Procedures heading pictures

Restorative Dentistry

Xray of jaw shown to patient

This is the restoration (rehabilitation) of a person's teeth and gums (dentition) from both an aesthetic and functional perspective. There are four major areas of dentistry that can be used, and sometimes combinations of one of more of them.

They are:-

Fixed Prosthodontics, known as crowns and bridges, and removable prosthodontics, such as dentures.

Periodontology - Surgical techniques to treat conditions that are affecting the gums and soft tissues.

Endodontics - Root canal treatments

Dental Implantology -The replacement of missing teeth usually by restorations fixed into titanium posts implanted into the bone. Click here for the Dental Implants page

 

Click on the tabs below for some typical procedures to common problems.

  • Adhesive
    bridgework
  • Bleaching
    (teeth whitening)
  • Cracked tooth
    syndrome
  • Crown and
    bridgework
  • Dentures

  • Periodontal
    surgery
  • Porcelain veneers
    and crowns
  • Root canal
    treatment

Adhesive bridgework

Adhesive bridgework differs from conventional bridgework in that it does not involve irreversible preparation of the teeth adjacent to the space to be filled.

A bridge is constructed with a conventional porcelain tooth and this includes a small metal retainer that is glued onto an adjacent tooth.

The advantage of this technique is that it requires minimal or no preparation and is also relatively cheaper.

The disadvantage is that such a bridge may de-bond. If adhesive bridgework de-bonds within the first year, it generally indicates that it will not be a suitable approach.

A detailed evaluation of the dental occlusion is necessary to ensure that it is a suitable situation for the provision of such bridgework. On occasions it may be inadvisable and conventional bridgework should be provided.

The metal retainer is hidden well by the supporting tooth. Adhesive bridge with metal retainer on supporting tooth. Patient wanted bridge to replace missing premolar. Ceramic lattice bridge on laboratory model. Since the retainer is ceramic it is not visible.
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Bleaching

BleachingAs the title implies, bleaching the teeth is a process designed to lighten the colour of teeth rather than undertake some irreversible treatment or dentistry, for instance, by applying veneers to alter the colour or to fit crowns. There are two bleaching techniques.

Vital

This technique is designed for teeth that are still alive (the nerves are still present within the teeth). It usually uses material called carbamide peroxide and is applied externally at regular intervals, often in some form of mouth guard. It can achieve impressive results but this should be professionally monitored and often vital bleaching will need to be performed at regular intervals to maintain the improvement. (Note that not all dentists will offer this treatment as there has been a dispute between the Department of Trade and Industry and the suppliers with regard to the usage of this material).

Non vital

This technique is designed for teeth that have already been root filled. The nerve has already been lost from the tooth and the root canal filled with some sort of obturating material such as gutta percha. Occasionally root filled teeth will discolour. It is possible to reverse this; a small hole is cut in the back of the tooth and a mixture of hydrogen peroxide gel and sodium perborate is put into the crown of the tooth for a period of 2-3 weeks at a time. If this dressing is repeated on 2 or 3 occasions then often a lightening of the tooth will occur.

There are some possible complications such as external resorbtion of the tooth but the supervising dentist should monitor the situation during treatment. The result from non vital bleaching cannot be guaranteed and if a tooth is severely discoloured it may still be necessary to consider another form of treatment such as a veneer or a crown to achieve the desired result.

Cracked tooth syndrome

Cracked tooth

This condition often affects the posterior teeth (the premolars and molars) particularly if these teeth have been root filled. As a result of the vertical loading on these teeth a fracture may develop on the biting surface of the tooth which may then extend below the gum level.

Typical symptoms include:

• Pain on biting
• Some sensation of movement within the tooth
• If the nerve of the tooth dies before diagnosis, possibly a throbbing pain and the development of an abscess.

Cracked tooth
This tooth has split vertically

The condition can become more frequent as people get older.

Investigation and diagnosis techniques include:

• Close clinical examination of the tooth.
• Use of a coloured dye to try to detect the fracture line.
• An attempt to get movement of the fractured segments by getting the patient to bite on a rubber cone.
• Transillumination with a very bright light.

The fracture line will not always be visible. A band can be placed around the tooth to try to stop movement of the fragments and if the pain resolves, a tentative diagnosis of cracked tooth syndrome can be made. The tooth will then usually be restored with a crown to hold the two segments together. If the fracture line is going very far below the gum level, the tooth may not be restorable and may require extraction.

Crown and bridgework

The principles behind crown and bridgework have been established for many years. Perhaps the most significant developments in recent years within this subject relate to the development of materials, for instance adhesives and modern ceramics.

An alternative and probably more appropriate term for this type of treatment is fixed prosthodontics.
The aim of fixed prosthodontics is to improve the appearance of teeth, replace any missing teeth or restore dental occlusion (the bite) if this has been significantly affected by tooth surface loss, missing teeth or poor quality of individual teeth.

It usually involves irreversible preparation of teeth to allow them to retain a crown or a bridge that has been fabricated in a dental laboratory. The restoration is cemented onto the prepared teeth (known as the abutment teeth) and will usually provide a good result. It is fair to say that most restoration can be expected to last 10-15 years but they may need replacement after this time. Restorations can fail due to recurrent decay, some form of structural failure of the restoration or death of the nerve of the tooth.

If all of the teeth are affected in some way it may be necessary to carry out a full mouth reconstruction. This will involve detailed planning, multiple appointments for preparation and impressions, followed by a trying and fitting of the work after any necessary adjustments. This type of work may well be referred to a specialist in restorative dentistry. It should also be noted that fixed prosthodontics will often involve the use of dental implants in place of natural teeth to support any restorations.

With all the development of modern adhesive techniques and newer generations of ceramics much less destructive techniques can be employed to support some forms of crowns or bridges which can produce truly aesthetic results. Typical examples of these would be found with either ceramic veneers or porcelain lattice bridgework.

Before

After

1of5.JPG Crown - after

Dentures

Dentures are removable appliances that are designed to replace missing teeth in the mouth.

If all the teeth are missing and the dentures are designed to replace the entire dention they are known as complete dentures. These tend to be made from acrylic and can feel reasonably bulky. If they are well constructed there is no reason why the dentures cannot have a good aesthetic result as well as functioning reasonably well. The denture that tends to be the most mobile is the lower one; this is because frequently there is resorption (dissolving away) of the lower jaw ridge. This tends to become worse with age and as a consequence retention of the lower denture significantly reduces. Individuals may complain of the lower denture moving during speech and chewing.

When fresh dentures are constructed an attempt can be made to enhance those features in the design to maximise stability but the benefit may be limited. Undoubtedly if the patient can consider the provision of dental implants to provide direct support for a mobile denture it can make a tremendous difference. This is because the denture can lock into the implant in a way that it cannot into a normal jaw ridge.

The other type of denture is called a partial denture when it is replacing only a few teeth in the mouth. These dentures can either be made from acrylic or have a chrome cobalt metal skeleton framework with acrylic teeth on the denture. The latter option is preferable in terms of comfort since the bulk of the denture is much reduced. It is important to bear in mind, however, that there have to be sufficient natural teeth left to support a metal based partial denture and that these tend to be a slightly more costly option than the all acrylic denture.

Dentures (removable prosthodontics) are an established dental technique and generally meet with a high degree of success. Frequently the provision of removable partial dentures will be in conjunction with other forms of restorative treatment (such as crown/bridgework or gums) to provide an overall restorative dental solution to any dental occlusion problem.

Denture image 1 Denture image 2 Denture image 3
Denture image 4 Denture image 5 Denture image 6

Periodontal surgery

This is used in the treatment of chronic inflammatory periodontal disease.

After initial therapy which consists of reinforcement of oral hygiene techniques and root planning (scaling underneath the gum level to remove any plaque and calculus) a reassessment is made of the health of the soft tissues. If there is still significant pocketing (a detachment of the gum from the root surface) in excess of 6-7 mm probing depth a decision is often made to proceed with pocket reduction surgery.

The aim of this surgery (which is carried out under local anaesthetic) is to reduce the probing depth by excising the pocket lining. This technique can be of more benefit to some individuals than others. The only way to evaluate this is to try an area of surgery and see the result. A side-effect of pocket reduction surgery is that it tends to increase the clinical crown height of the tooth because the tissues are positioned further up the root. This may have a deleterious effect from an aesthetic point of view and may also cause some root sensitivities.

Generally the latter problem is not too severe and it is often sensible to carry out surgery in the posterior region of the mouth in the first instance to evaluate the amount of recession that may occur. Approximately three months after surgery fresh examinations are carried out to see if there has been a significant reduction in probing depth. If that is the case in the area of the trial surgery then a decision can be made whether to proceed elsewhere in the mouth.

A more recent technique involves the placement of a membrane in between the gum and bone at the time of surgery. This creates a type of "tent" under the gum that allows refilling of this defect by both bone and cement/periodontal ligament. This does not occur in conventional pocket reduction surgery. This technique works best in localised areas and cannot be applied generally to the whole mouth. The modern membranes are simply implanted under the gum and are re-absorbed naturally.

There are also some materials such as bioactive glass or autologous bone that can be placed within bony defects to help refill. Sometimes these techniques can be used in conjunction with the placement of dental implants to augment the bone around the implant to improve its longer term chance of success.

Porcelain veneers and crowns

The new generation of porcelain/ceramics allows for the production of pleasing aesthetic restorations.

A veneer requires some irreversible preparation in the outer half of the enamel of the tooth. An impression is taken which is sent to a dental laboratory. This allows the production of a thin porcelain veneer that can be cemented onto the tooth with a variety of colours.

The advantage of this technique is that it is relatively minimal in preparation and can help disguise a number of problems such as mild discolouration, superficial tooth structure disorder, fluorosis/mottling and tooth shape. Veneers are a reliable approach and can be expected to last 10-15 years.

Ceramic crowns are made from similar material. The procedure involves more substantial reduction of the tooth to provide a more substantial foundation onto which the crown will be placed. The advantage is that there is no metal substructure in a ceramic crown (in contrast to a more conventional porcelain fused to metal crown) and this allows for a crown that is very aesthetic and looks alive.

There are certainly limitations to their uses and these should be discussed with the dentist. A slight variation is the porcelain lattice bridge which consists of an adhesive bridge stuck to the adjacent tooth and it is constructed from all ceramic with a small metal strengthener. This has certain indications and again should be discussed with the dentist. See also adhesive bridgework.

Before

Denture image 1

Before

Denture image 3

Before

Denture image 5

After

Denture image 2

After

Denture image 4

After

Denture image 6

Root canal treatment

If the nerve of a tooth dies, for instance as a result of infection, decay or trauma, it is usually necessary to remove it and obturate the root canal with some form of material (usually gutta percha).

If this is not done, the tooth can develop a chronic abscess and ultimately be lost.

Treatment involves removal of the dead nerve tissue followed by internal instrumentation of the root canal to determine its length prior to being filled.

If the correct negotiation of the root canal has occurred then it is obturated with a material that will help prevent further infection.

A vital part of the procedure is that the root canal is thoroughly cleansed prior to the placement of this obturating material.

Occasionally teeth do not settle down and a decision has to be made to:

• Carry out fresh root canal treatment.
• Consider a surgical procedure such as apicectomy where the infection is surgically removed at the tip of the tooth.
• Extraction of the tooth with some form of replacement.

Modern root canal treatment has a very high success rate and most teeth can be saved with this approach.

Root filled tooth
This tooth has been root filled

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25-Jun-2018