Q: Please explain your day-to-day work.

A: I am the clinical CAD/CAM director at UPenn, and we see a variety of patients with different restorative needs.

Q: How do you use digital dentistry to assist your cases?

A: It would be accurate to say that we no longer practice dentistry without the implementation of digital tools. We use them from the treatment planning phase through the design of the final restorations, as explained in the following clinical case.

A patient who was unsatisfied with the aesthetics of her maxillary anteriors (teeth Nos. 6 to 11) presented to our clinic. She had multiple failing restorations and gingival recessions but wanted to avoid any orthodontic or periodontal surgical treatment (Figure 1).

Figure 1. Preoperative photographs.

By using digital software for smile design (exocad), we were able to visualize how the smile line and existing gingival recession could affect the aesthetics of new restorations both before and after treatment (Figure 2). It is very difficult to show these types of simulations without the help of digital dentistry.

Figure 2. Smile line visualization (exocad).

Q: What was your restorative approach in this case?

A: For this case, we had to replace a full crown for tooth No. 9. The remaining maxillary anterior teeth were prepared for veneers. We selected KATANA STML zirconia (Kuraray Noritake) for this case due to its aesthetics, strength, and masking capability in cases where restorations have different thicknesses (Figure 3). The zirconia restorations were made by Sean Han, CDT (Master’s Arch, Phoenix). 

Figure 3. KATANA STML (Kuraray Noritake) restorations.

Q: What are the other key factors that you would consider for successful restorations?

A: There are many great material options; however, proper pretreatment and cementation are critical for long-lasting restorations. We always follow the “APC (Airborne particle abrasion, Primer, and resin Cement) Concept” introduced by Prof. Markus Blatz. These restorations were cemented with PANAVIA V5 (Kuraray Noritake). The final results are seen in Figures 4 and 5. The patient was very happy with the final aesthetic result. This simple digital workflow can be used by all dentists and laboratory technicians to achieve successful prosthetic outcomes. The implementation of digital dentistry and correct material selection is critical for successful long-term clinical results.

Figures 4 and 5. Postoperative photographs.

For more information, call Kuraray America at (800) 879-1676 or visit kuraraydental.com.

Q: Can you tell us about yourself and your dental practice?

A: I received my prosthodontic training from the University of Washington School of Dentistry. Then I worked as an assistant professor at the Dental College of Georgia at Augusta University, educating dental students, residents from numerous specialties, and other general dentists. Now I have my own private practice in Seattle and also work as an affiliate assistant professor in the restorative department at the University of Washington. My private practice is diverse, treating everything from patients’ simple restorative procedures, such as fillings and single crowns, to the most complex oral rehabilitation cases involving dental implants.

Q: What is your strategy for treating patients needing fixed prosthodontic treatment?

A: I like to take a step back and look at the big picture so as not to get lost in the minute details. The end goal of fixed prosthodontic treatment is to deliver restorations that blend into the patient’s smile and function in harmony with his or her existing dentition. After I visualize and map out the treatment outcome, I emphasize educating the patient about his or her conditions to bring the patient on board with the treatment process. When patients understand their conditions and are involved in the treatment process, they seem to appreciate the results even more. 

Q: How do you select materials for anterior/posterior cases?

A: As I noted above, every patient’s condition is unique. But in general, anterior teeth (Figure 1) demand aesthetics, while posterior teeth (Figure 2) demand more function or strength. Glass oxide ceramics (eg, IPS e.max [Ivoclar]) with higher glass content often become the material of choice for anterior cases. Aesthetic zirconia with well-balanced translucency and strength (KATANA Zirconia STML [Kuraray Noritake]) is currently my choice for most posterior cases. When it comes to full-mouth rehabilitation with multiple long-span units, zirconia, either in monolithic or layered form, becomes my material of choice.

Figure 1. In an anterior case, IPS e.max (Ivoclar) crowns were cemented with PANAVIA V5 (Kuraray Noritake). The result is shown here at the 4-year followup.

Figure 2. In a posterior case, KATANA Zirconia crowns (Kuraray Noritake) were cemented with PANAVIA SA Cement Universal and CLEARFIL Universal Bond Quick (Kuraray Noritake).

Q: What is your strategy for cementation?

A: Adhesive dentistry has improved so much over the last few decades. Many materials provide strong, stable bonds to enamel/dentin and almost all prosthetic surfaces. Material technique sensitivity is also very important since there are many errors that can happen during usage. PANAVIA family products with the original MDP technology are my materials of choice. In the anterior case shown in Figure 1, I used PANAVIA V5 (Kuraray Noritake), a cement that features great color stability and well-known adhesive strength. For the posterior zirconia case shown in Figure 2, I used PANAVIA SA Cement Universal and CLEARFIL Universal Bond Quick (Kuraray Noritake). PANAVIA SA Cement Universal contains MDP and a silane monomer in its paste, so I can bond to zirconia directly without relying on a separate primer.

For more information, call Kuraray America at (800) 879-1676 or visit kuraraydental.com.

Dr. Sinha is senior technical and marketing manager, Dental Division, of Kuraray America. 

Dr. Kim is a board-certified prosthodontist practicing in Seattle.

Managing complications associated with third molar removal is an enormous challenge for clinicians, and it’s painful and costly for patients. Historically, practitioners have had just 2 grim choices for managing third molars: (1) wait for the teeth to form and then prophylactically remove them before pathology develops or (2) monitor and treat patients after pathology advances sufficiently to become detectable.

To address inherent problems with both strategies, TriAgenics is developing Zero3 TBA, a fully guided third molar tooth bud ablation treatment designed to prevent third molars from ever forming. Based on animal trials, we expect this minimally invasive, preventive-care treatment for patients ages 6 to 12 will eliminate complications normally associated with surgical removal and monitor-and-treat approaches.

Recent publications demonstrate how pervasive third molar pathology becomes when prophylactic extraction is not a treatment option for patients. In countries where prophylactic removal is offered, patients generally elect to have their third molars removed early. Based on a study in the United Kingdom where prophylactic removal is prohibited by the National Health Service, there was a threefold increase in second-molar distal surface caries compared to European countries where prophylactic third-molar removal is provided.¹

Treating distal root caries secondary to third molar contact often requires clinicians to extract third molars before treating second molar caries. Unfortunately, extracting third molars in older patients increases the risk of complications. In one of the largest longitudinal studies to date, where patient morbidity was monitored following third molar removal, a team of researchers followed the post-extraction experience of 6,010 patients who had 15,357 third molars removed. They reported that increasing age was associated with increased rates of persistent pain, trismus, and swelling and a higher risk of iatrogenic injury to the inferior alveolar nerve.²

We expect TriAgenics’ fully guided 3TBA procedure will require no recovery time. Figure 1a shows the immediate postoperative surgical wound created by Triagenics’ 3TBA microablation handpiece during animal trials. Visual examination of the same treatment site 7 days later (Figure 1b) and subsequent histological evaluation revealed no evidence that oral mucosal tissue had been disrupted by microablation treatment.

Figure 1a. Immediate post-operative view showing a small puncture (arrow) made by the 3TBA microablation handpiece in a porcine animal study.

Figure 1b. During animal trials, visual examination of treatment sites 7 days following microablation treatment (arrow) revealed no evidence of disrupted oral mucosal tissue.

Fully guided 3TBA is a high-precision procedure. The placement of microablation treatment margins inside targeted tooth buds are prescribed with 0.1-mm planning resolution. This means that nearby structures, including the inferior alveolar nerve, will not be affected (Figure 2).

Figure 2. A radiograph of a human subject, which shows a 5- to 10-mm separation (arrows) from the inferior border of the third molar tooth bud to the superior aspect of the mandibular canal.

Other common risk factors, such as painful osteitis, is expected to be completely eliminated when 3TBA is used. The treatment site inside the boney crypt of the third molar tooth bud is spherically encapsulated by vital tissue, precluding the possibility for exposure to the oral cavity following treatment. Based on results from numerous animal studies, the risk of post-op infection is highly unlikely.

For more information, visit TriAgenics’ website at triagenics.com.

REFERENCES

1. Toedtling V, Marcov EC, Marcov N, et al. Radiographic detection rate of distal surface caries in the mandibular second molar in populations with different third molar management strategies: a multicenter study. J Clin Med. 2024;13:1656.

2. Vranckx M, Fieuws S, Jacobs R, et al. Prophylactic vs symptomatic third molar removal: effects on patient postoperative morbidity. J Evid Base Dent Pract. 2021;101582:1532-3382.

There are 2 major differentiating properties of Ecosite One as compared to other one-shade composite materials. The first is the material’s push-and-flow effect. At first it may seem a bit dense but once you begin modeling and packing the material, you’ll see (and feel) how it nicely fills in all the voids and undercuts, making it a perfect restorative composite. Ecosite One flows into the tooth and doesn’t run all over, making trimming and polishing the composite much easier, with less excess to clean up and less waste.

The second is Ecosite One’s unique NC-1 (non-clustering) material structure. With the precise silanization of individual ultrafine filler elements, NC-1 enables a particularly homogeneous distribution, resulting in optimum working characteristics, a maximum polish, and sparkling results.

As an added bonus for clinicians, the material’s ability to reliably cure to a depth of 3 mm in just 10 quick seconds saves valuable treatment time without compromising aesthetics, resulting in superior-quality restorations.

Having used the composite on several patients, I find that its top 2 advantages are how easily it (1) adapts to the cavity walls and (2) can be sculpted on the occlusal surface. It’s extremely easy to finish and polish. The entire procedure that follows is easy, fast, reliable, cost-effective, and highly aesthetic.

Figure 1. Initial situation with decay present under the mesial aspect of the existing restoration.

Figure 2. Preparation of tooth.

Figure 3. Slot preparation is made (minimally invasive) to access the decay.

Figure 4. Tooth isolation using an auto-matrix band.

Figure 5. Ecosite One application.

Figure 6. Final restoration that is indistinguishable from natural tooth.

Ecosite One is indicated for Class I and Class II restorations, core buildups, Class V restorations, deciduous teeth, and extended fissure sealants.

This tooth has a defective restoration with recurrent decay under the mesial aspect of the existing restoration.

The first step to doing the restoration was to prep the tooth and remove the decay. A slot prep was used to access the decay and a minimally invasive prep was used whenever possible to conserve tooth structure, especially since it bonds directly to the tooth.

The tooth was then isolated using an auto-matrix. This type of band is easy to use and place and also makes creating a contact point interproximally much easier. A wedge was used to keep the band in place and ensure that the proper interproximal contact point and the gingival margin were positioned and sealed correctly with the composite. This is the beauty of Ecosite One. The density or packability of the material makes this easy to achieve. The tooth was then etched for 15 seconds and air-dried.

Next, Ecosite Bond (DMG), a universal, one-bottle bonding agent was applied to the tooth structure and then light-cured.

Following the bonding step, Ecosite One was packed in the tooth preparation and light-cured.

After the composite was cured for at least 10 seconds per 3 mm of material, the wedge and matrix band were removed and discarded, and the restoration was polished using a polishing wheel or cup.

The final restoration is indistinguishable from the natural tooth. This was accomplished with the one universal shade of Ecosite One.

Ecosite One is a way to restore teeth using one material and an easy technique for an easily polished and extremely aesthetic result.

For more information, call DMG America at (800) 662-6383 or visit the website dmg-america.com.

ABOUT THE AUTHOR

Dr. Chanin is a graduate of the University of Pennsylvania School of Dental Medicine and immediate past president and current alumnus of the Executive Board of the Penn Dental Alumni Society. He is a distinguished Fellow of the Academy of General Dentistry, a member of the American Academy of Cosmetic Dentistry, a Fellow of the International College of Dentists, a Fellow of the International Academy for Dental Facial Esthetics, and one of the 9 dentists in New Jersey who have earned an honor as a member of the prestigious American Society for Dental Aesthetics. Dr. Chanin has more than 40 years of providing exceptional dental care and currently practices in Flemington, NJ, at his state-of-the-art dental practice, Diamond Dental Associates.

If you grip your air-driven handpiece like you are going to cut a tooth, you will notice that if you let go of it with your thumb and forefinger, the handpiece will fall backward. When you are prepping with an air-driven handpiece, you are constantly fighting the air hose and you pinch tightly with your thumb and forefinger, which is causing your pain.

Figure 1 shows how dentists hold an air-driven handpiece. The dentist grasps the handpiece in a pinch grip. The thumb and the finger muscles are flexed. This grip leads to hand fatigue and pain at the end of the day. This also leads to musculoskeletal pain, back and shoulder pain, and eyestrain.

Figure 1. An air-driven handpiece pinch grip.

I have been using an electric handpiece for more than 30 years. For 28 of those years, I have been using Bien-Air electric handpieces. A Bien-Air electric handpiece will prep teeth without pain for as long as you want. Now, let me introduce you to Bien-Air’s latest electric handpiece, the NOVA 1:5 MS. This handpiece gives me the constant quiet power to prepare teeth.

The NOVA 1:5 MS Electric Handpiece is pictured in Figure 2. Look at how I hold it in my hand. Notice that the motor and back of the handpiece are balanced on the area between the thumb and index finger. The thumb and finger are not flexed but are merely maintaining the balance of the handpiece and directing the bur on the tooth. I can open my thumb and forefinger and the handpiece stays because it is perfectly balanced. This helps avoid finger pain and wrist fatigue.

Figure 2. NOVA 1:5 MS Electric Handpiece (Bien-Air).

Figure 3. A dentist’s hand is cramping.

Figure 3 is the hand of a 48-year-old dentist, who needs to stop his hands from cramping so that he can pay off his school debt. He posted this photo and issue on Facebook asking for help. Notice the muscles cramped in his finger and thumb. He uses an air-driven handpiece and uses his finger and thumb to pinch the head of the handpiece. The muscles in his hand go into spasm and cramp at any time.

He should use an electric handpiece because it will help him no longer pinch the head of the handpiece and get rid of his hand cramps.

The ADA has published articles warning about electric handpieces causing oral-tissue burns. The NOVA 1:5 MS is the safest in the industry because it is equipped with a heat-arresting, cool-touch ceramic push button that is guaranteed not to elevate above 98.6°F during operation. No more tissue burns.

Constant high torque allows me to precisely prepare the tooth without having to stop to wait for the air pressure to catch up, so there is no feathering. The handpiece simply will not stall. Dentists who switch to NOVA 1:5 MS will find at least a 15% reduction in tooth preparation time.

The NOVA 1:5 MS allows the dentist to complete all restorative work, including the removal of caries, finishing, and polishing at any speed you desire. Bur speeds are variable from 500 to 200,000 rpm, which translates to 60 W of power. With this power, you will experience no slowdown when you apply pressure.

With my Bien-Air electric handpiece, I can practice the 3 Gs: Get in, Get it done, and Get out. My patients enjoy spending less time in the dental chair.

For more information, call Bien-Air USA at (800) 433-BIEN (2436) or visit bienair.com.

Figure 1. CandidPro clear aligner system.

I have been offering clear aligner therapy for many years, but last year an orthodontist introduced me to the CandidPro clear aligner system (Candid) (Figure 1). What captured my attention was the increased clinical oversight it offered.

Click here to finish reading this QUICK TECHNIQUE.

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REFERENCES

1. Tsichlaki A, Yee Chin S, Pandis N, et al. How long does treatment with fixed orthodontic appliances last? A Systematic Review. Am J Orthod. DentoFac Orthop. 2016;3:308-318

2. Buschang P, Shaw, S, Ross M, et al. Comparative time efficiency of aligner therapy and conventional edgewise braces. Angle Orthod. 2014;84(3):391–396.

3. Lucchese A, Bondemark L. Chapter 10: The Influence of Orthodontic Treatment on Oral Microbiology. In: Krishnan V, Kuijpers-Jagtman A, Davidovitch Z, eds. Biological Mechanisms of Tooth Movement, 3rd ed. Wiley. 2021;139-158.

4. Contaldo M, Lucchese A, Lajolo C, et al. The oral microbiota changes in orthodontic patients and effects on oral health: An Overview. J of Clin Medi. 2021;10(4):780.

ABOUT THE AUTHOR

Dr. Little received his DDS degree at UT Health San Antonio Dental School of Dentistry and now maintains a multidisciplinary, state-of-the-art dental practice in San Antonio, Texas. An accomplished national and international speaker, professor, and author, Dr. Little also serves the dental profession as a clinical researcher focusing on surgical placement and restoration of dental implants and technology integration. He also shares his expertise on emerging technologies, including CBCT, planning software, surgical guides, digital workflows, and restorative techniques.

Clinical management of third molars has remained largely unchanged for the past 100 years. Practitioners’ only choices are to surgically intervene prophylactically or address issues after symptoms become evident. In the presence of pathology, the latter approach is painful and costly. Unfortunately, both approaches pose considerable surgical risk. As a result, general practitioners refer more than 80% of third-molar surgeries to specialists.

With the evolution of guided implant placement, dentists have an opportunity to reimagine how they manage third molars. Recent research by TriAgenics describes a new preventive care procedure called fully guided third-molar tooth bud ablation (3TBA). A one-minute, minimally invasive thermal treatment, 3TBA has been shown to irreversibly induce third-molar agenesis in extensive animal trials.

As reported in the April 2023 issue of Journal of Oral and Maxillofacial Surgery, complete molar agenesis was achieved in 100% of TriAgenics’ 3TBA procedures using micro-ablation treatment cycles of 60 seconds or less. Radiographic and histological assessment indicated no presence of treated tooth bud tissue 28 days following 3TBA treatment. Figure 1a shows a typical one-day, pre-operative image of a targeted tooth bud. Figure 1b shows 28-day, post-operative healing results. Histological evaluation at 28-days post 3TBA treatment confirms the presence of complete bony infill with trabecular new bone growth and no detectable viable tooth bud tissue.

Figure 1a. Targeted porcine tooth bud (crosshairs) one day pre-operative.

Figure 1b. The treated site in Figure 1a (crosshairs) 28 days following 3TBA.

Based on animal trials, the 3TBA procedure in humans will be as fast and simple. Designed for children ages 6 to 12, fully guided 3TBA involves accurate positioning of a 3TBA micro-ablation handpiece using a 3TBA guide. Positioning of the 3TBA micro-ablation handpiece tip is predetermined with 0.1 mm planning resolution. The full-arch 3TBA guide is first seated onto patients’ teeth. The disposable 3TBA micro-ablation handpiece is then fully seated into the 3TBA guide, as shown in Figure 2. If an osteotomy is required, a 2-mm bone drill can be used to enable complete insertion of the 3TBA handpiece.

Figure 2. The mock 3TBA handpiece inserted into a full-arch 3TBA guide as part of a pilot human trial.

A predetermined microwave energy dose of one minute or less in duration would be delivered through the 3TBA handpiece using a proprietary microwave generator. After delivering the energy dose, the 3TBA handpiece is immediately removed and treatment is complete. The only post-op evidence of treatment in animals was a small puncture (Figure 3), which was not detectable 7 days following 3TBA treatment.

Figure 3. Immediate post-op view showing the small punc- ture made by the 3TBA micro-ablation handpiece in a porcine animal study.

To obtain complete molar agenesis, the diameter of the spherical zone of ablation is predetermined with 0.1-mm planning resolution. Accurate positioning of the 3TBA handpiece, combined with precise control of the ablation zone diameter, results in thermo-coagulation of the entire third molar tooth bud with no meaningful damage to tissues outside the bony crypt of the tooth bud (Figure 4).

Figure 4. The predetermined spherical zone of ablation results in complete thermocoagulation of the tooth bud with no meaningful damage to tissues outside the bony crypt of the tooth bud.

The most exciting aspect of minimally invasive 3TBA will be dramatically improved outcomes, which are simply unattainable using conventional surgical means. Based on animal trial data, there will be no recovery time nor any of the many painful complications that normally follow surgical removal of third molars. The zone of tissue ablation has no exposure to the oral cavity. As a result, there will be no possibility of painful dry sockets and there will be virtually no risk of immediate or delayed onset infections.

For more information, visit the website located at triagenics.com.

The role of attached keratinized gingiva (AKG) around a healthy dental implant cannot be overemphasized. AKG forms an important seal between the oral cavity and the integrated dental implant beneath the soft-tissue junction. It also contributes to thickness and robustness of the peri-implant soft tissue which, in turn, contributes to blood flow and immune support in the crucial soft- and hard-tissue interface. More recent evidence reminds us that the thickness and quality of the peri-implant tissue are much more important factors that influence preservation of crestal bone around the dental implant than known previously.

This case illustrates a surgical technique and use of a novel device in aiding the flap management around an immediate implant placement situation. The patient is a 41-year-old healthy male who presented with a non-restorable tooth No. 18.

A horizontally impacted tooth No. 17 was in the vicinity and was surgically removed. A conical connection dental implant (s-Clean [Dentis USA]) was placed in a one-stage surgical protocol concurrently with removal of teeth Nos. 17 and 18. The extraction socket defects were grafted utilizing “sticky bone” consisting of a composite of mineralized allograft and xenograft coagulated by autologous fibrin glue (Figure 5). The graft was enhanced with layers of pressed autologous platelet-rich fibrin (PRF), which accelerated the healing response and acts as a quasi barrier membrane. PRF tends to promote enhanced soft-tissue healing and tends to regenerate more voluminous soft tissue.

A small band of AKT on the facial aspect of tooth No. 18 was preserved and allowed to be pressed to be stable during the healing period. The triangular zone of AKT in the retromolar area distal to tooth No. 18 was mobilized and repositioned to the facial aspect of that tooth. A pre-formed resin structure Louis Button (Dentis USA), designed to adapt to facial soft tissue, was fixated to the healing abutment used in the surgery. The resin device fits over the healing abutment by friction and is removed after initial healing in approximately 14 days. Although this device makes suturing simple, suturing is necessary in many cases, as illustrated in this case, where complex repositioning of the keratinized gingiva was attempted.

REFERENCES 

1. Sohn D, Huang B, Kim J, et al. Utilization of autologous concentrated growth factors (CGF) enriched bone graft matrix (Sticky bone) and (CGF) enriched fibrin membrane in Implant Dentistry. J. Implant Adv. Clin. Dent. 2015, 7, 11–18.

2. Linkevicius T, Puisys A, Linkevicius R, et al. The influence of submerged healing abutment or sub-crestal implant placement on soft tissue thickness and crestal bone stability. A 2-year randomized clinical trial. Clin Implant Dent Relat Res. 2020;22:497-506.

3. Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier at implants and teeth. Clin Oral Implants Res. 1991;2(2):81-90.

ABOUT THE AUTHOR

Jin Y. Kim, DDS, MPH, MS, FACD is a board-certified periodontist with practices in Diamond Bar, Calif and Garden Grove, Calif. A graduate of the University of Sydney School of Dentistry and trained in periodontics at UCLA, Dr. Kim has been lecturing on the topics of periodontics, dental implants, and soft-tissue grafting. He holds university positions at several dental schools around the globe and is a founder and co-director of Global Dental Implant Academy (GDIA).

RELATED ARTICLES

Adhesives: An Invaluable Asset for Managing Denture Patients

Everyday Direct Composites in a New Technological Era

Using the Penguin RFA Implant Stability Monitor

For a complete denture to be successful, it should be retentive, stable, and optimally supported by the denture-bearing tissues.¹ Despite following the best prosthodontic practices, the presence of certain patient conditions, such as poor quantity and quality of saliva, extensive loss of volume of hard- and soft-tissues, and/or neuromuscular disorders may negatively affect the retention and stability of complete dentures.^2-6 A prosthesis that dislodges at rest or during functional movements may lead to dysfunctional oral activities, tissue trauma,⁷ social embarrassments, and deterioration of the quality of life of the patient.^8,9 Several studies have reported an improvement in the retention and stability of the prosthesis and the patient’s masticatory efficiency and force with implant therapy.^9-12 Also, implants help maintain the bone dimensions in locations where they are placed.¹³ However, not all patients are candidates for implant therapy and few patients refuse implants due to financial limitations or fear of invasive surgical procedures.^14-17 

Denture adhesives have been recommended for improving the retention and stability of the conventional complete denture.¹⁸ Owing to the improved retention of the prostheses following adhesive application, the masticatory efficiency and force, load distribution, patient comfort, and confidence are enhanced.^19-21 Adhesives augment the seal of the dentures, thereby inhibiting the ingress of food debris underneath the denture, tissue trauma, and malodor.¹⁹ They provide a cushioning effect that aids in decreasing the incidence of ulcers, tissue irritation, inflammation, and compression in patients with sensitive tissues/xerostomia.¹⁹ Denture adhesives may also be indicated for partial dentures.²² Finite element studies have concluded that adhesives not only help improve the fit between the partial denture and oral mucosa but also enhance the patient comfort.²² Adhesives can also be used to improve the stability and retention of trial denture bases during the jaw relation registration and wax-try-in appointment.²³ Adhesives, however, are contraindicated in patients who are allergic to their components, have poorly fitting dentures or poor oral hygiene, and/or need an improvement in the occlusal vertical dimension (due to extensive ridge resorption).²³ They should not be used to bond fractured dentures or improve the retention of dentures with lost flanges.²³

Most modern adhesives are supplied as a powder, paste, or cream.²³ They may be composed of a quick-acting adhesive (sodium carboxymethylcellulose), long-lasting adhesive (poly [methyl vinyl ether/maleic acid] partial calcium zinc salt), thickener (colloidal silicon dioxide), mineral oil/petrolatum (for turning powder into a convenient cream form), antimicrobial agents (hexachlorophene, sodium borate, sodium tetraborate, ethanol), and/or flavoring agents (peppermint).^{23, 24}

Adhesives improve the retention of well-fitting, removable complete dentures by enhancing the interfacial surface tension;²⁵ They augment the adhesive, cohesive, and viscosity of the interfacial surface layer.^{19, 23, 25} Adhesives swell by 50% to 150% by volume when hydrated, thus they fill the voids and improve the seal between the denture base and the denture-bearing tissues.¹⁹ However, it is important to educate the patients regarding the correct amount of usage and the technique for adhesive application and removal.^{19, 25} 

Patient Instructions for Adhesive Application 

1. Clean and completely dry the intaglio surface of the denture (Figure 1a). 

2. Apply 3 small dots of adhesive on the mandibular prosthesis (Figure 1b) and 4 small dots on the maxillary prosthesis.

3. Once dispensed onto the dentures, evenly disperse the paste over the entire intaglio surface of the prosthesis with a clean, dry finger (Figure 1c). This will result in a thin, even layer of adhesive.

4. Submerge the denture in a container of cool water or sprinkle water on the surface to maximally hydrate the adhesive (Figure 1d). 

5. Quickly place the denture in the mouth and firmly seat it with finger pressure for approximately 5 seconds (Figure 1e). Maintenance of seating pressure will cause the adhesive to flow throughout the interfacial space between the denture base and the denture-bearing soft tissues (Figure 1f).

6. Inform the patient that the use of excessive adhesive indicates an inadequate fit, necessitating denture reline or remake procedures.

Patient Instructions for Adhesive Removal

It is important to teach patients an effective method for adhesive removal from denture surfaces and oral tissues. Appropriate denture and oral hygiene should be accomplished by edentulous patients at least 2 times each day.

Removing biofilm, debris, and adhesive from the denture: 

1. For removing biofilm, debris, and adhesive from the prosthesis, submerge the prosthesis in a container filled with warm water. 

2. Place the brush head of an electric brush in the same container and slowly move it on the intaglio surface of the prosthesis (Figure 2a). Both the warm water and the oscillation-rotation-pulsation action of the brush aid in decoupling the biofilm, debris, and adhesive from the prosthesis (Figure 2b).

Removing biofilm, debris, and adhesive from the denture-bearing tissues: 

1.Sip warm water, hold it in the mouth, and secure it by pursing lips (Figure 3a). Pursing of the lips prevents the water from dripping out of the oral cavity while inserting the toothbrush into the mouth. 

2.Move the brush head slowly and gently on all the denture-bearing tissue surfaces. Both the warm water and the oscillation-rotation-pulsation action of the brush head aid in decoupling the biofilm, debris, and adhesive from the tissues (Figure 3b and 3c). Once all surfaces are clean, expectorate.

Summary

Adhesives play an important role in improving the retention of well-fitting, removable, complete dentures in patients prone to poor retention and their use should not be interpreted as a failure in the denture fabrication process.¹⁹ The prescription of conservative and appropriate denture adhesive application can substantially improve prosthesis retention and stability, as well as boost the confidence of the patient. The patients should be kept on a regular maintenance regimen (to keep a check on the amount of usage of the adhesive) and informed that after 5 to 7 years of clinical service the complete dentures may require re-adaptation to the denture-bearing tissues using standard reline or remake procedures.

REFERENCES

1. Patel J, Jablonski R, Morrow L. Complete dentures: an update on clinical assessment and management: part 1. Br Dent J 225, 707-714 (2018).

2. Bogucki ZA. Denture adhesives’ effect on retention of prostheses in patients with xerostomia. Adv Clin Exp Med. 2018 Sep;27(9):1247-1252.

3. Huumonen S, Haikola B, Oikarinen K, et al. Residual ridge resorption, lower denture stability and subjective complaints among edentulous individuals. J Oral Rehabil. 2012 May;39(5):384-90.

4. Saravanakumar P, Thirumalai Thangarajan S, Mani U, et al. Improvised Neutral Zone Technique in a Completely Edentulous Patient with an Atrophic Mandibular Ridge and Neuromuscular Incoordination: A Clinical Tip. Cureus. 2017 Apr 24;9(4):e1189. doi: 10.7759/cureus.1189.

5. Gul M, Ghafoor R, Nazeer MR. Prosthetic rehabilitation of edentulous mandible with two-implant retained fixed hybrid prosthesis: A case report. J Pak Med Assoc. 2018 Dec;68(12):1828-1832.

6. Vere J, Bhakta S, Patel R. Implant-retained overdentures: a review. Dent Update. 2012 Jun;39(5):370-2, 374-5.

7. Emami E, de Grandmont P, Rompré PH, et al. Favoring trauma as an etiological factor in denture stomatitis. J Dent Res. 2008 May;87(5):440-4. 

8. Jain P, Rathee M. Stability In Mandibular Denture. 2021 Feb 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. 

9. Batisse C, Bonnet G, Bessadet M, et al. Stabilization of mandibular complete dentures by four mini implants: impact on masticatory function. J Dent. 2016 Jul;50:43-50. 

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ABOUT THE AUTHORS

Dr. Massad is an associate professor in the department of graduate prosthodontics at the University of Tennessee Health Science Center (UTHSC) College of Dentistry in Memphis; a clinical professor at the University of Oklahoma College of Dentistry in Oklahoma City; an associate faculty at the Tufts University School of Dental Medicine in Boston; an adjunct associate faculty of the department of comprehensive dentistry at the University of Texas Health Science Center at San Antonio (UT Health San Antonio) School of Dentistry; and an adjunct professor in the department of restorative dentistry at Loma Linda University in Loma Linda, Calif. He has a private practice in Tulsa, Okla. He can be reached at joe@joemassad.com.

Dr. Garcia is dean and a professor at the University of Nevada, Las Vegas School of Dental Medicine. She was in private practice in Denver early in her career, then served as department chair of restorative dentistry at the University of Colorado Health Sciences Center School of Dentistry, as the department chair of prosthodontics at UT Health San Antonio, and as professor and associate dean for education at the University of Iowa College of Dentistry. She can be reached at lily.t.garcia@unlv.edu.

Dr. Ahuja worked at the UTHSC in Memphis as an assistant professor in department of prosthodontics for 3 and a half years. She has lectured nationally and internationally on various prosthodontic topics at various dental conferences. She has more than 50 publications in peer-reviewed national and international journals and is also the co-author of the textbook Applications of the Neutral Zone in Prosthodontics. She is a consultant scientific writer and a consulting prosthodontist for several private dental clinics in Mumbai, India, and also for NYU Langone Medical Center in New York. She can be reached via email at swatiahuja@gmail.com.

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Universal adhesives and universal one-shade composite resins are new trends in dentistry today. Dinesh Sinha, BDS, PhD, interviews Jorge Zapata, DDS, a full-time private practice dentist, about placing direct composites using simplified one-shade composites.

Q: What’s your overall perspective in performing direct composite restorations?
A: Direct composites allow us to minimally prepare and easily restore tooth structure for long-lasting restorations. I have great experience with direct composites, as they are more affordable for patients and easy to repair when necessary.

Figure 1. Workflow for posterior composite restorations.

Figure 2. Preoperative image before replacing leaking amalgam restorations.	Figure 3. Removing amalgam and preparing for composite restoration.

Q: What are the most important factors you consider when placing direct composites?
A: Adhesive strategy is very important. I use a 2-step, self-etch adhesive called CLEARFIL SE Protect (Kuraray Noritake) with selective enamel etching. The handling of composite material is very critical to me since most of my daily direct composites are posteriors. I need to place them accurately and easily. I don’t like to use materials that stick too much to instruments. The polishability and polish retention of the material is important to maintain a smooth surface over time. Physical properties, such as the wear of both the material and the antagonist enamel, are also important factors to consider when providing functionally stable restorations.

Q: What’s your opinion on recent universal adhesives?
A: I have used CLEARFIL Universal Adhesive (Kuraray Noritake) in some of my cases. It works great, saves time, and produces great results. Due to its antibacterial cavity-cleansing effect, CLEARFIL SE Protect is my first choice of adhesive for most cases. My everyday workflow for large posterior composites is shown in Figure 1. In anterior, Class V restorations and small posterior restorations, I just use MAJESTY ES Flow composite (Kuraray Noritake).

Q: What’s your opinion on recent one-shade composites?
A: Most manufacturers have advanced their technology to reduce the number of shades offered. I started using CLEARFIL MAJESTY ES-2 Universal (Kuraray Noritake) for several reasons. I use a flowable composite generally as a liner in my posterior cases. If the tooth is discolored, I use a darker dentin shade. When replacing amalgam restorations (Figure 2), we often see that the remaining tooth structure is severely stained (Figure 3). For this type of case, using a darker shade of flowable resin or CLEARFIL MAJESTY ES-2 Premium (Kuraray Noritake) in a dentin shade will easily mask the dentin color and recreate the natural tooth appearance. Then I use CLEARFIL MAJESTY ES-2 Universal as a single-shade composite since shade matching is not necessary. It perfectly matches the color of the surrounding tooth structure (Figure 4) and restores teeth to meet highly aesthetic demands.

CLEARFIL MAJESTY ES-2 Universal eliminates the need for a blocker shade. It easily streamlines my current procedure of placing composite, saving both the patient and dentist time.
For more information, call Kuraray America at (800) 879-1616 or visit the website kuraraydental.com.

Dr. Zapata is an internationally recognized lecturer and private practitioner at Gentle Family Dentistry in Ogden, Utah.