Clinical Treatments

Dental Veneers

Dental veneers (sometimes called porcelain veneers or dental porcelain laminates) are wafer-thin, custom-made shells of tooth-colored materials designed to cover the front surface of teeth to improve your appearance. These shells are bonded to the front of the teeth changing their color, shape, size, or length.

Dental veneers can be made from porcelain or from resin composite materials. Porcelain veneers resist stains better than resin veneers and better mimic the light reflecting properties of natural teeth. Resin veneers are thinner and require removal of less of the tooth surface before placement. You will need to discuss the best choice of veneer material for you with your dentist.

What Types of Problems Do Dental Veneers Fix?

Veneers are routinely used to fix:

• Teeth that are discolored — either because of root canal treatment; stains from tetracycline or other drugs, excessive fluoride or other causes; or the presence of large resin fillings that have discolored the tooth
• Teeth that are worn down
• Teeth that are chipped or broken
• Teeth that are misaligned, uneven, or irregularly shaped (for example, have craters or bulges in them)
• Teeth with gaps between them (to close the space between these teeth)

What’s the Procedure for Getting a Dental Veneer?

Getting a dental veneer usually requires three trips to the dentist – one for a consultation and two to make and apply the veneers. One tooth or many teeth can simultaneously undergo the veneering process described below.

Diagnosis and treatment planning

This first step involves your active participation. Explain to your dentist the result that you are trying to achieve. During this appointment, your dentist will examine your teeth to make sure dental veneers are appropriate for you and discuss what the procedure will involve and some of its limitations. He or she also may take X-rays and possibly make impressions of your mouth and teeth.

Preparation

To prepare a tooth for a veneer, your dentist will remove about 1/2 millimeter of enamel from the tooth surface, which is an amount nearly equal to the thickness of the veneer to be added to the tooth surface. Before trimming off the enamel, you and your dentist will decide the need for a local anesthetic to numb the area. Next, your dentist will make a model or impression of your tooth. This model is sent out to a dental laboratory, which in turn constructs your veneer. It usually takes 1-2 weeks for your dentist to receive the veneers back from the laboratory. For very unsightly teeth, temporary dental veneers can be placed for an additional cost.

Bonding

Before the dental veneer is permanently cemented to your tooth, your dentist will temporarily place it on your tooth to examine its fit and color. He or she will repeatedly remove and trim the veneer as needed to achieve the proper fit; the veneer color can be adjusted with the shade of cement to be used. Next, to prepare your tooth to receive the veneer, your tooth will be cleaned, polished, and etched — which roughens the tooth to allow for a strong bonding process. A special cement is applied to the veneer and the veneer is then placed on your tooth. Once properly position on the tooth, your dentist will apply a special light beam to the dental veneer, which activates chemicals in the cement, causing it to harden or cure very quickly. The final steps involve removing any excess cement, evaluating your bite and making any final adjustments in the veneer as necessary. Your dentist may ask you to return for a follow-up visit in a couple of weeks to check how your gums are responding to the presence of your veneer and to once again examine the veneer’s placement.

What Are the Advantages of Dental Veneers?

Veneers offer the following advantages:

• They provide a natural tooth appearance.
• Gum tissue tolerates porcelain well.
• Porcelain veneers are stain resistant.
• The color of a porcelain veneer can be selected such that it makes dark teeth appear whiter. Veneers offer a conservative approach to changing a tooth’s color and shape; veneers generally don’t require the extensive shaping prior to the procedure that crowns do, yet offer a stronger, more aesthetic alternative.

What Are the Disadvantages of Dental Veneers?

The downside to dental veneers include:

• The process is not reversible.
• Veneers are more costly than composite resin bonding.
• Veneers are usually not repairable should they chip or crack.
• Because enamel has been removed, your tooth may become more sensitive to hot and cold foods and beverages.
• Veneers may not exactly match the color of your other teeth. Also, the veneer’s color cannot be altered once in place. If you plan on whitening your teeth, you need to do so before getting veneers.
• Though not likely, veneers can dislodge and fall off. To minimize the chance of this occurring, do not bite your nails; chew on pencils, ice, or other hard objects; or otherwise put excessive pressure on your teeth.
• Teeth with veneers can still experience decay, possibly necessitating full coverage of the tooth with a crown.
• Veneers are not a good choice for individuals with unhealthy teeth (for example, those with decay or active gum disease), weakened teeth (as a result of decay, fracture, large dental fillings), or for those who have an inadequate amount of existing enamel on the tooth surface.
• Individuals who clench and grind their teeth are poor candidates for porcelain veneers, as these activities can cause the veneers to crack or chip.

How Long Do Dental Veneers Last?

Veneers generally last between 5 and 10 years. After this time, the veneers would need to be replaced.

Teeth Whitening

Teeth whitening is not permanent. People who expose their teeth to foods and beverages that cause staining may see the whiteness start to fade in as little as one month. Those who avoid foods and beverages that stain may be able to wait one year or longer before another whitening treatment or touch-up is needed.

How Long Do Teeth Whitening Effects Last?

The degree of whiteness will vary from individual to individual depending on the condition of the teeth, the level of staining, and the type of bleaching system used.
At-Home Teeth Whitening vs. Dentist-Supervised Teeth Whitening.

There are differences between whitening teeth at home and having them bleached in a dentist’s office, including:

• Strength of bleaching agent. Over-the-counter products and dentist-supervised at-home products usually contain a lower strength bleaching agent, with about a 10% to 22% carbamide peroxide content, which is equivalent to about 3% hydrogen peroxide. In-office, professionally applied tooth whitening products contain hydrogen peroxide in concentrations ranging from 15% to 43%.
• Mouthpiece trays. With dentist-supervised at-home bleaching products, your dentist will take an impression of your teeth and make a mouthpiece tray that is customized to exactly fit your teeth. This customization allows for maximum contact between the whitening gel, which is applied to the mouthpiece tray, and the teeth. A custom-made tray also minimizes the gel’s contact with gum tissue. Over-the-counter whitening products also contain a mouthpiece tray, but the “one-size-fits-all” approach means that the fit will not be exact. Ill-fitting trays can irritate the gum and soft tissue by allowing more bleaching gel to seep onto these tissues. With in-office procedures, the bleaching agent is applied directly to the teeth.
• Additional protective measures. In the office setting, your dentist will apply either a gel to the gum tissue or use a rubber shield (which slides over the teeth) prior to treatment to protect your gums and oral cavities from the effects of the bleaching. Over-the-counter products don’t provide these extra protective measures.
• Costs. Over-the-counter bleaching systems are the least expensive option, with in-office whitening being the costliest.
• Supervised vs. unsupervised process. Dentist-supervised at-home bleaching and in-office treatments offer additional benefits compared with over-the-counter procedures. First, your dentist can perform an oral exam and consider your complete medical history, which can be helpful in determining if bleaching is an appropriate course of treatment based on the type and extent of stains, and the number and location of restorations. Your dentist can then better match the type of stain with the best treatment, if appropriate, to lighten those stains. With dentist-supervised bleaching procedures, your dentist will likely want to see you a couple of times to ensure you are following directions, to make sure the customized tray is fitting properly, to inspect the gums for signs of irritation, and to generally check on how the teeth whitening process is proceeding. With over-the-counter bleaching products, you are on your own.

Risks Associated With Teeth Whitening

The two side effects that occur most often with teeth whitening are a temporary increase in tooth sensitivity and mild irritation of the soft tissues of the mouth, particularly the gums. Tooth sensitivity often occurs during early stages of the bleaching treatment. Tissue irritation most commonly results from an ill-fitting mouthpiece tray rather than the tooth-bleaching agent. Both of these conditions usually are temporary and disappear within one to three days of stopping or completing treatment.

If you do experience sensitivity, you can reduce or eliminate it by:

• Wearing the tray for a shorter period of time (for example, two 30-minute sessions vs. two 60-minute sessions).
• Stop whitening your teeth for two to three days to allow teeth to adjust to the whitening process.
• Ask your dentist or pharmacist for a high fluoride-containing product, which can help remineralize your teeth. Apply the fluoride product to the tray and wear for four minutes prior to and following the whitening agent.
• Brush teeth with a toothpaste made for sensitive teeth. These toothpastes contain potassium nitrate, which helps soothe the teeth’s nerve endings.

Whitening Product Safety

Some whitening products dispensed through dentists’ offices as well as professionally applied (in-office) bleaching products have received the American Dental Association (ADA) Seal of Acceptance, which indicates that the product has met ADA guidelines for safety and effectiveness. Currently, only dentist-dispensed home-use products containing 10% carbamide peroxide and office-applied products containing 35% hydrogen peroxide have received the ADA Seal of Acceptance. Over-the-counter bleaching products are not endorsed by the ADA, because the organization believes that professional consultation is important to ensuring safe and effective use.

No whitening products using lasers are on the ADA’s list of accepted products. Several whitening toothpastes that are available in drugstores have received the ADA Seal of Acceptance. For a list of specific toothpastes that have gained the ADA’s Seal of Acceptance, visit www.ada.org.

It should be noted that not all manufacturers seek the ADA’s Seal of Acceptance. This is a voluntary program that requires considerable expense and time on the part of a manufacturer. Just because a product does not have the ADA Seal of Acceptance does not necessarily mean that the product is not safe and effective. You can be assured, however, that products that do carry the seal meet the ADA’s standards for safety and effectiveness when used as directed.

Teeth whiteners are not drugs and therefore are not regulated by the FDA.

Tips to Consider When Choosing an Over-the-Counter Whitening Kit

• Try to select a teeth whitening kit that allows some customization of the mouthpiece. Some kits come with a mouthpiece that can be molded to some degree. These are better than others that come with a standard mouthpiece.
• Try to gain the opinion of others who may have already tried the kit you are considering.
• If at any time you experience a prolonged change in the color of your gums or an increased tooth sensitivity to hot or cold foods and beverages, stop wearing the mouthpiece and see your dentist immediately.

Tooth Contouring and Reshaping

Is there a small defect in your smile that always draws your eye in the mirror? A chip in a front tooth, some worn edges, or shallow pits or grooves in the tooth enamel are all minor issues, but they do stand in the way of having a perfect smile. If you suffer from one or more of these problems — even to the extent of a minor fracture or overlap… they all can be fixed using a procedure known as tooth contouring and reshaping.

Using a polishing instrument, the dentist removes small amounts of surface enamel of one or more teeth to compensate for the imperfections. Followed up with a smoothing and polishing of all the surrounding teeth, this quick, painless, and inexpensive procedure can make a big difference in your smile. Because it is relatively inexpensive and noninvasive, it is a good place to start changing your smile to the one that you have always wanted, but Mother Nature failed to give you.

What Are the Benefits of Tooth Contouring?

The goal of tooth contouring and reshaping is to change the size or shape of the teeth so that slightly damaged or out of proportion teeth are brought back into alignment with the rest. In essence a cosmetic procedure, it is most often performed on the upper central, lateral, and canine teeth. Beyond the outward benefits, there are often oral health gains, too, as smoothing the teeth and repairing overlaps can make them easier to clean, reducing the risk of The primary consideration for the suitability of cavities and gum disease. Reshaping can also be used to correct minor problems with bite and function.

What will happen at the initial consultation?

At the initial consultation, the dentist will examine your teeth and determine whether the defects that are present in your smile are sufficiently minor to be corrected using contouring and reshaping. He will also x-ray the teeth to make sure that they are healthy enough to undergo removal of a small amount of the surface enamel.

How is the tooth contouring procedure performed?

Tooth contouring and reshaping takes place generally in one visit to the dentist’s office, although a follow-up visit is sometimes necessary. Often the dentist will take a “before” photograph to use as a reference. Then, using various tools, the dentist carefully polishes off small areas of the tooth surface enamel and reforms the tooth into a more attractive shape. The edges of the newly shaped tooth are smoothed and polished, completing the procedure. An “after” photograph is made at this point so the differences can be easily seen. After contouring, the teeth are more uniform in shape and size making them appears less crowded and eye-catching imperfections are gone. The length of the procedure is dependent on the amount of changes that are being made to the teeth, but can run from under 30 minutes to over an hour.

How much pain is there with tooth contouring?

Because only surface enamel is removed, there is no pain involved with the procedure, so no anesthetic is administered. Occasionally, there is minor sensitivity to hot and cold for a day or two after the procedure, but this irritation is minor and almost uniformly disappear a short time after the procedure. Recovery for almost every patient undergoing tooth contouring or reshaping is instantaneous. You can generally eat immediately after the procedure. The removal of the small amount of enamel does not hurt the tooth nor is it replaced, so no healing is involved.

Ideal Candidate:

An ideal candidate would have minor imperfections in their teeth such as small chips, minor unevenness, slight overlaps, shallowly pitted surfaces, or worn biting areas in their teeth. Other indications for the procedure are one or more teeth out of proportion in size to the rest of the set, such as large, pointy canine teeth. Note that reshaping can only occur on healthy teeth, so x-rays are often taken before the procedure is done to check for problems.

Some characteristics of the teeth that might preclude reshaping are: thin enamel, previous extensive restorations of the tooth or surrounding teeth, recently erupted teeth, teeth having gum structure that would be disturbed by the procedure, or teeth that are still shifting. Some contouring is not recommended if it will adversely affect the patient’s bite.

Risks and Limitations:

The risks involved in the procedure include the removal of too much enamel, subjecting the tooth to a greater chance of breakage or decay, or reappearance of the problem if it is due to grinding of the teeth. However, seeing an experienced cosmetic dentist virtually eliminates these risks.

Wisdom Teeth Extraction

An oral and maxillofacial surgeon or your dentist can remove (extract) a wisdomtooth. The procedure often can be done in the dentist’s or surgeon’s office. You may have the surgery in the hospital, especially if you are having all your wisdom teethpulled at one time or if you are at high risk for complications.
If you have any infections, surgery will usually be delayed until the infection has cleared up. Your doctor or dentist may have you take antibiotics to help heal the infection.

How Your Oral Health Affects Your Overall Wellness?

Before removing a wisdom tooth, your dentist will give you a local anesthetic to numb the area where the tooth will be removed. Ageneral anesthetic may be used, especially if several or all of your wisdom teeth will be removed at the same time. A general anesthetic prevents pain in the whole body and will cause you to sleep through the procedure. Your dentist will probably recommend that you don’t eat or drink after midnight on the night before surgery so that you are prepared for the anesthetic.

To remove the wisdom tooth, your dentist will open up the gum tissue over the tooth and take out any bone that is covering the tooth. He or she will separate the tissue connecting the tooth to the bone and then remove the tooth. Sometimes the dentist will cut the tooth into smaller pieces to make it easier to remove.

After the tooth is removed, you may need stitches. Some stitches dissolve over time and some have to be removed after a few days. Your dentist will tell you whether your stitches need to be removed. A folded cotton gauze pad placed over the wound will help stop the bleeding.

What to Expect After Surgery?

In most cases, the recovery period lasts only a few days. Take painkillers as prescribed by your dentist or oral surgeon. The following tips will help speed your recovery.

• Bite gently on the gauze pad periodically, and change pads as they become soaked with blood. Call your dentist or oral surgeon if you still have bleeding 24 hours after your surgery.
• While your mouth is numb, be careful not to bite the inside of your cheek or lip, or your tongue.
• Do not lie flat. This may prolong bleeding. Prop up your head with pillows.
• Try using an ice pack on the outside of your cheek for the first 24 hours. You can use moist heat-such as a washcloth soaked in warm water and wrung out-for the following 2 or 3 days.
• Relax after surgery. Physical activity may increase bleeding.
• Eat soft foods, such as gelatin, pudding, or a thin soup. Gradually add solid foods to your diet as healing progresses.
• Do not use a straw for the first few days. Sucking on a straw can loosen theblood clot and delay healing.
• After the first day, gently rinse your mouth with warm salt water several times a day to reduce swelling and relieve pain.
• You can make your own salt water by mixing 1 tsp (5 g) of salt in a medium-sized glass [8 fl oz (240 mL)] of warm water.
• Do not smoke for at least 24 hours after your surgery. The sucking motion can loosen the clot and delay healing. Also, smoking decreases the blood supply and can bring germs and contaminants to the surgery area.
• Avoid rubbing the area with your tongue or touching it with your fingers.
• Continue to brush your teeth and tongue carefully.

Your dentist will remove the stitches after a few days, if needed.

Why It Is Done?

A wisdom tooth is extracted to correct an actual problem or to prevent problems that may come up in the future. When wisdom teeth come in, a number of problems can occur:

Your jaw may not be large enough for them, and they may become impacted and unable to break through your gums.

Your wisdom teeth may break partway through your gums, causing a flap of gum tissue to grow over them. Food and germs can get trapped under the flap and cause your gums to become red, swollen, and painful. These are signs of infection.

More serious problems can develop from impacted teeth, such as infection, damage to other teeth and bone, or a cyst.

One or more of your wisdom teeth may come in at an awkward angle, with the top of the tooth facing forward, backward, or to either side.

Wisdom tooth removal usually is effective in preventing:

• Crowding of the back teeth.
• A wisdom tooth becoming stuck in the jaw (impacted) and never breaking through the gums.
• Red, swollen, and painful gums caused by a flap of skin around a wisdom tooth that has only partially come in.
• Gum disease and tooth decay in the wisdom tooth, which may be harder to clean than other teeth, or in the teeth and jaw in the area of the wisdom tooth.

Risk

After a wisdom tooth is removed, you may experience:

• Pain and swelling in your gums and tooth socket where the tooth was removed.
• Bleeding that won’t stop for about 24 hours.
• Difficulty with or pain from opening your jaw (trismus).
• Slow-healing gums.
• Damage to existing dental work, such as crowns or bridges, or to roots of a nearby tooth.
• A painful inflammation called dry socket, which happens if the protective blood clot is lost too soon.
• Numbness in your mouth and lips after the local anesthetic wears off, due to injury or inflammation of nerves in the jaw.

Rare side effects, including:

• Numbness in the mouth or lips that does not go away.1
• A fractured jaw if the tooth was firmly attached to the jaw bone.
• An opening into the sinus cavity when a wisdom tooth is removed from the upper jaw.

Dental surgery may cause bacteria in the mouth to enter the bloodstream and cause infections in other parts of the body. People who have difficulty fighting off infections may need to take antibiotics before and after dental surgery. Such people include those who have artificial heart valves or were born with heart defects.
Anesthetic (local and/or general) almost always is used during the extraction procedure. All surgeries, including oral surgery, that use general anesthetic have a small risk of death or other complications.

What to Think About?

If your wisdom teeth are not causing problems, it may be difficult to decide whether to have these teeth removed to prevent possible dental problems later in life.

Think about the following:

• You may never have any problems with your wisdom teeth.
• It is rarely harmful to your health to have your wisdom teeth removed, but there are slight risks involved with any surgery.
• In younger people (late teens and early 20s), the wisdom tooth’s roots are not fully developed and the jaw bone is not as dense, so it is easier to remove the tooth. The easier it is to remove the tooth, the easier your recovery is likely to be.
• Most problems with wisdom teeth develop between the ages of 15 and 25.
• If you are older than age 30, you have only a small risk of having problems with your wisdom teeth. Few people older than 30 develop problems that require removal of their wisdom teeth.
• Medical insurance does not always cover this procedure.
• If you have a medical condition that may get worse over time and your teeth may cause problems, consider having your wisdom teeth removed while you are healthy.
• Possible complications include dry socket (alveolar osteitis), infection, bleeding, and numbness.

Women on birth control pills who decide to have their wisdom teeth removed should try to schedule the surgery for the end of their menstrual cycle (usually days 23 through 28). There seems to be less risk of dry socket during this time.

After a wisdom tooth is removed, you may have or notice:

• Pain and swelling in your gums and tooth socket where the tooth was removed.
• Bleeding that won’t stop for about 24 hours.
• Difficulty with or pain from opening your jaw (trismus).
• Slow-healing gums.
• Damage to dental work, such as crowns or bridges, or to roots of a nearby tooth.
• A painful inflammation called dry socket.

Numbness in your mouth and lips after the local anesthetic wears off, due to injury or inflammation of nerves in the jaw. Numbness will usually go away, but in rare cases it may be permanent.1

Dental surgery may cause bacteria in the mouth to enter the bloodstream and cause infections in other parts of the body. People who have difficulty fighting off infections may need to take antibiotics before and after dental surgery. Such people include those who have artificial heart valves or were born with heart defects.

Orthodontics

Orthodontics, formerly orthodontia (from Greek orthos “straight or proper or perfect”; and odous “tooth”) is the first specialty of dentistry that is concerned with the study and treatment of malocclusions (improper bites), which may be a result of toothirregularity, disproportionate jaw relationships, or both. Orthodontic treatment can focus on dental displacement only, or can deal with the control and modification of facial growth. In the latter case it is better defined as “dentofacial orthopaedics”. Orthodontic treatment can be carried out for purely aesthetic reasons with regards to improving the general appearance of patients’ teeth. However, there are orthodontists who work on reconstructing the entire face rather than focusing exclusively on teeth.

Modern Orthodontics

The use of digital models in orthodontics is rapidly increasing as the industry undergoes analog to digital conversions in record keeping. The University of Minnesota recently developed Three Dimensional Dental Models for Computer Automated Treatment Simulation that can be used to reduce the amount of human input needed for orthodontic treatment planning. This software tool has the ability to automatically segment teeth from one another and the gums. Digital laboratories are currently being used by many orthodontists, but can be very expensive. This software provides an efficient and cost-effective method for completing the segmentation process.

Methods

For comprehensive orthodontic treatment, most commonly, metal wires (Jushi’) are inserted into orthodontic brackets (see dental braces), which can be made from stainless steel or a more aesthetic ceramic material. The wires interact with the brackets to move teeth into the desired positions. Other methods may include invisalign. Invisalign consists of clear plastic aligners that move teeth.

Additional components—including removable appliances (“plates”), headgear, expansion appliances, and many other devices—may also be used to move teeth and jaw bones. Functional appliances, for example, are used in growing patients (age 5 to 14) with the aim of modifying the jaw dimensions and relationship if these are altered. This therapy, termed Dentofacial Orthopedics, is frequently followed by fixed multibracket therapy (“full braces”) to align the teeth and refine the occlusion.

Orthodontics is the study of dentistry that is concerned with the treatment of improper bites, and crooked teeth. Orthodontic treatment can help fix the patient’s teeth and set them in the right place. Orthodontists usually use braces and retainers to set the patient’s teeth.[2] There are, however, orthodontists who work on reconstructing the entire face rather than focusing exclusively on teeth. After a course of active orthodontic treatment, patients will typically wearretainers, which maintain the teeth in their improved positions while surrounding bone reforms around them. The retainers are generally worn full-time for a period, anywhere from just a few days to a year, then part-time (typically, nightly during sleep) for as long as the orthodontist recommends.

It is possible for the teeth to stay aligned without regular retainer wear. However, there are many reasons teeth will crowd as a person ages, whether or not the individual ever experienced orthodontic treatment; thus there is no guarantee that teeth will stay aligned without retention. For this reason, many orthodontists prescribe night-time or part-time retainer wear for many years after orthodontic treatment (potentially for life). Adult orthodontic patients are more likely to need lifetime retention.
Diagnosis and treatment planning

In diagnosis and treatment planning, the orthodontist must;

• recognize the various characteristics of a malocclusion or dentofacial deformity;
• define the nature of the problem, including the etiology if possible;
• design a treatment strategy based on the specific needs and desires of the individual; and
• present the treatment strategy to the patient in such a way that the patient fully understands the ramifications of his/her decision.

Inlays and Onlays

In dentistry, an inlay is an indirect restoration (filling) consisting of a solid substance (as gold or porcelain) fitted to a cavity in a tooth and cemented into place an onlay is the same as an inlay, except that it extends to replace a cusp. Crowns are onlays which completely cover all surfaces of a tooth.

Inlays

Sometimes, a tooth is planned to be restored with an intracoronal restoration, but the decay or fracture is so extensive that a direct restoration, such as amalgam or composite, would compromise the structural integrity of the restored tooth or provide substandard opposition to occlusal (i.e., biting) forces. In such situations, an indirect gold or porcelain inlay restoration may be indicated. When an inlay is used, the tooth-to-restoration margin may be finished and polished to such a super-fine line of contact that recurrent decay will be all but impossible. While these restorations might be ten times the price of direct restorations, the superiority of an inlay in terms of resistance to occlusal forces, protection against recurrent decay, precision of fabrication, marginal integrity, proper contouring for gingival (tissue) health, and ease of cleansing offers an excellent alternative to the direct restoration.

Onlays

When decay or fracture incorporate areas of a tooth that makeamalgam or composite restorations inadequate, such as cuspalfracture or remaining tooth structure that undermines perimeter walls of a tooth, an onlay might be indicated. Similar to an inlay, an onlay is an indirect restoration which incorporates a cusp or cusps by covering or onlaying the missing cusps. All of the benefits of an inlay are present in the onlay restoration. The onlay allows for conservation of tooth structure when the only alternative is to totally eliminate cusps and perimeter walls for restoration with a crown. Just as inlays, onlays are fabricated outside of the mouth and are typically made out of gold or porcelain. Gold restorations have been around for many years and have an excellent track record. In recent years, newer types of porcelains have been developed that seem to rival the longevity of gold. If the onlay or inlay is made in a dental laboratory, a temporary is fabricated while the restoration is custom-made for the patient. A return visit is then required to fit the final prosthesis.

Dentures & Bridges

DENTURES

Dentures, also known as false teeth, are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clasping onto teeth or dental implants. There are two main categories of dentures, depending on whether they are used to replace missing teeth on the mandibular arch or the maxillary arch.

Removable Partial Dentures

Removable partial dentures are for patients who are missing some of their teeth on a particular arch. Fixed partial dentures, also known as “crown and bridge”, are made from crowns that are fitted on the remaining teeth to act as abutments and pontics made from materials to resemble the missing teeth. Fixed bridges are more expensive than removable appliances but are more stable.

Complete Dentures

Conversely, complete dentures or full dentures are worn by patients who are missing all of the teeth in a single arch (i.e. the maxillary (upper) or mandibular (lower) arch).

Modern dentures are most often fabricated in a commercial dental laboratory using a combination of a tissue shaded powder polymethylmethacrylate acrylic (PMMA) for the tissue shaded aspect, and commercially produced acrylic teeth available in hundreds of shapes and tooth colors.

The process of fabricating a denture usually begins with a dental impression of the maxilla or mandible. This impression is used to create a stone model that represents the arch. A wax rim is fabricated to assist the dentist or denturist with establishing the vertical dimension of occlusion. After this a bite registration is created to marry the position of one arch to the other.

Once the relative position of each arch to the other is known, the wax rim can be used as a base to place the selected denture teeth in correct position. This arrangement of teeth is tried in the mouth so that adjustments can be made to the Occlusion. After the occlusion has been verified by the dentist with the patient, and all phonetic requirements are met, the denture is processed.

Processing a denture is usually performed in a lost-wax process whereby the form of the final denture, including the acrylic denture teeth, is invested in stone. This investment is then heated, and the wax is removed through a sprue when it melts. The remaining cavity is then either filled by forced injection or pouring of the uncured denture acrylic. After a curing period, the stone investment is removed, the acrylic is polished, and the denture is complete.

BRIDGES

A dental bridge is an appliance used to replace one or more missing teeth. These appliances are cemented into place and cannot be removed by the patient.

How is a dental bridge constructed?

As the name of this appliance implies, the bridge is made out of three pieces that fit into the open space in the mouth, “bridging” the gap. Most bridges are made of a pontic tooth (or false tooth), held together by two crowns (a “cap” that covers the tooth, approximating its normal size and shape). This trio is then attached (cemented) to the abutment teeth (the surrounding teeth of each side of the gap).

Who is a candidate for bridges?

Nearly everyone who has one or more missing teeth is a candidate for a dental bridge. However, the difference between proper and improper oral hygiene is, generally, what determines the success of the dental bridge. The teeth that will support the bridge must be in good periodontic health.

What are the different types of dental bridges?

There are several different types of dental bridges. Your dentist or oral health specialist will recommend the most appropriate one for your mouth condition and the location of the missing tooth or teeth.

• Traditional bridge – as described above, this bridge consists of a pontic (false) tooth held together by two crowns. The trio is cemented to the surrounding teeth on each side of the gap.
• Resin-bonded bridge (also known as a Maryland bridge) – this type of bridge involves the pontic (false) teeth being fused to metal bands that are bonded to the back of the abutment teeth with a resin cement. This type of procedure is common when the teeth missing are in the front of the mouth.
• Cantilever bridge – this type of procedure is most appropriate when there is only one abutment tooth on either side of the span.

Oral Health Care and Bridges

The following recommendations will help to eliminate, or reduce, any oral health problems while your teeth are bonded by a bridge:

• Brush your teeth carefully after every meal with fluoride toothpaste and a soft-bristled toothbrush, as food may become lodged causing the gums and teeth to become infected. This may lead to further complications resulting in the loss of the bridge.
• Floss daily. Your dentist, or other oral health specialist, may recommend using a floss threader to carry floss under the pontic (false) tooth so it and the abutment (support) teeth can be cleaned.
• Have your teeth cleaned every six months by an oral health professional.
• Limit your sugar and starch intake, as debris left behind from these types of foods may turn into damaging acids, which, in addition to promoting plaque formation, may also be harmful to teeth and gums.
• Avoid hard and/or sticky snacks. This includes foods such as popcorn, hard or chew candy, caramel, and/or nuts.
• Most bridges last more than 10 years with proper oral hygiene.

Dental Fillings

To treat a cavity your dentist will remove the decayed portion of the tooth and then “fill” the area on the tooth where the decayed material was removed. Fillings are also used to repair cracked or broken teeth and teeth that have been worn down from misuse (such as from nail-biting or tooth grinding)

What Steps Are Involved in Filling a Tooth?

First, the dentist will use a local anesthetic to numb the area around the tooth to be filled. Next, a drill, air abrasion instrument, or laser will be used to remove the decayed area. The choice of instrument depends on the individual dentist’s comfort level, training, and investment in the particular piece of equipment as well as location and extent of the decay.

Next, your dentist will probe or test the area to determine if all the decay has been removed. Once the decay has been removed, the dentist will prepare the space for the filling by cleaning the cavity of bacteria and debris. If the decay is near the root, your dentist may first put in a liner made of glass ionomer, composite resin, or other material to protect the nerve. Generally, after the filling is in, your dentist will finish and polish it.

Several additional steps are required for tooth-colored fillings and are as follows. After your dentist has removed the decay and cleaned the area, the tooth-colored material is applied in layers. Next, a special light that “cures” or hardens each layer is applied. When the multilayering process is completed, the dentist will shape the composite material to the desired result, trim off any excess material, and polish the final restoration.

What Types of Filling Materials Are Available?

Today, several dental filling materials are available. Teeth can be filled with gold; porcelain; silver amalgam (which consists of mercury mixed with silver, tin, zinc, and copper); or tooth-colored, plastic, and glass materials called composite resin fillings. The location and extent of the decay, cost of filling material, patients’ insurance coverage, and your dentist’s recommendation assist in determining the type of filling best for you.

Cast Gold Fillings

Advantages of cast gold fillings:

• Durability — lasts at least 10 to 15 years and usually longer; doesn’t corrode
• Strength — can withstand chewing forces
• Aesthetics — some patients find gold more pleasing to the eye than silver, amalgam fillings.

Disadvantages of cast gold fillings:

• Expense — gold cast fillings cost more than other materials; up to 10 times higher than cost of silver amalgam fillings.
• Additional office visits — requires at least two office visits to place
• Galvanic shock — a gold filling placed immediately next to a silver, amalgam filling may cause a sharp pain (galvanic shock) to occur. The interaction between the metals and saliva causes an electric current to occur. It’s a rare occurrence, however.
• Aesthetics — most patients dislike metal “colored” fillings and prefer fillings that match the rest of the tooth.

Silver Fillings (Amalgams)

Advantages of silver fillings:

• Durability — silver fillings last at least 10 to 15 years and usually outlasts composite (tooth-colored) fillings.
• Strength — can withstand chewing forces
• Expense — is less expensive than composite fillings

Disadvantages of silver fillings:

• Poor aesthetics — silver fillings don’t match the color of natural teeth.
• Destruction of more tooth structure — healthy parts of the tooth must often be removed to make a space large enough to hold the amalgam filling.
• Discoloration — amalgam fillings can create a grayish hue to the surrounding tooth structure.
• Cracks and fractures — although all teeth expand and contract in the presence of hot and cold liquids, which ultimately can cause the tooth to crack or fracture, amalgam material — in comparison with other filling materials — may experience a wider degree of expansion and contraction and lead to a higher incidence of cracks and fractures.
• Allergic reactions — a small percentage of people, approximately 1%, are allergic to the mercury present in amalgam restorations.

Tooth-colored Composites

Advantages of composites:

• Aesthetics — the shade/color of the composite fillings can be closely matched to the color of existing teeth. Composites are particularly well suited for use in front teeth or visible parts of teeth.
• Bonding to tooth structure — composite fillings actually chemically bond to tooth structure, providing further support.
• Versatility — in addition to use as a filling material for decay, composite fillings can also be used to repair chipped, broken, or worn teeth.
• Tooth-sparing preparation — sometimes less tooth structure needs to be removed compared with amalgam fillings when removing decay and preparing for the filling.

Disadvantages of composites:

• Lack of durability — composite fillings wear out sooner than amalgam fillings (lasting at least five years compared with at least 10 to 15 for amalgams); in addition, they may not last as long as amalgam fillings under the pressure of chewing and particularly if used for large cavities.
• Increased chair time — because of the process to apply the composite material, these fillings can take up to 20 minutes longer than amalgam fillings to place.
• Additional visits — if composites are used for inlays or onlays, more than one office visit may be required.
• Chipping — depending on location, composite materials can chip off the tooth.
• Expense — composite fillings can cost up to twice the cost of amalgam fillings.

In addition to tooth-colored, composite resin fillings, two other tooth-colored fillings exist — ceramics and glass ionomer.

Other Filling Types

• Ceramics — These fillings are made most often of porcelain, are more resistant to staining than composite resin material but are also more abrasive. This material generally lasts more than 15 years and can cost as much as gold.
• Glass ionomer —  is made of acrylic and a specific type of glass material. This material is most commonly used for fillings below the gum line and for fillings in young children (drilling is still required). Glass ionomers release fluoride, which can help protect the tooth from further decay. However, this material is weaker than composite resin and is more susceptible to wear and prone to fracture. Glass ionomer generally lasts five years or less with costs comparable to composite resin.

Dental Bonding

Dental bonding is a procedure in which a tooth-colored resin material (a durable plastic material) is applied and hardened with a special light, which ultimately “bonds” the material to the tooth to restore or improve person’s smile.

For What Conditions Is Dental Bonding Considered?

Dental bonding is an option that can be considered:

What’s the Procedure for Having a Tooth Bonded?

Preparation. Little advance preparation is needed for dental bonding. Anesthesia is often not necessary unless the bonding is being used to fill a decayed tooth. Your dentist will use a shade guide to select a composite resin color that will closely match the color of your tooth.

The bonding process. Next, the surface of the tooth will be roughened and a conditioning liquid applied. These procedures help the bonding material adhere to the tooth. The tooth-colored, putty-like resin is then applied, molded, and smoothed to the desired shape. An ultraviolet light or laser is then used to harden the material. After the material is hardened, your dentist will further trim and shape it, and polish it to match the sheen of the rest of the tooth surface.

Time-to-completion. Dental bonding takes about 30 to 60 minutes per tooth to complete.

What Are the Advantages and Disadvantages of Dental Bonding?

Advantages: Dental bonding is among the easiest and least expensive of cosmetic dental procedures. Unlike veneers and crowns, which are customized tooth coverings that must be manufactured in a lab, bonding usually can be done in one office visit unless several teeth are involved. Another advantage, compared with veneers and crowns, is that the least amount of tooth enamel is removed. Also, unless dental bonding is being performed to fill a cavity, anesthesia is usually not required.

Disadvantages: Although the material used in dental bonding is somewhat stain resistant, it does not resist stains as well as crowns. Another disadvantage is that the bonding materials do not last as long nor are as strong as other restorative procedures, such as crowns, veneers, or fillings. Additionally, bonding materials can chip and break off the tooth.

Because of some of the limitations of dental bonding, some dentists view it as best suited for small cosmetic changes, for temporary correction of cosmetic defects, and for correction of teeth in areas of very low bite pressure (for example, front teeth). Consult with your dentist about the best cosmetic approach for your particular problem.

Do Bonded Teeth Require Special Care?

Bonded teeth do not require special care. Simply follow good oral hygiene practices. Brush teeth at least twice a day, floss at least once a day, and see your dentist for regular professional check-ups and cleanings.

Because bonding material can chip, it is important to avoid such habits as biting fingernails; chewing on pens, ice, or other hard food objects; or using your bonded teeth as an opener. If you do notice any sharp edges on a bonded tooth or if your tooth feels odd when you bite down, call your dentist.

How Long Does Bonding Material Last?

The lifespan of bonding materials for the teeth depends on how much bonding was done and your oral habits. Typically, however, bonding material lasts from three years up to about 10 years before needing to be touched up or replaced.

Root Canals

A root canal is the space within the root of a tooth. Part of a naturally occurring space within a tooth, it consists of the pulp chamber(within the coronal part of the tooth), the main canal(s), and more intricate anatomical branches that may connect the root canals to each other or to the surface of the root.

What Happens During a Root Canal?

A root canal requires one or more office visits and can be performed by a dentist or endodontist. An endodontist is a dentist who specializes in the causes, diagnosis, prevention, and treatment of diseases and injuries of the human dental pulp or the nerve of the tooth. The choice of which type of dentist to use depends to some degree on the difficulty of the root canal procedure needed in your particular tooth and the general dentist’s comfort level in working on your tooth. Your dentist will discuss who might be best suited to perform the work in your particular case.

The first step in the procedure is to take an X-ray to see the shape of the root canals and determine if there are any signs of infection in a surrounding bone. Your dentist or endodontist will then use local anesthesia to numb the area near the tooth. Anesthesia may not be necessary, since the nerve is dead, but most dentists still anesthetize the area to make the patient more relaxed and at ease.

Next, to keep the area dry and free of saliva during treatment, your dentist will place a rubber dam (a sheet of rubber) around the tooth.

An access hole will then be drilled into the tooth. The pulp along with bacteria, the decayed nerve tissue and related debris is removed from the tooth. The cleaning out process is accomplished using root canal files. A series of these files of increasing diameter are each subsequently placed into the access hole and worked down the full length of the tooth to scrape and scrub the sides of the root canals. Water orsodium hypochlorite is used periodically to flush away the debris.

Once the tooth is thoroughly cleaned, it is sealed. Some dentists like to wait a week before sealing the tooth. For instance, if there is an infection, your dentist may put a medication inside the tooth to clear it up. Others may choose to seal the tooth the same day it is cleaned out. If the root canal is not completed on the same day, a temporary filling is placed in the exterior hole in the tooth to keep out contaminants like saliva and food between appointments.

At the next appointment, to fill the interior of the tooth, a sealer paste and a rubber compound called gutta percha is placed into the tooth’s root canal. To fill the exterior access hole created at the beginning of treatment, a filling is placed.

The final step may involve further restoration of the tooth. Because a tooth that needs a root canal often is one that has a large filling or extensive decay or other weakness, a crown, crown and post, or other restoration often needs to be placed on the tooth to protect it, prevent it from breaking, and restore it to full function.