A dental bonding procedure, which is performed to fill a cavity or to cosmetically repair a chip, fracture, enamel defect or gap between teeth is known as a “direct composite restoration.” For a direct composite restoration, both artistry and precision are required as the dentist places the selected shade of composite resin and carefully sculpts it to rebuild or improve the appearance of a tooth.

In terms of the cosmetic repair of dental defects, the masking of discolorations or the closure of gaps between teeth, a dental bonding procedure is considered the most economical and quickest method of care out of all the cosmetic solutions available for these types of corrections. Unlike porcelain veneers or ceramic crowns, dental bonding is a minimally invasive, one-visit cosmetic procedure. Moreover, unless a cavity is being cleaned and prepared prior to a dental bonding procedure, no drilling of tooth structure and no anesthesia is required.

How is a dental bonding procedure performed?

When performing a bonding procedure, it is important to enable the composite resin to firmly adhere to the underlying tooth structure. To do this the surface of the tooth is etched and then painted with a liquid bonding agent just prior to the placement of the filling or cosmetic bonding. As the dentist places the composite resin, it is carefully sculpted to achieve the desired shape and then cured with a special light or allowed to set. Once hardened, the newly bonded restoration is polished and buffed for a smooth finish. Some dentists may offer composite veneers as an alternative to porcelain veneers, artistically bonding and blending successive layers of composite resin to transform the appearance of a tooth.

Caring For Bonded Teeth

While a bonding procedure offers an excellent and cost-effective method of care for the treatment of minor cosmetic dental issues, there are a couple of considerations with this approach. Teeth that are restored or cosmetically enhanced with a dental bonding procedure are as a rule more susceptible to staining and chipping than with other types of cosmetic treatments. For this reason, highly pigmented foods and drinks are to be avoided along with tobacco products. As dental bonding can easily chip and break, it is also important not to bite into hard objects or foods and to avoid oral habits such as biting one’s nails or chewing on pens. However, with proper hygiene and care, a bonded restoration can last for many years.

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When a tooth requires a full coverage restoration to rebuild its structural integrity and appearance, how good the crown will look and how well it will withstand the forces of oral function are major considerations in choosing the type of crown. In the past, only metal crowns or ones fabricated out of porcelain fused to an underlying substructure of metal offered the strength required to bite and chew without breaking. While porcelain fused to metal crowns to this day remain a popular choice for strong, attractive and long-lasting restorations to rebuild teeth that are damaged, decayed, misshapen, worn down, undersized, or have had a root canal procedure, there are some drawbacks. For one thing, the thin metal margin at the collar of a PFM crown may be visible at the gumline (especially in the presence of receding gums). Also, due to the presence of an underlying metal shell, porcelain fused to metal crowns do not come close to handling light in the same way as natural tooth structure or dental ceramics.

Advantages of Ceramic Crowns

While the trade off between appearance and strength used to mean that porcelain or all-ceramic crowns looked better but did not have the strength and durability of porcelain fused to metal crowns that is no longer the case. All-ceramic crowns are not only capable of producing incredibly lifelike results, but thanks to the range of materials available today, all-ceramic crowns are stronger and more reliable than ever before.

Some of the advantages of all-ceramic crowns include:

• All-ceramic crowns interact with light in much the same way as natural teeth and can closely mimic their translucency and luster
• All-ceramic crowns can be made thinner and require less tooth reduction
• All-ceramic crowns are kinder to the surrounding tissues, for potentially healthier long-term results
• All-ceramic crowns are resistant to stain and discoloration
• All-ceramic crowns are metal-free and safer for individuals with allergies or sensitivities to metal

With the range of engineered dental ceramics available today, which material is selected for crown fabrication depends upon the location of the tooth, the stresses on that tooth and the esthetic requirements of the case. Certain all-ceramic crowns are more suited for back teeth, while others are able to fulfill the aesthetic requirements presented by a front tooth. Some of the all-ceramic crowns used today include Feldspathic porcelain crowns, Empress crowns, Procera crowns, Lava crowns, Zirconia crowns, and Emax crowns.

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One of the ways to replace missing teeth to restore oral function and appearance is with dentures. Depending upon the needs of a case, dentures can be used to replace either a few teeth that have been lost or all of the teeth in the upper or lower jaws. In addition to reestablishing the look of a complete and natural smile, dentures also restore support to the natural contours of the face to eliminate the “sunken” appearance that results from losing multiple teeth. Whether teeth have been lost for reasons of tooth decay, gum disease, a medical condition, congenital anomaly, or trauma, dentures are an effective method of care.

Dentures are removable appliances that are designed to precisely and comfortably rest on top of the gums that cover the jawbones. They can be taken out of the mouth for brief periods of time to fulfill the oral hygiene requirements of maintaining the underlying tissues, cleaning the dentures, and sleeping.

Types of Dentures

The two main types of dentures are: full dentures and partial dentures. Both types are custom fabricated based on the exact specifications obtained from dental impressions and detailed functional as well as esthetic information provided by the dentist.

Full Dentures

Full dentures, which can also be referred to as, “complete dentures,” are designed to replace all of the upper or lower teeth. A complete maxillary denture, more commonly known as a, full upper denture, typically consists of a base that covers the roof of the mouth with a full complement of artificial teeth set around the section covering the dental arch. On the other hand, a complete mandibular denture, or full lower denture, is designed to accommodate the tongue and is horseshoe shaped with teeth set along the portion that covers the underlying dental arch.

• Conventional Full Denture – A conventional full denture is fabricated and placed after all of the remaining teeth have been removed and the tissue is healed. It takes several weeks for extraction sites to heal and for all of the surrounding bone and gum tissues to fill in and remodel. By allowing this process to reach completion before taking the final impressions for a new denture, the most precise and comfortable fitting prosthesis can be fabricated.
• Immediate Denture – An immediate denture is one that is inserted on the day the remaining teeth are removed. With this method of care, a patient does not have to be without teeth while waiting for complete healing of the extraction sites. Immediate dentures offer the distinct cosmetic advantage of not having to be without teeth. However, since the healing of the extraction sites is occurring while wearing the denture, a reline or new denture may be required later for improved comfort and fit.
• Overdenture – An overdenture is a type of complete denture that receives added stability and support from special attachments that are secured to the remaining underlying teeth or strategically placed dental implants.

Partial Dentures

A partial denture is a type of removable prosthesis that is designed to restore a complete and functional smile in cases where multiple teeth are missing or require extractions, while some healthy teeth remain in the dental arch. Custom fabricated for a precise fit and cosmetically pleasing appearance, partial dentures are typically secured and stabilized with clasps or precision attachments to select teeth adjacent to the edentulous areas. Depending upon the number of teeth being replaced as well as the functional and aesthetic requirements of the case, a partial denture can be fabricated from a combination of cast metal and acrylic materials, acrylic alone, or thermoplastic resins such as ValplastTM, Flexite®, Duroflex® and tcs®.

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A fixed bridge is a non-removable appliance fabricated to replace missing teeth, which closely resembles a patient’s natural dentition. Besides serving to restore the appearance and performance of a complete smile, a fixed bridge also prevents teeth that are adjacent to or opposite the edentulous area from shifting to protect the integrity of the occlusion. Fixed bridges are strong, durable and natural looking restorations, which once they are permanently cemented into place allow all manner of normal oral function.

How are fixed bridges fabricated?

Fixed bridges are typically fabricated over the course of multiple visits and involve the preparation of the adjacent supporting teeth, impression taking, the placement of a temporary bridge as well as the try-in and cementation of the permanent restoration. The teeth located on either side of the edentulous area that are crowned to provide support for the bridge are referred to as the “abutment teeth,” while the artificial tooth (or teeth) spanning across the empty space are known as “pontics.”

With the dental technology available today, bridges can also be completely supported by implants without any preparation or crowning of the adjacent natural teeth required. Depending upon the aesthetic and functional needs of a case, fixed bridges can be fabricated from different dental materials including porcelain, porcelain fused to metal, or engineered ceramic-like products such as zirconia.

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A dental implant is a small, biocompatible post that is surgically positioned by means of a minimally invasive procedure into the jawbone beneath the gums. Once healing takes place and the implant integrates with the bone, it behaves in much the same way as the root of a natural tooth to provide support for an aesthetically appealing dental crown or bridge. A period ranging from 3 to 6 months is required for the jawbone to fuse with the implant via a process known as osseointegration.

What are the benefits of replacing lost or missing teeth with dental implants?

Dental implants offer several advantages over traditional methods of tooth replacement including:

• Dental implants come the closest to replicating the look, feel, and function of natural teeth.
• With precise placement, good oral hygiene and routine care, dental implants can last for many years.
• Dental implants provide continued stimulation to the underlying bone to prevent the bone loss that occurs when teeth are missing to preserve natural facial contours.
• Since implants behave like natural teeth, there is no chance that they will slip or dislodge like removable dentures when speaking or eating.
• With dental implants, it is possible to speak with ease as well as eat and taste all types of food with virtually no restrictions.
• Dental implants do not decay and will not develop cavities.
• Unlike a fixed bridge, dental implants do not require any preparation or crowning of teeth adjacent to the edentulous area.

Who is a candidate for a dental implant procedure?

According to clinical studies, dental implants have a demonstrated long-term success rate of well over 95%. One key to the success and longevity of a dental implant is that sufficient bone is present to provide stable support for the implanted surgical post. If insufficient bone is present, a bone grafting procedure is often recommended prior to the placement of a dental implant. Additionally, candidates for dental implants should be free of periodontal disease and be aware that a continued, effective oral hygiene routine and care is necessary to maintain a strong and functional implant.

Treatment Planning for Dental Implants

Treatment planning a patient for the precise placement of a dental implant involves advanced scanning technology and software to map out the details of care from both a prosthetic and surgical prospective. In this way a case can be planned and meticulously executed from the beginning with the final restoration in mind. With advances in implant dentistry multiple approaches to care are now being offered. In certain cases an implant can be placed at the same time a dental extraction is performed. This procedure is known as, “immediate dental implant placement.” Additionally, it is also sometimes possible to place “same-day dental implants.” With this procedure a temporary crown or bridge can be attached to the implants at the same time they are placed. In all cases, complete healing and osseointegration is required before the placement of the final prosthesis.

Types of Dental Implants

Most dental implants are made of titanium but are also available in “metal-free” zirconia. Both titanium and zirconia are biocompatible materials, which integrate well with the hard and soft tissues in the jaw. Depending upon the requirements of the case, a single dental implant can be restored with a crown to replace one missing tooth, or multiple implants can be used to support a fixed bridge. In cases where all of the upper and/or lower teeth are missing a full-arch, implanted supported bridge can be placed. Special implants can also be placed for added support and stability for removable overdentures or as anchorage devices in orthodontics called “TAD’s” or Transitional Anchorage Devices.

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By performing a gum graft procedure, which is also known as a “gingival graft or soft tissue graft,” the dentist replaces the soft tissue over the exposed area of the tooth to address the problems created by receding gums. Gum tissue for grafting procedures can be harvested from a nearby site in the mouth or obtained from another donor source. A gum graft may be performed on a single tooth or multiple ones. And, based upon the needs of the case, the dentist will determine which type of gum graft to employ.

The three types of gum grafts include the following:

• Free gingival graft-This graft utilizes a small piece of tissue that is taken from the palate. It is often indicated when extra thick tissue is needed to prevent further recession.
• Connective tissue graft- This frequently used graft is harvested from a sub-layer of connective tissue located under the uppermost tissue layer on the roof of the mouth.
• Pedicle graft-This type of graft is created from a flap of tissue that is adjacent to the area of the gum recession.

Following a gum graft procedure, the dentist will provide detailed post-operative care instructions as well as set up appointments to make sure the surgical site is healing properly and to check that the graft is successful.

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With proper surgical treatment and maintenance care, the chances of tooth loss, further damage to the bone and soft tissues supporting the teeth, and complications from health problems that are linked to periodontal disease can be decreased.

Gum disease is typically the result of inadequate or ineffective oral hygiene practices that lead to the accumulation of dental plaque, which is sticky film that is colonized by oral bacteria. The harmful bacteria and the products they produce provoke a defensive, inflammatory response in the gums. When this inflammation is not resolved, tissue damage ensues and spaces between the gums and teeth that are known as periodontal pockets develop. As the periodontal pockets deepen, the bacteria become more difficult to remove and the gaps between the surface of the teeth and gums get larger. When pocket depth increases to the point of being beyond the reach of deep cleanings and other conservative methods of care (5mm or more), gum surgery to clean and treat the damage to gums and underlying bone is recommended.

By performing pocket reduction surgery the following is accomplished:

• Sub-gingival bacteria beneath the gums and from the surfaces of the roots of the teeth is removed
• Damage to the underlying bone is halted and affected bone is re-contoured
• Effective oral hygiene to clean the teeth and gums is made easier

While a surgical procedure known as flap surgery during which the tissue is surgically reflected away from the teeth and bone so that the area can be treated before the tissue is sutured back into place, is typically performed, some practitioners are now using soft tissue laser procedures to reduce pocket depth.

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When a tooth is extracted, the natural stimulation to the underlying bone that is generated by the forces of biting or chewing is lost. In fact, bone width can be reduced by as much as 25% in the first year following tooth loss.

With grafting procedures, the dental bone can be restored to its original dimensions to maintain facial esthetics, repair the damage caused by periodontal disease as well as facilitate the success of procedures such as the placement of dental implants. A bone graft provides a platform or “scaffolding” for new bone growth and the material for a bone graft can be derived from the patient, other donor sources or be comprised of synthetic, bone-like materials.

There are several types of grafting procedures that can be performed with the particular approach depending upon the needs of the case.

A bone graft can be placed immediately upon the extraction of a tooth or some time after tooth loss. Placing a bone graft at the time of tooth removal reduces the amount of bone loss in the area to maintain the hard tissue support that is required for the future placement of a dental implant. When a bone graft is placed a while after tooth loss, a separate surgical procedure is required to reflect the soft tissue, expose the underlying bone, place a graft and then suture the soft tissue back into place.

For patients lacking a sufficient amount of bone for a dental implant to replace a maxillary back tooth (upper back tooth), a procedure known as a “sinus lift” may be performed. During this surgical procedure, the sinus membrane is lifted and bone graft material is added between the jaw and the floor of the sinus to provide the needed bone height to successfully support a dental implant.

In addition to bone grafting for purposes of ridge preservation or augmentation to allow for dental implants, an aesthetic ridge augmentation procedure to restore the natural contours of the bone is sometimes performed in preparation for fixed bridgework to achieve a more cosmetically pleasing result.

To guide tissue regeneration as well as protect the graft and promote healing, special membranes and biologically active materials may be placed over the grafting material.

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The American Academy of Periodontology emphasizes achieving periodontal health by means of the least invasive and cost effective treatment approaches to care. Deeper cleanings, which include Scaling and Root planing, are non-surgical procedures that are considered the first line of defense against the progression of periodontal disease.

With scaling and root planing, any plaque and tartar (hardened dental plaque) that have accumulated below the gumline are carefully removed and then the root surfaces of the teeth are smoothed. Since, periodontal disease is an inflammatory response to plaque, tartar and bacterial toxins, by simply mechanically eliminating these agents, the progression of gum disease can be halted. In addition to removing plaque and tartar with a scaling and root planing procedure, antimicrobial medication placed under the gumline or systemic medications can be used as adjuncts to care to further reduce the bacterial population.

If non-surgical approaches to managing periodontal disease do not achieve the desired outcome, surgery may be recommended to halt its progression and repair damage as possible.

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Alternatively, a crown lengthening procedure can also be performed for reasons that are purely aesthetic to reduce the appearance of a “gummy smile” when too much of the gums and far too little tooth structure is displayed when smiling. It can be performed on a single tooth to make the gum line appear even with the other teeth or on several teeth to improve a smile’s overall appearance

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