Esthetic Management of Carious Anterior Teeth by Giomer - Case Report

Dr.Foysal Sirazee
MS (PART B) Dept. of Conservative Dentistry & Endodontics BSMMU

Abstract

In todays world, where esthetic and function is given equal importance by the patient, there is a need for restoration which should be economic and exhibit good physical properties. Adhesive bonding techniques enable clinicians to predictably place tooth-colored materials and provide viable alternatives to amalgam and other metalbased restorations. This is significant because patients demand for esthetic restorations is greater than ever before. Options for toothcolored restorations include giomer and direct and indirect compositebased materials. Patients with discolored teeth frequently present to the dentist requesting restorations designed to improve their appearance. A direct technique of Giomer placement is being discussed in this article with an aim of imparting esthetic restorative knowledge to the general practitioners. Key Words: Esthetic, Adhesive bonding, Tooth colored materials, Giomer, Composites.

INTRODUCTION

Dentists are now faced more than ever before with the challenge of reversing the physical and esthetic signs of aging in teeth and smiles. Facial appearance and, specifically, the oral region, are of considerable importance in the realm of attractiveness and appearance in our society. What has caused the transition from metallic to tooth colored restorative materials? The growing demands for esthetic restorations have cased great improvement of the materials and their properties and the change of the treatment philosophy to more conservative approach. One of the most important tasks in esthetic dentistry is the creation of harmonious proportions between the widths of maxillary anterior teeth when restoring or replacing them.2,3 Dental caries (tooth decay) is one of the most common diseases in the field of dentistry.4 It is an infectious disease, caused by bacteria

(germs), but many factors are involved in the process. 5 Tooth decay is a spot on a tooth where minerals have melted away and a hole has formed. This process, called demineralization, is caused by acids that are created by certain types of bacteria living in our mouths. Tooth decay is caused by specific types of acid-producing bacteria that cause damage in the presence of fermentable carbohydrates such as sucrose, fructose, and glucose.4 The mineral content of teeth is sensitive to increases in acidity from the production of lactic acid. Specifically, a tooth (which is primarily mineral in content) is in a constant state of back-and-forth demineralization and remineralization between the tooth and surrounding saliva. When the pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than remineralization (i.e. there is a net loss of mineral structure on the tooth's surface). This results in the ensuing decay.6 Depending on the extent of tooth destruction, various treatments can be used to restore teeth to proper form, function, and aesthetics, but there is no known method to regenerate large amounts of tooth structure. Instead, dental health organizations advocate preventive and prophylactic measures, such as regular oral hygiene and dietary modifications, to avoid dental caries.8 A vital part of caries diagnosis is to decide whether a lesion is active and rapidly progressing or already arrested. This information is essential to plan logical management. However, lesion activity should be judged in the patient. Several factors must be considered when designing the esthetic smile. For instance; appearance zone, symmetry, harmony, dominance, and colour. The appearance zone consists of the teeth and gingival tissue shown when smiling. It varies depending on factors such as mouth size, smile width, tooth length, lip size and tightness, age, sex, and self-image. Women tend to have a higher smile line than men and show nearly twice as much maxillary central incisors. Men tend to show more mandibular incisors than women. With age, the smile line sags in both sexes and less maxillary incisors are visible.2 This paper attempts to outline the factors a clinician must consider to achieve patient satisfaction and expectation and to deliver the most esthetically pleasing result while maintaining strength and function. We report a case of successful management of carious anterior teeth corrected using a Direct technique of Giomer placement.

CASE REPORTS:

Report 1: A girl of 16 years old came to the department of Conservative Dentistry & Endodontics, BSMMU with the complaint of discoloration.

On clinical examination, caries was found and there was no pain and/or sensitivity of any kind during and after vitality test. So my diagnosis was, it was a case of enamel caries. Report 2: A boy of 28 years old came to the department of Conservative Dentistry & Endodontics, BSMMU with the complaint of discoloration and mild sensitivity. On clinical examination, caries was found and there was no pain but the tooth was mildly sensitive during cold test. So my diagnosis was, it was a case of dentinal caries.

Treatment Plan:
Due to aesthetic consideration, both the cases were done by Giomer restoration. Firstly, the carious portions were removed by judicious use of diamond bur with adequate cooling arrangements. The restorative design was outlined with beveling. In the 2nd case the exposed dentin was covered by lining with resin modified glass ionomer. Then, shade was selected shade guide. Teeth were isolated with cotton roll. After drying off the tooth surface a uniform layer of 7th generation self etch adhesive bonding were applied. Light curing was done for 10 seconds. Initial build up with BEAUTIFILL ll Giomer restorative was performed and light curing was done for 10 seconds. Then a flowable framework was created to make an outline of the restored tooth structure and light cured. Incremental application of dentin layer followed by enamel layer (incisal) was performed. Finally, the whole restoration was light cured for 40 seconds. The tooth was left alone for 10 minutes due to prevent polymerization shrinkage. After, the restoration was polished using super-snap polishing discs in accordance to manufacturers instructions.

Discussion:
The growing demand for aesthetics are met by available restorative materials such as, composite resin, compomer, resin modified glass ionomer and recently giomer. Previously, the traditional glass ionomer were used in such cases like these, such as, KETAC-FIL (3M ESPE) and FUJI TYPE II (GC America) has some important properties such as fluoride release, fluoride rechargebility and chemical bonding to tooth

structure, they also have well known shortcoming, that are poor aesthetics, moisture contamination, dessication and solubility on oral fluid are some of them.9 Resin modified glass Ionomer (FUJI II LC, VITREMER) have much better aesthetics and handling characteristics than glass ionomers. They also release long term fluoride and ability to recharge with topically applied fluoride. But they tend to discolor over time.7 Another material Compomers are the class of dental materials that provide combined advantages of composite and glass ionomer. Having much better aesthetic, being easier to place and polish and handled better than GIC. But release much less fluoride and can not be recharged. Physical properties decrease with time.7 Resin based composite materials have been used widely for a long period of time to restore teeth for aesthetic purpose. However, the long term clinical result remained controversial as studies report inconsistencies. It produces better aesthetics but have some possible limitation including polymerization shrinkage, marginal leakage, discoloration and post operative sensitivity.9

Regarding my present case, considering the above facts, I chose the newly invented Giomer. The name Giomer is hybrid of the words glass

ionomer and composite. Giomer is a light cured, fluoride releasing, direct restorative material was developed S-PRG technology (surface pre reacted glass ionomer) to provide superior aesthetics with excellent shade match, enhanced handling characteristics and antiplaque effect while maintaining strength and durability. Base on PRG technology where a stable phase of glass ionomer is formed to incorporate added benefits such as, fluoride release and recharge to the restorative material without causing material degradation. Properties of S-PRG technology are, maintaining the property of multi functional glass (same hardness as enamel, high water resistance with out dissolution, high radio opacity), properties of glass ionomer like, fluoride release and recharge and biocompatibility. Shade conformity, that is aesthetics close to natural teeth. Significant fluoride release and recharge that means, S-PRG filler contains a stable phase of glass ionomer with the ability to release and recharge fluoride responding to the concentration of fluoride in the mouth while maintaining the strength and stability of a composite resin. On recently published study

compared the fluoride release of a glass ionomer, resin modified glass ionomer, compomer and giomer, it found that while the giomer release fluoride, it did not have an initial burst type of release than glass ionomers and its long term (that is 28 days) release and recharge than glass ionomer but higher that that of other materials. The higher fluoride release and recharge of giomers may account for their significantly better demineralization inhibition effect at the margin of restoration when compared to compomer and composite.1,10 The giomer filler structure has been developed to stimulate the internal structure of natural teeth with ideal light transmission and optical characteristics. The moderate translucency and light transmission of enamel combine with the light diffusion of dentin offers predictable aesthetics with a close shade match to natural teeth. Giomer have recommended 14 shades (A1, A2, A3, A3.5, A4, B1, B2, C2, C3, Inc, BW and opacious dentin shade- A20, A30). Excellent natural shade reproduction can be achieved with a chameleon effect, using a single shade that blends well with surrounding teeth making the restoration undetectable. In aesthetically demanding cases, additional shades can be used to achieve exceptional results.10 Excellent handling has been achieved with the inclusion of nanoparticles making giomer a use friendly material that is easy to sculpt with no slum, non sticky and wet preparation. Recently a flowable giomer has been developed which provides better application with syringe. 1,10 Giomer have anti plaque effect. A material film layer is formed by saliva that is reported to minimize plaque adhesion and inhibit bacterial colonization. In addition to S-PRG fillers discrete nano fillers (10- 20 nm) have been included in the giomer to obtain a filler load of 83.3 wt% for fast and easy polishing with an outstanding surface lustre which retains over time. Study found that a giomer, after polishing with Sof- lex discs had a smoother surface than a glass ionomer and one that was comparable to that of a compomer and resin composite.1

Conclusion:
Aesthetic dentistry is considered a form of art which requires vision to express possibilities and skill to meet the demands of the patient. Perfection in aesthetic restorations cannot be achieved without unstinted dedication, commitment, and passion toward the profession. Based on the clinical researches, it could be concluded that, giomer is a satisfactory material in the treatment of carious teeth where aesthetics is a vital consideration.

References:

1. Koirala S, Yap A.A. Clinical Guide to Direct Cosmetic Restoration with Giomer 2008; 1st end: 71-133. 2. Bhatnagar S, Sharma S, Bhatnagar M. Esthetic Restorative Treatment for Carious AnteriorTeeth - A Case Report; JIDA, Vol. 5, No. 8, August 2011. 3. Elias AC, Sheiham A. The relationship between satisfaction with mouth and number and position of teeth. J Oral Rehabil 1998; 25: 649-61. 4. MedlinePlus Encyclopedia Dental Cavities: http://www.cavity.ca/wiki/MedlinePlus 5. Cavities/tooth decay, hosted on the Mayo Clinic website: http://www.mayoclinic.com/health/cavities/DS00896/DSECTION=7 6. Hardie JM (May 1982). "The microbiology of dental caries". Dent Update 9 (4): 199200, 2024, 2068: http://www.ncbi.nlm.nih.gov/pubmed/6959931 7. Garg N, Garg A. Text Book of Operative Dentistry, 2010; 1st edn: 262-263. 8. http://www.cavity.ca/ 9. Vimal S.K. Textbook of Operative Dentistry, 2008; 2nd edn: 499-505. 10. The 2nd Generation Giomer Aesthetic Dental Restorative Material: www.shofu.com