
Specialist in Restorative
very thin ceramic veneers, with a thickness of approximately
Dentistry at Bauru School
0.3 mm (which may be the conventional thickness of dental
of Dentistry (University of
contact lenses). These structures are very translucent, and
São Paulo, SP, Brazil). MS
therefore they are not capable to provide any opacification,
in Restorative Dentistry at
which contraindicates its use in teeth with severe dental
Araraquara School of Dentistry
discoloration.
(University of the State of São Paulo, SP, Brazil).
FGM News: THE ADHESIVE CEMENTATION OF CERAMIC VENEERS HAS BEEN OFTEN DESCRIBED IN THE LITERATURE. HOWEVER, SOME STUDIES HAVE REPORTED THAT DUAL-CURE RESIN CEMENTS USED FOR CEMENTATION OF TRANSLUCENT VENEERS MAY COMPROMISE THE ESTHETICS OWED TO THE LACK OF COLOR STABILITY. WHAT ARE THE ADVANTAGES OF EMPLOYING A LIGHT-CURING RESIN CEMENT FOR CEMENTATION OF CERAMIC VENEERS? Dr. Claudio Sato: Actually dual-cure
Dr. Claudio Sato
resin cements are prone to color change
Specialist in Restorative Dentistry (School
over time owed to the presence of a tertiary
of Dentistry; University of São Paulo –
amine for chemical activation. Surely, by
FOUSP, Brazil). MS in Restorative Dentistry
selecting a light curing resin cement, one can
(Department of Dental Materials, FOUSP).
perform the cementation of several veneers
Residence in Operative Dentistry (University
simultaneously, without the risk of chemical
of Minnesota, USA), Coordinator of the
cure. Additionally, the material has improved
Disciplines of Operative and Restorative
color stability and does not require hand
Dentistry (University Braz Cubas, UBC,
mixing, differently than chemically activated
Brazil).
resin cements. The advantage of avoiding hand mixing is that less air bubbles, that may jeopardize the material polymerization, are incorporated into the material. edition 6
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FGM News: CERAMIC VENEERS ARE VERY THIN (APPROXIMATELY 0.3 mm THICK) AND TRANSLUCENT. THEREFORE, IT IS IMPORTANT TO CHOOSE A RESIN LUTING CEMENT CAPABLE TO REPRODUCE THE TEETH COLOR, AS FAILURE IN THIS STEP MAY JEOPARDIZE THE ESTHETICS OF THE COSMETIC PROCEURE. WHAT ARE THE ADAVANTAGES, IN TERMS OF ESTHETIC PREDICTABILITY, OF THE USE OF TRY-IN PASTES? Dr. Américo Mendes Carneiro Junior: We cannot
should apply a small amount of the try-in paste with
evaluate the final color of a ceramic veneer by only placing
the selected color on the inner surface of the veneer
it on the dental preparation. The presence of air between
and place it on the dental preparation. The material has
the ceramic and dental structure prevents the evaluation of
enough bonding to keep the veneer into position during
the color that will be reached after cementation. The final
clinical evaluation. If the esthetic result is not satisfactory,
esthetic result depends on the color of the resin cement
the paste can be rinsed out and another try-in paste can
color, the dental structure, and the ceramic veneer. As the
be tested. Once the ideal color is found, the try-in paste
ceramic veneers are very thin and translucent structures,
is removed, and the cementation procedure followed with
the resin cement has a profound influence on the final
the same shade of resin cement.
color of the esthetic treatment. To predict the final color of the esthetic
Dr. Américo Mendes Carneiro Junior
restorative treatment, the best strategy is
Specialist, MS, and PhD in Restorative
the use of try-in pastes. These pastes are
Dentistry at the School of Dentistry
hydrophilic, and therefore they can be easily
(University of São Paulo, SP, Brazil).
removed after use. They are available in the
Specialist in Implantology. Professor of
same colors of the definitive resin cements,
the Courses of Esthetic Dentistry and
which favor the safe simulation of all possible
Implantology. Lecturer of national and
outcomes. Their use is quite simple: one
international courses.
“As ceramic veneers are very thin and translucent structures, the resin cement has a profound influence on the final color of the esthetic treatment. To predict the final color of the esthetic restorative treatment, the best strategy is the use of try-in pastes.”
FGM News: EIN AN AIM TO OVERCOME THE LACK OF COLOR STABILITY OF DUAL-DURE RESIN CEMENTS, SOME PROFESSIONALS HAVE OPTED TO USE FLOWABLE COMPOSITE RESINS FOR VENEER CEMENTATION. IS THIS PRACTISE INDICATED? Dr. Guilherme Garone: There are
Dr. Guilherme Garone
in the dentistry market specific light-curing
MS in Restorative Dentistry (School of
resin cements for veneer cementation. I
Dentistry; University of São Paulo - FOUSP).
believe they have more suitable viscosity
Professor of Restorative Dentistry (University
than flowable resins for this procedure, being
City of São Paulo – Unicid).
therefore, capable to produce a thinner
Professor of the Update Courses in Esthetic
cementation line.
Dentistry at FUNDECTO (University of São Paulo – FOUSP) and CETAO (São Paulo, Brazil).
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Sanzio Marques Specialist in Dental Prosthodontics and Implantology. MS in Restorative Dentistry. Author of the book intitled “Esthetics in anterior teeth with composite resins: perception, art, and naturalism.”
Enhancing the patient’s smile with dental ceramic “contact lenses” INTRODUCTION The foundation of the current adhesive dentistry is based on two basic
Coordinator of the Course of Excellence in Esthetic Dentistry – IEO - Belo Horizonte (MG, Brazil).
principles: the esthetic reproduction of the optical aspects of the natural teeth
Coordinator of the Course “Mastering the Art with Composite Resin “ - IEO – Belo Horizonte (MG, Brazil).
Nowadays, it is possible to make esthetic restorations without the need of
Coordinator of the Course “Immersion in Ceramic Veneers” IEO - Belo Horizonte (MG, Brazil). Coordinator of the course Excellence in Oral Rehabilitation – Institute Implante-Perio - São Paulo (SP, Brazil).
and the greater conservation of dental tissues during cavity preparation. excessive dental preparations of the sound dental structures. The principles of these conservative procedures meet the current objectives of the dental practice, which is focused on being conservative while promoting oral health. Within this context, the so-called “dental ceramic contact lenses” are a new modern treatment option that enables dentists to offer new smiles to their patients with minimal, or even no wear of sound dental structures. CLINICAL CASE REPORT The following clinical case reports the step-by-step protocol used to solve the inadequate esthetic condition of two upper central incisors with excessive wear and esthetic and functional impairment. For such purpose, these teeth were restored with very thin ceramic veneers, called “dental contact lenses”. A good clinical-laboratory communication was of paramount importance for the achievement of the high esthetic pattern observed in this clinical case.
José Vagner Ferreira Prosthetic Technician Owner and Director of the Vagner laboratory (São Paulo, SP, Brazil)
1a.
1b.
1a-1b. Initial aspects of the clinical case, showing an excessively wear of the incisal edges of teeth 11 and 21, which led to esthetic and functional impairment. The restoration of incisal edges with composite resins does not have a good prognosis owed to the reduced thickness of the composite resin (< 2 mm) that is used for this type of restoration. Under very low thickness, composite resins present reduced strength.
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2a.
2b.
3.
4.
5.
6a.
2a - 2b. Photographs were taken during color recording with proper shade guides. This step is very important to guide the communication with the laboratory. High quality photographs are important benchmarks of clinical-laboratory communication. 3. Prior to dental preparation and impression, we performed the careful insertion of retraction cord Pro Retract 00 (FGM) for gingival retraction. 4. Flattening and rounding the incisal edge with coarse abrasive disks (Diamond Pro, FGM). Note the minimal wear performed during dental preparation. 5. Simultaneous impression using an addition silicone, which is a material with optimal reproduction of details and dimensional stability. 6a - 6d. The ceramic veneers (â&#x20AC;&#x153;dental contact lensesâ&#x20AC;?) were fabricated with a lithium dissilicate system (e-max system; Ivoclar Vivadent). Observe the thin thickness of the veneer (approximately 0.2 mm) responsible for the high translucency of the piece.
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6b.
6c.
6d.
7.
8a.
8b.
9a.
9b.
9c.
7. Dry try-in of the ceramic veneers, showing a perfect adaptation with the dental structures. 8a - 8b. Wet try-in of the ceramic veneers using Allcem Veneer Try-In (FGM). This step was performed to allow for an adequate selection of the resin cement (Allcem Veneer, FGM). For high translucent ceramic veneers, choosing the correct color of the resin cement is of utmost importance for the final esthetic outcome of the clinical case. 9a - 9c. Dental preparation. Acid etching with phosphoric acid (Condac 37, FGM) followed by the application of the adhesive Ambar (FGM). The adhesive was not light-cured.
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10a.
10b.
10c.
11. 10a-c. Preparation of the ceramic veneers. They were etched with hydrofluoric Condac Porcelain (FGM) for 20 seconds. The ceramic veneers were silanized with Prosil (FGM). One coat of adhesive Ambar (FGM) was applied. 11. Application of the resin cement Allcem Veneer (FGM) in the inner surface of the ceramic veneers.
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12.
13a.
13b.
14a.
14b.
12. Careful seating of the veneer on the dental preparations. 13a - 13b. The resin cement was light cured for only 2 seconds. This procedure facilitates the removal of the resin cement excesses. After excess removal, the final light curing was performed on the buccal and the palatal surface for 60 seconds each.
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14c.
14d.
14a - 14d. Final result. We can observe a perfect esthetic harmonization of the â&#x20AC;&#x153;dental contact lensesâ&#x20AC;? with the neighboring teeth. The incisal guides were properly recovered, and the patient now presents a more beautiful and youthful smile. Small composite resin restorations were performed in the lateral incisors with Opallis (FGM) for dental reanatomization. The treatment was completed in a very conservative manner reaching excellent esthetic results.
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Maciel Jr. Specialist in Restorative Dentistry at Bauru School of Dentistry (University of São Paulo, SP, Brazil). MS in Restorative Dentistry at Araraquara School of Dentistry (University of the State of São Paulo, SP, Brazil).
Indirect veneers for rehabilitation of anterior teeth
INTRODUCTION Indirect veneers are a very interesting treatment option for dental reEduardo Nassif Prosthetic technician, Conceição da Aparecida (MG, Brazil)
anatomization of teeth shape, for correction of minor tooth misalignment and structural defects, for management of color changes, for occlusal rehabilitation, among others. It is often possible to achieve an esthetic smile with little or no dental preparation, which characterizes the procedure as minimally invasive and relatively conservative when compared with full dental crowns that always require major reduction of the dental structure. CLINICAL CASE REPORT In the present clinical case, the main patient’s complain was the aged appearance of her teeth because of inadequate shape and texture. One can notice the presence of Class IV composite resin restorations and mild dental wear in the cervical area of the teeth owed to erosion. After clinical evaluation of the remaining dental structure, the occlusal contacts with the anterior teeth and arch alignment and amount of enamel, we proposed the placement of indirect ceramic veneers. For the upper incisors (12 to 22) we performed a moderate dental preparation; while in the upper canines, no dental preparation was performed and very thin ceramic veneers (dental contact lenses) were fabricated. As ceramic veneers are very thin structures, the dental discoloration was treated previously. We opted to perform in-office dental bleaching with Whiteness HP Blue 35% (FGM). The esthetic result achieved was very satisfactory and yielded to the patient a very youthful smile appearance. edition 6
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1.
2.
3a.
3b.
4.
5a.
5b.
1. Initial clinical condition. 2. Recording the baseline teeth color (2L - Vita 3D). 3a-b. The photographs are comparing the patientâ&#x20AC;&#x2122;s teeth color before and after two in-office bleaching sessions with Whiteness HP Blue 35% (FGM). 4. Wax-up stone model with the anatomy of the future ceramic veneers. 5a-b. Impression of the wax-up model with silicone. The impression was cut to guide the amount of dental wear during preparation and to aid in the preparation of the provisional restorations.
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6a.
6b.
6c.
6d.
7a.
6a-d. Dental preparations: a retractor cord (Pro-Retract, FGM) was positioned before guided reduction of interproximal, incisal, and buccal areas with the silicone impression. 7a-b. The dental preparations are ready.
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7b.
8.
9.
10a.
8. Fabrication of the provisional veneers. 9. Ceramic veneers. 10a-b. Positioning of the veneers with Allcem Veneer Try-in paste.
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10b.
11a.
11b.
12a.
12b.
13a.
13b.
14.
11a-b. Impression of the patientâ&#x20AC;&#x2122;s teeth with the positioned ceramic veneers. This procedure was performed to keep the veneers inside the silicone impression, allowing for their easy handling during acid etching and adhesive application. After impression, the try-in paste on the dental preparations and inner surfaces of the veneers was removed by water rinsing. 12a-b. Acid etching of the inner surface of the ceramic veneers with 10% hydrofluoric (Condac Porcelain, FGM). Observe the rough aspect of the conditioned surface, visually detected by the loss of brightness and opaque-white appearance. 13a-b. Application of silane (Prosil, FGM) on the inner surface of the ceramic veneer. After air drying, one coat of adhesive (Ambar, FGM) was applied. 14. Dental prophylaxis.
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15a.
15b.
16.
17a.
17b. 15a-b. Acid etching (Condac 37, FGM) for 30 s, water rinsing, air drying, and adhesive application (Ambar, FGM), which was light-cured. 16. Cementation of the veneers with Allcem Veneer (FGM), removal of resin cement excesses and light curing for 40 s. 17a-b. Acid etching and adhesive application (Ambar, FGM) on dental surfaces of teeth 22 and 12.
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18a.
18b.
19.
20a.
20b.
18a-b. Cementation of the veneers, removal of resin cement excess, and light-curing. 19. Aspect of the ceramic veneers after cementation. 20a-c. The aspect of the â&#x20AC;&#x153;dental contact lensesâ&#x20AC;? fabricated for the upper canines.
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20c.
21.
22a.
22b.
23a.
23b.
24a.
24b.
21. Checking the adequate resin cement color by positioning the ceramic veneers on the dental preparation with Allcem Veneer Try-in. 22a-b. Acid etching of the inner surfaces of the veneers (Condac Porcelain, FGM). 23a-b. Application of silane (Prosil, FGM) and adhesive (Ambar, FGM) on the inner surface of the veneers. 24a-c. Acid etching (Condac 37, FGM) and adhesive application (Ambar, FGM) in the canines.
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24c.
25a.
25b.
25c.
25d.
26.
25a-d. Veneer cementation, removal of resin cement excess and light-curing. 26. Polishing.
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27a.
27b.
27a-b. Final aspect of the treatment.
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ONE PRODUCT. THREE FUNCTIONS. Post Cementation Cementation of intraradicular glass fiber posts (White Post-FGM), carbon or quartz and even metal posts.
Core Build-up Cementation of core build-up and core filling (devitalized or vital teeth).
Crown Cementation Cementation of ceramic, resin, metal and metal ceramic crowns.
www.fgm.ind.br/en
EASY AND SAFE TO USE. Learn more about the resinous cement that makes the restoration of large tooth loss easier, as it can be used as a three in one product.
Available in dual syringe (mix base + catalyst) + 8 syringe tips, A1, A2, A3 or Opaque Pearl shades
Youâ&#x20AC;&#x2122;re Worth it.
Everyday questions about
Endodontic post cementation
and core buildup
What do clinicians need to know? Endodontic posts are important materials for the rehabilitation of teeth with severely destroyed crowns. The endodontic post cementation and core buildup are critical steps for the clinical success of single crowns. FGM News invited specialists in this field to answer some frequently asked questions from clinicians who work with dental rehabilitation:
FGM News: THE MANAGEMENT OF TEETH THAT REQUIRE ENDODONTIC POST CEMENTATION EITHER FOR STRUCTURAL REINFORCEMENT OR RESTORATION RETENTION IS VERY OFTEN IN THE CLINICAL PRACTICE. CONSIDERING THE ENDODONTIC POSTS AVAILABLE IN THE MARKET, CAN ONE CONTEMPLATE THE FIBERGLASS POSTS THE SAFEST OPTION? Dr. Guilherme Garone: I believe fiberglass posts
if they are not adequately indicated and cemented, an
are the safest and most conservative option, as they do not
adhesive failure instead of root failure is likely to occur,
require the removal of excessive dental tissue. Additionally,
contrary to what it is reported with metallic posts.
FGM News: BESIDES SAFETY AND RELIABILITY, DENTAL TREATMENTS NEED TO BE SIMPLE AND NOT TIME-CONSUMING TO MAKE THE CLINICIAN’S WORK EASIER. IN THIS SENSE, FIBERGLASS POSTS ARE ADVANTAGEOUS, AS THEY DO NOT REQUIRE A LABORATORY STEP. IS IT POSSIBLE TO REPLACE DEFINETELY THE METALLIC POSTS BY THE FIBERGLASS POSTS? WHAT ARE THE ADVANTAGENS AND CONTRAINDICATIONS OF FIBERGLASS POSTS?
we
Dr. Guilherme Garone: I believe
Dr. Guilherme Garone
cannot
MS in Restorative Dentistry (School of
replace
completely
metallic
posts by direct fiberglass posts. The only
Dentistry; University of São Paulo - FOUSP).
contraindication of fiberglass post is for
Professor of Restorative Dentistry (University
clinical cases where the remaining crown is
City of São Paulo – Unicid).
completely absent. For direct endodontic
Professor of the Update Courses in Esthetic
posts, the remaining dental crown should be 2
Dentistry at FUNDECTO (University of São
mm high. The dentin should have a thickness
Paulo – FOUSP) and CETAO (São Paulo,
of 1.5 mm around the fiberglass post.
Brazil). edition 6
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FGM News: WHAT DOES THE LITERATURE REPORT ABOUT THE LONGEVITY OF FIBERGLASS POST WHEN ADEQUATELY PLANNED AND CONSTRUCTED? Dr. Claudio Sato: The longevity of
Dr. Claudio Sato
fiberglass posts is directly related to their
Specialist in Restorative Dentistry (School
cementation and retention into the root
of Dentistry; University of São Paulo –
canals.
FOUSP, Brazil). MS in Restorative Dentistry
Therefore, the correct application
of the adhesive system, the adequate
(Department of Dental Materials, FOUSP).
polymerization of the resin cement and the
Residence in Operative Dentistry (University
formation of a thin cementation film may
of Minnesota, USA), Coordinator of the
contribute significantly to the longevity of the
Disciplines of Operative and Restorative
treatment.
Dentistry (University Braz Cubas, UBC, Brazil).
FGM News: BONDING MATERIALS HAVE BEEN INDISPENSIBLE FOR PROSTHETIC REHABILITATION OF TEETH. MULTIFUNCTIONAL, DUAL-CURE RESIN CEMENTS USED FOR CEMENTATION AND CORE BUILDUP HAVE CALLED CLINICIAN’S ATTENTION BY THE SIMPLIFICATION OF THE RESTORATIVE PROCEDURE. WHAT ARE THE BENEFITS OF THIS TYPE OF RESIN CEMENT IN THE CLINICAL PRACTICE? Dr. Maciel Jr.: Agility and efficiency are important
cementation of metal-free ceramic or indirect composite
characteristics of procedures for the clinical practice,
resin crowns, which demonstrate the multifunctional
especially for extensive prosthetic rehabilitation. These
character of the material.
features are in line with the benefits produced by the multifunctional resin cement Allcem Core during restorative procedures. Shortening the work time reduces the patient and professional’s stress, augments productivity and, so,
Dr. Maciel Jr.
the financial reward. When I need a material that facilitates
Specialist in Restorative
the prosthetic rehabilitation for adhesive procedures,
Dentistry (Bauru School of
the resin cement Allcem Core is the material of choice,
Dentistry; University of São
as it allows for the cementation of endodontic posts and
Paulo). MS in Restorative
core buildups in a very simple and practical way. Owed
Dentistry (Araçatuba School
to its excellent rheological properties, few increments are
of Dentistry; University of the
required. Additionally, the same material can be used for
State of São Paulo, Brazil).
35
FGM News: THE MULTIFUNCTIONAL DUAL-CURE RESIN CEMENTS (USED FOR CEMENTATION AND CORE BUILDUP) ARE A PRACTICAL ALTERNATIVE FOR THE RESIN COMPOSITES USED FOR CORE BUILDUP. HOWEVER, ARE THEY EQUIVALENT IN TERMS OF MECHANICAL STRENGTH? Dra. Vanessa Cardoso: Yes, they are at least
The degree of conversion, polymerization shrinkage
analogous. Internal and external data comparing Allcem
stress and depth of cure of Allcem Core were also similar
Core and a composite resin showed that Allcem Core had
to the composite resin. Only in the microhardness test, the
higher flexural strength and higher bond strength to a lithium
composite resin was superior to Allcem Core, because of
dissilicate ceramic than the composite resin. About ultimate
the higher filler loading of the composite resin. However, it
tensile strength, compressive strength, water sorption
seems this property did not affect the general performance
and solubility and bonding strength to dentin and indirect
of Allcem Core.
materials, Allcem Core was similar to the composite resin.
FGM News: ALBEIT THE USE OF A SINGLE MATERIAL FOR ENDODONTIC POST CEMENTATION AND CORE BUILDUP MAKES THE PROCEDURE SIMPLER; THEY USUALLY REQUIRE MATERIALS WITH DIFFERENT VISCOSITIES. A MATERIAL USED FOR CEMENTATION NEEDS TO HAVE HIGHER FLOWABILITY, WHILE A MATERIAL FOR CORE BUILDUP REQUIRES A MORE VISCOUS CHARACTERISTIC. HOW COULD THE COMPANY DEVELOP A VIABLE MATERIAL FOR TWO DISTINCT SITUATIONS? Dra. Vanessa Cardoso: Our chemistry strategy
easier. However, once the material is expelled from the
was reached by adding special filler particles capable to
automix syringe, there is no acting force on the resin
act as a thickening agent. These particles allowed the
cement and thus, the material returns to its original
achievement of an ideal thixotropic feature for the Allcem
viscosity, which is ideal for the buildup of filling cores.
Core. Under static conditions, the material is viscous but acquires increased flow after application of pressure or shear forces. Allcem Core
Dra. Vanessa Cardoso
becomes less viscous when it is expelled
Full Research of Dentscare/FGM. PhD
from the automix syringe tip or during
in Biochemistry at the University of São
manual mixing. This makes the cementation
Paulo. Post-doctoral stage in Innovation at
of endodontic posts and prosthetic crowns
Sustenare School of Business.
“Allcem Core showed higher flexural strength and higher bond strength to a lithium dissilicate ceramic than a composite resin. About ultimate tensile strength, compressive strength, bonding strength to dentin and indirect materials, water sorption and solubility, Allcem Core was similar to a composite resin.” edition 6
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Sanzio Marques Specialist in Dental Prosthodontics and Implantology. MS in Restorative Dentistry. Author of the book intitled “Esthetics in anterior teeth with composite resins: perception, art and naturalism “. Coordinator of the Course of Excellence in Esthetic Dentistry – IEO - Belo Horizonte (MG, Brazil). Coordinator of the Course “Mastering the Art with Composite Resin “ - IEO – Belo Horizonte (MG, Brazil). Coordinator of the Course “Immersion in Ceramic Veneers” IEO - Belo Horizonte (MG, Brazil). Coordinator of the course Excellence in Oral Rehabilitation – Institute Implante-Perio – São Paulo, SP, Brazil.
Crown buildup with fiberglass post
INTRODUCTION The rehabilitation of teeth with reduced remaining dental crown can be accomplished with the cementation of endodontic posts and indirect restorations. Some important features should be considered for the restorative procedure. The length of the root, its anatomy, the characteristics of the remaining dental structure (height, thickness and tissue quality), the incidence of masticatory forces in the tooth, esthetic needs, among others should be taken into consideration during rehabilitation. When correctly planned and indicated, the use of direct endodontic posts has an excellent cost-benefit. Additionally, its implementation is easier than metallic cast posts. Additionally, new dental materials are released in the market with the aim to simplify even more the professional’s work. Among them, there are the multifunctional resin cements, released for endodontic post cementation and core buildup. CLINICAL CASE REPORT A patient with teeth 11 and 21 in need of extensive prosthetic rehabilitation sought for dental assistance. The remaining crown of the teeth had enough ferrule and mirroring areas for rehabilitation with direct endodontic posts. We planned the placement of esthetic endodontic posts with metal-free full ceramic crowns. The entire procedure was performed using only one dual-cure resin cement (Allcem Core, FGM) indicated for endodontic post cementation,
Roberto Devólio
core buildup and crown cementation.
Prosthetic Technician – Curitiba – PR, Brazil.
1a.
1b.
1a-d. Initial aspect of the teeth, showing the remaining dental structure, and the preparation of the root canal with the White Post DC2 bur (FGM) for the adaptation of the endodontic post.
37
1c.
1d.
2a.
2b.
2c.
3a.
3b.
2 a-c. Acid etching (Condac 37, FGM) for 15 seconds, followed by adhesive application (Ambar, FGM). 3 a-d. The resin cement Allcem Core (FGM) was introduced into the root canals through a special tip for endodontic application. The fiberglass post (White Post DC2, FGM) was positioned inside the root canal, and the excess resin cement was used for core buildup. New increments of the resin cement were placed around the post for core buildup. The light curing of the resin cement at this moment ensured a pre-determined design for the filling core.
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3c.
3d.
39
4a.
4b.
5a.
5b.
4 a-b. Filling cores before and after bur preparation. 5 a-b. Cementation of the ceramic crowns with the same dual-cure resin cement, revealing the material practicality.
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Placement of prosthesis and support for inlay and onlay restorations
Placement of intraradicular posts
Application of dental adhesives
Compaction of composite resins, glass ionomer and endodontic cements
Application of desensitizing and other low viscosity materials
Supports cavities and conduits disinfection process
www.fgm.ind.br/en
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Syringe tips that are thinner which avoid wastes and control dosages.
Whiteness perfect has been a market leader for years since it allows dental surgeons and patients to experience more practical and more effective procedures. In order to remain a market leader this classical at-home bleaching product is constantly evolving in to provide even more perfect smiles in the whole world.
• Desentizing agents: potassium nitrate and sodium fluoride. • Ideal pH: avoids dentin and enamel demineralization. • Last longer: 3g of gel per syringe, lasts up to 9 applications. • Excellent flowability: does not overflow trays. • Suitable wetability that penetrates dental structure.
At-home dental bleaching based on carbamide peroxide available in concentrations 10%, 16% and 22%. Available in Kits, Mini Kits and spare syringes.
You’re Woth it.
Bruno Lippmann Undergraduate at the School of Dentistry at the University of Joinville (Univille, SC, Brazil) Student of the Specialization Course at the Thum Institute of Graduation and Bioresearch (Joinville, SC, Brazil)
Dentist-supervised at-home bleaching INTRODUCTION Among the dentist-supervised bleaching protocols, the most widespread technique is the at-home bleaching. This bleaching technique is usually performed with carbamide or hydrogen peroxide gels of different concentrations. The professionals often have doubts about the choice of the ideal bleaching gel for each clinical case, as it is the professionalâ&#x20AC;&#x2122;s clinical experience that guides the choice of the most suitable product for each patient. Apparently, the action of both types of bleaching products is based on the oxidation of pigments. This chemical reaction makes the molecules of the pigments smaller and easier to be removed from the teeth. It is this process that makes patientâ&#x20AC;&#x2122;s teeth whiter.
Rafael Cury Cecato Undergraduate at the School of Dentistry at PUC (PR, Brazil) Specialist in Periodontics at PUC (PR, Brazil)
The carbamide peroxide gel can be considered a precursor of the hydrogen peroxide, which is the active component of bleaching. The carbamide peroxide acts as a source of hydrogen peroxide in low concentration. Albeit carbamide peroxide has a slower action, it also presents a reduced risk of bleaching-induced tooth sensitivity.1 Clinicians should opt for carbamide peroxide gels with low concentrations (10 and 16%) in patients with high risk of developing tooth sensitivity and for those indifferent to the period they should wear the bleaching tray. For patients who want a faster whitening result and prefer to wear the bleaching tray for shorter periods of time, one should choose 4% or more concentrate hydrogen peroxide gels, although this choice may increase the risk of tooth sensitivity.1 In summary, we may say that both gels (carbamide and hydrogen peroxide gels) have the same efficacy,2,3 but they may require less or more time to reach the same outcome, because of the different concentrations of the active hydrogen peroxide component. Generally, more concentrate gels produce more bleaching-induced tooth sensitivity,4 which is a side effect managed by the application of desensitizing agents.4 CLINICAL CASE REPORT This clinical case aims to report a very common situation in the daily clinical practice when carbamide and hydrogen peroxide gels are employed: both can reach the same result but at different periods of time. edition 6
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The dentist-supervised at-home bleaching was
were both non-smokers and had similar baseline teeth color.
performed similarly in two patients: the only exception was
The patients were given the bleaching trays and the same
the type of bleaching gel employed. One of the patients
instructions about diet and hygiene. They were also instructed
(D.C.O., 25-years old) received a 4% hydrogen peroxide
on how to load the bleaching tray with the bleaching gel
gel (White Class 4%, FGM) and she was instructed to
and the period they should wear them (the posology of the
wear the bleaching tray for 2 hours daily. The other patient
bleaching gels was different from each patient).
(J.P., 27-years old) received 10% carbamide peroxide
The dental visits were scheduled every 5 days to
(Whiteness Perfect 10%, FGM) and she was instructed to
monitor the color change. One could notice that even using
wear the bleaching tray for 4 hours daily. The clinical and
low concentrations of bleaching gels, the treatment time
radiographic examination of the patients did not show any
was relatively short. Albeit the concentrations of active
condition that contraindicated the bleaching treatment.
hydrogen peroxide was very similar between the bleaching
Both patients had recently removed fixed orthodontic
gels, the 4% hydrogen peroxide gel reached clinically visible
appliances and had never had their teeth bleached because
results faster than the 10% carbamide peroxide gel. Both
of fear of experiencing tooth sensitivity, as they reported
patients had the same baseline tooth color; however the
feeling some discomfort when swallowing cold liquids.
patient using White Class 4% had their teeth whitened to
Eating habits were quite similar between both patients; they
B1 in a period of 10 days, while the patient using Whiteness
1a.
1b.
2a.
2b.
1 a-b. Baseline color of the patient J.P. The general teeth color was A2, while the upper canine was A4. 2 a-b. Baseline color of the patient D.C.O. The general teeth color was A2, while the canines were A3.
51
Perfect 10% did not present such a strong color change in
None of the patients reported bleaching-induced
the same period. After 20 days, both patients reached the
tooth sensitivity and gingival irritation during bleaching.
same teeth color with equivalent results.
In this treatment modality, the professionalâ&#x20AC;&#x2122;s contact with
3a.
3b.
3c.
4a.
4b.
4c.
5a.
5b.
5c.
6a.
6b.
7a.
7b.
3 a-c. 10% carbamide peroxide Whiteness Perfect (FGM) and 4% hydrogen peroxide (White Class 4%, FGM) gels were employed in the patients J.P. and D.C.O., respectively. 4 a-c. Teeth color of the patient J.P. after ten consecutive days of treatment with Whiteness Perfect 10% (FGM). One can notice slight change color. 5 a-c. Teeth color of the patient D.C.O. after ten consecutive days of treatment with White Class 4% (FGM). A general tooth color of B1 was observed. The clinical case was practically concluded. 6 a-b. Patient J.P. showing teeth with color B1 after ten consecutive days of treatment. Before and after pictures. 7 a-b. Patient D.C.O. after 20 days of treatment. Before and after pictures.
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the patient is very important, so that we can monitor
was unnecessary in the present clinical cases, but it is a
possible side effects. The change in the concentration
feasible alternative to accelerate the whitening to certain
of the bleaching gel used during the bleaching treatment
patients.
8.
9. 8. Extra-oral picture of the patient J.P. after the end of the treatment. 9. Extra-oral picture of the patient D.C.O. after the end of the treatment.
REFERENCES 1. Francci, C., Marson, F.C., Briso, A.L.F., Gomes, M.N. Clareamento dental – técnicas e conceitos atuais. Rev Assoc Paul Cir Dent, Ed. Esp, v. 1, p. 78-89, 2010. 2. De la Peña, V.A., Cabrita, O.B. Comparison of the clinical efficacy and safety of carbamide peroxide and hydrogen peroxide in at-home bleaching gels. Quintessence Int, v. 37, n. 7, p. 551-556, 2006. 3. Caballero, A.B., Navarro, L.F., Lorenzo, J.A. At-home vital bleaching: a comparison between hydrogen peroxide and carbamide peroxide treatments. Med Oral Patol Oral Cir Bucal, v. 11, e94-99, 2006. 4. Nathoo, S., Santana, E. 3rd., Zhang, Y.P., Lin, N., Collins, M., Klimpel, K., DeVizio, W., Giniger, M. Comparative seven-day clinical evaluation of two tooth whitening products. Compend Contin Educ Dent, v. 22, n. 7, p. 599-604, 2001.
53
Product available at 4%, 6%, 71/2% and 10% hydrogen peroxide also available in Kits and spare syringes. Each syringe containing 3g of gel.
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White Class is a dental bleaching system developed for sophisticated people that demand exclusivity and style on a daily basis. With a touch of refinement, the product accompanies a syringe case as well a tray case and a next appointment notepad with an exclusive design.
Youâ&#x20AC;&#x2122;re Worth it.
Maciel Jr. Specialist in Restorative Dentistry (Bauru School of Dentistry; University of S達o Paulo, SP, Brazil) MS in Restorative Dentistry (Araraquara School of Dentistry; University of the State of S達o Paulo, SP, Brazil)
Combined at-home and in-office dentist-supervised bleaching technique
INTRODUCTION The combined at-home and in-office bleaching technique associates the quickness of the in-office technique with the versatility of the dentist-supervised at-home protocol, bringing the benefits of both techniques for the patient. On some occasions, patients need a stimulus to discipline themselves to wear bleaching trays for the at-home dentistsupervised technique. An interesting strategy is to start the bleaching treatment with one in-office bleaching session. Once the patients perceive the initial results produce by the in-office bleaching, they become more motivated to adhere to the at-home protocol. Another benefit of the combination of techniques is the fact the result is achieved more quickly. Normally, when only the at-home technique is employed; the treatment extends for three to four weeks, while the combined technique reduces the treatment time to approximately two weeks. The technique generally has good patient acceptance, especially when the patient realizes the rapid initial result. This can transform an unruly patient in a collaborator.
1a.
1b.
2.
3.
1 a-b. Initial clinical condition. 2. Baseline shade recording (3R - Vita 3D). 3. Dental prophylaxis using a prophylactic paste.
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CLINICAL CASE REPORT This clinical case reports the treatment performed in a patient whose baseline color of the teeth was 3R (Vita 3D). The clinical and radiographic examination confirmed the presence of a healthy oral condition. For this clinical case, we suggested the combined bleaching technique. For the in-office protocol, we applied the Whiteness HP Blue 20% in a single clinical appointment of 50 minutes. The bleaching continued with the at-home technique. The patient was instructed to apply the product Whiteness Perfect 10% into the bleaching trays for a period of two weeks. The clinical result was satisfactory, achieving the shade of OM (Vita 3D). The patient reported very mild tooth sensitivity, probably owed to the low concentration of the active components in the two bleaching products selected.
4a.
4b. 4 a-b. Placement of a lip retractor (ArcFlex, FGM), and a light-curing gingival barrier (Top dam, FGM). The eventual lack of sealing of some areas can be remedied by applying more material followed by light-curing.
57
5.
6a.
6b.
7.
8.
9.
10.
5. Bleaching gel preparation. Mixing the contents of both phases (hydrogen peroxide and thickener) by pressing the plungers of the syringes alternatively in opposite directions up to eight times. 6 a-b. The gel was applied onto the enamel surfaces and left in place for 50 minutes as suggested by the manufacturer. This is only possible owed to the stable pH of the product; the pH does not reduce during the 50-min application period. The gel can be removed from the dental surfaces using an endodontic or surgical aspirating tip. 7. Bleaching result after a single in-office bleaching session. 8. Stone models and bleaching trays were prepared. The Whiteness Perfect 10% (FGM) was the product selected for bleaching. 9. Checking the adaptation of the bleaching tray. The patient was instructed to wear it for two weeks. 10. At the end of the procedure, the dental enamel was polished with felt disks (Diamond Flex, FGM) and diamond paste (Diamond Excel, FGM) to restore the enamel smoothness at the microscopic level.
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11a.
11b.
12. 11a-b. Resultados logrados luego de finalizado el tratamiento 12. Sonrisa de la paciente despuĂŠs del blanqueamiento con la tĂŠcnica combinada.
59
With just one application you will reach incredible results through your bleaching procedures and will also be able to count on the protection of the Ca++, which reduces patients sensitivity. Try Whiteness HP Blue and add more results and provide comfort to your in-office bleaching procedures.
Hidrogen Peroxide for in-office bleaching at 20 and 35%. Available in Kit, Mini Kit and spare syringes.
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Youâ&#x20AC;&#x2122;re Worth it.
Bruno Lippmann Undergraduate in Dentistry at Univille, Joinville (SC, Brazil) Student of the Specialization Course in Orthodontics of the Thum Institute of Post graduation and Bioresearch, Joinville (SC, Brazil)
In-office dental bleaching for improvement of the smile esthetics INTRODUCTION Dental tooth bleaching is considered a safe practice,1-6 and can be currently performed in different techniques to meet the patientsâ&#x20AC;&#x2122; preferences. The in-office dental bleaching is a quick and practical protocol and has been increasingly sought as a complement to various esthetic procedures performed daily in the dental office. This procedure is performed exclusively by a trained dental professional and employs more concentrate hydrogen peroxide bleaching gels than those used for at-home bleaching. Two to three bleaching sessions is usually required to complete a clinical case with moderate dental discoloration, which makes the procedure very attractive for patients with a very hectic life.
Rafael Cury Cecato Dentist and Specialist in Periodontics at Pontificia Catholic University (PUC, PR, Brazil)
As many dental procedures, a proper treatment planning should be conducted taking into consideration some local and systemic characteristics of the patients. Additionally, the clinician should monitor the clinical technique until the conclusion of the case. CLINICAL CASE REPORT A 23-year old patient was examined clinically to identify any factor that would contraindicate the bleaching protocol, such as presence of gingivitis, periodontitis, active caries lesion, restorations with lack of adaptation, tooth fracture or chipping, pulp pathologies, among others. The local contraindications can be managed before initiating the bleaching protocol. The patient reported good general health, and she was not pregnant or nursing an infant.
1.
2a.
1.Initial clinical condition. One can observe that the patientâ&#x20AC;&#x2122;s teeth have a very saturated chromatic appearance. Additionally, one can also visualize the presence of white and sparse stains in the enamel. 2 a-b. Recording teeth color: incisors were B2 and canines B3 (Vita).
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Before bleaching, dental prophylaxis was conducted for removal of the dental biofilm. After this step, we recorded the baseline color of the patientâ&#x20AC;&#x2122;s teeth through photographs and shade guides. This step aid in the treatment conduction and permitted the prediction of the number of clinical sessions required for the treatment (Figs. 1 to 2b). To prevent or reduce the bleaching-induced tooth sensitivity, a 5% potassium nitrate/2% sodium fluoride desensitizing gel (KF 2% Desensibilize, FGM) (Fig. 3) was applied before bleaching. This procedure was shown to be an effective measure without jeopardizing the bleaching result.7,8
2b.
3. 3. To prevent or reduce the bleaching-induced tooth sensitivity, Desensibilize KF 2% (FGM) was applied during 10 minutes before the bleaching protocol.
63
4.
5a.
5b.
6.
7a.
7b.
4. The lip retractor Arcflex (FGM) was placed in the patientâ&#x20AC;&#x2122;s mouth to provide lips, cheeks, and tongue retraction and thus, allow for easy access of the operative field. Then the light-curing gingival barrier (Top dam, FGM) was applied for soft tissue protection. 5 a-b. In-office 35% hydrogen peroxide bleaching gel (Whiteness HP Maxx, FGM). Initially, the gel has a red color that gradually becomes green indicating the progress of the chemical reaction. 6. Seven days after the first in-office bleaching session and before the beginning of the second bleaching session, one can observe a color change to A1 (Vita). 7 a-b. The clinical case concluded after three in-office bleaching sessions. Teeth reached a B1 or whiter color (Vita). The enamel stains, identified before bleaching, were minimized. 8. Harmonic smile, reaching patientâ&#x20AC;&#x2122;s satisfaction.
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8.
The lip retractor Arcflex (FGM) was placed in the patient’s mouth to allow easy access of the operative field (Fig. 4). Then, the light curing gingival barrier Top Dam (FGM) was applied for soft tissue protection. The 35% hydrogen peroxide gel (Whiteness HP Maxx, FGM) was prepared by mixing the active peroxide and thickener in a 3:1 proportion. The number of drops of each component depends on the number of teeth to be bleached. The product was applied on the teeth surface and left undisturbed for 15 minutes (Figs. 5a-b). Then, the product was removed and reapplied twice in the same clinical appointment, so that the gel remained on the enamel surface for a total of 45 minutes in each clinical session. A total of three in-office bleaching sessions were performed with a 7-day interval. We recorded the teeth color after each clinical session (Fig. 6), to monitor the progress of the bleaching treatment. We reached a satisfactory result after the accomplishment of the third in-office bleaching session (Figs. 7a-8), reaching the B1 color (Vita). REFERENCES 1. Collins, L.Z., Maggio, B., Gallaguer, A., York, M., Schäfer, F. Safety evaluation of a novel whitening gel containing 6% hydrogen peroxide and a commercially available whitening gel containing 18% carbamide peroxide in an exaggerated use clinical study. Journal of Dentistry, v. 32, p. 47-50, 2004. 2. Fugaro, J.O., Nordahl, I., Fugaro, O.J., Matis, B.A., Mjör, I.A. Pulp reaction to vital bleaching. Operative Dentistry, v. 29, n. 4, p. 363-368, 2004. 3. Giannini, M., Silva, A.P., Cavalli, V., Paes Leme, A.F. Effect of carbamide peroxide-based bleaching agents containing fluoride or calcium on tensile strength of human enamel. J Appl Oral Sci, v. 14, n. 2, p. 82-87, 2006. 4. Haywood, V.B. Frequently asked questions about bleaching. Compendium, v. 24, n. 4A, p. 324-337, 2003. 5. Haywood, V.B. Nightguard vital bleaching: indications and limitations. US DENTISTRY, p. 2-8, 2006. 6. Hirata, R. et al. Tips: dicas em odontologia estética. São Paulo: Artes Médicas, 2011. 576p. (1). 7. Tay, L.Y., Kose, C., Loguercio, A.D., Reis, A. Assessing the effect of a desensitizing agent used before in-office tooth bleaching. J Am Dent Assoc, v. 140, n. 10, p. 1245-1251, 2009. 8. Paula, E.A., Martins, G.C., Pereira, S.K., Gomes, O.M., Loguercio, A.D., Reis, A. In-Office Bleaching: Effect of Preliminary Use of a Desensitizing Agent. J Dent Res 90 (Spec Iss A): 559, 2011.
65
Larissa Cavalcanti Monteiro Dentist undergraduate at Federal University of Paraíba (PB, Brazil)
Enamel microabrasion for conservative removal of superficial white stains
INTRODUCTION Enamel white stains have often been observed in the daily clinical practice and patients have sought increasingly for esthetic management of this type of enamel alteration. Their etiology may be owed to demineralization produced by caries lesions or may result from dental fluorosis or enamel hypoplasia.1 Sônia Saeger Meireles MS and PhD in Restorative Dentistry at Federal University of Pelotas (RS, Brazil) Adjunct Professor at Federal University of Paraíba (PB, Brazil) Professor of the Post graduation Course in Dentistry at Federal University of Paraíba (PB, Brazil)
Currently, there is a great concern in relation to the development of conservative techniques for management of color changes and/or dental discolorations.2 The esthetic treatment of the various types of dental discolorations represents a great challenge for the dentist. After correct diagnosis of the dental discoloration, the professional can opt for performing the best treatment technique or for combining different protocols. To solve the staining caused by dental fluorosis, different acids associated with abrasive particles have been used in various enamel microabrasion techniques.3,4 The enamel microabrasion has been accepted as an extremely effective technique for removal of stains and surface enamel irregularities. There are several reasons for using this technique, such as safety, efficacy, minimally wear of the dental structure and esthetics.2,5,6 CLINICAL CASE REPORT This article reports the clinical case of the female, 10-year old patient R.J.S. with dental fluorosis in teeth 12,11, 21 and 22. According to the Modified Index of Developmental Defects of Enamel, the superficial opacities were classified as diffuse confluent, extending at least 1/3 and less than 2/3 of the enamel surfaces of the four anterior superior teeth (upper lateral and central incisors) and six anterior inferior teeth (from right canine to left canine) (Fig. 1). During anamnesis, the patient reported having received considerable topical fluoride applications during the period of dental formation. The average areas of the enamel opacities were 53.6 mm2 (Fig. 2). A sequence of figures will be presented to report the clinical steps performed for the management of this clinical case (Figs. 3, 4, 5, 6, 7, 8, 9). edition 6
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1.
2.
3.
1 and 2. Initial aspect of the enamel white stains. 3. Baseline picture took with a digital camera with a millimeter ruler.
67
4.
5.
6.
7.
8.
9.
10.
4 and 5. Commercial microabrasive paste employed (Whiteness RM, FGM). 6. Application of the microabrasive paste (Whiteness RM, FGM) on the entire buccal enamel surface of the four upper incisors. The material was scrubbed on the enamel surfaces with a rubber cup (12 applications). 7. Application of the microabrasive paste (Whiteness RM, FGM) on the entire buccal enamel surface of the six lower anterior teeth. The material was scrubbed on the enamel surfaces with a rubber cup (12 applications). 8. Enamel polishing with felt disks (Diamond, FGM) and diamond polishing paste (Diamond Excel, FGM). 9. At the end of the clinical session, 1,23% fluoride foam was applied for 1 min (Fluorcare, FGM). 10. Patientâ&#x20AC;&#x2122;s smile one week after the end of the treatment.
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At the end of treatment, the patient received oral and written information about oral hygiene and the need to avoid the intake of colorful food/beverages. After one week, one could notice that the extension of the opacities reduced to no staining (teeth 12, 11 and 21) to less than 1/3 of the enamel surface (other teeth). The final average area, covered by enamel opacities, was 17.9 mm2, representing a reduction of 66.6%. The patient reported being very satisfied with the result of the treatment (Fig. 10). REFERENCES 1. MATOS, A. B.; TURBINO, M. L.; MATSON, E. Effects of enamel microabrasion techniques: scanning electron microscopy study. Rev Odontol Univ São Paulo, v. 12, n. 2, p. 105-111 , abr./jun. 1998. 2. AROUCA, S.E.; ANDRADE, M.F.; HIRATA, R. Microabrasão do esmalte dental e clareamento dentinário como opção estética conservadora. Jbd Rev Ibero Americana Odontol Est Dent; v. 3, n. 9: 41-48, 2004. 3. BOSQUIROLI, V.; UEDA, J.K.; BASEGGIO, W. Fluorose dentária: tratamento pela técnica da microabrasão associada ao clareamento dental. UFES rev. odontol; v. 8, n. 1: 60-65, jan.-abr. 2006. 4. MEIRELES, S.S.; ANDRÉ, D.A.; LEIDA, F.L.; BOCANGEL, J.S.; DEMARCO, F.F. Surface Roughness and Enamel Loss with Two Microabrasion Techniques. The Journal of Contemporary Dental Practice, v. 10, n. 1, janeiro 2009. 5. HEIN, N.; WRBAS, K.T. Enamel microabrasion and in-office bleaching for fluorosis: a case report. Schweiz Monatsschr Zahnmed.; v. 117, n. 9: 947-56, 2007. 6. HIGASHI, C.; DALL’AGNOL, A.L.; HIRATA, R.; LOGUÉRCIO, A.D.; REIS, A. Association of enamel microabrasion and bleaching: a case report. Gen Dent.; v. 56, n. 3: 244-9, 2008.
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Lucas Silveira Machado Postdoctoral student of Restorative Dentistry (Department of Restorative Dentistry; Araรงatuba School of Dentistry; UNESP, SP, Brazil)
Clinical protocol for sealant application in pits and fissures
INTRODUCTION Dental caries, defined as a localized destruction of the dental tissues caused by bacterial acids, still affect a high proportion of the population mainly children and young adults.1,2 As it is considered an infectious and multifactorial disease, strongly influenced by fermentable carbohydrate of the diet (e.g. sucrose, starch), its control is difficult in some situations.1-7 Laura Molinar Franco MS student in Restorative Dentistry (Department of Restorative Dentistry; Araรงatuba School of Dentistry; UNESP, SP, Brazil)
The occlusal surface is an area highly susceptible to the development of caries lesions owed to the presence of grooves, pits and fissures which are of difficult hygiene (Fig. 1).5 In face of that, a caries lesion may start in pits and fissures shortly after teeth eruption, and may lead to tooth loss over time, if not prevented or treated.12 One of the preventive measures for these cases is through mechanical obliteration of such enamel defects by application of pit and fissure sealants,
Daniel Sundfeld Neto PhD student in Restorative Dentistry (Piracicaba School of Dentistry, University of Campinas - Unicamp, SP, Brazil)
1.
Renato Herman Sundfeld Full Professor in Restorative Dentistry. Department of Restorative Dentistry; Araรงatuba School of Dentistry; UNESP, SP, Brazil
1. Longitudinal sectioning of a premolar showing a caries lesion in the occlusal fissure (arrow). Optical microscopy Axiophot (Zeiss) with a x20 magnification. (E) Enamel (D) dentin. (Sundfeld, 2001 - Thesis).
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CLINICAL CASE REPORT that can be composed of resin, glass ionomer and resin-
The application of the sealant should be preferentially
modified glass ionomer. Several longitudinal studies
initiated after rubber dam isolation (Fig. 2), followed by
have demonstrated that this protocol is excellent, safe,
dental prophylaxis with pumice and water. We should
durable and effective to avoid the development and
employ a minimally invasive technique for the management
progression of caries lesions, allowing for considerable
of pits and fissures with localized chromatic alterations.
control of the cariogenic activity in this region.
Prior to occlusal sealing, a spherical carbide bur (#1/4; KG
1-4, 6-9
Therefore, the objective of this case report is to
Sorensen, Barueri, SP, Brazil) should be used only in the pits
describe a scientifically supported clinical protocol for
and fissures with chromatic alterations (Fig. 3 and 4). After
application of a pit and fissure sealant.
this step, dental prophylaxis is performed (Fig. 5) and then,
2.
3.
4.
5.
2. Rubber dam isolation of the teeth to be sealed with the sealant Prevent (FGM). 3. Minimally invasive technique for pits and fissures with chromatic alterations in the molar teeth; use of spherical carbide bur Âź (KG Sorensen, Barueri, SP, Brazil) only in the pits and fissures with chromatic alterations. 4. Occlusal surface after removal of the chromatic alterations. 5. Dental prophylaxis with pumice and water.
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6.
7.
8.
9.
10a.
10b.
10c.
10d.
10e.
10f.
10g.
10h.
10i.
6. Acid etching of the enamel for 30 seconds using a 37% phosphoric acid (Condac 37, FGM). 7. After acid etching, the enamel surface should present a white opaque appearance, free of contaminants. 8. Application of the sealant Prevent (FGM) in all pits and fissures, with the aid of an explorer. Contact areas in maximum intercuspidation should be avoided. 9. After light curing, the sealant adaptation and the occlusal contacts should be checked. When required, occlusal adjustments can be performed with abrasive rubber points. 10. Laboratory sequence for visualization of resin tags in polarized light microscopy. A – Pits and fissures of an extracted molar; B – Dental prophylaxis with pumice and water; C – Acid etching with 37% phosphoric acid (Condac 37, FGM); D – Total etching for 30 seconds; E – White-opaque aspect of the enamel after acid etching; F – Sealant application (Prevent, FGM); G – Sealant application on the entire occlusal surface; H – Light curing for 20 seconds; I – After sealant application, the tooth was sectioned with a cutting machine and the slices were polished down for visualization of the sealant adaptation and formation of the resin tags in polarized light microscopy.
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the entire enamel surfaces are conditioned with a 37% phosphoric acid gel (Condac 37, FGM). The material can be applied with an explorer under vibration for 30 seconds (Fig. 6). After copious water rinsing and air-drying (Fig. 7), the sealant (Prevent, FGM) should be applied in the pits and fissures with the aid of an explorer under vibration (Fig. 8). The material should be light cured for 20 seconds using a halogen or LED curing unit, with adequate light intensity (higher than 400 mW/cm2) (Fig. 9). When required, occlusal adjustments should be performed in maximum intercuspidation using a carbon paper. The patient should be seated in a way that to keep the occlusal plane parallel to the floor. The premature contacts, when presented, should be removed with a spherical diamond bur # 1014 (K.G. Sorensen) under high speed and water-cooling. After this step, the surface should be polished with abrasive rubber points. DISCUSSION According to the clinical studies published by Sundfeld et al. in 1990, 1992,3 1993,4 2001,3 2004,6 2006, 20078 e 2010,9 it is highly 1
recommended to perform a careful clinical radiographic examination of the teeth to be sealed, to achieve clinical success either using a resin or glass ionomer sealant. Teeth eligible for sealant application should be sound under clinical and radiographic examination and should not have chromatic alterations. When localized and small chromatic alterations are presented, which may be suggestive of incipient enamel lesions,10 the sealant can only be applied after removal of these areas with a spherical carbide bur 1/2 or 1/4 (K.G. Sorensen) under high speed, as performed in the present clinical case. It is noteworthy that teeth with extensive carious lesions that extend for all pits and fissures and reach dentin are not eligible for sealant application. Kramer et al. (199111 and 199712) considered that early-erupted teeth are the ideal candidates for sealant application. Besides that, it is debatable the concept that teeth that did not develop caries lesions during the first 2 years after eruption is contraindicated for sealing, since this concept is based only on the post-eruptive maturation factor. An individual does not become definitely protected against the development of caries lesions in occlusal surfaces during the next years, since there are many other factors that influence the development of caries lesions such as oral hygiene, occlusal anatomy, diet, and other secondary factors. The association of these factors can change a good patientâ&#x20AC;&#x2122;s oral healthy condition in a way that a low-risk patient can become caries active.13 On occasion, it is noteworthy that the incorrect application of the principles governing the sealing technique has been identified as a major and decisive factor for sealant failure. If clinicians will seal an occlusal
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11.
12.
13. 11. Longitudinal section of a posterior tooth after occlusal sealant application (Prevent, FGM). 12. Image sequence showing the adaptation of the sealant Prevent (FGM) in the fissures and the resin tags responsible for the micromechanical bonding of the sealant to enamel. (E) Enamel, (D) dentin (S), sealant for pits and fissures (Prevent, FGM), and (T) resin tags. Photos (a) x25 magnification, (b) x50 magnification, and (c) After enamel decalcification in x100 magnification. 13. After visualization of the sealant adaptation, the tooth was decalcified for visualization of the resin tags produced by the sealant Prevent (FGM) on the enamel surface. (T) Resin tags responsible for the micromechanical bonding of the sealant to enamel.
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surface, they should do it properly; otherwise, they should
REFERENCES
not do it.
1. Sundfeld, R.H. Análise microscópica da penetração — in vivo de selantes de fóssulas e fissuras; efeitos de tratamentos superficiais e materiais. Araraquara, 1990. 146p. Tese (Doutorado) — Faculdade de Odontologia de Araçatuba, Universidade Estadual Paulista.
1-4, 6-9
Sundfeld, in 2001,2 highlighted that the excellent clinical behavior of the occlusal sealings of their longitudinal
2. Sundfeld, R.H. A eficiência da aplicação de selantes na prevenção das lesões de fóssulas e fissuras: análise clínico-fotográfica e clínico-computadorizada. Araçatuba, 2001. 277p. (Tese Livre Docência) — Faculdade de Odontologia de Araçatuba, Universidade Estadual Paulista.
11-year clinical study was owed to the extreme accurate sealing technique performed. The authors strongly emphasized that the material was applied on conditioned,
3. Sundfeld RH, Mauro SJ, Komatsu J, Rahal S. Retenção dos selantes: avaliação clínica fotográfica: 18 meses de análise. RGO, v.40, n.6, p.424-6, 1992.
dry, and uncontaminated enamel surfaces. This fact surely
4. Sundfeld RH, Mauro SJ, Komatsu J, Rahal S. Análise clínica fotográfica da retenção de selantes de fóssulas e fissuras: 36 meses de análise. Âmbito Odontol, v.3, n.14, p.334-9, 1993.
contributed to the considerable retention of sealants employed. As the entire occlusal enamel was conditioned,
5. Serra MC, Pimenta LAF, Paulillo LAMS. Dentística e manutenção de saúde bucal. IN: KRIEGER, L. ABOPREV. Promoção de saúde bucal. 2.ed. São Paulo: Artes Médicas, 1999. 475p.
the sealant was not applied in non-conditioned areas, fact that would inevitably lead to marginal leakage around the
6. Sundfeld RH, Mauro SJ, Briso ALF, Sundefeld MLMM. Clinical/photographic evaluation of a single application of two sealants after eleven years. Bull Tokyo Dent Coll, v.45, n.2, p.67-75, 2004.
bonding interface. In this longitudinal clinical study,2 the authors reported that no sealant was lost and no caries
7. Sundfeld RH, Croll TP, Mauro SJ, Briso ALF, de Alexandre RS, Sundefeld MLMM. Longitudinal photographic observation of the occurrence of bubbles in pit and fissure sealants. J Appl Oral Sci, v.14, n.1, p.27-32, 2006.
lesion was detected around the sealants, regardless of the sealant composition and presence of fluoride.
8. Sundfeld RH, Mauro SJ, Dezan E Jr, Sundefeld MLMM. Measurement of sealant surface area by clinical/computerized analysis: 11-year results. Quintessence Int, v.38, n.7, p.384-392, 2007.
However, it is recommendable to take regular bitewing radiographs to control the patient’s oral hygiene,
9. Sundfeld RH, Briso ALF, Mauro SJ, de Alexandre RS, Sundfeld Neto D, Oliveira FG, Machado LS. Twenty Years Experience with Pit and Fissure Sealants. Int J Clin Dent, v.2, n.4, p1-12, 2010.
and to instruct the intelligent consumption of sucrose and fermentable carbohydrates to prevent the development
10. Eklund SA, Ismail AI. Time of development of occlusal and proximal lesions: implications for fissure sealants. J Public Health Dent, v.46, n.2, p.114-21, 1986.
of a caries lesion on the proximal surfaces. This clearly
11. Kramer PF, Fernandes Neto PG, Fernandes RM, Corrêa MSNP, Fazzi R. Selantes oclusais: revisão da literatura: os selantes oclusais, seus aspectos clínicos e a importância de um programa de prevenção. Rev Assoc Paul Cir Dent, v.45, n.3, p.473-7, 1991.
demonstrates that the dental caries are a multifactorial disease, where each factor has a specific function, being their interaction responsible for the development of the
12. Kramer PF, Feldens CA, Romano AR. Promoção de saúde bucal em odontopediatria: diagnóstico, prevenção e tratamento da cárie oclusal. 2.ed. São Paulo: ArtesMédicas, 1997. 144p
carious process.1,2 Within this context, occlusal sealing plays an
13. Croll TP & Sundfeld RH. Resin-based composite reinforced sealant. J Dent ChiId, v.66, n.4, p.233-8, 1999.
important role on the considerable progress in the caries disease eradication. This is a painless protocol and has good clinical acceptability. Additionally, it is considered a conservative adhesive procedure. CONCLUSION It can be concluded that sealant application is indubitably an effective and safe tool in the prevention of caries lesions when properly performed in occusal pits and fissures.
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www.fgm.ind.br/en
Youâ&#x20AC;&#x2122;re Worth it.
R&D
Section
A new idea
“The mind, once expanded to the dimensions of larger ideas, never returns to its original size” (Albert Einstein). It is within this context that FGM is now: a company that constantly invests in new areas and ideas. Is it an easy task? Definitely, it is not. Not only by the complexity of conquering new values, but also by the high investments required for staff qualification, consultants hiring, equipment purchase, partnership with universities, among others. To be able to support large projects, FGM has relied on FINEP partnership. FINEP is a Brazilian Innovation Agency from the Ministry of Science and Technology that aims to transform Brazil by promoting its economic and social development. This is achieved by the governmental sponsoring of funds for science, technology and innovation in companies, universities, technology institutes and other public or private institutions. Over the past 6 years, FGM had eight projects approved by FINEP, indicating that its model of strategic management is aligned to the country’s development policy. Among the strategic issues of interest to the government is the development of nanotechnology and biomaterials. In these areas, FGM has currently two large projects under development, whose products are planned to be release in the market in 2014, marking its debut in the biomaterials line. And what is behind this new idea? Osteoconductive biomaterials and Dental Implant System! But then, some people will ask us: Is this really a new idea? And our answer will be simply yes! Do you know why? Because these two projects are full of innovation with amazing results.
Osteoconductive biomaterials Are calcium phosphate-based materials all equal?
In the 13° edition of the FGM News we presented in
They may be in its chemical composition, but their
the section P&D, the Nano-P technology. This is a product
morphology (three-dimensional structure) can be quite
based on calcium phosphate nanoparticles, developed
different, which may alter the biological. Is the chemical
by FGM, with the aim to functionalize dental materials.
reaction rate of macro-particulate compounds the same
From this technology, we obtained hydroxyapatite (Hap)
as micro- or nanostructured compounds? Do genuinely
and β-tricalcium phosphate (β-TCP) nanoparticles and
macro-particulate compounds develop similarly to micro-
we combined them to produce an implantable synthetic
or nanostructured aggregates compounds? Do compact
biomaterial with the osteoconductive action for bone
structures induce the same cell attraction and viability as
replacement, called NanoSynt.
porous structures? What does the biology say?
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NanoSynt is a granular material (200-500 μm in
also modulates the rate of the biomaterial resorption by
diameter) based on the biphasic calcium phosphate (60%
providing suitable quantities of the biomaterial during the
Hap: 40% (β-TCP)). It is designed for dental professional
repair process (Figs. 2 and 3).
use for filling small-sized bone defects. The material is
When placed in contact with the bone, NanoSynt
resorbed and replaced by living bone tissue during bone
supports the regeneration of new bone tissue. The
remodeling with the aim to achieve a functional bone
material’s permeability allows for bone growth within the
reconstruction with a natural esthetic.
micro and nanostructured porosity. This 1) enables the
The great advantage of NanoSynt is the fact that the
nutrient transport to the bone tissue, accelerating their
product is composed of micro-particulate agglomerates
rate of formation and 2) permits the connection of bone
of nanostructured compounds containing interconnected
tissue under formation and/or newly formed bone with the
micro and nanostructured pores with an overall porosity
surrounding bone tissue.
rate of 80 to 90% (Fig. 1). This morphological pattern
From a biochemical point of view, the micro- and
has positively modulated the biological response of bone
nanoporous structure also allows for a better oxygenation
formation in qualitative, quantitative and chronological
of the newly formed bone tissue by the presence of specific
aspects. Aside from the stimulation of bone formation, the
chemical groups on the biomaterial interfaces.
differentiated morphology (nanostructured) of NanoSynt
A. NanoSynt (Hap: β-TCP/60:40).
B. Competitor 1: biphasic calcium phosphate material (Hap: β-TCP/60:40).
C. Competitor 2: Bovine hydroxyapatite-based biomaterial.
Figure 1. Characterization of the biomaterial for bone grafting in scanning electron microscopy.
A very-skilled look
110 110
Clinical studies in rabbit models, conducted by the
100 100
research group of Prof. Paulo G. Coelho from the New York
90 90
University (NYU), indicated that NanoSynt showed better
80 80
characteristics than two available commercial products
70 70 60 60
% %
that are considered the gold standard in the literature. Nanosynt promoted greater amount of bone formation,
50 50 40 40
which was observed in the early stages after bone grafting
30 30
(especially after four weeks in vivo) (Fig. 2).
20 20 10 10 0 0
1 22 1 le nntt oole SSyy nnttee nnttee nnttrr noo rrrree rrrere CCoo oo NNaan ccoo ncnc onon CC CoCo
Figure 2. Quantification of the non-mineralized tissue (soft tissue), remaining biomaterial for bone grafting, and newly formed bone in repair areas (critical defects in the calvaria of rabbits) after four and eight weeks in vivo. Groups analyzed: NanoSynt (FGM) (Hap:βTCP/60:40); Competitor 1 - biphasic calcium phosphate material (TCP :-Hap / 60:40) and; Competitor 2 - bovine hydroxyapatite-based biomaterial. Control group: blood clot. Source: Freitas GP, Tovar N, Coelho PG. New York University (NYU, USA).
semanas en vivo 44semanas in vivo
% Tejido no mineralizado % Biomaterial remanente % Hueso formado
79
--
22 11 le nntt oole ttee SSyy nnttee nnttrr eenn noo rrrree CCoo oorrrr NNaan ccoo ncnc onon CoCo CC
semanas en vivo 88semanas in vivo
“A better temporal healing pattern was observed with the biomaterial NanoSynt when compared to competitors one and two. During the period investigated, NanoSynt produced higher bone formation within the defect and a greater ability to maintain the defect space, which was assessed by the sum of the amount of the biomaterial into the defect and the amount of newly formed bone.” (Freitas GP, Tovar N, Coelho PG –New York University, USA)
Altogether, these results suggest an excellent performance of NanoSynt in humans. The material has an excellent osteoconductive action with differentiated performance throughout the repair process. Additionally, it also brings new perspectives for clinical treatment in the first post surgical quarter. These data show that A. 4 semanas en vivo.
NanoSynt is a functional material with optimized solubility in biological systems. This is owed to the surface area of the material be modulated by its nano-particulate feature and its nano texture morphology of interconnecting pores. Human clinical trials are underway. Additional data regarding the healing pattern of
B. 8 semanas en vivo.
NanoSynt show bone formation from the margins to the
Figure 3. Cross-sectional histological image showing the healing pattern of NanoSynt after four (A) and eight (B) weeks in vivo. The soft tissue is bluish-green, the mineralized tissue is red-orange, and the graft material appears in dark brown. Source: Freitas GP, Tovar N, Coelho PG. New York University (NYU, USA).
center of the repair area (critical defects in the calvaria of rabbits), at different periods of times in vivo (four and eight weeks) (Fig. 3). Interestingly, a bone bridge, joining the edges of the defect in their entire length, could be observed in early stages, after four weeks in vivo. This pattern was not observed with the competing materials
Liberación acumulativa de calcio (mMolar)
(data not shown). In the composition of NanoSynt, the Hap was shown to prevent the excessive material resorption because of its low absorption rate and this maintains the mechanical stability of the grafted volume. Meanwhile, due to its higher rate resorption rate than that Hap, the β-TCP stimulates the biological response in the early stages of bone formation process (Fig. 4). For NanoSynt,
Tiempo (Días)
this behavior is also influenced by the nanostructured
Figure 4. Calcium release from the different compositions of nanostructured calcium phosphate. Source: Coelho PG. New York University (NYU, USA).
morphology of the biomaterial.
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“The best temporal healing pattern described for the biomaterial NanoSynt is owed to its particle size, micro- and nano-scale pore configuration and the phase fraction of calcium phosphate. Altogether, these factors resulted in a very suitable three-dimensional framework for osteoconductivity, both in a macro-scale (due to their micro-texture) and micro-scale (maintenance of the defect area). Moreover, these features increase the stabilization of the blood clot and the subsequent interaction between the biomaterials and biological components during the evaluated in vivo periods.” (Freitas GP, Tovar N, Coelho PG –New York University, NYU, USA) Among the main advantages of the NanoSynt, one can cite: • The material is 100% synthetic contributing to biological safety; • The material has differentiated morphology (nanostructured agglomerates with interconnected micro and nanopores); • Optimized porosity favoring vascularization, osteoblast migration and bone deposition; • The material is gradually resorbed, thus preserving the bone volume; • The material has a granular structure facilitating the connection and interconnection of the material in the cavity (Fig. 5), and increasing its mechanical stability; • Biocompatibility;
Figura 5. Micro-computer tomography image, showing the packing profile of the material’s particles. Source: Coelho, PG. New York University (NYU, USA).
• Excellent wettability, and handling characteristics.
Dental Implants If one makes a closer look on today’s market of
is already ready, including the necessary validations for
dental implants, we can notice the available products
clean room. The certification of Good Manufacturing
share the same concepts. By studying this scenario, FGM
Practices and Control (CBPFC) of products for Health has
assessed another direction and made an unlikely option
already been obtained. Only few details are missing, and
into a patentable concept.
very soon we will be able to share and get these new values to you.
Imagine yourself working with a simplified dental multifunctional
Did you find it interesting? The novelty does not stop
characteristics! A system with well defined protocols
there, because our mind is always open to new ideas!
capable to permit surgical and prosthetic agility and
One thing is sure: again the FGM provides breakthrough
quickness. Think about it!
technology concept and guarantee to its products. After
implant
system
with
universal
and
all, you are worth it!
The new facility that will host the biomaterials area
DEPARTMENT OF RESEARCH & DEVELOPMENT, FGM DENTAL PRODUCTS If you want to share your opinion about this article or suggest new ideas to be addressed in future magazine issues, contact fgm@fgm.ind.br.
81
Daniel Gheur Tocolini Specialist in Pediatric Dentistry, OFM and Orthodontics
Direct bonding of an esthetic self-ligating orthodontic appliance
MS in Orthodontics at UNIARARAS (SP, Brazil) Coordinator of the Ortho Fast Self Ligation Center (Curitiba, PR, Brazil) Member of the Damon System. Coordinator of the Specialization Course in Orthodontics IMED/ THUM Joinville (SC, Brazil)
INTRODUCTION The orthodontic treatment consists of several essential steps for achieving success. One of the steps of utmost importance is the correct positioning of brackets and accessories, which are critical to maintain the bracket system features, yield more consistent results and reduce possible positioning errors. Therefore this provides a three-dimensional accuracy for the bonding step. With the development of pre-adjusted appliances, great importance has been given to bracket bonding. The reduction of positioning failures during Iduilton Grabowski Jr Specialist in Orthodontics MS in Orthodontics at UNIARARAS (SP, Brazil) Professor of the Specialization Course in Orthodontics IMED/ THUM Joinville (SC, Brazil)
this process resulted in an orthodontic treatment with greater agility to the professional, avoiding the need for archwire bending, and greater comfort to the patient, owed to the optimization of the process. The objective of this clinical case is to report a simple and precise indirect bonding of the esthetic self ligating system Damon Clear (Ormco, USA). CLINICAL CASE REPORT The indirect bonding of brackets begins after impression of the patientâ&#x20AC;&#x2122;s dental arches to obtain stone models (Fig. 1). This procedure is performed in two steps. The first stage is carried out in the laboratory, and the second in the patientâ&#x20AC;&#x2122;s mouth. First step: with the aid of a pencil and bracket positioner, one should identify in the stone model the area for the correct positioning of the brackets.
Ellena Ometto Antoniali Specialist, and MS in Orthodontics at FHO-UNIARARAS (SP, Brazil) Professor of the Specialization Course in Orthodontics IMED/ THUM Joinville (SC, Brazil)
After identification of these areas (Fig. 2), the brackets are bonded to the stone model with water-soluble glue. In this clinical case, we selected the esthetic self-ligating brackets system Damon Clear (Ormco, USA). After bracket bonding on the stone model (Fig. 3), a transfer tray is fabricated by covering the teeth and brackets with hot glue (Figs. 4a-c). edition 6
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2.
1.
3.
1. Stone models. 2. Pencil identification of the areas for correct bracket positioning. 3. The brackets were bonded on the stone models with water-soluble adhesive.
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After this step, the stone models are immersed in water
Second step: after completion of the first step, the
(Fig. 5). As the adhesive used for fixation of brackets on
transfer tray containing the brackets is positioned directly into
the stone model is soluble in water, the brackets debond
the patientâ&#x20AC;&#x2122;s mouth (Fig. 7) for adjustment check. If properly
easily form the stone model, but become bonded to the
adapted, the enamel surfaces are acid-etched (Condac 37,
transfer tray. To assist in the removal of the adhesive
FGM) for 30 seconds, water rinsed and air-dried.
from the bracket bases, we suggest the use of an air-
The bonding resin Orthocem (FGM) is applied at the
water spray (Fig. 6).
4a.
base of the brackets (Fig. 8); the transfer tray is positioned
4b.
4c.
5.
6.
4 a-c. A transfer tray was fabricated with hot adhesive to allow for transference of the brackets to the patientâ&#x20AC;&#x2122;s mouth. The transfer tray molds the stone model teeth and partially incorporates the brackets. 5. After fabrication of the transfer tray, the set is immersed in water for bracket debonding from the stone model. 6. The removal of the residual water-soluble adhesive from the bracket bases is performed using a water-air spray.
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and the brackets are gently pressed against the enamel
The indirect bonding technique increases the safety
surfaces. At this stage, the excess material is removed (Fig.
and accuracy of a critical step of the orthodontic treatment,
9). Then, a preliminary light curing is performed (Fig. 10).
minimizing bonding errors. The correct positioning of the
The transfer tray can be easily removed with an explorer
brackets on teeth facilitates the finalization of the case and
with slight pressure (Figs. 11a and 11b). To complete the
reduces the chair-side time for the patient.
case, the bonding resin should be additionally light-cured around the brackets.
7.
9.
8.
10.
11a.
11b.
7. Checking the adaptation of the transfer tray in the patientâ&#x20AC;&#x2122;s mouth. 8. Placement of the Orthocem adhesive (FGM) on the base of the brackets. 9. Adaptation of the transfer tray into the patientâ&#x20AC;&#x2122;s mouth. The enamel was previously acid etched with 37% phosphoric acid (Condac 37, FGM) and did not receive any bonding adhesive, since the Orthocem resin is a self adhesive resin. 10. The resin cement was light-cured for fixation of the brackets on the enamel surfaces. 11 a-b. Removal of the transfer tray. Visualization of the case after bracket bonding and archwire placement.
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Liliana Ávila Maltagliati PhD, and Professor of the Specialization Course in Orthodontics at the University of Sagrado Coração and PROFIS (Bauru, SP, Brazil)
Use of the Top Comfort resin (FGM) to substitute stainless steel stops used in the self-ligating bracket mechanics
INTRODUCTION The increasing use of self-ligating brackets in orthodontic practice requires professionals to handle a material with low friction. The absence of resistance to sliding on a wire produces mechanical differences that may offer Mauricio de Almeida Cardoso PhD, and Professor of the Specialization and Master of Science Courses in Orthodontics at the University of Sagrado Coração (Bauru, SP, Brazil)
advantages, but also has some complications that need to be identified. A clear example is the possibility of rotation of the leveling archwire, causing excess of wire in the distal of tube and lack of wire on the other side.1 This occurrence causes not only discomfort and injury to the soft tissues, but may limit or cause unwanted dental movements. The wires commonly used are pre-contoured and superelastics. Therefore, the movement of the orthodontic leveling archwire, transferring the midline to one of the sides, may move the pre-contoured curve of the canine regions to the region of the premolars, which may cause unnecessary and unwanted expansion in this region. To avoid this occurrence, we employ smaller diameter round wires called “stops”, which are appliances composed of small stainless steel telescopic tubes. They are found with sizes of about 2 to 3 mm long and should be
Leopoldino Capelozza Filho
inserted and kneaded in the archwire to adhered firmly to the wire, without the
PhD, and Professor of the Specialization and Master of Science Courses in Orthodontics at the University of Sagrado Coração (Bauru, SP, Brazil)
risk of changing the position.2 The strategic localization of these “stops” can influence the behavior of wire deactivation and straightening, promoting greater lateral or anterior movement of the teeth.1 Generally, when these devices are positioned in the anterior arch, near or within the midline, the low diameter wire, which has little resistance to sliding, can move to the channels of brackets positioned backwards, where it encounters less resistance. For wire rectification in a forward position, there is need to overcome the resistance of anterior teeth that perform a buccal movement as well as the muscular strength of the lips. edition 6
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As the friction is reduced and the posterior sliding
of a light-cured resin, although they are more prone to
resistance is lower, the wire loses length. Thus, the leveling
fracture. The stops made of stainless steel are more
archwire can rectify without causing protrusion of the
resistant to fracture and dislodgement as they deform
incisors. This may occur when there is more arch length, a
against the wire.
common condition with conventional brackets. Therefore,
In the midline region of the archwire, the resin can be
the indication of “stops” in the midline aims to provide
used as it is a low stress area, acting only by the presence
dental alignment and leveling in the first archwire without
and the mesial contact with the brackets in the upper
accentuated protrusion of the incisors. Antagonistically,
central incisors. In the posterior region, the wire itself will
when they are placed in the posterior region, the “stops”
be pressed, tending to rectify with a posterior sliding. If
will prevent the sliding to the distal end, forcing the dental
the wire is not resistant, it may break the “stop” or the
protrusion until the point where all the wire is rectified.
stop may slide through it without producing the desirable
3
By knowing the role of “stops” and the differential
effects. Therefore, in the posterior region the resistance of
character introduced by its location, it seems important
the “stop” material is very important.
to discuss how to execute them. They can also be made
In clinical tests, the resin Top Comfort (FGM) (Fig. 1) –
1.
1. Top Comfort resin (FGM)
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developed and commercially available to avoid injury to the
curing. The mechanical resistance of the resin was enough
soft tissues produced by brackets (Figs. 2a-c) and tubes
to resist the time between clinical sessions and allow easy
(Figs. 2d-f) – was employed as “stop” and showed very
removal by the professional with common pliers. In the
good results. According to the manufacturer,4 Top Comfort
clinical practice, the material has been show to have a
is a light curing resin for bracket protection and professional
high strength, making it likely suitable for other uses, such
application, which the aim to avoid injuries to the soft tissue
as “stops”.
produced by the contact of fixed appliances with the soft
Thus, aside from increasing patient comfort,
tissues. The Top Comfort is a light curing resin available in a
covering hooks of brackets and tubes, this material can
syringe that makes its application easy.
be still applied as “stops”. Depending on the goal and
The resin is bonded to the mechanical appliances
the moment of use, this light-curing resin can be applied
by mechanical interlocking and becomes rigid after light
after the placement of the archwire, resulting in a more
2a.
2b.
2c.
2d.
2e.
2f.
3a.
3b.
3c.
2. Placement of the resin Top Comfort directly on the hooks of the canines (a-c) and upper first molars (d-f). The primary objective of this material is to prevent injuries to the soft tissues caused by the metallic appliances of the orthodontic device. 3. Example of using the resin Top Comfort in the midline (a-e) as “stop” with the aim to promote dental alignment and leveling, and to incorporate all teeth in the first archwire without causing accentuated protrusion of the incisors.
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accurate positioning. This would reduce the time needed and provide more working comfort. It is noteworthy that the region where the resin is placed should be free of moisture and saliva contamination, so that the resin can be firmly adhered to the archwire without sliding. Thus, this resin can be used as â&#x20AC;&#x153;stopsâ&#x20AC;? in the following situations: 1. Midline region (Figs. 3a-e); 2. Mesial surface of upper and lower molars; 2.1. Unilateral use: for corrections of asymmetries in the arches; 2.2. Bilateral use: for maintenance of the arch perimeter.
3d.
3e.
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4a.
4b.
4c.
5a.
5b.
5c.
4. Example of using the resin Top Comfort (FGM) in the mesial side of the upper first molars (a-c), with the aim to keep the arch perimeter. 5. Example of using â&#x20AC;&#x153;stopsâ&#x20AC;? with the resin Top Comfort in the mesial region of the upper first molars with the aim to produce anterior protrusion. The resin is applied in the mesial region of the molars, checking the anterior activation, and prior to the complete archwire positioning â&#x20AC;&#x201C; which is inserted in the molar tubes, premolars, and canines (a-c). The brackets of the incisors should remain with their clips open, and only after this, the archwire is inserted in brackets of the incisors (d). Observe the archwire deflection in the mesial region of the tooth 12 (e).
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In this case, the resin should be applied to the mesial of the molars in the later stages of alignment (Figs. 4a-c); or with the aim to promote anterior protrusion. In this case, the resin should be applied prior to the complete positioning of the archwire - which is inserted into the tubes of the molars, premolars and canines – and the resin is applied to the mesial area of the molars checking the previous activation (Figs. 5a-c). The brackets of the incisors should remain with their clips open, and only after this, the archwire is inserted in the brackets of the incisor (Figs. 5d-e).
5d.
5e.
REFERENCES 1. Maltagliati, LA. Desmitificando a utilização dos STOPS. Rev Clinica Ortodontia, 2012, 11(1): Jan/fev/mar. 2. Bagden A. The damon system: questions and answers Clinical Impressions, 2005;14(1):413. 3. Harradine NWT., Birnie D. Self-ligating brackets: theory and practice Excellence in Orthodontics 2006: 197-222. 4. www.fgm.ind.br 15/07/2013.
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www.fgm.ind.br/en
Oppalis composite resin confers all requirements to enable you to reach excellence in indirect restorations, both on anterior and posterior teeth. Easy to sculpt, high polishing ability, provides mechanical resistance and a wide variety of shades among other characteristics, such features will transform your work into a master piece.
Intro Kit - 4 syringes 1 Condac 37 syringe 1 4-ml Ambar EA1, EA2, EA3, DA2
Basic Kit - 6 syringes EA1, EA2, EA3.5, DA2, DA3. T-Neutral Refil - 35 shades 5 translucent levels Shade Selection - 35 shades
Clinical Kit - 15 syringes 1 4-ml Ambar EA1, EA2, EA3, EB2, DA1, DA2, DA3, DB2, D-Bleach. T-Blue, T-Neutral, T-Yellow, E-Bleach, H, Opaque Pearl. VH
Youâ&#x20AC;&#x2122;re Worth it.
Edson Araujo Specialist, MS, and PhD in Restorative Dentistry at Federal University of Santa Catarina (SC, Brazil)
Color and form: the objectives of esthetic treatments
Professor of the Advanced Zenith Center of Continuing Education
INTRODUCTION The great importance of esthetic values is a real concern in the contemporary world. The resources and treatments available on the market reflect the search for a healthy and youthful appearance. Within the current proposed esthetic standard, the face is of great significance being the smile appearance essential. Besides symmetry, balance between harmony and subtlety, color and form are the two main goals and challenges of any esthetic treatment. Dental bleaching has become one of the first and/or more important steps in most ceramic and composite resin restorations. Among the restorative materials available in the market for rehabilitation of the dental form, these two materials have great importance. They have particular characteristics that should always be respected and explored by the dentist, according to need or priority demanded by each clinical situation. Thus, it is the professionalâ&#x20AC;&#x2122;s decision to correctly choose ceramics or composite resins for a specific clinical situation, so that we can take full advantage of the characteristics of these two different materials, optimizing the final clinical result. CLINICAL CASE REPORT The clinical case herein reported depicts the cosmetic treatment of a young patient who had discolored teeth and two esthetically impaired composite resin restorations (teeth 11 and 21). The proposed clinical treatment consisted of dental bleaching followed by the placement of two direct composite resin restorations. edition 6
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1a.
1b.
1c.
2a.
2b.
2c.
1 a-c. In different angles and magnifications, one can visualize the initial aspect of the patientâ&#x20AC;&#x2122;s teeth. Observe the lack of esthetics of the patientâ&#x20AC;&#x2122;s smile, because of the yellowish color of the teeth and the presence of restorations (teeth 11 e 21) with excessive wear and chromatic alterations (monochromatic restoration without brightness). 2 a-c. Photographs of the bleaching trays and the bleaching gel (Whiteness Perfect 16%, FGM) used for the bleaching treatment. Buccal view of the patient after at-home bleaching for 25 days.
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3a.
3b.
4.
5.
6.
7a.
7b.
7c.
3 a-b. Buccal and occlusal view of the patientâ&#x20AC;&#x2122;s teeth after removal of the defective restorations and selection of composite resin color. 4. Buccal view after restorative assay to confirm the color of the composite resins selected. 5. Rubber dam isolation. 6. Checking the adaptation of the silicone guide. 7 a-d. Acid etching (Condac 37, FGM) and adhesive application (Ambar, FGM).
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7d.
8a.
8b.
8c.
8 a-c. Placement of a resin composite increment (Opallis E-Bleach H, FGM) on the silicone guide for restoration of the palatal enamel. The silicone guide was then positioned on the tooth, and the resin increment light-cured.
99
9.
10a.
10b.
11.
12.
13.
14.
15.
9. Buccal view after removal of the silicone guide. The length, width, design/form of the incisal edge and proximal contacts were practically defined. 10 a-b. Buccal view after placement of a resin composite increment (Opallis DB3, FGM) to reproduce the opaque halo of the incisal edge. Buccal view after reconstruction of the opaque halo. 11. Buccal aspect after placement a resin increment (DA3) for restoration of the body and dentin lobules. 12. Buccal view after placement of a composite resin increment (T-Blue) for reproduction of the opalescent effect in the incisal and proximal areas. 13. Buccal aspect after placement and light curing of the first composite resin layer (E-Bleach H) for restoration of the buccal enamel. 14. Photograph with higher magnification showing the application of a white dye to reproduce the subtle enamel hypoplasia stains presented in the neighboring teeth. Observe that a brush with a tapered edge was used for this purpose. 15. After application and light curing of the white dye, a last enamel composite layer was applied on the entire buccal surface of the restoration. During this step, we employed a special brush to smooth the superficial composite resin of the restorations.
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16a.
16b.
17a.
17b.
16 a-b. Sequential photographs were taken during the initial finishing of the restorations with abrasive disks of decreasing coarseness (Diamond Pro, FGM). 17 a-d. Delimitation of small markings with graphite, to set the correct positioning of developmental grooves and vertical ridges. Sequential photographs were taken during delimitation of grooves and vertical ridges with an extrafine diamond bur (KG Sorensen) and abrasive rubber points.
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17c.
17d.
18a.
18b.
19a.
19b.
20.
21a.
18 a-b. Sequential view during proximal finishing with abrasive strips (Epitex). 19 a-b. Buccal view during the demarcation of small details and incisal recontouring of the restorations. A photographic image was taken showing the reproduction of the restoration texture (horizontal texture) with an extra-fine diamond bur (#2135FF, KG Sorensen). 20. Image of the felt disks (Diamond Flex, FGM) used with sequential polishing pastes for the achievement of a high brightness and final polishing of the restoration.
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21b.
21c.
21 a-c. In a higher magnification, one can see the buccal view after conclusion of the restorative treatment. In different angles and magnifications, the final aspect of the restoration. Observe the natural esthetic result obtained.
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Mônica Kina Specialist, MS, and PhD In Restorative Dentistry, UFSC (SC, Brazil) Specialist in Periodontics - APCD – Araçatuba (SP, Brazil) Professor of Dental Materials and Restorative Dentistry of the School of Dentistry – UNICASTELO (Campus Fernandópolis)
Composite resin restoration with Opallis (FGM) in a posterior tooth INTRODUCTION The replacement of posterior restorations can be required owed to
Juliana Kina Specialist, MS, and PhD at Araçatuba School of Dentistry, UNESP, SP, Brazil Specialist in Periodontics - APCD - Araçatuba (SP, Brazil)
secondary caries, tooth sensitivity, fracture of the restoration, or remaining dental structure, patient’s esthetic demands, among other reasons. Direct composite resin restorations have many advantages. It is a simple, easy, and more conservative technique than amalgam restorations and indirect procedures. However, to reach clinical success, the clinicians should carefully choose the appropriate adhesive system, and perform a very accurate clinical protocol, respecting the indications and features of the material. A clinical
Aubrey Fernando Fabre
protocol for placement of a direct composite resin restoration in a Class II cavity
Specialist, MS, and PhD at Araçatuba School of Dentistry, UNESP, SP, Brazil
with the composite resin Opallis (FGM) is described in this article. CLINICAL CASE REPORT A 33-year old, female patient reported tooth sensitivity owed to the fracture of the disto-occlusal area of the restoration in teeth 46 (Fig. 1). After
Humberto Carlos Pires MS in Restorative Dentistry at Bauru School of Dentistry, USP, SP, Brazil Professor of Dental Materials and Restorative Dentistry of the School of Dentistry – UNICASTELO (Campus Fernandópolis)
clinical and radiographic examination we opted for the replacement of the restoration with the direct composite resin Opallis (FGM).
Ovídio César Lavesa Martins MS in Biomaterials at the University of Vale do Paraíba (UNIVAP, PB, Brazil) Professor of Dental Materials and Restorative Dentistry of the School of Dentistry – UNICASTELO (Campus Fernandópolis)
Nagib Pezati Boer MS in Health Sciences – FAMERP (SP, Brazil) Specialist in Restorative Dentistry – Araçatuba School of Dentistry, UNESP (SP, Brazil) Professor of Dental Prosthodontics and Coordinator of the Course of Dentistry – UNICASTELO (Campus Fernandópolis)
1.
2.
1. Clinical aspect of the tooth 46. 2. Selection of the composite resin color DA3 for dentin and EA2 for enamel.
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After anesthesia, dental prophylaxis was performed with pumice, water and a rotating brush. Then, we selected the composite resin color by light-curing a small increment of the composite resin Opallis DA3 in the occlusal surface of the tooth (Fig. 2). Rubber dam isolation was performed to control the moisture, and facilitate the removal of the defective restoration (Figs. 3 and 4).
3.
4. 3. Rubber dam isolation. 4. Aspect of the cavity after removal of the defective restoration.
105
5.
6.
7.
8.
9.
5. Placement of the metallic matrix and elastic wedge. 6. Acid etching with 37% phosphoric acid (Condac 37, FGM). 7. Adhesive application. 8. Light-curing. 9. Placement of composite resin increments for reconstruction of the distal wall of the cavity.
A metallic matrix and elastic wedge were positioned
resin (Opallis, shade DA3) were adapted in the proximal
in the distal area of tooth 46 (Fig. 5). The cavity was
box to reconstruct the distal wall. Each increment was
acid etched with 37% phosphoric acid (Condac, FGM).
light-cured for 20 seconds (Fig. 9). After this step, the
The acid was applied for 30 seconds on enamel and
metallic matrix and elastic wedge was removed and the
the conditioning was extended 2 mm beyond the cavo-
body of the cavity was incrementally filled. Again, each
surface margin. The dentin surfaces were conditioned for
increment was light-cured for 20 seconds (Fig. 10).
15 seconds (Fig. 6).
The final layer, representative of the enamel surface,
After rinsing with an air-water spray for 60 seconds,
was incrementally placed with composite resin increments
the cavity was dried with the aid of a cotton pellet and air
(Opallis EA2). The entire restoration was light cured for 60
stream, and the two-step etch-and-rinse adhesive Ambar
seconds. Then, the rubber dam isolation was removed,
(FGM) was applied according to the manufacturerâ&#x20AC;&#x2122;s
occlusal adjustments performed and the restoration was
recommendations (Fig. 7). The material was light cured
submitted to finishing and polishing procedures. The
for 30 seconds (Fig. 8).
immediate aspect of the restoration can be seen in Figure
The first increments of the micro-hybrid composite
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10.
11.
10. Aspect of the restoration after incremental filling with Opallis DA3, used to restore the occlusal dentin. 11. Final aspect of the restoration after placement of the composite resin EA2, occlusal adjustments and final polishing. One can see an excellent esthetic result.
CONCLUSION LDirect composite resin restorations promote excellent functional and esthetic results as long as they are carried out with an accurate technique and good restorative materials. REFERENCES BERNARDON, J.K. Avaliação Comparativa das propriedades físio-mecânicas de diferentes resinas compostas. 2007. 114f. Dissertação (Mestrado). Programa de Pós graduação em Odontologia, Universidade Federal de Santa Catarina, Florianópolis. BERNARDON, J.K. Avaliação Clínica de uma Resina Composta em Restaurações de Dentes Posteriores: 18 meses. 2008. 114f. Tese (Doutorado). Programa de Pós graduação em Odontologia, Universidade Federal de Santa Catarina, Florianópolis.
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RogĂŠrio Luiz Marcondes Specialist in Restorative Dentistry FAB - PUC (PR, Brazil)
Esthetic restorations in the daily practice: is it possible?
Professor of the Dental Esthetic Training - Curitiba (PR, Brazil) Clinical Director of the Dental Esthetic Center - Curitiba (PR, Brazil) Fellow in Esthetic Dentistry by the Ohio State University (EUA) Vice-president and Member of the Brazilian Association of Esthetic Dentistry (SBOE)
INTRODUCTION For esthetic demands, the placement of composite resin restorations provides a conservative, efficient, and safe alternative protocol when adequately used within its indications. The major challenge during minimally invasive protocols with any restorative material is to mask the interface between teeth and restorative material without wearing the remaining dental structure, or performing an excessive resin overcontour. Another challenge when using composite resins is the proper application of adhesives, since failures in the adhesive protocol can lead to marginal discoloration and adhesive failure in a short period. In this article, we discuss the use of the composite resin system Opallis (FGM) associated with the
Henrique de Castro e Souza Pires Dentist undergraduate at Pontificia Catholic University (PUC - PR, Brazil) Professor of the Dental Esthetic Training - Curitiba (PR, Brazil) Member of the Clinical Staff of the Dental Esthetic Center - Curitiba (PR, Brazil)
adhesive Ambar (FGM) for the rehabilitation of two fractured maxillary central incisors. CLINICAL CASE REPORT A 25-year old patient sought for dental assistance, as he was unsatisfied with the aspect of the restorations in his tooth 11 and 21. These restorations were placed 4 years earlier because of dental trauma. The clinical examination was performed and we noticed the presence of discolored restorations with inadequate anatomy (Figs. 1-2). Both teeth had pulp vitality, absence of dental mobility and no changes or signs of root fracture was noted in the periapical radiographic examination. The treatment plan was the following: 1. Dental prophylaxis. 2. Dentist-supervised in-office and at-home bleaching. 3. Dental impression for diagnostic wax-up. 4. Removal of the defective restorations. 5. Placement of composite resin restorations. 6. Finishing and polishing procedures. edition 6
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The treatment began with dental prophylaxis. Then,
Before in-office bleaching, we applied the desensitizing gel
we recorded the color of the patientâ&#x20AC;&#x2122;s teeth (Fig. 3) before
Desensibilize KF 2% (FGM) for 10 minutes, to prevent the
starting the dental bleaching protocols. The combined in-
bleaching-induced tooth sensitivity during treatment (Figs.
office and at-home bleaching techniques was performed.
4-6).
1.
2.
3.
4.
5.
6.
1. Initial clinical case, showing the patientâ&#x20AC;&#x2122;s smile. 2. Intraoral initial view of the clinical condition. 3. Checking the baseline teeth color. 4. Placement of the lip retractor Arcflex (FGM). 5-6. Application of the desensitizing gel Desensibilize KF 2% (FGM) before in-office bleaching.
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Two sessions of dentist-supervised in-office bleaching
13-16). The diagnostic wax-up was conducted to restore
were performed with the bleaching gel Whiteness HP
the incisal edge anatomy and close the diastema between
BLUE 35% (FGM) for 45 minutes in each application (Figs.
the two teeth. A silicone guide (Zetalabor, Zhermack, Italy)
7-12). The interval between these two in-office bleaching
was then prepared by performing the impression of the
sessions was 30 days. Meanwhile, the patient performed
wax-up model to transfer the new dental anatomy to the
the at-home bleaching with the Whiteness Perfect 10% for
patientâ&#x20AC;&#x2122;s mouth.
60 minutes daily.
Rubber dam rubber isolation, which is a very
The restorative procedures were delayed for 10 days
important step in adhesive procedures, was performed and
with the aim to provide color stabilization and also allow for
used throughout the restorative procedure. As the success
(Figs.
of an adhesive procedure depends on the professionalâ&#x20AC;&#x2122;s
the release of oxygen from the dental structures.
2,3
7.
8.
9.
10.
11.
12.
7. Protection of the gingival tissues with the light-curing gingival barrier Top Dam before bleaching. 8-10. Application of the bleaching gel Whiteness HP BLUE 35% (FGM) for 45 minutes. 11-12. Removal of air bubbles produced by the chemical reaction of the hydrogen peroxide with the hard dental tissues.
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13.
14.
15.
16.
13. Recording the teeth color after bleaching. 14. Patientâ&#x20AC;&#x2122;s smile after bleaching. 15-16. One can observe color and adaptation mismatch of the defective restorations with the teeth. Additionally, one can observe an excessive composite resin overcontour.
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knowledge about the characteristics of the dental tissues,
etched with 37% phosphoric acid (Condac 37, FGM) for
the acid etching step should be carried out with very careful
15 seconds. Then, the dental surfaces were rinsed out
attention. The acid etching time, the method of adhesive
for 30 seconds and the excess water removed with an
application as well as the light-curing steps should be
endodontic aspirating tip (Figs. 17-20). On a moist surface,
respected to avoid post-operative sensitivity and to
a 2% chlorhexedine solution (Chlorhexedine S, FGM) was
guarantee a high quality and long-lasting bonding.
applied for 30 seconds, with the aim to inhibit the action of
In this clinical case, the two-step etch-and-rinse
the matrix metaloproteinases (MMPs), which are a class of
adhesive Ambar (FGM) was employed. After the removal
proteases involved in the degradation of the resin-dentin
of the defective restoration, the dental surfaces were acid
bonded interfaces (Fig. 21).
17.
18.
19.
20.
21.
22a.
17. Rubber dam isolation was used throughout the restorative procedure. 18. The removal of the defective restorations wad performed with fine-grit diamond burs to avoid excessive wear of the dental structure where the overcontour was performed. 19-20. The acid etching was performed for approximately 15 seconds in the remaining dental structure with 37% phosphoric acid (Condac 37, FGM). 21. Before adhesive application, one drop of 2% chlorhexedine (Chlorhexedine S, FGM) was applied on the dental surfaces to inhibit the activity of matrix metaloproteinases, which are proteases involved in the degradation of the resin-dentin bonds. 22a-b. Application of the two-step etch-and-rinse adhesive Ambar (FGM) on a slightly moist dental surface.
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The excess of chlorhexedine solution was removed
a silicone guide (Figs. 24-25) the palatal enamel was
with the endodontic aspirating tip and the adhesive Ambar
reconstructed. Then, the dentin color Opallis DA2 (FGM)
(FGM) was applied on the dental structures. Before light
was applied in the middle third of the tooth, while the
curing, the material was left on the dental surfaces for 30
Opallis DA1 was used in the incisal third for reproduction
seconds to allow for solvent evaporation. The use of a slight
of the dentin mamelons (Fig. 26). After light curing the
air stream facilitates solvent evaporation and improves the
dentin increments, an effect resin (Opallis T-Blue) was used
quality of the adhesive interface (Figs. 22-23).
in the mesial and distal buccal ridges and between dentin
The first composite resin layer used was Opallis
mamelons. The effect resin Opallis T-Orange (Fig. 27) was
T-Neutral (FGM). By placing this resin on the surface of
used between the dentin mamelons. Effect resins were
22b.
23.
24.
25.
26.
27.
23. Adhesive light curing for 20 seconds. 24-25. A composite resin increment (Opallis T-Neutral, FGM) was placed on the surface of the silicone guide (Zetalabor, Zhermack) and the material was transferred to the teeth for reconstruction of the palatal surface. 26. Reconstruction of the middle third of dentin with Opallis DA2 (FGM). Reconstruction of the incisal third, and dentin mamelons with Opallis DA1 (FGM). 27. The effect resin Opallis T-Blue (FGM) was applied in the mesial and distal ridges of the buccal surface and between the dentin mamelons. The effect resin Opallis T-Orange (FGM) was applied on the dentin resin used to reproduce the dentin mamelons.
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used to create a visual sense of depth in the restoration
The composite resin excess, re-anatomization and
and simulate the opalescence and counter-opalescence
smoothing of the dental surfaces were performed with
phenomenon. An increment of Opallis EA1 was used to
the abrasive disks Diamond Pro (FGM) with decreasing
reproduce the entire buccal enamel surface and also used
coarseness (Fig. 30). To reproduce the dental surface
in the proximal area (Figs. 28-29).
texture, the restoration surfaces were marked with a colored
28.
29.
30.
31.
32.
28. One increment of Opallis A1 (FGM) was applied on the buccal surface to reproduce the enamel surface. 29. Aspect of the restorations immediately after the end of the restorative procedure. 30. The preliminary finishing, the demarcation of the plain area and the teeth form were performed with the abrasive disks Diamond Pro (FGM) with decreasing coarseness. 31-32. Refining the superficial enamel texture.
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pencil to avoid permanent restoration staining (Figs. 31-32).
diamond paste Diamond R (FGM) (Fig. 33). The restorations
Before final polishing, abrasive rubber points should
were re-evaluated in a second clinical appointment to
be used to smooth the abrasive risks produced by the burs
allow for complete teeth rehydration. We could observe an
during surface texture. The final polishing was performed
excellent composite resin polishing and a perfect matching
with the felt disks Diamond Flex (FGM) associated with the
between the teeth and restoration (Figs. 34-38).
33.
34.
35.
36.
37.
33. The polishing procedure was performed with the felt disks Diamond Flex (FGM), and with the diamond paste Diamond R (FGM). 34-38. The restoration was concluded. Observe the bright and good matching of the composite resin Opallis (FGM) with the dental structures.
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38.
CONCLUSIÓN
REFERENCES
Currently, it is possible to achieve a very satisfactory
1. Kose C, Reis A, Loguercio AD. Rev Assoc Paul Cir Dent. 2010;64(5):352-54.
esthetic result with composite resins. The treatment plan
2. Machado JS, Candido MSM, Sundfeld RH, Alexandre RS, Cardoso JD, Sundefeld MLMM. The influence of time interval between bleaching and enamel bonding. J Esthet Restor Dent. 2007;19(2):111-8
of each case is critical for clinical success. The knowledge of the material’s limitations and techniques used in the daily
3. Cadenaro M, Breschi L, Antoniolli A, Mazzoni A, Di Lenarda R. Influence of whitening on the degree of conversion of dental adhesives on dentin. Eur J Oral Sci 2006;114:257–62.
practice permits the correct indication of the materials to achieve clinical success in any treatment level.
4. Carrilho MRO, Geraldeli S, Tay FR, De Goes MF, Carvalho RM, Tjaderhane L, Reis AF, Pashley DH. Chlorhexidine Preserves In Vivo Hybrid Layers. Transactions Academy of Dental Materials. 2006.
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www.fgm.ind.br/en
Ambar reveals the high technology applied to FGM products, since it is the first national adhesive with MDP technology, despite containing nanoparticles which will ensure high performance throughout restorations. You will see there is no mystery in performing safe and resistant procedures. Available in 4 and 6 ml.
Youâ&#x20AC;&#x2122;re Worth it.
Juan Carlos Pontons-Melo Specialist, and MS in Restorative and Esthetic Dentistry (Bauru School of Dentistry, University of SĂŁo Paulo, SP, Brazil) Professor of Restorative and Esthetic Dentistry - EO-UPC e FE-UCSUR, Lima (Peru)
Improving patientâ&#x20AC;&#x2122;s smile by minimally invasive procedures
INTRODUCTION Currently, the concepts of esthetic dentistry have risen significantly within Dentistry. Patients have increasingly searched for teeth with a greater natural appearance and harmony with the face. Owed to the development of new techniques and advances in restorative materials, clinicians can restore dental esthetics and function with minimal, or even no teeth wear.1-3 These techniques are predictable and present good longevity.3-6 Additionally, the development of restorative materials brought a variety of composite resin systems, allowing for the use of different combinations of resins with different colors, saturations, translucencies and opacities. Specific details on existing natural dentition can be now reproduced1 while maintaining appropriate color stability and wear resistance over time.2 In the interim, new cosmetic and conservative techniques for the management of tooth discoloration have also become available for clinicians. Among them, it is very common the enamel microabrasion and dental bleaching. The principles of enamel microabrasion were firstly described by Croll.11,7 in this protocol, the very superficial enamel surface is removed by an erosive agent, exposing a deeper enamel layer with normal characteristics.8 This treatment is considered a fast, safe and atraumatic procedure.9 The objective of this article is to describe a clinical case of a patient who was unsatisfied with the esthetic appearance of their anterior teeth. To restore the harmony of the smile, we have performed direct composite resin restorations associated with the ultraconservative enamel microabrasion technique.
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CLINICAL CASE REPORT A patient sought for dental treatment complaining
examination, study models were prepared and used for
about the color, inadequate proportion of their teeth and
treatment planning. This consisted in performing enamel
the presence of a dental diastema, which compromised
microabrasion followed by the placement of adhesive
the appearance of his smile. During the evaluation, one
restorations in the maxillary anterior teeth for diastema
could notice dental discoloration and irregularities on the
closure and dental re-anatomization.
enamel surface along with a lack of esthetic spacing ratio
Initially, dental prophylaxis of all dental surfaces was
between teeth. After
clinical,
performed with pumice and water and a Robinson brush. radiographic
and
photographic
Enamel microabrasion was performed in the buccal
1.
2a.
2b.
2c.
1. Initial clinical situation showing the inadequate anterior-superior relation of the teeth with the lips as well as the presence of diastema and dental discoloration. 2 a-c. A close view of the clinical situation highlights the esthetic dental alterations.
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surfaces of all anterior-superior teeth using an abrasive
of the study model to the patientâ&#x20AC;&#x2122;s teeth and allow for an
paste composed of 12% hydrochloric acid and silicon
effective communication with the patient (Fig. 5). Before
carbide (Whiteness RM, FGM), with the aim to remove
rubber dam isolation, we determined the patientâ&#x20AC;&#x2122;s teeth
dental stains (Fig. 4).
color with a shade guide (Opallis, FGM) (Fig. 6). The
A diagnostic waxing was then performed and a
enamel surfaces were sandblasted with aluminum oxide
silicone guide was prepared. The aim of this guide was to
and abrasive disks (Diamond Pro, FGM) to expose a more
allow for the transference of the new anatomic dimensions
reactive enamel surface (Fig. 7). Then, the surfaces were
3.
4.
5.
6.
7.
3. The lateral view of the study model permits the evaluation of the teeth position and symmetry. 4. Enamel microabrasion (Whiteness RM, FGM) for removal of dental stains. 5. Diagnostic waxing for evaluation of the dental re-anatomization, communication with the patient and silicone guide build-up. 6. Shade guide (Opallis, FGM) for color matching. 7. Preparation of the dental surfaces for restoration.
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treated with phosphoric acid (Condac 37, FGM) for 30
and adapted on the patientâ&#x20AC;&#x2122;s teeth for conformation of the
seconds (Fig. 8) and the adhesive was applied according
palatal dental surfaces. This allowed for the determination
to the manufacturerâ&#x20AC;&#x2122;s instructions (Fig. 9).
of the new cervical-incisal height of the teeth (Figs. 11
The composite resin placement followed the
and 12). After removal of the resin composite excess, we
stratification technique (Opallis, FGM) (Fig. 10). For the
light-cured the material for 20 seconds. The artificial resin
first resin increment, a very thin layer of translucent enamel
dentin (Opallis DA3, FGM) was placed and sculpted over
(Opallis T-Neutral, FGM) was applied on the silicone guide
the first resin increment.
8.
9.
10.
11.
12.
8. Acid etching with 37% phosphoric acid. 9. Application of the adhesive system after water rinsing and drying. 10. Composite resin Kit (Opallis, FGM). 11. Application of a thin layer of translucent resin on the silicone guide to reproduce the palatal surfaces. 12. Intra-oral view immediately after the placement of the palatal layer.
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The last increment, which corresponded to the
whereas the achromatic resin was used to reproduce
artificial enamel layer, was restored with the chromatic
the incisal third and buccal enamel ridges (Fig. 13) of the
(EA1 and EA2 Opallis, FGM) and achromatic (Opallis
teeth. These layers were carefully placed and flattened
VH, FGM) resins. These two chromatic resins were used
with the aid of a spatula and a flat-tip brush.
for the cervical and middle third of the proximal areas,
The resin increments were subsequently light-cured,
13.
14.
15.
16.
17.
18.
19.
20.
21. 13. Placement of the chromatic and achromatic resins for reproduction of the enamel surface. 14. Checking the new cervical-incisal height and dental dimensions, flattened during diagnostic step. 15. Initial finishing with abrasive disks (Diamond Pro, FGM). 16. Finishing with a multi-laminate bur. 17. Polishing of the proximal surfaces with a goat-hair brush. 18. Final polishing with a felt disk (Diamond Flex, FGM) and diamond paste (Diamond Excel, FGM). 19. Buccal view showing the final result obtained with the sculpture and composite resin stratification. 20. Final aspect of the composite resin restorations showing a very natural aspect and excellent esthetic result. 21. 36-month follow-up showing the excellent behavior of the composite resin used in the restorative protocol.
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according to the manufacturer’s instructions. After the end of this step, we placed the silicone ced into position again to check whether or not the originally planned dental re-anatomization and the cervical-incisor height were re-established (Fig. 14). Once this process was finished, the initial finishing (primary anatomy) was accomplished by removing the resin composite excess with a scalpel blade #12, abrasive disks (Diamond Pro, FGM) and abrasive strips (Fig. 15). In another clinical appointment, after teeth rehydration, the final finishing and polishing procedure was performed with fine-grit and multi-laminate burs (Fig. 16) coupled in a 1:4 torque multiplier hand-piece to allow for an adequate control of the composite finishing. Abrasive rubbers were used in descending order of coarseness, to minimize the minor irregularities left during the finishing step. The final brightness was achieved by application of felt brushes and wheels (Diamond Flex, FGM) with a diamond polishing paste (Diamond Excel, FGM) under intermittent movements. This combination of minimally invasive techniques yielded a satisfactory esthetic result, capable to improve the appearance of the patient’s teeth (Figs. 19 and 20). A symmetrical and harmonious smile was produced with an excellent clinical performance up to 36 months (Fig. 21). Direct adhesive restorations, when employed for diastema closure and dental re-anatomization of shape, size and texture can reproduce the atypical features of the dental structure and treat minor defects on the enamel surface. The individualization of the enamel microabrasion and other procedures to patients, make these minimally invasive protocols predictable and with excellent esthetic results. REFERENCES 1. Pontons-Melo JC, Furuse AY, Mondelli J. A direct composite resin stratification technique for restoration of the smile. Quintessence Int. 2011; 42:205-11. 2. Pontons JCM, Furuse AY, Freitas CA de, Mondelli J. Optimizando la estética en el tratamiento de diastemas. Rev Asoc Odontol Argent. 2009;97:239-43. 3. Pontons-Melo JC, Pizzato E, Furuse AY, Mondelli J. A conservative approach for restoring anterior guidance: a case report. J Esthet Restor Dent. 2012;24: 171-84. 4. Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations. Quintessence Int 2006;37:91–102. 5. De Munck J, Van Landuyt K, Peumans M, et al. A critical review of the durability of adhesion to tooth tissue: Methods and results. J Dent Res 2005; 84:118–132. 6. Furuse AY, Herkrath FJ, Franco EJ, Benetti AR, Mondelli J. Multidisciplinary management of ante- rior diastemata: Clinical procedures. Pract Proced Aesthet Dent 2007;19:185–192. 7. Croll Tp. Enamel microabrasion: The technique. Quintessence Int. 1989;20:395-400. 8. Mondelli RF, Silva e Souza MH Jr., Carvalho RM. Odontología estética. fundamentos e aplicaçoes clínicas. Microabrasao do esmalte dental. Sao Paulo: Ed. Santos; 2001. 9. Benbachir N, Ardu S, Krejci I. Indications and limitations of the microabrasion technique. Quintessence Int. 2007; 38:811-15.
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Sônia Saeger Meireles MS, and PhD in Restorative Dentistry (Federal University of Pelotas, UFPel, RS, Brazil) Adjunct Professor of Federal University of Paraíba (UFPB, PB, Brazil). Professor of the MS course in Dentistry at UFPB (PB, Brazil)
Dental bleaching associated with anterior composite restorations
INTRODUCTION The increased demand for cosmetic and esthetic dentistry has redefined the Dentistry market. The dental companies have focused their researches on the development of new materials that join adequate mechanical properties with good esthetic behavior. Within this context, bleaching protocols are commonly associated with restoration techniques in order to provide a more harmonious smile for patients. CLINICAL CASE REPORT The objective of this article is to report the clinical results obtained after
Mara Ilka Holanda de Medeiros Batista
three in-office bleaching sessions and the composite resin replacements in
Dental clinician (Federal University of Paraíba, PB, Brazil)
teeth. We recorded the baseline teeth color as being A3.5, by comparing the
Specialist in Forensic Dentistry (COESP/PB, Brazil). MS student in Forensic Skill at Pernanbuco School of Dentistry, University of Pernanbuco, (FOPUPE, Brazil)
the upper incisors of a patient who was dissatisfied with the color of her color of the middle buccal third of her teeth with the value-oriented shade guide Vitapan Classical. Before application of the bleaching agent (Whiteness HP Blue 35%, FGM), we applied a desensitizing agent (Desensibilize KF2%, FGM) for 10 minutes with the aim to prevent/minimize the bleaching-induced tooth sensitivity. At the end of each clinical session, the bleaching agent was removed with an endodontic aspirating tip and the dental surfaces were rinsed with water. Then, the desensitizing agent (Desensibilize KF2%, FGM) was reapplied for 10 minutes. A total of three clinical sessions with a 7-day interval was performed, reaching the final teeth color A1. After 2 weeks, we removed the amalgam and composite resin restorations from the palatal surfaces of teeth 12 and 22, as well as the composite resin restoration in the distal surface of tooth 21. With the aid of the Vitapan Classical shade guide, we performed the color selection. The microhybrid composite resin EA2 (Opallis, FGM) and DA2 for enamel and dentin respectively was employed. Before the beginning of the restorative procedure, we performed dental prophylaxis with pumice and water for removal of extrinsic stains. edition 6
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1.
2.
3.
4.
1. Initial clinical condition. 2. Baseline color recorded with the shade guide Vitapan Classical. 3. Three 40-minute in-office bleaching sessions (Whiteness HP Blue 35%, FGM) were performed. 4. This was the clinical result obtained after the end of three in-office bleaching sessions.
127
In a second clinical appointment, we made a
were performed using the composite resin Opallis (FGM)
silicone guide with an addition silicone. The Class III
in the colors T-neutral, DA1, EA1 and VH. At the end
restorations of the mesial surfaces of teeth 11 and 21
of the procedure, we performed occlusal adjustments.
were then removed. The new composite resin restorations
We finished the restorations with fine- and ultra-fine grit
5.
6a.
6b.
7.
8.
5. Palatal view showing the restorations in the anterior teeth. 6 a-b. The palatal restorations were replaced. 7. Removal of the unsatisfactory composite restorations in teeth 11 and 21. 8. Acid etching with 37% phosphoric acid (Condac 37, FGM) for 15 seconds in dentin and 30 seconds in enamel. Water rinsing and removal of the moisture excess.
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diamond burs, abrasive disks (Diamond Pro, FGM) and
and ultra-fine diamond pastes (Diamond AC I e II, FGM).
abrasive strips for the interproximal area. The polishing
After the end of the restorative procedure, we could
procedure was performed with abrasive rubber points
notice that the harmony of the smile was re-established,
and felt disks (Diamond Flex, FGM) associated with fine
reaching patientâ&#x20AC;&#x2122;s satisfaction.
9a.
9b.
10.
11.
12.
9 a-b. Application of the adhesive system (Ambar, FGM) in two coats followed by light-curing for 10 seconds in each tooth. 10. Incremental composite resin filling (T-neutral, DA1, EA1 and VH). 11. Occlusal adjustments. 12. Finishing with burs and abrasive strips.
129
13.
14.
13. Polishing with felt disks (Diamond, FGM) and diamond paste (Diamond AC I e II, FGM). 14. Final aspect of the completed restorations.
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Schott
a consistent partner in the supply of glass fillers
Quality has always been a priority in the supply chain
formulations available around the world. Schott provides
of FGM products, ensuring high quality products and
more than 20 different types of filers available for dental use.
effective results. Therefore supplier selection is a must since
Another point praised by the technical director is
FGM is always focused on suppliers of excellence, such as
the quality of the customer care. “Schott competitive
Schott, a German company that provides micronized glass
advantage is the technical support, with a specialized
fillers that are available in the Opallis, Llis resins as well as
team that provides support throughout the process.
other resin-based products.
High quality allied to great service defines why Schott
Schott manufactures the most modern fillers in the
is such an outstanding glass filler supplier, defines
world, offering the highest degree of purity, finer grains
Friedrich”.
Located in Landshut, Germany, 125 years ago
(with up to 180 nanometers), refractive index similar to the resin and excellent radiopacity, such properties are
Schott is featured in the manufacture of special glasses
required to provide an outstanding composite. According
with much of its product are ranked as the market leader
to FGM technical director, Friedrich Georg Mittelstadt, “the
in the segments, such as in the appliance industry,
dental composites. That is why FGM has incorporated
and architecture. In constant innovation, defines higher
company offers a glass filler that fits in what is best in
pharmacy, electronics, optics, solar energy, transportation
such quality and technology to its products”.
standards in relation to quality, production and services,
Currently, the composites are the most versatile
offering high production capacity, technical support,
materials for dental restorations, since they provide an
training, and high process capability (ISO 9001:2008, ISO
aesthetic result similar to the own tooth structure along
15378:2006, OHSAS 18001:2007, DMF 19950 USA and
with good durability.
ISO 14000:2004 certified, including the IMSU certification).
With over 40 years experience, Schott has developed
This quality assurance ensures trust for FGM products,
increasingly sophisticated fillers, developed specifically for
which are among the safest and most respected products
dental composites in order to increase the gain properties
in the market.
This image is a courtesy of SCHOTT AG, Germany.
of these formulations and also to meet the diversity of
Figure 1. Image obtained by electron microscopy transmission showing the average size of particles and Opallis composite resin filler particles distribution pattern.
Figure 2. Dental composite process obtained from raw glass. 1. Raw Glass. 2. Glass powder after grinding and monomer composition. 3. Mixture of glass powder with the monomer composition. 4. Compound being applied on the teeth. 5. Curing of the composite.
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www.fgm.ind.br/en
Whitepost, a glass fiber post that provides quality and convenience that fit perfectly on your daily routine. Since the post comes with an specific drill that provides a perfect placement of intraradicular posts which enables the development of a suitable restoration system for teeth that are fully or partially destroyed by cavities. Enables perfect restorations due to its excellent light translucency that does not interfere with aesthetic of restorative materials. Due to a flexural strenght similar to dentin the product provides safety to the dental root when submitted to cyclic masticatory forces leading to long-lasting restorations.
PACKAGING
CONTENT
WHITE POST DC COMPLETE KIT (DC 0.5, DC 1, DC 2, DC 3 E DC-E 2)
5 POSTS OF EACH SIZE AVAILABLE (25 POSTS) + SPECIFIC DRILLS + RULER TO SUPPORT SIZE SELECTION
WHITE POST DC-E SPECIAL COMPLET KIT (DC 0.5, DC-E 0.5, DC 1, DC-E 1 E DC-E 2)
5 POSTS OF EACH SIZE AVAILABLE (25 POSTS) + SPECIFIC DRILLS + RULER TO SUPPORT SIZE SELECTION
WHITE POST DC INTRO KIT (DC 0.5, DC 1, DC 2, DC 3)
5 POSTS OF THE SAME SIZE + SPECIFIC DRILLS
WHITE POST DC-E INTRO KIT (DC-E 0.5, DC-E 1 E DC-E 2
5 POSTS OF THE SAME SIZE + SPECIFIC DRILLS
WHITE POST DC REFIL (DC 0.5, DC 1, DC 2, DC 3)
5 POSTS OF THE SAME SIZE
WHITE POST DC-E REFIL (DC-E 0.5, DC-E 1 E DC-E 2)
5 POSTS OF THE SAME SIZE
Youâ&#x20AC;&#x2122;re Worth it.
Guilherme M. Garone MS in Restorative Dentistry School of Dentistry – USP (SP, Brazil)
The use of fiberglass posts for retention of direct composite resin restorations
Professor of Restorative Dentistry at Unicid (SP, Brazil) Professor of the Update Courses in Esthetic Dentistry at FUNDECTO – USP (SP, Brazil) and CETAO (São Paulo, Brazil)
INTRODUCTION The longevity of non-vital teeth depends not only on the quality of the endodontic treatment, but also the quality of the root sealing and restoration. For Peroz et al. (2005), the treatment decision, and the chosen technique should be Ana Carolina P. de Freitas
based on the best and most currently evidence.
Specialist, MS, and PhD in Restorative Dentistry at School of Dentistry, USP (SP, Brazil)
structural loss can be lost in the medium-term. Pre-fabricated fiberglass posts
Professor of the Update Course in Esthetic Dentistry – Fundecto, USP (SP, Brazil)
indication of posts is dependent on the amount and quality of the remaining
We often observe that adhesive restorations in restored teeth with large were designed to provide increased retention for crown filling materials. The dental structure. The choice for pre-fabricated fiberglass post to increase the retention of restorative material is not clearly defined in the literature, and should be based on literature studies, and on the professional’s experience. This article will describe the case of a female patient (26 years old) with a dislodged composite resin restoration in tooth 35. Under clinical examination, we observed an adequate endodontic treatment. This dislodgement probably occurred because of lack of retention, and adhesive failure of the restorative material to the cavity walls. This restoration defect can jeopardize the endodontic treatment, as it will not prevent infiltration and contamination.
Narciso Garone Netto Full Professor. Department of Restorative Dentistry. USP (São Paulo, Brazil) Professor of the Update Courses in Esthetic Dentistry - Fundecto, USP (SP, Brazil)
After clinical and radiographic examination, we opted to place a fiberglass post (White Post DC-E, FGM) inside the root canal with the resin cement (Allcem, FGM), followed by a direct composite resin restoration (Llis, FGM). This treatment has the advantages of being low cost and fast. Additionally, fiberglass post provides better retention of the restorative material, strengthens the crown structure, and provides efficient sealing of the endodontic treatment. edition 6
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CLINICAL CASE REPORT The patient came to the dental clinic reporting
material (Fig. 2), we observed the presence of an adequate
restoration fracture. During clinical examination, we
endodontic sealing. The treatment plan was based on the
detected a small fracture in the marginal distal ridge and
use of a fiberglass post (Fig. 3) associated with a direct
lack of marginal sealing of the restoration (Fig. 1). After
composite resin restoration to provide adequate root
radiographic examination, and removal of the restorative
sealing, and increased retention for the composite resin.
2.
1.
3.
1. A fracture in the distal region and restoration dislodgement can be seen in the occluso-distal restoration of the second lower premolar in the left side. 2. After removal of the defective composite resin restoration, one could notice the endodontic access. 3. Fiberglass post Whitepost DCE 1 (FGM).
135
We selected the diameter of the fiberglass post
The fiberpost was then clinically, and radiographically
based on the anatomy of the root canal (Fig. 4). The root
checked for adaptation in the root canal (Fig. 6). In the
was prepared with the corresponding drill of the fiberpost,
radiograph, the fiberglass post can be seen because of its
which is available in the post kit. Initially, the gutta-percha
radiopacity. During adaptation checking, we demarcated
filling was removed with heated instruments and Gate
with a pencil the local for post sectioning. The crown
drills. After reaching the desired length for the fiberpost,
portion of the post should be 2 mm below the occlusal
the root canal was prepared with the compatible fiberpost
plane (Fig. 7). The sectioning was performed with a high-
drill (Fig. 5).
speed diamond bur under water-cooling (Fig. 8).
4.
5.
6.
7.
4. Superposition of the bur on the radiograph to check the proper length and width of the root canal preparation. 5. Preparation of the root canal with a bur. 6. Checking the adaptation of the fiberglass post. 7. Delimitation of the area for post sectioning before cementation.
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Before luting procedures, fiberglass post was firstly
rinsed out and dried before the adhesive procedure. We
prepared. Initially, the post was cleaned with 70% ethanol
applied the 37% phosphoric acid (37 Condac, FGM) firstly
(Fig. 9). A silane (Prosil, FGM) (Fig. 10) was applied for 1
on enamel (Fig. 13) and then inside the root canal and on
minute with disposable applicators (Cavibrush, FGM). The
dentin surfaces, for 15 seconds.
second step was the preparation of the root canal. The
The root canal was copiously rinsed out and
root canal was cleaned with an anionic detergent (Fig. 11).
carefully dried with cone papers (Fig. 14). The adhesive
The detergent was scrubbed on the root walls with an
system (Ambar, FGM) was applied according to the
endodontic file wrapped in cotton (Fig. 12). The cavity was
manufacturerâ&#x20AC;&#x2122;s instructions with extrafine microbrushes
8.
9.
10.
11.
8. Sectioning of the fiberglass post with a diamond bur under water-cooling. 9. Cleaning the surface of the post with 70% ethanol. 10. Application of a pre-hydrolyzed silane (Prosil, FGM). 11. Water rinsing of the root canal with an anionic detergent.
137
(Cavibrush Extrafino, FGM) (Fig. 15) to guarantee the
We selected the resin cement Allcem (FGM). This
adequate application of the material in all conditioned
material has an automixing system and an endodontic tip
surfaces (Fig. 16). The solvent evaporation was performed
that allows the placement of the material directly inside the
with a slight air stream and the adhesive was light-cured
root canal (Fig. 18 and 19). With the aid of clinical pliers,
for 1 minute to allow for adequate polymerization (Fig. 17).
the fiberglass post was positioned into the root canal (Fig.
12.
13.
14.
15a.
15b.
16.
12. The anionic detergent was scrubbed on the root canal with an endodontic file wrapped in cotton. 13. Acid etching with 37% phosphoric acid (Condac 37, FGM). 14. Drying the root canal with cone papers. 15 a-b. Application of the adhesive system (Ambar, FGM) with an extrafine microbrush (Cavibrush, FGM). 16. Root canal view after adhesive application (Ambar, FGM).
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20 and 21) and the excess cement was removed with suitable instruments before light curing for 40 seconds (Fig. 22). A metallic matrix and a wood wedge were adapted to the tooth to allow for proximal rehabilitation (Fig. 23).
17.
18.
19. 17. Adhesive light-curing. 18. Placement of the dual-cure resin cement with an automixing system (Allcem, FGM) into the root canal. 19. Resin cement inserted into the root canal.
139
20.
21. 20. Seating the fiberglass post into the root canal during cementation. 21. Aspect of the fiberglass post positioned in the root canal, and surrounded by the resin cement.
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22.
23.
24.
25.
22. Light curing of the dual cure resin cement (Allcem, FGM). 23. Adaptation of the metallic matrix and the wood edges for restoration of the class II cavity with composite resin (Llis, FGM). 24. Direct composite resin restoration was concluded (Llis, FGM). 25. Final periapical radiograph of the tooth 35.
REFERENCES 1. Peroz I, Blankenstein F, Lange KP, Naumann M. Restoring endodontically treated teeth with posts and cores- A review. Quintessence Int 2005;36:737-746.
The direct composite resin was incrementally filled to reproduce the anatomy and occlusal contacts (Fig.
2. Bergolin CD, Amaral M, Boaro LCC, Braga RR, Valandro LF. Fiber post dementation strategies: Effect of mechanical cycling on push-out bond strength and cement polymerization stress. J Adhes Dent 2012;14:471-478.
24). The final radiograph (Fig. 25) showed an adequate adaptation of the fiberglass post and the restorative
3. Soares SJ, Valdivia AD, da Silva GR, Santana FR, Menezes M de S. Longitudinal clinical evaluation os post systems: a literature review. Braz Dent J. 2012;23(2):135-140.
material.
141
Sandra Kalil Bussadori Specialist in Pediatric Dentistry MS, and PhD in Pediatric Dentistry – USP (São Paulo, Brazil) Postdoctoral in Sciences – Department of Pediatrics and Applied Sciences to Pediatrics – UNIFESP/EPM Professor of the Master of Science and PhD Courses in Biophotonics – Uninove (SP, Brazil) Coordinator of the Specialization and Update Courses in Pediatric Dentistry - APCD/Central (SP, Brazil)
Chemo-mechanical removal of caries lesion with Papacarie Duo and posterior rehabilitation: a case report INTRODUCTION The glass ionomer cement (GIC) is a material that relies on the acid-base reaction in the presence of a polyalkenoic acid.1 The material presents different properties, such as bonding to tooth structure, biocompatibility, and release of fluoride ions,2 which may provide a health condition for caries-active patients with deep carious lesions.3 Wilson and Kent1 developed this material in the seventies and owed to its good physical properties, the material has been used mainly in the atraumatic restorative treatment and dental sealing after chemo-mechanical removal of the caries lesions.2 The chemo-mechanical removal of the caries lesion involves the softening of the caries lesion by application of proteolytic substances, followed by the easy removal of the affected tissue using manual instruments.5 This is an alternative technique to the conventional drilling method, which is performed under high and low speed. It is a painless method that preserves more dental tissues and avoids the use of drills and local anesthesia.6-8 Among the products
Thays Almeida Alfaya ESpecialist in Stomatology – State University of Rio de Janeiro - UERJ (RJ, Brazil)
available for this purpose, there is the papain and chloramine-based gel, called Papacárie Duo®. This product has bactericidal, bacteriostatic, and antiinflammatory properties.11
MS student. Program of Dentistry clinics – Federal University Fluminense – UFF (RJ, Brazil)
1.
2.
1. Clinical appearance of the part 36. 2. Bacteria observed with the use of SEM.
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The aim of this article is to report a clinical protocol
a rotating brush was performed. After rubber dam
for rehabilitation of a permanent tooth from a child. The
isolation, the gel was applied in the dental cavity and
clinical steps from the diagnosis of the caries lesion until
left for 30 seconds (Fig. 4). The infected tissue from
the treatment conclusion will be described.
the caries lesion was scooped out with a blunt spoon excavator, so that only the soft dentin and the gel would be removed, leaving the sound dentin preserved inside
CLINICAL CASE REPORT An 11-year old, male patient sought for dental
the dental cavity (Fig. 5).
assistance with the main complaint of pain to cold stimuli.
The cavity was rinsed out, dried and clinically
Under clinical and microbiological examination (Fig. 1 and
inspected. If the infected tissue was not completely
2), we diagnosed the presence of a caries lesion in tooth
removed, the gel was reapplied, and the procedure
36, classified as ICDAS score 06 (deep cavity with dentin
repeated. The texture of the remaining dentin was
exposure).
checked clinically with a blunt explorer. If the dentin from
We planned to remove the infected tissue with a
the cavity presented a vitreous aspect (Fig. 6), one could
chemo-mechanical caries removal method with a papain-
consider it caries-free (Fig. 6).
based gel (Papacárie Duo ®, Formula e Ação, São Paulo,
The cavity was cleaned with a solution of 2%
Brazil), following the manufacturer’s recommendations
chlorhexedine digluconate. The restoration was performed
(Fig. 3).
with the conventional glass ionomer cement Maxxion R
Dental prophylaxis with fluoride toothpaste and
(shade A3, FGM), as demonstrated in figures 7 and 8.
3.
4.
3.Papacarie Gel Duo. (E Açao Formula, São Paulo, Brazil). 4. Applying gel Papacárie Duo on infected tissue.
143
5.
6.
7.
8.
5. Removal of the infected tissue with an dentin excavator without cutting edges 6. Vitreous cavity after chemical-mechanical removal of infected tissue. 7. Glass Ionomer Maxxion R (FGM). 8. Clinical appearance of the part 36 placed after restoration with the glass ionomer Maxxion R (FGM).
DISCUSSION The present article reports the easy application
Regarding
time
and
cost,
papain-based
gel
method of Papacarie Duo for chemo-mechanical removal
associated with a glass ionomer cement is significantly
of the carious lesions. These findings were also observed
cheaper and less-time demanding than the conventional
in other similar clinical reports that used the papaina-based
drilling method.14 This point is important because economic
gel.8,12 Some clinical studies have investigated the efficacy
factors exert a strong influence on the patientâ&#x20AC;&#x2122;s decision to
of this gel. In the study developed by Matsumoto et al.
seek dental treatment. A study comparing the atraumatic
(2013), the authors highlighted that this method of caries
restorative treatment, amalgam and resin composite
removal is easy, does not cause patient discomfort, and
restorations demonstrated that atraumatic restorations are
injuries to the dental structure.13 The lack of pain deserves
50% cheaper than the conventional restorations.16
ÂŽ
attention. Fewer pain complaints have been reported
Another study followed up fourteen young permanent
by patients submitted to the chemo-mechanical caries
molars treated with PapacarieDuoÂŽ and restored with glass
removal method.6-8 The literature emphasizes the principles
ionomer cement. Thirteen of the fourteen elements were
of minimally invasive therapies that allow for the elimination
successful at follow-up. The authors did not observe any
of anesthesia and reduction of the painful symptoms.
alteration of the lamina dura, pulp alterations or caries lesion
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progression.7 Under the radiographic examination, the authors observed a radiolucent area with radiopaque points, suggestive of a remineralization process of the affected dentin. The results of this study showed the importance of this type of treatment when associated with glass ionomer cement. CONCLUSION It is concluded that the chemo-mechanical removal of carious lesions associated with the restorative treatment with glass ionomer cement is a very important method within the minimally invasive dentistry. Its use allows for painless caries lesion removal without the need of local anesthesia, preserving sound dental structure. Additionally, it is an easy protocol and does not require technological devices. REFERENCES 1. Xie D, Brantley WA, Culbertson BM, Wang G. Mechanical properties and microstructures of glass-ionomer cements. Dent Mater. 2000;16(2):129-38. 2. Chadwick BL, Evans DJ. Restoration of class II cavities in primary molar teeth with conventional and resin modified glass ionomer cements: a systematic review of the literature. Eur Arch Paediatr Dent. 2007;8(1):14-21. 3. Croll TP, Bar-Zion Y, Segura A, Donly KJ. Clinical performance of resin-modified glass ionomer cement restorations in primary teeth. A retrospective evaluation. J Am Dent Assoc. 2001;132(8):1110-6. 4. Wilson AD, Kent BE. The glass-ionomer cement, a new translucent dental filling material. J Appl Chem Biotecnol. 1971;21(11):371. 5. Mathre S, Kumar S, Sinha S, Ahmed BMN. Chemo-Mechanical Method Of Caries Removal: A Brief Review. IJCDS. 2011;2(2):52-7. 6. Bussadori SK, Castro LC, Galvao AC. Papain gel: a new chemo-mechanical caries removal agent. J Clin Pediatr Dent. 2005;30(2):115-9. 7. Bussadori SK, Guedes CC, Bachiega JC, Santis TO, Motta LJ. Clinical and radiographic study of chemical-mechanical removal of caries using Papacarie: 24-month follow up. J Clin Pediatr Dent. 2011;35(3):251-4. 8. Bussadori SK, Guedes CC, Hermida Bruno ML, Ram D. Chemo-mechanical removal of caries in an adolescent patient using a papain gel: case report. J Clin Pediatr Dent. 2008;32(3):177-80. 9. Martins MD, Fernandes KP, Motta LJ, Santos EM, Pavesi VC, Bussadori SK. Biocompatibility analysis of chemomechanical caries removal material Papacarie on cultured fibroblasts and subcutaneous tissue. J Dent Child (Chic). 2009;76(2):123-9. 10. Correa FN, Rocha Rde O, Rodrigues Filho LE, Muench A, Rodrigues CR. Chemical versus conventional caries removal techniques in primary teeth: a microhardness study. J Clin Pediatr Dent. 2007;31(3):187-92. 11. Jawa D, Singh S, Somani R, Jaidka S, Sirkar K, Jaidka R. Comparative evaluation of the efficacy of chemomechanical caries removal agent (Papacarie) and conventional method of caries removal: an in vitro study. J Indian Soc Pedod Prev Dent. 2010;28(2):73-7. 12. Guedes CC, Aldrigui JM, Martins MD, Fernandes KP, Bussadori SK. Remoção química e mecânica de lesão de cárie em dente hipoplásico utilizando-se gel à base de papaína Papacárie: relato de caso clínico. ConScientiae Saúde. 2006;5:59-65. 13. Matsumoto SF, Motta LJ, Alfaya TA, Guedes CC, Fernandes KP, Bussadori SK. Assessment of chemomechanical removal of carious lesions using Papacarie Duo ™: Randomized longitudinal clinical trial. Indian J Dent Res. 2013;24(4):488-92. 14. Aguirre Aguilar AA, Rios Caro TE, Huaman Saavedra J, Franca CM, Fernandes KP, Mesquita-Ferrari RA, et al. [Atraumatic restorative treatment: a dental alternative well-received by children]. Rev Panam Salud Publica. 2012;31(2):148-52. 15. Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clin Oral Investig. 2010;14(3):233-40.
145
Letícia de Souza Lopes Dentist undergraduate at UERJ (RJ, Brazil)
Treatment of dentin hypersensitivity
Member of the PET-UERJ Assistant of the Discipline of Dental Materials
INTRODUCTION This article aims to report and discuss the diagnosis and step-by-step treatment of a clinical case of dentin hypersensitivity. The diagnosis was performed with a cold sensitivity test, and the treatment was based on in-office application of a desensitizing gel. Fernanda Signorelli Calazans Specialist in Restorative Dentistry – UFRJ (RJ, Brazil) MS, and PhD in Restorative Dentistry – UERJ (RJ, Brazil) Professor of the Specialization and Update Courses in Restorative Dentistry – Dentistry Institute – PUC (RJ, Brazil) Substitute professor of Integrated Clinics – UERJ (RJ, Brazil)
LITERATURE REVIEW One of the clinicians’ difficulties when managing patients with the chief complaint of pain in their teeth is that there are several clinical conditions that can cause this symptom, and these conditions must be excluded prior to the correct diagnosis of dentin hypersensitivity.1 Dentin hypersensitivity is defined as the pain resulting from exposed dentin in response to chemical, thermal, tactile or osmotic stimuli and cannot be explained by structural defects or other dental diseases. More recently, it has been suggested that dentists should distinguish the dentin hypersensitivity from individuals with a good health oral condition of those whose pain may be the result of periodontal disease and/or its treatment. Recently, the terms root sensitivity, root dentin sensitivity, and radicular dentin hypersensitivity have been used to described the sensitivity produced by periodontal disease or its treatment.2,4 Currently, most studies of prevalence do not distinguish these different types of dentin sensitivity and there is few data about this condition. A good definition provides a very useful description
Mauro Sayão de Miranda
of the clinical dilemma and permits the differential diagnosis of other types of
Associate Professor – UERJ and UFRJ (RJ, Brazil)
painful conditions.2,3
Coordinator of the PhD Course in Restorative Dentistry – UERJ (RJ, Brazil)
may or may not be sensitive to stimuli. Macroscopically, sensitive or insensitive
Coordinator of the courses of Restorative Dentistry – IO-PUC (RJ, Brazil)
The occurrence of dentin hypersensitivity requires dentin exposure, which dentin has similar features. However, under scanning electron microscopy, dentin tubules from sensitive dentin are open, while in insensitive dentin, the dentin tubules are obliterated by hydroxyapatite crystals.5 The intensity of dentin edition 6
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hypersensitive varies from mild to severe discomfort. It
the contact with the oral environment for eradication of
differs between individuals and teeth, as it is correlated
the dentin hypersensitivity.
with the pain patient’s tolerance to emotional and physical
Different techniques and substances can be used for
factors.
in-office and at-home treatment of dentin hypersensitivity.
2,3
There are some methods described in the literature
Additionally, a high number of techniques and products
for measurement of pain. They are subjective methods
are available in market for this purpose, which prevents
based on scores. An example is the air-induced tooth
clinicians from developing an effective protocol. The
sensitivity test. In this method, the tooth under evaluation
addition of fluorides in most of the dentifrices and
is isolated by the placement of the operator’. For such
mouthwashes has been effective for caries prevention.
test, the operator place their fingers on the neighboring
Some fluoride compositions have been reported to assist
teeth and an air stream (60 psi) is applied perpendicular to
in the dentin hypersensitivity treatment and among them
the buccal surface of the tooth, at a distance of 1 cm for 1
there are the sodium fluoride, sodium silicofluoride and
second. This is a very simple, fast, and effective method.
sodium monofluorphosphate.
6
The evaluation of pain is then based on the patient’s
The obliteration of the dentinal tubules with oxalates
response according to the following score system:
is based on its chemical reaction with the calcium from the
• Score 0 – the patient does not respond to the
dentinal fluid, so that an insoluble, calcium oxalate crystal
stimuli.
of reduced diameter deposits within the open dentinal
• Score 1 – the patient feels the stimuli, but does not
tubules. However, some studies report that as oxalates
ask for its interruption.
are instable in an acidic environment, improved results for
• Score 2 – patient feels the stimuli, asks for its
reduction of dentin hypersensitivity was observed when
interruption or moves during application.
oxalates were associated with buffering substances for
• Score 3 – patient feels the stimuli, asks for its
pH neutralization.
interruption or moves during application, and
Potassium salts are usually used for the management
reports pain.
of dentin hypersensitivity. The most frequently used are
The treatment of dentin hypersensitivity has been
the oxalates, nitrates, and citrates. By increasing the
focus of many studies in Dentistry. The great majority
extracellular potassium, the nerve fibers are depolarized
of these studies evaluate techniques for obliteration of
blocking the passage of the pain stimuli so that the dentin
dentinal tubules to seal the area, insulating dentin from
hypersensitivity is reduced.
147
Besides that, citrates chelate calcium, produce
For evaluation of the effectiveness of the treatment,
tubule obliteration, and reduce the dentin hypersensitivity.
we performed the cold air test described earlier in the
Nanometric hydroxyapatite, when used for treatment of
literature review.6 In this method, the tooth was isolated by
dentin hypersensitivity, is capable to diffuse easier into
the placement of the operator’s fingers on the neighboring
the dentinal tubules and dental cracks producing a high
teeth and an air stream (60 psi) was applied perpendicular
quality dental sealing and restoring the microstructure and
to the buccal surface of the tooth, at a distance of 1 cm
chemical composition of the teeth. The hydroxyapatite
for 1 second (Fig. 2).6 The evaluation of pain was then
crystals are highly stable and resistant to acidic challenges
based on a sensitivity scale associated with the patient’s
when compared with amorphous calcium phosphates.
response to the stimuli.
Therefore, it produces a long-lasting desensitizing effect, and an effective remineralization.
The measurement was performed in the following periods:
8
• Before the first application of the Desensibilize Nano P (FGM);
CLINICAL CASE REPORT The patient that sought for dental assistance
• 10 minutes after the first application;
complained of considerable tooth sensitivity in some teeth.
• 1 week after the first application, and before the
During clinical examination, we observed the presence of
second application;
gingival recessions in some of the sensitive teeth. Only the
• 10 minutes after the second application;
buccal surface of tooth 13 (Fig. 1) was not subjected to
• 1 week after the second application, and before the
restorative procedure. Albeit the root dentin was exposed,
third application;
there was no cavity. In face of that, we opted to apply
• 10 minutes after the third application;
an in-office desensitizing product that associates fluorides
• 1 week after the third, and last application.
and nanoparticles of hydroxyapatite (Desensibilize Nano
After the baseline measurement of the dentin
P, FGM).
hypersensitivity, the following clinical protocol, used for 3 consecutive weeks, was performed:
1.
2.
3.
4.
5.
6.
1. Initial aspect of the lesion, revealing exposure of root dentin in tooth 12 without cavitation. The operative field should be isolated with cotton rolls and saliva ejectors. 2. Standardized testing of the dentinal hypersensitivity by the application of a cold air on the buccal surface of the tooth. 3. Application of Desensibilize NanoP (FGM) in the area. 4. Friction of the product with a felt disk (Diamond Flex, FGM) for 10 seconds. 5. Removal of the paste excess after 5 minutes. 6. During application, patient is instructed to avoid eating or drinking for 30 minutes after product application.
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RESULTS The following results were observed (Chart 1): Score
Assessment time Before the first application
3
10 minutes after the first application
1
1 week after the first application, and before the second application
1
10 minutes after the second application
1
1 week after the second application, and before the third application
1
10 minutes after the third application
1
1 week after the third, and last application
1
Chart 1 – Results obtained from a sensitivity score system that analyses the patient’s response to cold air stimuli. The scores are: 0 – the patient does not respond to the stimuli; 1 – the patient feels the stimuli, but does not ask for interruption; 2 – patient feels the stimuli, asks for its interruption or moves during application; 3 – patient feels the stimuli, asks for its interruption or moves during application, and reports pain.6
CONCLUSION Dentin hypersensitivity is a condition that can be treated. The treatment starts with patient education about hygiene, parafunctional habits, reduced intake of acidic foods, etc., as well as an adequate follow-up treatment by the dentist according to the severity of the problem. There are many materials being used for the treatment of dentinal hypersensitivity, such as fluorides, nitrates, citrates, oxalates, and hydroxyapatite. The desensitizing materials are commercialized in different concentrations, and they have distinct application methods, such as toothpastes, mouthwashes, gels, and varnishes. In the present case, we obtained a favorable result with the desensitizing paste Desensibilize Nano P (FGM) since the first application of the product and throughout the 3 weeks of use. Therefore, this product could be considered a good option for desensitization in the dental practice. REFERENCES 1. David G. Gillam (2013) Current diagnosis of dentin hypersensitivity in the dental office: an overview. Clin Oral Invest 17 (Suppl 1):S21–S29. 2. Addy M (2000) Dentin hypersensitivity: definition, prevalence distribution and etiology. In: Addy M, Embery G, Edgar WM, Orchardson R (eds) Tooth wear and sensitivity. Martin Dunitz, London, pp 239–248. 3. Gillam D, Orchardson R (2006) Advances in the treatment of root dentin sensitivity: mechanisms and treatment principles. Endod Top 13:13–33 4. Troil BV, Needleman I, Sanz M (2002) A systematic review of the prevalence of root sensitivity following periodontal therapy. J Clin Periodontol 29(Suppl 3):173–177. 5. Addy, M.; Mostafa, P. (1989) Dentine hipersensitivity II: effects produced by the uptake in vitro of tooth paste onto dentine. J Oral Rehabil., v.16, n.1, p.35-48. 6. Hongchun Liu and Deyu Hu (2012) Efficacy of a Commercial Dentifrice Containing 2% Strontium Chloride and 5% Potassium Nitrate for Dentin Hypersensitivity: A 3-Day Clinical Study in Adults in China Clinical Therapeutics 34(3): 614-622. 7. Lussi A. Dental erosion: from diagnosis to therapy. Karger Ed., 2006. 8. Eliane Ramos Toledo de Carvalho, Helio Rodrigues Sampaio Filho, Fernanda Pitta Ritto, Raimundo Alexandre da Silveira Vidigal Lacerda, Renato Mayhe e Elizabeth Peixoto Nunes (2013) Hipersensibilidade dentinária e seu manejo clínico PRO-odonto prevenção. 6(3):9-37.
149
Reasearches with
fgm products
FGM acknowledges the effort and commencement of professionals who have the opportunity to take part in scientific researches held at Universities and research centers which will provide relevant subjects in order to improve even more the field of Dentistry.
Aiming at providing high quality and consistent scientific content, this section reveals some interesting results obtained with FGM products which is result of a competent and serious work performed by professionals around the world.
1
Silva, F.M.M.; Nacano, L.G.; Gava Pizi, E.C. Clinical trial of two bleaching systems. Ver Odontol Bras
Central, v. 21, n. 56, p. 473-479, 2012. Title: Clinical trial of two bleaching systems. Objective: Clinically evaluate two at-home bleaching systems based on daily wear-time and bleaching effect, sensitivity and patient satisfaction. Methods: 10 patients were selected and randomized in two groups (n=5). G1 (carbamide16% peroxide, FGM Whiteness Perfect 16%) and G2 (7,5% hydrogen peroxide FGM White Class 7,5%). Results were collected by following a survey, through pictures and shade guide comparison for three weeks. The age group varied from 17 up to 23 ( average 19 years old). In order to analyze the accuracy of the bleaching process, the number of shades bleached were taken into account. Results: the nonparametric Mann-Whitney test showed no aesthetic difference in the accuracy among bleached superior teeth. However the lower teeth were statistically different according to the bleaching material. The average of superior teeth shades bleached in G1 was 8,2 and in G2 was 6,8; on the inferior teeth the averages were 7,4 (G1) and 5,8 (G2). The sensitivity tests were submitted to the Mann-Whitney statistic test and showed variance between the groups. Bleaching of superior teeth reached higher averages when compared to inferior teeth; all patients were satisfied in terms of aesthetics, despite that in regards the inferior arch, some were partially satisfied with the results. In terms of daily wear-time of the bleaching agent, all patients were satisfied. Conclusion: for both groups the researched materials showed accurate results based on the chosen protocol reaching high levels of dental bleaching.
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2
Rezende, M.; Loguercio, A.D.; Reis, A.; Kossatz, S. Clinical effects of exposure to coffee during at-
home vital bleaching. Operative Dentistry, v. 38, n. 5, 2013. Title: Clinical effects of exposure to coffee during at-home vital bleaching. Objective: The goal of the this study was to evaluate if exposure to coffee during Carbamide Peroxide dental bleaching at 16% (Whiteness Perfect 16%, FGM) affects the bleaching and dental hypersensitivity levels. Methods: Forty patients with central incisors darker than A2 were selected for the trial. Some of the patients that did not intake coffee were placed in the control group (CG), while the patients that had coffee at least twice a day were selected for the experimental group (EG). Highly pigmented food were restricted for the control group. While there were no restrictions for the experimental group, the patients were requested to rinse their mouth with coffee for 30 seconds four times a day. 16% carbamide peroxide was used for both groups as the bleaching agent three hours a day for 3 weeks. The shade evaluation was accomplished with the Vita Classic shade guide as well as with a spectrophotometer for initial evaluation, throughout the bleaching process (first, second and third weeks), and after the bleaching process (after one week and then after one month). Patients used a scale from 0-10 to indicate their perception in regards to dental hypersensitivity. The two-way analysis of variance and the turkey test (α=0.05) were use to analyze variance in scale units between the two shades (AE). The absolute risk of hypersensitivity reaction as well as hypersensitivity intensity were evaluated by the Fisher’s exact test and Mann-Whitney (α=0.05). Results: The effective bleaching was reached in both groups after three weeks, without any statistical difference. No difference in terms of risk or levels of dental hypersensitivity were detected between the groups. Approximately 57% of the participant experienced some mild hypersensitivity reaction. Conclusion: Exposure to coffee through bleaching sessions seems not to interfere with the final aspect of bleaching procedure as well as with dental hypersensitivity.
151
3
Fragnan, L.N.; Bonini, G.A.V.C.; Politano, G.T.; Camargo, L.B.; Imparato, J.C.P.; Raggio, D.P. Knoop
hardness of three glass ionomer cements. Pesq Bras Odontoped Clin Integr, v. 11, n. 1, p. 73-76, 2011. Title: Knoop hardness of three glass ionomer cements.
days.
Objective: Evaluate the Knoop hardness of three glass ionomer cements (national cements) after 24 hours and seven
Method: The materials were dosed and manipulated according to manufacturer instructions and then divided into
groups (n=10): G1: Vidrion R (SS White, conventional), G2: Vitro Molar (DFL, high viscosity) and G3: Maxxion R (FGM,
high viscosity). After that, the specimens were made of HIPS. After that were immersed in oil solution (liquid Vaseline) at
37Ë&#x161; for 24 hours, the surfaces were polished with 600-grit sandpaper (Buehler) in a polishing machine Aropol 2V (Arotec). Then the durometer hardness tests was performed (Pantec digital micro-hardness tester HVS-10000) tests were run on loads of 25g for 20s, with a Knoop indenter. Three indentations were made in each sample and repeated after one week, respecting the patterns. Results: The mean Knoop hardness (and standard deviation) after 24 hours were: G1: 47,65 (20,1) , G2: 52,06
(10,6) and G3: 72,43 (17,4); after one week G1: 74,25 (16,5), G2: 87,55 (12,1) and G3: 132,17 (39,7). after analysis of variance and Tukey test for complement, a statistical significance was observed for the hardness values of G3 compared to G1 and G2 (p<0.05) also on the results obtained after 24 hours and one week. Conclusion: Maxxion R, high viscosity glass ionomer cement, shows superior mechanical properties if compared to Vidrion R and Vitro Molar cements. Timing increases hardness of these three national glass ionomer cements.
4
Cerezetti, R.V.; Tenuta, L.M.A.; Del Bel Cury, A.A.; LeitĂŁo, T.J. e Cury, J.A. Anticaries potential of
products for Professional fluoride application. J Dent Res #91 (Spec Iss A): 1160, 2012. Title: Anti-caries potential of products for Professional fluoride application.
Objectives: A variety of products based on fluoride are available in the market for professional application, however
a direct comparison among them in a clinical trial is hard considering demand, time and cost.
Methods: In a crossover study of short-term and 6 steps, the anticaries potential of some products were tested:
2% sodium fluoride gel (DFL., 0,9% F), acidulated phosphate fluoride gel (APF) (DFL., 1,23% F), foam APF (Laclede,
1,23% F), fluoride varnish (Duraphat, 2,25% F) bifluoride varnish (Duofluorid XII, FGM, 6% NaF + 6% CaF2; 5,6 F).
Application of the product was held under manufacturer instructions performed extra-orally on bovine enamel blocks. The blocks that were treated were then kept in artificial saliva renewed daily for 7 days, which simulates intraoral exposure, and the initial superficial hardness (SH) was determined. Blocks of each treatment group and the untreated control were mounted on palatal devices in touch with S. Mutans count on plaque test. The devices were then placed on the mouth of 12 volunteers and after 30 minutes, a 20% sucrose solution was sprayed, simulating a cariogenic challenge. After 45 minutes, the enamel blocks were collected, the superficial hardness was determined again and percentage loss (% SHL) was used as a demineralization index. Yet, CaF2 products retained on enamel after being washed by saliva were
determined on additional blocks.
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Results: The highest (p<0.05) CaF2 concentrations (μg F/cm2) was observed on enamel treated with varnishes and
the lower values were observed in the controlled groups, but among the other groups there was no difference (p<0.05) observed. All products reduced enamel demineralization if compared to the controlled group (%SHL=19.3±10.4). No difference was observed in regards to %SHL among NaF gel, APF gel and APF foam (12.9±9.6, 14.7± 7.1, 14.9±8.9, respectively) however the lowest demineralization was found on fluoride and bifluoride varnish (4.3±8.4 and 2.6±7.5, respectively). Conclusion: The findings suggest that all F professional fluoride products tested showed anti-caries potential, however those able to retain more “CaF2” on enamel after being exposed to saliva were more effective.
5
Burmann, P.; Palma, D.C.; Cardoso, P.E. e Santos, J.F.F. Fracture resistance of FPD over Direct/Indi-
rect Cores. J Dent Res #91 (Spec Iss A): 998, 2012. Title: Fracture resistance of FPD over Direct/Indirect Cores. Objective: Evaluate fracture resistance and failure mode of fixed partial dentures (FPD) over direct/indirect cores in swine mandible. Methods: 15 swine mandible bone segments with 1st, 2nd and 3rd mollars, preserved periodontal ligament and bone tissue (Laskowski Solution) were divided into 3 groups. To simulate a situation for a FPD with 2 pillars and 2 pontics, the coronal portion of second molar and the distal half of first molar were removed. The crowns for Group I (control group) were prepared for metal-ceramic. The pillars for Group II were restored with a cast metal core and for Group III, with fiber post (White Post DC, FGM, BRA) and resin composite (Opallis, FGM, BRA). The cores were standardized in shape and volume. Metallic structures for metal-ceramics in Ni-Cr (Wironia Light, Wilcos, BRA) were cemented with dual self-cure resin cement (RelyxU100, 3MESPE, BRA) and submitted to fracture resistance test with the load applied in the center of occlusal side (DL-1000, EMIC, BRA). Failures were analyzed with a stereomicroscope (Stereo Discovery V20, Carl Zeiss, ALE) and tomography scan and classified in F1 (fracture to bone level) and F2 (fracture below bone level). Results: Data was analyzed using One-way ANOVA (p<0.05) showed no statistical significant difference among the groups tested. Groups I and III presented 100% failures of type FI while Group II presented F2 failures in 80% of the samples (Fisher’s Exact Test, p<0.05). Conclusion: The different type of core tested in this study offered similar fracture resistance and the analysis of the type of fracture allowed for a relation between the core and fracture mode, indicating that the catastrophic failures were associated with the cast metal cores.
If you have a scientific study or clinical trial with FGM products that you wish to publish on our promotional materials, please call 0800 644 6100 or send us an e-mail bruno@fgm.ind.br. 153
A Guideline for clinical trials disclosure Dear Doctor FGM favors the dissemination of high quality knowledge and relies on its partners, dentists surgeons from all over Brazil, to succeed in such task. Currently, the company invests in various ways to disseminate knowledge through online publications, brochures, books, special folders, materials in large-circulation magazines, dentistry-related press, television media, FM radio stations, among others. A major means of spreading information is the FGM News, an own periodical where FGM discloses interesting and updated contents for all partners. With an average of 100 thousand prints, the magazine is free of charge and it is distributed at product point of sale, trade fair shows, conferences, universities, among others places, becoming available in the whole country. Versions translated into other languages are also in circulation in Latin America, the European Community, Africa and Asia. In order to ease communication among professionals and FGM, some guidelines were put together for professionals who wish to support FGM news technical content by sending documented clinical cases. To do so, follow the detailed guidelines below.
SUBMISSION OF DOCUMENTED CLINICAL CASES 1. LEGAL DOCUMENTS INVOLVED
2. 2. CLINICAL PROCEDURE
1.1 To facilitate the utilization of the clinical case, the
2.1 All relevant clinical steps for understanding the case
author is required to transfer the publication copyrights
should be photographed. The record of the initial and final
of the material provided to FGM, through an specific
oral condition is essential.
term that should be signed and sent via post office to 2.2 Cases should only contain FGM products, except
the company.
when the material in question is not contemplated in the 1.2 Another term should also be signed by the
line of products sold by the company.
corresponding patients to the clinical cases in question, authorizing the publication of their images. Note: besides
2.3 The sequence of the case shall be conducted in
sending via post office, we also request the scanned
accordance with the instructions provided for
copy of the signed authorization form to be send to the
product.
e-mail bruno@fgm.ind.br. Both terms templates may be requested in the email mentioned above. edition 6
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september 2014
each
3. photo quality
5. REFERENCES
3.1 Photographs must keep the issue in focus and
5.1 Possible references must be cited after the legends.
centralized, with standard brightness, cut in the ratio of 10 x 15.
6. A dynamic shipping cases:
3.2 All photographs must be in high resolution (minimum
6.1 The author must all necessary documents (photos
5MP or 300dpi) in JPG or TIF format.
in JPG or TIF format and text format “DOC” / Microsoft Word) to the e-mail consulting FGM: bruno@fgm.ind.br. The terms of authorization signed by the practitioner and
4. TEXT
the patient may be scanned and sent to the same e-mail 4.1 The text regarding the case report must contain:
before sending through the post office. This will expedite
a) Title: It should clearly translate the issue of the case
the process of selection of cases, once only cases with
clinical;
complete documentation will be evaluated;
b) Authors: mini updated resume and photo; c) Introduction (up to 30 lines): technical / scientific basis
6.2 The cases received will be evaluated by the technical
for the procedure that was performed;
team of the company within thirty working days from the
d) Case report (up to 30 lines): details diagnosis and
receipt of the complete documentation;
treatment plan. If relevant, a paragraph of “conclusion” should be added at this stretch of text;
6.3 If it is selected, the case will be FGM disclosure law,
e) Legends: legends of the photos must be clear and
that will reference all the authors in the publication.
objectively describe the stage of photography. 6.4 If it is not selected, the (a) author (s) will be informed and your case will be published elsewhere disclosure of your choice.
FGM THANK YOUR CONTRIBUTION
Consultoría Científica FGM FGM Produtos Odontológicos Av. Edgar Nelson Meister, 474 – Districto Industrial Caja Postal 89219-501 – Joinville – SC bruno@fgm.ind.br 155