Gingival Recession:Cause,Classification & Treatment

[drmithila]

 Why Do So Many Dentists Mistrust Composite To Treat Black Triangles?

Like many clinicians, Michael’s (the patient in question) dentist in North Carolina hadn’t heard of Bioclear and was unfamiliar with injection molding of composites. Therefore he was leery of treating Michael with "bonding." At that point Michael decided to cross the country for a different solution because porcelain veneers and periodontal surgeries did not appeal to him as ideal treatments. After he saw my "Black Triangle" and "Restoratively Driven Papilla Regeneration" articles on the Internet and videos on YouTube, he opted to fly to the west coast for treatment. 
After spending many hours working with manufacturers and tens of thousands of dentists, I compiled a "top 5" list of composite and porcelain fallacies that have steered dentists away from minimally invasive composite treatments for black triangles, or has doomed their previous attempts leaving them gun-shy to try it again:

1. "Acid-etching cleans the tooth." 
   False. Phosphoric acid barely touches plaque. Biofilm is so tenacious and we forget that phosphoric acid removes the mineral, not the organic component of tooth surfaces. Biofilm is organic, not a mineral. This residual biofilm at the margins is likely the number one reason why Class V and interproximal composites turn brown at the margins. No bonding agent can bond to biofilm, and most dentists are leaving biofilm on their hard to access margins.
2. "A stronger dentin bonding agent is the answer." 
   False. They (the manufacturers) keep selling us new and improved dentin bonding agents with higher and higher dentin bond strengths. The problem is twofold; first of all, in a case like this, most dentists are bonding to plaque, calculus, and contaminated dentin and no current resin bonds to biofilm. Secondly, with an approach using the Bioclear matrix; uncut, blasted, and rinse-etched (with phosphoric acid) enamel is leveraged to provide the bulk of the retention and reliance on the dentin is lessened. We can trust enamel bonding. The key is in the design of the Bioclear Matrix and the ability to "wrap" the tooth with seamless composite jacket.
3. "A full crown is better." 
   False. If you were the patient with otherwise healthy teeth, would you choose full crowns? Consider that a full crown destroys 70% of coronal tooth volume with a 10% to 20% chance of eventual resultant pulpal death.
4. "A porcelain veneer is better than bonding." 
   In a case like this, false. First, porcelain veneers cannot reach far enough to the lingual, so the space is blocked from view but becomes a plaque trap on the lingual. Secondly, bonding a veneer to this much cervical dentin should make you nervous. Very nervous.
5. "Direct bonding is too difficult."

In the past this may have been true. But today, false. In the modern resin era, we utilize anatomic Bioclear matrices coupled with injection molding filling technique with, for example, a universal nanocomposite, thus creating and ideal a flowable/paste interlace.

CASE WORKUP
First, I consulted 2 renowned microscope-equipped periodontists. I would have normally immediately excluded the surgical option based on this patient’s situation but, in this case, because of the severity of the embrasures attrition, I felt that second and third opinions were warranted. In addition, if a follow-up surgical approach were needed, the periodontist would already be on board. 
Noted periodontist, Dr. Peter Nordlands’ summary of this patient: "Dear David, the papilla height across the lower anterior teeth is located at the same level as all of the other adjacent papillae. This means that the individual papillae are not deficient but instead, the patient has suffered incisal edge wear and extrusion of the incisors. Although root coverage could be very predictable, I would recommend a restorative solution as you have so beautifully shown in the Bioclear video. My experience is that surgical papilla reconstruction is most predictable in situations where the papilla has been surgically abused previously."

CASE PRESENTATION
Figure 1 shows the functional and aesthetic dilemma. The retracted view (Figure 2) shows the magnitude of the black triangles on the lower. The patient’s first priority was treating the lowers, and he would return to the west coast in a few months to treat the upper black triangles. Facial abrasions and recession tripled the complexity of treatment (Figure 3). Blasting, which is application of a mild abrasive with air-water mix, is an absolute necessity for this treatment (Figures 4 to 7). Once the facial abrasions are restored up to the line angle areas, a rubber dam is placed. The interproximal areas are nicely managed with the rubber dam and the DC-203 Bioclear matrices together (Figures 8 to 15). To try to treat the facial abrasions at the same time that the matrices are in position is not recommended. The Bioclear method is almost the inverse of the old flat matrix technique. The facial surfaces are left with some excess because this is the loading area. The interproximals, when molded, will require little or no finishing. Immediate postoperative views demonstrate the dramatic emergence profiles, mirror finish, and regenerated papillae (Figures 16 to 18). Dentists and periodontists often ask these patients, "Are these veneers? Are these crowns?" No. This is done with an injection molding technique performed with high-level magnification using a universal nanocomposite (in this case,