Assessment of the dentition brings new challenges in the era of tooth-colored restorations - recognizing and detecting esthetic materials and smile evaluation.
Kristine A. Hodsdon, RDH, BS
The search for restorations that reproduce natural dentition has changed operative dentistry and dental hygiene. Adhesive materials, techniques, and related continuing education forums allow dental professionals to deliver and maintain various direct, semi-direct, and indirect restorations, including a broad spectrum of composite resins and ceramic materials. The materials involve minimal invasive preparation, tooth reinforcement, and sealing the tooth. When completed and polished meticulously, it can be virtually impossible to tell apart from adjacent dentition.
The dental hygiene process of care includes assessment, diagnosis and care planning (for oral hygiene), implementation, and evaluation. The traditional assessment phase embraces:
- Health, dental, and behavioral data
- Vital signs
- Oral and intraoral structures
- Dentition
- Periodontal tissue
- Oral hygiene
Assessment of the dentition brings new challenges in the era of tooth-colored restorations - recognizing and detecting esthetic materials and smile evaluation.
To differentiate a porcelain/ ceramic restoration from composite or enamel, visual, clinical, and radiographic examinations can be used. Radiographic images can aid in the identification due to the varying radiopacities of the esthetic materials. The most radiopaque shades are from metal, such as amalgam or gold. Composite resins containing glass-filler particles (hybrids) and ceramic materials have varying radiopacities. Microfill composite resins, which contain only small silica particles, appear radiolucent.
Conventional radiography generally shows about 16 shades of gray, but still may limit our ability to determine the restoration/tooth interface. However, newer digital imagery can show several hundred variations of color and may further aid a hygienist in the radiographic identification.
The visual and clinical examination involves a sharp explorer, mirror, dental floss, air-tips, magnification loupes, and accurately documented esthetic treatment forms. Visual identification begins by applying air to clear debris or to dry the tooth surfaces.
Since most composite and ceramic materials reflect, refract, absorb, or transmit light rays differently than enamel and dentin, a method known as transillumination can be used to visually distinguish restorations. This is achieved by reflecting light through the tooth from the lingual surface using a mouth mirror and a specialty or operatory light. The light source illuminates the tooth and restorative materials differently for visual recognition.
Careful tactile instrumentation is essential in distinguishing the restorative material/ tooth structure margin. Use gentle pressure with exploratory strokes. If the margin is incorrectly identified as calcified deposit and is aggressively scaled, damage to the esthetic restoration and possible tooth structure may occur. However, if the margins were poorly finished and polished, these areas are more vulnerable to stain. In addition, if the rough margins are subgingival, the result can be localized inflammation.
An esthetic form may be designed to contain the esthetic therapy schedule, dental hygiene care plan, type of material used, surface(s), interdisciplinary referral(s), provisional stages, recommended polishing agents, debriding instruments, etc.
Auditing the esthetic form prior to the hygiene session and making necessary preparations allows the clinician to work seamlessly while adding value for the client. The client perceives the dental hygienist as prepared, efficient, professional, and knowledgeable.
Identifying composites
A hygienist should be able to identify between microfill, hybrid, and small-particle composites. Clinical examination will show that microfill composites, when finished and polished precisely, are very glossy and feel smooth to the tip of an applied explorer. To further aid in their identification via location, as a general guide, microfills can be used in Class III, IV, and V restorations, hand-sculptured veneers, and diastema closures.
An additional microfill category, reinforced microfills, may be used in additional enamel replacement areas. Due to their small particle size, microfills are easily polishable to gain a shine. So, if you are unsure what material the restorative team used, quickly polish the restoration with a composite rubber polisher. If it regains its shine after five to 15 seconds, then it is probably a microfill.
Hybrid composites composites have a combination of large filler particles (glass) for strength and smaller particles (silica) for polishability and esthetics. They may be the most common type of composites used in contemporary esthetic practices. Hybrids may cause more of a drag when an explorer is drawn across the surface. They can easily be mistaken for microfills, but cannot be polished as effortlessly.
According to 2000 Reality, a dental publication which analyzes esthetic materials, the rubber instruments D-fine (Clinician`s Choice) and Diacomp (Brassler) produce the "glossiest" surface for hybrids. The final polishing step includes the use of a polishing paste. Regular Prisma-Gloss and Prisma-Gloss Extra-fine (Dentsply/Caulk) and Porcelize (Cosmedent) can consistently deliver a shine on hybrid composites.
Small-particle composites are considered obsolete as a restorative material because they have a rough surface. However, many clients may still have serviceable small-particle restorations. Clinically, these are unmistakable because of the rough feeling when navigating the surface with an explorer. Due to the early introduction, a majority of small particle composites contain "quartz" as a filler particle. Black lines may appear after an explorer crosses a small particle composite resin because the instrument scratches the quartz.
Identifying ceramic materials
Ceramic materials have developed rapidly in esthetic dentistry. Based on the expertise of the restorative/technician team, their use can be for inlays, onlays, veneers, and metal-free/all-ceramic crowns. Since unpolished or rough ceramic restorations have the ability to cause increased wear of the opposing teeth, they must be identified and polished appropriately. When an explorer glides over porcelain or ceramic materials, which have a glass-like hard surface, a Oscratchy sensationO can be felt and probably heard. The possible keys to many years of a glossy finish is retaining its initial shine during seating and finishing, refinishing the restoration if adjustments were warranted, eliminating abusive client care approaches, and proper clinician management during professional sessions.
The first step in identifying esthetic dentistry is to develop a clear understanding and first hand knowledge. It?s hard to spotlight the OsmileO if too many demands keep hygienists from exploring unfamiliar solutions. Consider the opening lines in a A.A. Milne?s classic, Winnie the Pooh, and try to avoid a similar professional fate: OHere is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is as far as he knows the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.O After years of mainly focusing on periodontal structures, hygienists need to understand, observe, and welcome various esthetic components and the enhancements that they can bring our clients and profession.
References:
Y Darby, Michele Leonardi, BSDH, Ms and Margaret M. Walsh, RDH, MA, MS, EdD, Dental Hygiene Theory and Practice, W.B. Saunders Company, Philadelphia1995; 47-55, 327-359.
Y Garber, David A, Increased Application of Digital Radiography for Implant Therapy. Practical Periodontics & Aesthetic Dentistry; January/February 2000, Volume 12 No.1: 73-74.
Y Hodsdon Kristine, Postoperative Care for Aesthetic Restorations: A Challenge to Dental Hygienists. Journal of Practical Hygiene March/April 1998; 19-24.
Y McGuire Michael K., Miller, Lynn. Maintaining Esthetic Restorations in the Periodontal Practice. Int. Periodontl. Rest Dent 1996; Vol 16, No. 3: 231-239.
Y Miller MB. Reality Publishing Co. Houston: January 2000; Volume14.
Y Nash Linda, Improving Aesthetics with Porcelain Laminate Veneers. Journal of Practical Hygiene May/June 1996; 21-25
Y Nash Linda, The Hygienist?s Role in Aesthetic and Cosmetic Restorations. Journal of Practical Hygiene 1994; 3 (3); 9-12
Kristine A. Hodsdon, RDH, BS presents seminars nationally about
esthetic hygiene. Her company, Dental Essence, is based in Hudson, N.H. She can be e-mailed at [email protected].
