A Detailed Look at Complex Restorative Dentistry Procedures
Prophylactic Teeth Cleaning
Often the first phase of a restorative treatment plan, a prophylactic teeth cleaning eliminates plaque and tartar deposits from tooth surfaces above the gum line. A prophylaxis is generally recommended every six months in patients who have not been diagnosed with periodontal disease. Mechanical removal of tooth surface deposits occurs with hand instruments, ultrasonic scalers or a combination of both. Polishing of the coronal portions of the teeth (or that which is visible above the gum line) is performed for extrinsic stain removal. Keeping regular prophylactic appointments as recommended by the dentist is essential for ensuring a healthy smile.
Periodontal Treatment
When periodontal disease affects gum and bone tissues, special care must be received to preserve these structures and prevent tooth loss. Certain types of oral bacteria cause harm to the gum tissues, periodontal ligament (which aids in attaching a tooth to surrounding bone) and supporting bone. The gums begin to detach and pull away from the surfaces of the teeth. Bone deterioration also occurs. Damage to these structures can ultimately lead to tooth loss if treatment is not received in a timely manner. Several types of periodontal treatment exist to address this progressive oral condition, including:
Scaling and Root Planing Therapy: A non-surgical procedure, scaling and root planing provides therapeutic benefits to the root surfaces of the teeth and surrounding gum tissues by mechanically removing plaque and tartar deposits from above and beneath the gum line. Treating periodontal disease early on with this procedure can help reduce the chance of further bone destruction and the risk of tooth loss.
Osseous/Flap Surgery: When periodontal disease has progressed to deeper levels, osseous surgery may be indicated. This procedure allows the dentist to retract the gum tissue away from the teeth to gain better access to the tooth roots and supporting bone. Tartar and plaque deposits are removed from the roots, and the surfaces of both the roots and surrounding bone are smoothed to promote reattachment of the gum tissues. The gum tissue is then sutured to encourage proper healing.
Laser Gum Therapy: Laser technology has been harnessed into effective methods for treating periodontal disease. Minimally invasive lasers are directed beneath the gum line to eradicate harmful bacteria and diseased tissue. No incisions or sutures are required, and post-operative recovery time is reduced with laser gum therapy techniques.
Periodontal Maintenance: A program for maintaining gum and bone tissues following periodontal disease treatment, periodontal maintenance helps prevent the progression of infection and bone loss. Thorough, below the gum cleanings are performed every three to four months to better manage disease-causing bacteria and allow for retreatment of recurring active infection. Periodontal pocket depths and overall gum and bone health are closely monitored by both the dental hygienist and dentist or periodontist.
If complex restorative dentistry is planned, the foundation of the teeth must first be made healthy and stable. Together, the gums and supporting jaw bone make up this foundation. Any unhealthy portions of either of these structures could cause subsequent dental procedures to fail or otherwise be ineffective. Achieving periodontal health is therefore a necessary component of preparing for complex restorative dentistry procedures.
Crown Lengthening
Excess tissue in one or more areas can present a number of oral concerns, ranging from unfavorable esthetics to difficulty in placing a dental restoration. Crown lengthening helps to alleviate these issues by removing excess gum and bone tissue. Two types of procedures exist:
Esthetic Crown Lengthening: Performed to eliminate excess gum tissue, esthetic crown lengthening helps improve balance in the tooth-to-gum ratio. It can rid the smile of a “gummy” appearance and improve gum health in diseased areas.
Functional Crown Lengthening: When a dental restoration is necessary, yet not enough tooth structure exists to which it can attach, functional crown lengthening may be performed. This procedure enables the dentist to remove a small amount of gum and/or bone tissue around a tooth, exposing more of the tooth structure to the oral cavity and providing adequate surface area to support a dental restoration (such as a crown, bridge or filling).
Crown lengthening procedures may be necessary to support the overall goals of complex restorative dentistry treatment planning.
Orthognathic Surgery
When the maxilla (upper) and mandible (lower) jaws do not meet together properly or form as they should, a number of oral issues can result. Orthognathic surgery procedures correct these disturbances, which may be caused by genetic abnormalities, trauma or injury due to accidents, or problems resulting from environmental influences. Some of the conditions that may require orthognathic surgery include:
- TMJ disorder
- Sleep apnea
- Facial or jaw injuries
- High or narrow palatal arch
- Cleft lip, cleft palate and other congenital defects
- Overbite, underbite and crossbite (when orthodontic treatment alone will not resolve the issue)
Orthognathic surgical efforts work towards removing interferences, restructuring portions of the jaw for better function and rebuilding areas of deficit for improved esthetics. Such treatment may be combined with orthodontics, periodontics or other specialty procedures to achieve the desired goals of the dental treatment plan.
Gum Tissue Recontouring
Oral disease and environmental factors can lead to uneven gum tissues throughout the mouth. When gum tissues are affected and impact gum health or smile esthetics, gum tissue recontouring procedures can be performed to improve the tissue’s positioning in relation to the teeth. When too much gum tissue is present, teeth often become overpowered by the gums and appear small. Soft tissue recontouring involves sculpting and reducing existing gum tissue (and sometimes the underlying bone) to create better balance between the gums and exposed tooth surface, eliminating overgrown tissue and improving a “gummy smile.” Gum health may also be improved, as excess tissue offers greater space for disease-causing bacteria to hide and cause oral damage.
Reduction of Tooth Structure
When teeth seem too long or uneven compared with nearby areas, a tooth structure reduction procedure may be recommended. Other indications for the procedure include discrepancies in the biting surfaces of the teeth that cause interference when coming together. When such disturbances exist in the bite, tooth pain, jaw discomfort and other functional problems can result, leading to the need for further treatment in certain cases. Reduction of tooth structure is also necessary when placing dental restorations, such as crowns, bridges or veneers, in order to prepare the teeth for placement of restorative prosthetics.
Temporary Dental Restorations
When a tooth has been prepared to receive a dental restoration, such as a dental crown, bridge or veneer, a temporary restoration will be fabricated and placed to maintain the space until the permanent prosthetic is ready. Typically crafted of high quality resin, temporaries are often made chairside on the day of tooth preparation. The temporary restoration is cemented in place with a non-permanent adhesive and adjusted for biting comfort. While the temporary will not be as refined and esthetic as the permanent dental restoration, technology has advanced such that provisional restorations are excellent stand-ins or “place holders” until the final restoration is placed.
Permanent Dental Restorations
By their very nature, permanent dental restorations “restore” or return teeth to their original or anatomical size, shape and structure. Restorative dentistry procedures today allow for exact replicas of natural tooth structure that look, feel and function much like real teeth. Permanent dental restorations may be indicated for a number of oral concerns, such as:
- Tooth decay
- Fractures, chips, breaks or wear
- Intrinsic stain (caused by age, tobacco use or medications)
- Misshapen teeth
- Inadequate tooth structure
- Missing teeth (when replacing with a bridge)
- Following root canal therapy
To address these oral issues, a number of restorative dentistry options may be explored, each of which serves a different function in the mouth. Permanent dental restorations often incorporated into restorative dentistry treatment plans include the following:
Crowns: Providing full coverage of the clinical crown (or the exposed portion), dental crowns offer stability, support and natural esthetics. When a significant portion of tooth structure is lost to damage or decay, a crown is often necessary to restore the tooth’s form and function. Crowns can be fabricated in a number of materials, such as all porcelain, porcelain fused to metal, all metal (gold or other metals), zirconia and other highly esthetic materials.
Inlays: Restoring a tooth that has sustained decay or damage, an inlay is a dental restoration created outside of the mouth to fit the tooth in need. The tooth is prepared and an impression taken, which is used to fabricate the permanent inlay. The inlay is then seated into the prepared space and permanently cemented in place. Inlays are typically made of composite material, gold (and other metals) or porcelain.
Onlays: Similar to inlays, onlays also restore damaged or decayed teeth, but are placed when one or more cusps (points on the chewing surface) are involved in the dental restoration. Materials used to fabricate onlays also include composite, gold (and other metals) or porcelain.
Veneers: Typically part of a cosmetic treatment plan, veneers add continuity and brilliance to the front (anterior) teeth that show when smiling. Veneers are made of composite resin, porcelain or other highly esthetic materials and are created either chairside or in a dental lab, depending on the material used. To prepare for veneer placement, the dentist removes a small amount of tooth enamel to ensure a proper fit. Temporary veneers may be placed while the permanent dental restorations are created. The thin, shell-like veneers are then permanently bonded to the teeth.
Bridges: Permanent dental bridges are a restorative dentistry option to address tooth loss. Consisting of two or more fused crown units, dental bridges replace a missing tooth or teeth by spanning the space between surrounding teeth. Teeth adjacent to the missing space are prepared by reducing the tooth structure to accommodate the anchor ends (abutments) of the bridge, while the center piece (pontic) replaces the missing tooth. Like dental crowns, permanent bridges can be constructed of all porcelain, porcelain fused to metal, all metal (such as gold) or other esthetic materials.
Due to their versatility, strength and restorative properties, permanent dental restorations are often a core component of a complex restorative dentistry treatment plan.
Orthodontics
Orthodontics is the field of dentistry that addresses and corrects how the teeth come together and their relationship to one another with respect to alignment. Traditional orthodontics rely on brackets, band and wires to slowly reposition the teeth into an ideal relationship, improving the appearance of the smile and function of the bite. A number of oral conditions are addressed by orthodontic treatment plans, such as:
- Tooth misalignment
- Overbite, crossbite and underbite
- Narrow arch
- High palatal vault
- Overcrowding
- Diastemas (spacing between the teeth)
- Unerupted or partially erupted permanent teeth
While traditional orthodontic materials and processes are still widely used, computer guided treatment protocols have given way to a new era of orthodontics. Clear, plastic, custom crafted aligner systems have become a popular, discreet method of straightening teeth and correcting the bite.
Dental Implants / Anchor Bridge Restorations
Dental implants are often part of a complex restorative dentistry treatment plan. Revered as the preferred method of tooth replacement, dental implants offer the closest replication of natural tooth structure compared to all other replacement options. Implants are composed of three equally important parts. A titanium implant post replaces the root portion of a missing tooth, while a natural looking implant restoration sits in for the crown structure. These two components are attached by a connector piece (known as an abutment).
Dental implants can be used to replace one missing tooth or an entire arch of missing teeth, and offer the following benefits to patients:
- Stable, permanent tooth replacement
- Replication of natural dentition in both function and esthetics
- Implant post aids in bone retention and health
- Adjacent, healthy teeth do not need to be utilized for support
- Chew, bite and tear food the same as with natural teeth
- Seamless integration into the smile line
Patients missing multiple teeth can opt for single, individual dental implants at each site or tooth replacement with an implant bridge if consecutive teeth have been lost. Dental implant posts can be integrated into the jaw bone to anchor an implant bridge, providing necessary support for the restoration to span the space of missing teeth. In the same fashion, implant posts are placed to support a removable or fixed implant denture when full arch replacement is required.
Bone Grafting
Bone tissue is an important part of a healthy mouth. When bone is lost to periodontal disease, tooth decay or injury, support for the teeth becomes compromised. Extensive bone loss often leads to tooth loss, causing a cascade of negative effects within the mouth and body. To restore lost bone and provide necessary support for teeth or tooth replacement options, dentists often perform bone grafting procedures. Bone grafts utilize human or non-human bone samples, allowing for integration of these tissues into existing bone and increasing bone levels in areas of deficit. The variations of bone grafting procedures commonly used include:
Autogenous Grafting: For this procedure, a bone sample is collected from the patient’s own body (often the chin area) and applied to the treatment site.
Allogeneic Grafting: Tissue is sourced from a bone bank or other supplier of human bone samples for this grafting method. An additional benefit of this procedure is avoiding the need for a second surgical site on the patient’s body.
Xenogeneic Grafting: Using non-human bone tissue, this method incorporates bone samples typically bovine in nature. Xenografts also have the benefit of not requiring a second surgical site, and available bone tissue is often plentiful in quantity.
Regenerative materials may be placed in conjunction with bone grafts to encourage the integration of the sample into existing tissue. Bone grafting may be recommended in several complex restorative dentistry treatment plans, from building bone support around a tooth to preparing for dental implant placement. Grafted sites typically take six to nine months to fully heal.
Soft Tissue Grafting
Receding gum tissues often necessitate the need for soft tissue grafting procedures. When gum tissue is healthy and in proper position, they provide the necessary coverage for the root portions of the teeth. However, when the relationship between the teeth and gums is compromised, the gums begin to recede down the roots, exposing these delicate surfaces to the oral environment. Not only can harmful bacteria attack these areas, causing decay and disease, but mechanical actions can abrade the root surfaces, resulting in tooth structure damage and loss.
To protect the root surfaces from these unfavorable occurrences, soft tissue grafting may be performed. This surgical process enables the dentist to excise tissue from other areas of the mouth and suture the sample to receded locations. Common soft tissue grafting procedures include:
Connective Tissue Graft: Sourcing tissue from beneath a flap created on the surface of the hard palate, dentists apply this supportive bodily tissue to areas of deficit. The sample is sutured to existing gum tissue and allowed to heal.
Free Gingival Graft: Taken directly from the surface of the hard palate (rather than from beneath this top layer), free gingival grafts provide necessary coverage where recession has occurred. Once sutured in place, the healing process can begin.
Pedicle Grafts: When adequate tissue is located near the tooth in question, a flap in the gums can be created and the tissue stretched over the exposed root surface. The flap is then sutured for healing.
Without sufficient tissue coverage, the root portions of the teeth are at significant risk for damage and disease, a situation which could ultimately place the entire tooth in jeopardy of becoming lost. Soft tissue grafting provides a means to eliminate these risks and restore a heathier, more esthetic smile line to the patient.
Are You a Candidate for Complex Restorative Dentistry?
Whatever your dental needs may be, keeping regular appointments for cleanings and periodic exams is a necessary foundation of future oral health. It is often during these appointments that treatment needs are identified, discussed and planned. To learn if you might benefit from complex restorative dentistry procedures, contact your dentist for a consultation today.