By Lee Ann Brady, DMD 

Balancing Benefits and Risks in Restorative Dentistry 

As restorative dentists, our commitment to providing high-quality, lasting care is unwavering. Ideally, we’d offer our patients restorative solutions that last a lifetime without needing repair or replacement. However, in reality, no restoration is permanent, so balancing the benefits and potential risks is essential in choosing the right solutions for each patient. 

What Makes Resin-Bonded Bridges Unique? 

Among restorative options, resin-bonded bridges may not be the first to come to mind, yet they serve as a unique solution for specific cases. Resin-bonded bridges are known for their conservative approach—they don’t require extensive alteration of the surrounding teeth and can often be placed without surgical intervention. For young patients, in particular, this minimally invasive option has a range of benefits. 

Preserving Alveolar Ridge Development in Young Patients 

One of the reasons resin-bonded bridges are favorable for younger patients is their flexibility in preserving the natural development of the alveolar ridge. By delaying more permanent options, such as implants, patients can avoid the potential complications related to ridge development and aesthetics that could arise years later. These bridges also offer an unobtrusive alternative, especially for patients who need a solution but may not be ready for an implant due to age or other factors. 

Setting Realistic Expectations with Patients 

Recommending a resin-bonded bridge requires a balanced approach to patient communication. These bridges are more likely to become loose over time, demanding a higher level of care and caution from patients. They must be aware of dietary limitations, avoiding hard or sticky foods that could disrupt the bond. Educating patients on the longevity and maintenance requirements of resin-bonded bridges helps set realistic expectations while ensuring they understand the care involved. 

A Conservative Yet Valuable Solution 

Despite their potential for detachment, resin-bonded bridges remain a valuable choice when the clinical situation calls for it. They offer patients a pathway to maintain oral functionality and aesthetics without the invasiveness of traditional restorative methods. Especially in younger individuals or those with adjacent unrestored teeth, this solution balances the need for stability with the importance of conserving natural tooth structure. 

Up Next in Part 2 

Part 2 of this series will discuss how resin-bonded bridges compare with other restorative options, such as traditional fixed bridges and implants. By understanding these options more fully, we can better guide our patients toward the solution that best fits their unique needs and preferences. 

By Charlie Ward, DDS,

You’ve done your digital planning, printed your models, and created a mockup. That’s great! But before you start prepping those teeth, we need to make sure that mockup is spot on. Why? Because a precise mockup ensures that our preparations create enough space for the restorative material. 

Here’s where the magic happens: digital calipers. Yep, those little measuring tools are our secret weapon. We measure the distal-most tooth on each side and one in the middle. Then, we compare those measurements to the ones we took from the model. If they’re within a tenth of a millimeter, we’re good to go! 

A quick tip: If you’re right-handed like me, be mindful of applying even pressure when seating the matrices. You don’t want to push harder on one side than the other. 

The next step is the prep stage. When working with veneer patients, we must be very intentional while removing tooth structure from our mockup so that we can create adequate room for restorative material. On Restorative Nation, Veneers Tips and Tricks Prep With Intention – Restorative Nation, I demonstrate various burs. It’s through a thorough understanding and careful selection of burs that we can guarantee an accurate preparation. 

Lee Ann Brady, DMD 

The origin of a patient’s dental wear may be deceiving. Is it physiological or pathological? This minor difference could spell major consequences for the lifetime oral health of your patients. We care about understanding the differences and how to manage them for the benefit of our patients. 

What is the amount of normal tooth wear? 

To understand normal tooth wear, let’s compare the size of teeth at age 10 to their size at age 70. Based on extensive research, we’ve found that the average loss of tooth structure over this 60-year period is approximately: 

• 1.74 millimeters on posterior teeth (first molars) 

• 1.01 millimeters on upper anterior teeth (centrals and laterals) 

This equates to roughly 15-26 microns of wear per year, depending on the tooth type. 

It’s important to note that this includes all forms of wear, such as attrition, erosion, and abrasion. Even with this normal wear, most people should still have a layer of enamel on their teeth at age 70. In fact, you might expect to retain at least half of the original enamel thickness on your incisal edges and cusps. 

While a certain amount of tooth wear is a normal part of aging, it’s important to distinguish between physiologic wear and pathologic wear. Physiologic wear is a natural part of aging and includes abrasion, erosion, and attrition. It occurs at a predictable rate and typically does not result in significant tooth structure loss. If you notice excessive tooth wear beyond the expected range of 15-26 microns of wear per year, it may be a sign of an underlying issue that requires further evaluation. 

What is the patient-centered approach to discussing wear and understanding the cause of tooth wear? 

When discussing tooth wear with patients, it’s essential to approach the conversation with empathy and understanding. By using a patient-centered approach, you can foster open communication and encourage patients to take an active role in their oral health care. 

• Open-Ended Questions: Ask open-ended questions to encourage patients to share their observations and experiences. For example, you might say, “I’ve noticed some wear on your teeth. Have you noticed any changes in how your teeth feel or look?” 
• Avoid Assumptions: Don’t jump to conclusions about the cause of tooth wear. Instead, ask questions to gather more information and explore potential contributing factors. 
• Emphasize Collaboration: Emphasize that you’re working together to identify the cause of tooth wear and develop a treatment plan. This fosters a sense of partnership and encourages patient involvement. 
• Avoid Blame: Avoid blaming the patient for tooth wear. Instead, focus on identifying the underlying causes and developing strategies for prevention and treatment. 

What do I say to my patients? 

I always start from a place of curiosity. I might say, “When I examine your teeth, I notice some wear that seems more than what’s typical for your age. I’m curious if you’ve noticed any changes in how your teeth feel or look. Sometimes, unusual wear can be a sign of underlying issues like teeth grinding, acid reflux, or other factors.” 

Many times, patients will then say to me, “I don’t know. Do you think I grind my teeth?” or “I don’t know. I do have acid reflux.” If the patient says, “Gosh, I don’t know what that’s about,” the next piece of the puzzle is to take my curiosity and help them understand what we would do diagnostically to figure that out and potentially what we would do to manage that. 

If I think the wear is erosive, the conversation can turn to acid reflux or an acidic diet or abrasive toothpaste. If I think it’s erosive, the conversation leads to “seeing if we can learn what your teeth are doing when you sleep at night. If you’re grinding your teeth, that is something we can manage.” 

I never start with “I think you grind your teeth,” or “I think you have acid reflux,” no matter how confident I am that that is the case. I don’t approach it that way for a couple of reasons. I need to give the patient a chance to process that information and come to terms with the fact that something may be going on that they weren’t aware of beforehand. There’s an emotional impact from hearing that information, so we want to deliver it in a gentle way. And I want the patient to become aware of what may be happening on their own. I want to create a co-discovery process.  

The general message is “We can work together to figure out what might be causing this. By understanding the cause, we can work together to determine the best course of action to protect your teeth and prevent further wear.” 

Christopher Mazzola, DDS 

The purpose of looking at recent research data is to see how we can improve our clinical success. Different scholarly journals inform us of ways to decrease risk and hopefully increase the longevity of the services that we’re providing to our patients. In this article, I’ll summarize what I’ve learned from recent research literature about the various types of zirconia we receive from our dental laboratories and properties of zirconia that influence the quality and longevity of the dentistry we do. I found these facts fascinating from the perspective of wanting to know how to use zirconia optimally.  

Composition: There are three primary compositions of zirconia on the market: 3y, 4y, and 5y. The Y in the composition descriptor refers to Yitria or Yttrium Oxide (Y2O3). The more Yitria the zirconia contains, the more translucent the crown will be. Adversely, the more Yitria the crown contains, the less flexural strength the crown has. The 3y zirconia can handle adjustments better than 4y and 5y in terms of both strength and optical properties. 

Color: The marketplace offers zirconia that is prestained and zirconia that is not prestained. In the case of prestained zirconia, we have about a tenth of a millimeter in reduction capability before we notice a color change. Knowing this is important when we need to adjust a restoration, so we can manage adjustments to deliver the shade of restoration our patient expects. 

Wear on Other Materials: If zirconia is rubbing against other zirconia there is less wear than if zirconia is rubbing against lithium disilicate and softer ceramics or composites. When you’re setting up an occlusion or you are looking at a hybrid denture versus a normal denture, you must take this into account. If a patient has an upper fixed-hybrid denture, zirconia is going to wear those denture teeth relatively fast. Knowing this, we can best prepare our patient for the wear that is likely to occur. 

Zirconia Removal Burs Vs. Restorative Diamond Burs: In an in vitro study, the burs that are marketed specifically for adjusting zirconia restorations did not perform better on 3y, 4y, or 5y zirconia, and they did not generate less heat. 

Note About Polishing Zirconia: When we are polishing high-strength ceramics like zirconia and lithium disilicate, we must be careful not to push too hard, and we must use a continuous cooling spray of water. Otherwise, we risk nerve damage due to thermal irritation. Also, if we generate too much heat, we will overheat the glue that bonds the fine diamond particles on the bur and are likely to render the bur useless. 

By Daren Becker, DMD 

A 16-year-old girl presented with the worst case of ectodermal dysplasia I had ever seen.. She was missing all of her lower teeth except for her 12-year molars. She presented with a lower denture (made by a previous dentist) on two temporary implants in the canine position.  She had only a few maxillary teeth that were malformed; some of these were still her primary teeth.  The appearance of her smile made her look like she was a 9 year old child. 

She was embarrassed by her smile and realized she would need implants and restorative dentistry down the road. At the time, she was too young. Our hearts went out to her. 

Another dentist had recommended direct bonding, which certainly could have worked, but I thought that we could get a better aesthetic result for her with significantly less time in the chair. So, we captured preclinical digital impression scans with our iTero scanner and along with Matt Roberts at CMR Dental Lab in Idaho, we designed a digital wax-up for an improved occlusion and smile. From there, we had milled PMMA (Polymethyl Methacrylate) overlays created that we direct bonded onto the existing dentition as a long-term temporary solution. We did not need to prep any teeth, and we quickly gave her a broad beautiful smile that looked natural and age appropriate. 

She was in tears. We were in tears. Her mom and sister were in tears. It was the best day ever! 

Soon after, she got a part as an extra in a series filmed here in Georgia, and is thinking about a career in acting. Seeing her life change with simple, comfortable clinical procedures has been priceless. 

By Kelley Brummett, DMD 

A situation occurred in my office when I was working with a patient who needed a 30-year-old PFM crown replaced on #8. I was struggling with the shade because the adjacent teeth were an in between color. What I did was take a shade photo of the brightest one, which was B1, and then I took a shade photo with A1–because those were the two shades that matched the best. They weren’t what we were looking for. So, I made a provisional out of the A1 shade and a a provisional out of the B1 shade. I took the extra time to place both of them onto the tooth and let the patient look with me and help me decide. The patient chose the A1 shade. 

After I placed the A1 provisional, we sent  photos to my lab. These photos included the first shade photos of B1 and A1 alongside the tooth, photos of the B1 and A1 provisionals, and photos of the provisional I placed on the tooth from various aesthetic views. I then talked to the lab over the phone while we viewed the photos together so they could create the right in-between shade.  

At the end of the process, my patient expressed gratitude for taking the extra steps and meeting her expectations for a beautifully blended smile. 

By Lee Ann Brady, DMD 

A patient chipped a tooth on her lower hybrid denture and loosened an implant screw. The denture had been placed 18 years ago, so she had an old titanium bar with denture teeth and pink acrylic. That day, I put the screw back in and smoothed out where the tooth was chipped. During this visit we had a great conversation about the future of her hybrid denture. 

I have had a similar conversation with several patients in recent months. They have the original, traditional bar retained hybrid denture that is nearing the end of its lifespan. And so, what are the options? 

1. If the bar is in great shape, new denture teeth and a new denture base can be milled and placed over the existing titanium bar. 

1. Alternatively, we can get rid of the bar and go to something that is all zirconia. 

If there is a preference for the first option, the first requirement is to make sure the titanium bar is in good condition. After 18 years, we would take it off and have the laboratory examine it under microscopy.  

If converting to all-zirconia and the patient has had upper and lower dentures, we must consider if one arch can be converted without converting the second arch. A zirconia arch is going to wear an opposing original denture fast if there is parafunction, and the zirconia arch is likely to fracture the opposing original prosthetic teeth. 

We have options today we can think about with our patients, but many have in their minds that when they got their hybrid dentures years ago, the dentures would last. All the time, energy, and dollars to freshen up or replace their denture is a big deal to them. Shifting their mindset from “I thought I was done investing in dentistry” to “My denture is at the end of its lifespan” is a big hurdle. So, the earlier we can start those conversations before they need to invest, the easier they can transition their minds to accept care with grace when the time comes. 

When your bar retained hybrid denture patients visit for perio maintenance and your exams, inform them of the lifespan of their denture is at most 20 years and set expectations for discussing the best available options at some point in the future.  

By David R. Rice, DDS 

I travel a lot for speaking engagements and often ride to and from the airport using Uber. As I make small talk with the drivers, inevitably they ask what I do for a living. One day, as I shared that I was a dentist, the driver said, “I’m finally straightening my teeth with those aligners.”  

I thought, “Okay, he’s either seeing a dentist or he’s doing this thing on his own.” Either assumption would’ve potentially painted me into a corner, so instead of assuming, I asked a simple, yet leading question: “Good for you. Is your dentist happy with the progress?” 

Leading questions like that help us walk a patient down the path we want. His response was, “Wait a second, this should be done with a dentist?” 

With one question, I got to the heart of the matter. From there, I responded and asked a series of simple (and again leading) questions: “Yes, seeing a dentist helps to know if you are a good candidate to move your teeth at all. How is the health of your mouth? Are your gums healthy? Do you have any cavities?” 

Now he was thinking, “Wow, not only should I be going to the dentist but there are things that could go wrong.” 

I asked him one more simple set of questions: “Would you like to know basic things that could go wrong? Or would you like to know what might really go wrong and harm you?” He, of course, wanted to know what could harm him. 

Simple, leading questions get to the point. So, when restoring a patient, I think about the simplest questions to ask to understand what the patient understands, what the patient really wants, and why. In short, I want to know what matters most to them and connect that to the dentistry I know they need. As an example, I might ask, “Do you want to replicate mother nature when we restore that tooth, or do you want to improve upon mother nature? Would you like to discuss preventing future problems that will save you time and money or just focus on today’s problems?” 

These leading, simple questions prompt a response that enables me to determine if the patient wants just a slice of pizza—say a crown, the patient wants the whole pie—an optimal smile, or the patient wants something in between. Based on that input, I know how to best have a great conversation with the patient—a conversation the patient will appreciate and through which I can earn more trust.  

Lee Ann Brady, DMD 

I’m a big fan of retraction pastes, which are aluminum-based hemostatic agents. Their attributes make them highly effective when I need them, but they are also technique sensitive. 

• They are great for hemostasis within sixty seconds
• For a stringent retraction, you can leave them in place for two to five minutes
• They are so thick and viscous you can see them and easily rinse them off
• They do not cause prep discoloration like liquid hemostatic agents do
• They can interfere with the set of VPS or polyether impression materials but are less likely to do that than the liquids because they are so easily rinsed off

We must still be careful, though, to remove retraction paste from the sulcus. If residue is left behind, the impression material will not fully polymerize around the margin. So, while I love retraction pastes for hemostasis, I don’t use them unless I need them. I still prefer a two-cord technique using plain cord and epinephrine. When I do use a retraction paste, I am extremely methodical about rinsing the paste out of the sulcus. 

By Lee Ann Brady, DMD 

When a crown comes off and we are going to put it back in the mouth, we need to remove the old resin cement that is inside the crown. What is the best way to go about this? 

First, we need to know if the crown is made of zirconia or lithium disilicate. If you have a radiograph of that restoration, you can tell immediately which one of those two things it is. If you don’t, you can always attempt to X-ray it. (That’s what I do.) Alternatively, you can assume the crown is made of lithium disilicate, which is the more technique-sensitive material when it comes to removing cement. 

For crowns confirmed to be zirconia, employing 30-micron aluminum oxide air abrasion effectively clears out the old resin cement. Subsequently, re-etching the inside of the zirconia prepares it for reseating. For crowns presumed to be lithium disilicate, this approach should be avoided to prevent crack propagation. 

In the case of lithium disilicate crowns, two alternative methods can be employed: 

1. The crown can be placed in a porcelain oven to liquefy and evaporate the old resin. However, caution must be exercised to avoid rapid heating of the hydrated ceramic that has been in the oral environment. Rapid dehydration will introduce cracks and lead to crown fracturing. 

1. An alternative method involves using a brown silicone point in a high-speed handpiece, adjusted to lowest speed. A brown silicone point at slow speed effectively removes resin without damaging ceramic. 

How will you know when all the resin has been removed? When etching lithium disilicate, whether using red 5% hydrofluoric acid or Monobond Etch & Prime from Ivoclar Vivadent, any remaining resin will be evident because the dye sticks to it after the etching solution is rinsed off.