PATIENT M A IN T E N A N C E O F

ESTHEI RESTORATIONS
R O N A L D E. G O L D S T E IN , D .D .S .; D A VID A . G A R B E R , D .M .D .;
O A T H V G O LD S T E IN S C H W A R T Z , D.D .S .; C A R V E. G O LD S T E IN , D .M .D .

ABSTRACT 0 linical reports have shown th a t m ost p atients require assistance

w ith th eir home care regim en.1'3 Personal oral hygiene habits vary
T h is a r tic le ex p lo res greatly, and m any patients resen t the tim e it tak es to clean n a tu ra l
p a tie n t h om e ca re and teeth, m uch less esthetically restored teeth.
It’s common for a p atien t to promise to tak e care of “newly
o ffers c o n v e n ie n t, m od ern
restored” teeth, only to resort, after a short tim e, to neglectful
m a in te n a n c e reg im en s habits. Help these patients to develop a regim en of oral home care
ta ilo r e d to in d iv id u a l th a t is sim ple, effective and quick. If any feature is m issing, the
p a tie n t n eed s. p a tie n t’s home care m ay also be lacking.4
E sthetic restorations require m eticulous m aintenance. Unless
plaque is removed routinely, the soft tissue fram ing th e restoration
can become inflam ed and spoil both the desired esthetic and
functional result.
Basic problems th a t can affect all esthetic restorations are
discoloration or stain, poor tissue response and fracture. Most
p atients experience one or all of these factors a t some tim e in the
life of th eir restorations. If your patient adheres to some definitive
oral physiotherapy guidelines, however, these problem s can be
m inim ized and the esthetic and functional lifespan of the
restorations extended.5
All esthetic restorations—including composite resin bonding,
porcelain lam inate veneers, etched ceramic onlays/inlays and the
full crown—require ongoing m aintenance and m ay include periodic
refinishing.6 Although each restoration presents its own problems
and conditions for m aintenance, the objective rem ains the same:
preservation or promotion of healthy functional and esthetic
periodontal ap p aratu s.78 This article explores p atien t home care
and offers m odern m aintenance regim ens.
The cu rren t methods for m aintaining dental restorations consist
of brushing, flossing, oral irrigating and in terd en tal stim ulation.
These m odalities still play a m ajor role, b u t w ith scientific
developm ents and increased epidemiological knowledge, the success
ra te is different.
FINISHING THE ESTHETIC RESTORATION

All subgingival restorations leave an altered surface a t the critical

JADA, Vol. 123, January 1992 61

soft tissue and tooth interface.
The ideal finishing for esthetic
restorations requires surfaces
th a t do not prom ote plaque
retention. U nfortunately, while
all restoratives vary in how
plaque accum ulates, only the
all-glass ceram ic (Dicor)
restoration has been reported to
inhibit plaque form ation.9
The d en tist’s objective is to
create a sm ooth surface w ith an
im perceptible m argin th a t
m inim izes plaque retention and
is easily m aintained—a highly
polished surface, for example,
w ith m argins free of any Figure 2—A short pointed tip works best interproximally, especially
overhang. State-of-the-art when tissue has receded, and works well for interdental cleaning when
orthodontic brackets are in place.
finishing for composite resin
includes subgingival finishing
w ith eith er a 30-blade carbide lam inate veneers are finished staining and usually can be
or 8-micron diam onds.1011 m ost effectively with the 30- removed w ith a thorough
D epending on the restorative blade carbide (E.T. 3 or U.F. 4, prophylaxis.
m aterial used, either diamond Brasseler) for subgingival Although some patients are
or carbide ro tary instrum ents m argins, which leaves an effective a t m anual tooth-
m ay be preferred.12 Hybrid equally finished surface on the brushing, m ost do not spend
composites and porcelain tooth, the veneer and the enough tim e or do not have the
composite interface.6 For necessary dexterity to remove
microfill composites, the 8- stain and plaque accum ula­
micron diam ond (D.E.T.U.F. 3 tions. For m any years, various
or D.E.T.U.F. 4, B rasseler) electronic brushes have been
seems to develop th e best available.
surface.6,33,34 It is not th a t they are more
Clinically evaluated tissue effective th a n m anual brushing
responses to finishing w ith in rem oving plaque, but they
these in stru m en ts have been appear to be more effective
excellent. Use one of th e newer w ithin the tim e constraints
third-generation dentin imposed by patients. W ith these
adhesives to prevent percolation constraints in mind, we
and m icroleakage betw een the developed a regim en for our
tooth and restorative m aterial p atients th a t lim its both the
when cem entum is exposed and tim e spent and the instrum ents
to help prevent rough surfaces used.
a t the m argins. An article by B ader and
Dubrovic13 found th a t an elec­
STAINING
tronic plaque removal device
Effective oral hygiene tech­ (Rota-dent, Pro-dentec) was as
niques and dietary aw areness effective as a combination of the
can prevent a certain am ount of three most prevalent methods
Figure 1—The subgingival
surface discoloration, but some of oral hygiene—brushing,
margins of this patient’s
composite resin bonding are staining eventually occurs flossing and interproxim al
being finished with a D.E.T.U.F. around all restorations. Most stim ulation—in controlling
8-micron diamond (Brasseler).
discoloration is actually surface stain.

62 JADA, Vol. 123, January 1992

HOME CARE p atien t to a periodontist or an sary aids, p atien t compliance
IMMEDIATELY AFTER
RESTORATION oral m edicine specialist. increased fourfold. It was less
PLACEMENT We recommend for our fru stratin g for hygienists and
Any oral physiotherapy p atients an electrical plaque practitioners, and patien ts had
in strum entation can be abused removal device, such as Rota- less oral disease as a resu lt of
either by overuse or by use with dent, an in stru m e n t th a t cleans the improved hygiene protocol.
excessive pressure. W hen only one tooth a t a tim e. 15' 17 Tits
l
Furtherm ore, by using prod­
tissues are inflam ed and site-specific action em phasizes ucts dispensed only through a
sensitive im m ediately after the im portance of cleaning each dental office, the dental team
restoration insertion, in stru ct tooth ra th e r th a n tooth groups. achieves greater control, more
the p atien t to use the gentlest W hen cleaning more th a n a successful follow-through w ith
possible touch th a t will achieve single tooth, it is easy to miss recall appointm ents and the
all plaque removal. Even the asym m etrical gingival m argins necessary one-on-one in stru c­
usual pressure exerted with or proxim al surfaces in non- tion in use of these products.
plaque rem oval devices should aligned teeth. 1729 D ental staff mem bers:
be eased slightly. We also recom mend different ■* provided the appropriate
D uring this tim e, when brush tips for different cleaning equipm ent;
optim al cleaning is difficult, we needs. There are pointed tip ■■ developed a simple, rapid
recom mend a chem otherapeutic brushes th a t effectively clean and effective routine;
agent, such as Peridex (Procter th e interproxim al surfaces.
& Gamble), to help control Extra-fine bristles of the
plaque. Dipping the brush tip in hollow-cup tip extend under the
th e m outhw ash before using is free gingival m argin and into
an excellent m ethod of applying the sulcus for efficient plaque
the solution to th e teeth, to rem oval in th is critical area.
obviate some of th e staining The p atien t can remove
problems associated w ith the plaque in less tim e th a n w ith
m outhw ash.14 conventional methods. This has
It should not take more th an been a factor in altering
about eight days before the p atien ts’ traditional, less
junctional epithelium effective oral hygiene habits.
redevelops and norm al pressure
SHOULD YOU DISPENSE
can be applied again. Re­ CLEANING DEVICES?
exam ine th e p atien t two weeks
after restoration insertion to For a num ber of years, our
ensure there is no rem aining office opposed dispensing
inflam m ation. Often, a cement cleaning devices because of the
spicule or sm all overhang th a t need to m ain tain an inventory
was not entirely removed may and th e equipm ent repair
be located subgingivally, problems. U nfortunately, over
causing inflam m ation. the years we experienced a high
Figure 3— A hollow cup tip works
Do not re tu rn th e patien t to ra te of non-compliance on oral well on facial and lingual
the norm al recall cycle until the disease control or prevention surfaces, cleaning most
tissue is norm al. This could instructions. A fter patients effectively just into the gingival
sulcus.
m ean continued weekly or bi­ obtained the list of necessary
weekly visits for m onths after hygiene item s, th eir intentions *■» m onitored the p atien ts for
tre a tm e n t—until the team has were often forgotten after compliance and technique;
m otivated th e p a tie n t to per­ leaving the office. ■* reinforced good dental
form the desired oral hygiene to By changing our approach hygiene habits.
restore and m ain tain tissue and dispensing not only the
BONDING
integrity. If persisten t signs of necessary inform ation but also
inflam m ation exist w ithout any th e rotary cleaning device, Since composite resin bonding
ap p aren t cause, refer the fluoride and any other neces­ is porous, it accum ulates stain.

JADA, Vol. 123, January 1992 63

 of rem inders regarding
porcelain lam inates.2
CROWNS

The full-crown restoration is

difficult to m aintain, because
the restorative m argins
compromise the tooth circum-
ferentially.26 While rotary
cleaning devices appear to be
effective, flossing is an
im portant adjunct. All the
restorative m argins m ust be
kept plaque-free to avoid
cem ent w ashout, caries and
periodontal disease.
Aids such as interdental
Figure 4—A patient with fixed splinting using floss at the metal
framework try-in stage. stim ulation and subgingival
irrigation m ay also be useful
The life expectancy of the them to use it twice daily, but depending on the p atien t’s
composite restoration can be m anual brushing is acceptable specific problem. I t is critical,
affected by im proper home for th is second session. however, not to overburden the
care4'23 or aggressive hygiene patient w ith an a rra y of
PORCELAIN LAMINATES
recall visits.24 Incorrect extra- devices, complex instructions
coarse prophy paste can also Most porcelain lam inate and an unrealistic time
cause increased surface rough­ m argins are either a t or slightly requirem ent. This often results
ness which fu rth er attracts below the free gingival m argin. in oral hygiene “burnout” and
plaque and stain .25 Therefore, sim ilar oral hygiene lack of fu rth er compliance.
As resin restorations age and procedures such as those for full
SPLINTED
th e surface wears, small voids bonding are advocated. A RESTORATIONS
rise from below the surface and hollow tip b rush is indicated to
become targ e ts for food, liquid remove plaque from the labial, M aintaining splinted ceramo-
and plaque.2 In stru ct the lingual and interproxim al m etal restorations begins with
p a tie n t w ith composite bonding surfaces. M iller provides a chart fram ew ork constructions. Leave
to:
™ avoid foods th a t stain;
*■ avoid parafunctional chewing
habits;
“ ensure optim al home hygiene
procedures;
“ schedule prophylaxis
appointm ents a t least three to
four tim es yearly for
professional m aintenance and
constant re-evaluation.
P a tie n ts should note if and
where floss shreds during home
care because these areas need
to be refinished. Assum ing the
restorative m argins are
adequate, the patien t m ay have
to use the m echanical device Figure 5—Patient correctly holding the electrical plaque removal
only once daily. It is best for device close-up for maximum control.

64 JADA, Vol. 123, January 1992

sufficient space interproxim ally
so the p atien t can use floss
th read ers and a pointed brush
tip to clean the areas. A fram e­
work try-in ensures th a t th e
esthetic dem ands of th e p atien t
will be m et and the restorations
can be cleaned hygienically. The
reason for this initial try-in is
th a t it is virtually impossible to
look a t the m aster study cast to
determ ine the relative tissue
relationships after the dies have
been trim m ed. At th e try-in,
th is can be evaluated and, if
necessary, sufficient space
created by m achining the Figure 6—Several years after bonding was placed, the patient was
framework. examined again and her flossing habit was reviewed. It was
After placing and cem enting discovered she was “guillotining” her tissue by moving side to side
without first returning to the height of papilla contact.
the fixed bridge, show patients
exactly how to hold the cleaning any dental cleaning devices to applying too m uch force or th a t
device to remove plaque from th is appointm ent so the the b rush h as been in use too
interproxim al areas adjacent to technique can be evaluated and long.
each abutm ent. Sometimes possibly adjusted to achieve the Two
floss, th e rotary device and, hygiene goal. Provide floss excellent
occasionally, an oral irrigator
m ay be necessary to remove
plaque accum ulations from all
pontic areas and abutm ents.
W ith ovate pontics, esthetics
th re a d ers a t th a t tim e and urge
patien ts to perform th eir home
care routine for evaluation by a
sta ff m ember. P a tie n ts’ descrip­
tions of th eir home care
devices for in ­
office cleaning
may be contra­
indicated for
&Dr. Garber is in

use on esthetic private practice,

AtSanta.
and hygiene can be achieved. routines will not suffice—nor restorations:
P atients, however, need to will verbal instruction alone by *" U ltrasonic
u nd erstan d the physiology as th e hygienist effectively explain scaling has enhanced hand
well as the m echanics of the the process. scaling b ut can compromise
design to ensure plaque restorations or im plants. To
PREVENTIVE ESTHETICS
rem oval from these areas. avoid debonding of restorations
Auxiliaries m ust devote a g reat The hygienist is in one of the by high-frequency vibration,
deal of tim e and effort to best positions to m onitor and scratching, chipping or other
p a tie n t education and periodically scrutinize your potential damage, do not use
m otivation p atients for potentially harm ful this in stru m en t on esthetic
goals. habits. Recognizing symptoms restorations.27
Schedule a such as abnorm al enam el w ear ■■ Air abrasive polishing
separate or tooth abrasion are examples system s are effective in elim i­
prophylaxis of how the hygienist can and nating hard-to-rem ove stains.
w ith the should help your patients. For This technique, however, can
hygienist after Dr. Ronald Goldstein any p a tie n t using m anual also dam age esthetic resto ra ­
cem entation to is in private practice, brushing and having unusual tions.28'30 Use hand scaling and
review the West Paces
w ear p attern s, the hygienist polishing for long-term in-office
Professional Park,
effectiveness of 1218 West Paces should ask th a t the patient esthetic m aintenance.
home care Ferry Road, Suite bring in the brush for evalua­
200, Atlanta 30327. MOTIVATION FOR
procedures. Address requests fo r
tion to determ ine correct use. IMPROVED HOME CARE
The patient reprints to Dr. Frayed or splayed bristles
should bring Goldstein.
usually indicate the p atien t is Even conscientious p a tie n ts are

JADA, Vol. 123, January 1992 65

sometim es lax about home care. porcelain bond.31 ations. After esthetic tre a tm e n t
One of our patien ts had been ■“ Use only sodium fluoride at is completed, schedule a m anda­
particularly faithful in everyday home. Stannous or acidulated tory postoperative appointm ent
cleaning, m aintaining his soft phosphate fluorides are not to m ake certain th a t w hatever
tissue and exposed roots for recommended for bonding or technique the p atien t uses is
m any y ears in excellent condi­ porcelain. effective.32At the postoperative
tion. D uring a ■■ If you grind or clench your visit, it should be ap p a re n t th a t
stressful teeth, a custom bite guard could the p atien t’s tissue is healthy. If
period, prevent restoration fracturing the tissue has not healed, some
however, his while you sleep. change in home care or addi­
priorities **■ Do not pick a t your tional periodontal or restorative
changed. He restoration. You could pull open treatm en t may be necessary.
lost in te rest in a small overextension and There are virtually hundreds,
Dr. Schwartz is in the hygiene shorten the life of your bonded perhaps even thousands of
private practice,
routine, and or porcelain restoration. If you home plaque removal devices.
Atlanta.
the oral tissues feel a rough edge w ith your The ones m entioned here have
became tongue, call for an appointm ent worked for us and are therefore
progressively more inflam ed to have the edge properly discussed. It isn’t the type of
and hypertrophic. refinished. device th a t is critical, however,
An effective way to rekindle * Do not bite your fingernails but patient compliance. The
your p atien t’s in terest in proper or try to open bottles w ith your described regim ens have
home care is to let them know front teeth. The force can crack worked effectively for us in
th a t periodontal surgery is your new restorations. overcoming this obstacle of
preventable. This rem inder, ■■ To prevent staining, try to compliance. A ppropriate recall
coupled w ith an innate fear of avoid or keep to a m inim um the visits w ith the hygienist should
surgery, encourages patien ts to use of coffee, tea, soy sauce, be m ade a t one- to six-m onth
practice home care routines curry, colas, grape juice, intervals.
again. blueberries or red wine. In the final analysis, your
A recent poll showed 73 " To prevent fracture, avoid success with esthetic
percent of people queried spend biting any h ard foods w ith your restorations m ay well depend
three m inutes or less each day front teeth. Avoid, or keep to a on your patien ts’ success with
on home care.1D unlap reported m inim um , esthetic m aintenance. ■
th a t “more th a n three m inutes sticky, sugary
Inform ation about th e m an u factu rers o f the
of home care is, for m ost people, foods th a t can products m entioned in th is article m ay be available
simply boring.” from th e authors. The Am erican D ental Association
dam age or h as no in te re st in th e products m entioned.
Give p atients w ritten w eaken the
1. D unlap JE . Home care th a t works. D ent Today
esthetic m aintenance in stru c­ bond between 1990;28:59.
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66 JADA, Vol. 123, January 1992

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