By Dr. Frank Milnar

To place an effective Class V restoration, it is important to understand how teeth absorb and distribute stress. According to Milicich and Rainey, “stress distribution in human tooth structure can be visualized through the use of Moiré fringes,” which show the “peripheral rim of enamel transferring occlusal load directly to the root of the tooth.” The load on the incisal edge of a tooth moves vertically and then horizontally to the DEJ before transferring vertically and accumulating in the Class V area where the enamel is at its thinnest (approximately 0.3 millimeters). The cervical third of the tooth absorbs the greatest stress, which can cause adhesive delamination.

To ensure best outcomes in Class V restorations, I have started using ACTIVA BioACTIVE-RESTORATIVE, which contains a patented rubberized resin that is more fracture resistant than traditional composite materials. According to the manufacturer the toughness of ACTIVA, measured by deflection at break, is 2-3 times greater than composites and 5-10 times greater than GIs and RMGIs. The material exhibits high compressive and diametral tensile strength while also having very low wear. In addition, ACTIVA BioACTIVE is hydrophilic, making it ideal for Class V restorations and other instances where it is difficult to ensure a dry field.

The patient presented with several failing Class V restorations. The pre-operative image of tooth #8 indicates a cervical abfraction and failing composite restoration (Figure 1). The tooth was prepared using rotary abrasion with the goal of exposing prismatic enamel to promote micromechanical retention and leverage the bond strength of enamel. Figure 2 shows the preparation with a radius bevel.

The peripheral rim of enamel around the Class V restoration can be considered a tension ring (Milicich G & Rainey J) which, when properly reinforced, can mitigate the occlusal forces accumulating in the Class V area. Similar to caulking a window, an adhesive seal was placed around the preparation (Figure 3). The adhesive was placed first on the gingival margin followed by a 10 second light cure, then the top of the “window” was “caulked” and sealed with a 10 second light cure, and finally each side was “caulked” and sealed before light curing for 10 seconds. After “caulking the window” the final restoration was placed using ACTIVA BioACTIVE-RESTORATIVE. The material was back filled into the preparation and placed slightly beyond the radius bevel, and then finished and polished. Figure 4 shows the final restoration.

Reference
Milicich G, Rainey J. Clinical presentations of stress distribution in teeth and the significance in operative dentistry. PPAD 2000; 12 (7): 695-700.

About Dr. Frank J. Milnar

Frank J. Milnar DDS, AAACD is a graduate from the University of Minnesota, School of Dentistry in 1976. He is an Accredited member of the American Academy of Cosmetic Dentistry, Board Examiner for Accreditation and Diplomat of the American Board of Cosmetic and Esthetic Dentistry. Dr. Milnar maintains a full-time practice in St. Paul, Minnesota emphasizing Minimally Invasive and appearance related dentistry. He has published over 50 peer reviewed articles about the direct placement of composites, shade selection and porcelain materials and is on editorial review boards for dental journals. Dr. Milnar is co-founder of the Minnesota Academy of Cosmetic Dentistry and has lectured extensively within the US Armed Forces as well as internationally on the subject of direct composite restorations, shade selection and porcelain materials. He has been voted “Top Dentist” and voted into the” Top Dentist Hall of Fame” for the last five years by his peers in the Minneapolis/St. Paul Magazine.He has been voted by Dentistry Today as one of the top 100 dentists contributing to dental education. Most recently, Dr.Milnar was nominated to the University Of Minnesota School Of Dentistry Continuing Education Advisory Board and is a Visiting Faculty Member for the BIOCLEAR Learning Center.

By Amber Auger RDH, MPH

As a practicing hygienist, I come across a lot of misconceptions about treatment options, especially fluoride varnish. Here are the top four myths I’ve heard about fluoride varnish and what you need to know:

Myth #1: It’s all about the flavor
From Salted Caramel to Tutti Frutti, fluoride varnishes are available in a dizzying array of flavors. While great taste can help increase case acceptance, it is not the only factor to keep in mind when selecting a fluoride varnish. Consider the other ingredients in the varnish and the role they play in reducing the risk of dental decay.

Myth #2: Fluoride is the key ingredient
Fluoride is one of several important ingredients to look for in a fluoride varnish, including:

Calcium and Phosphate
During demineralization it is calcium and phosphate ions, not fluoride, that are released by the tooth. When the process of demineralization happens more quickly than remineralization, subsurface lesions develop, leaving the patient susceptible to tooth decay. The appearance of a white spot lesion indicates that, while subsurface mineral content has been lost, there is still potential for remineralization. The combination of calcium, phosphate, and fluoride help support remineralization and preserve tooth structure.

Xylitol
Xylitol promotes an increased salivary flow and a balanced pH which work to reduce the number of cariogenic and periodontopathic bacteria. The use of xylitol has been shown to lead to a reduction in the proportion of streptococci mutants in plaque, neutralize plaque acids, and help remineralize white-spot lesions.

Click here to learn about fluoride varnish with calcium, phosphate, fluoride, and xylitol.

Myth #3: More is better
Counterintuitive as it may seem, using more fluoride varnish is not necessarily better. Patients tend to be less compliant when they have multiple layers of fluoride varnish on their teeth.
Some may even chip away at a varnish treatment that feels “thick” or uncomfortable. To ensure patient compliance, the varnish should be uniformly mixed and placed in a thin, even layer, so that it can dry quickly.

Myth #4: Parts Per Million (PPM) Determines Efficacy
Many varnishes contain a high concentration of parts per million of fluoride (usually 22,600 PPM) in order to extend the contact time between fluoride and tooth surfaces. Research shows that it is the mechanism of action, rather than the parts per million of fluoride ions, that matters most. This mechanism involves interaction of fluoride from the varnish with saliva to form calcium fluoride (CaF2). The CaF2 deposits slowly release fluoride ions into the oral environment, supporting the natural remineralization process.

Interested in learning more about hygiene and prevention? Join the Embrace Prevention Facebook Group to engage with dental hygiene professionals from all over the world. Click here to join Embrace Prevention on Facebook.

References

1. Collins, Fiona. The Development and Utilization of Fluoride Varnish. 2014. Available at: https://www.dentalacademyofce.com/courses/2093/PDF/1106cei_varnish_web4.pdf.  Accessed October 23, 2018.
2. Nordblad A, Suominen-Taipale L, Murtomaa H, Vartiainen E, Koskela K. Smart Habit xylitol campaign, a new approach in oral health promotion. Community Dent Health. 1995;12:230–234.[PubMed]
3. A Maguire, A J Rugg-Gunn. Xylitol and caries prevention — is it a magic bullet? British Dental Journal volume194, pages429–436 (26 April 2003)
4. Gold, J. Fluoride Varnish Products in the U.S. Market. J Res Development 2013. DOI: 104172/2311-3278.1000e102. Accessed November 6, 2018.

About Amber Auger, RDH, MPH
Amber Auger, RDH, MPH, is a hygienist with experience in multiple clinical settings, including facilities abroad. Amber obtained a master’s degree in public health from the University of New England and a bachelor’s in dental hygiene from the University of New Haven. She holds a part-time position at an elite dental office in Boston, and is chief of clinical technology for Jameson Management. Amber Auger is a key opinion leader for several dental companies, speaker and published author, and can be contacted at amberaugerrdh.com.

In the following case Dr. Todd Snyder shows how he replaced crowns on teeth #8 and #9 using ACTIVA BioACTIVE-CEMENT.

About Dr. Todd Snyder

Dr. Todd Snyder received his doctorate from the UCLA School of Dentistry and trained at the F.A.C.E. institute. He is an Accredited Fellow of the American Academy of Cosmetic Dentistry, a Member of the American Society for Dental Aesthetics and a member of Catapult Education. Dr. Snyder created and co-direct at UCLA the first two-year graduate program in Aesthetic and Cosmetic Restorative Dentistry. He lectures internationally and has authored numerous articles in publications worldwide. Dr Snyder is a consultant for numerous companies and has his own online training program known as Legion Pride. Dr Snyder also owns two software companies, is a professional race car driver and entrepreneur.

By Dr. Susan McMahon

Older patients are at increased risk for root caries because of  gingival recession that exposes root surfaces and  increased use of medications that produce xerostomia. Age related visual impairment and decreased dexterity also can lead to higher caries rates and a decreased ability to adequately maintain good oral hygiene. This makes the margins of restorations particularly susceptible to recurrent decay. Choosing a cement that will not only retain the restoration but also help stimulate remineralization is extremely beneficial for these patients.

ACTIVA BioACTIVE-CEMENT helps stimulate apatite formation, supporting the natural remineralization process and helping seal the margin between the tooth and the restoration. ACTIVA helps to prevent microleakage, maintain the integrity of a sealed margin, and keep the restoration, tooth and surrounding tissues healthy.  ACTIVA BioACTIVE-CEMENT is a combination of bioactive resin, rubberized resin and ionomer glass filler.  It is dual cure, moisture tolerant, and indicated for  all indirect restorations except veneers.  ACTIVA is very easy to use, with no additional etching or adhesive steps, and clean-up is simple and quick.

This 93-year-old female patient had mobility in her upper central and lateral incisors. A four-unit splinted HT Zirconia restoration was indicated for functionality and to increase the likelihood of keeping these teeth for the duration of the patient’s life.   Previous PFM crowns were removed and the central and lateral incisors were prepared for a four-unit splinted zirconia restoration.

The patient had +1 mobility on the central and lateral incisors (Figure 1). After removal of the old crowns, the visible areas of demineralization on the central incisors and dark staining on the preps were noted (Figure 2). New splinted crowns would increase a favorable prognosis for these teeth.

Because of the oral health challenges facing geriatric patients (gingival recession, xerostomia, and home care issues), the margins of this new restoration have an increased susceptibility to recurrent decay.  I chose ACTIVA BioACTIVE-CEMENT because of its bioactive properties, which help support the natural remineralization process and seal the margins.

At the insert appointment, the provisional restoration was removed, the preps were cleaned, and the restoration was tried in. After assuring the fit of the restoration, it was cleaned with Ivoclean, loaded with ACTIVA BioACTIVE-CEMENT, and  seated (Figure 3). The restoration was initially flash cured  to set the excess cement to the gel-like set. The excess cement was then very easily removed (Figure 4). The bioactivity and the ease of use of ACTIVA BioACTIVE-CEMENT make it an excellent choice, not just for geriatric applications like this, but also for many other indirect restorations where recurrent caries is a concern.

About Dr. Susan McMahon
Dr McMahon, an University of Pittsburgh School of Dental Medicine graduate, is in private practice in Pittsburgh and at University Dental Professionals in Chicago. She is an accredited member of the American Academy of Cosmetic Dentistry, the American Society for Dental Aesthetics, and a fellow in the International Academy of Dental Facial Esthetics. She is the Director of Product Evaluation for Catapult Education and a member of Catapult Speaker’s Bureau. She can be reached at 412.298.2734 or drsusan@wowinsmile.com.

By Dr. Robert Lowe

The following case demonstrates how to place a minimally invasive restoration using the caries detection mode of an intraoral camera and ACTIVA BioACTIVE-RESTORATIVE.

Figure 1 is an occlusal view of tooth number 29 taken with caries detection mode of an intraoral camera (SoproCare: Acteon USA) showing active caries in the central fissure of the tooth.  It is important to note that this lesion is not yet able to “stick” with an explorer because of the depth of this narrow fissure and inability of the explorer tip to reach the lesion due to its larger size.  A fissurotomy bur (micro NTF 6066: SS White) is used to carefully eradicate only the area that fluoresced positive (looks clinically like stain). 

As the preparation is made, the intraoral camera on caries detection (Cario) mode can be used to check for complete active caries removal (Figure 2). 

Because ACTIVA supports the natural remineralization process with release of calcium and phosphate, “white” areas of decalcified enamel can be preserved rather than removed during preparation. After using a total etch protocol, adhesive placement and light curing, ACTIVA BIOACTIVE-RESTORATIVE is placed into the micro-preparation using its automix tip with a bendable cannula (Figure 3). 

Figure 4 shows a view of the completed restoration taken with the intraoral camera.  Note that it is difficult if not impossible to detect the restoration even at extreme magnification. Restorative margins are imperceptible. The tooth looks untouched like virgin enamel.

References

1. Ferracane JL, Pfeifer CS, Bertassoni LE, “Biomaterials for Oral Health”,  Dental Clinics of North America, vol.61, no.4, October 2017, pp. 651-872.
2. Chao W, et al. Deflection at break of restorative materials. J Dent Res 94 (Spec Iss A) 2375, 2015 (iadr.org).
3. Slowikowski L, et al. Fluoride ion release and recharge over time in three restoratives. Paper presented at: AADR Annual Meeting & Exhibition 2014; March 19, 2014; Boston, MA.
4. Garcia-Gadoy F, Morrow BR, Pameijer CH, “Flexural Strength and Fatique of Activa RMGICs”, College of Dentistry UTHSC, Memphis and UConn School of Dentistry, Farmington, CT, White Paper Presentation at IADR, 2014.
5. Maj J, Merritt J, Ferracane J, “Adhesion of S. Mutans Biofilms on Potentially Antimicrobial Dental Composites”, J dent Res 96 (Special Issue A); 2560, 2017.
6. Comba A, Breschi L, et.al., J Dent Res 97 (Special Issue A) 0273, 2018.
7. Girn VS, et.al., J Res Dent 93 (Special Issue A): 1163, 2014.

About Robert A. Lowe, DDS
Robert A. Lowe, DDS, received his Doctor of Dental Surgery degree from Loyola University School of Dentistry. After completing his residency, Dr. Lowe went into private practice and began to pursue another passion: clinical teaching. While running his own practice, Dr. Lowe served as a Clinical Professor in Restorative Dentistry at Loyola University School of Dentistry until its closure in 1993. In 2000, he relocated to Charlotte, NC.

Well-known dentist and educator Dr. Susan McMahon will present “Just Do It… Better – Digital Diagnostics and Regenerative Restorative Materials Team Up For Better Restorations,” a Continuing Education (CE) webinar on October 23, 2019 at 7:00 PM ET/ 4:00 PM PT. This live webinar is free and open to the public.

Sign up for Dr. McMahon’s webinar.

For many years dentists have used metal explorers and radiographs to detect dental decay. These approaches work best when there is extensive decay that can be felt with an explorer or seen in the radiograph. In this webinar Dr. McMahon will share how to use advanced diagnostic tools to detect dental decay earlier and restore teeth using bioactive materials.

About Dr. Susan McMahon
Dr McMahon, an University of Pittsburgh School of Dental Medicine graduate, is in private practice in Pittsburgh and at University Dental Professionals in Chicago. She is an accredited member of the American Academy of Cosmetic Dentistry, the American Society for Dental Aesthetics, and a fellow in the International Academy of Dental Facial Esthetics. She is the Director of Product Evaluation for Catapult Education and a member of Catapult Speaker’s Bureau. She can be reached at 412.298.2734 or drsusan@wowinsmile.com.