Pathologic Phenomena










Chapter
9
Pathologic
Phenomena
Jordi
Ma
nauta
Anna
Salat
Interview
with
Bernd
Klaiber

''
Whatever
iyoo
do
111aiy
see111
insignificant,
bot
it
is
mo
s t
important
that
iyoo
do
it.
Mahatma
Gandhi
,,

332
Prof Bernd Klaiber was born in Karlsruhe, Germany, and completed
his doctoral and postdoctoral studies in
dentistry
at the University
of Freiburg.
Prof
Klaiber was honored with the Annual Award of the German
Society for Dentistry and Oral Medicine
in
1980
and 1998.
He
was appointed Professor at the University of Freiburg in 1981.
In
1986, Prof Klaiber won the Walther-Engel Award of the Academy
for
Dental Studies, Karlsruhe.
He
has served
as
director
of the Department of Operative Dentistry
and
Periodontology, University of WUrzburg, Germany, since 1987.

Q:
It
is
controversial to advocate the reproduction of
pathologic phenomena
in
restorations.
Why
do
you
think it
is
important to know how to do
it?
A:
The
location and form of the restoration are,
in
my
opinion, of outmost importance when
we
consider
whether to
mimic
pathologic phenomena. Therefore,
the imitation of stained fissures, opaque spots, or
even
caries in the functional zone may
be
regarded
as
irrelevant or overtreatment.
However,
we
may take a different view in the esthetic
area.
In particular, when adjacent teeth reveal small
aberrations such
as
opaqueness, staining,
or
enamel
cracks,
it
is
critical to imitate these characteristics in
the restoration.
In these situations,
an
immaculate and ideally
reconstructed single tooth will always look artificial or
unnatural. If crowns or veneers can
be
identified
as
restorations, and therefore
as
fake,
we
have
failed to
perform our job
properly.
333

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Chapter 9 Pathologic Phenomena Jordi Manauta • Anna Salat Interview with Bernd Klaiber '' Whatever iyoo do 111aiy see111 insignificant, bot it is mos t important that iyoo do it. Mahatma Gandhi ,, 332 Prof Bernd Klaiber was born in Karlsruhe, Germany, and completed his doctoral and postdoctoral studies in dentistry at the University of Freiburg. Prof Klaiber was honored with the Annual Award of the German Society for Dentistry and Oral Medicine in 1980 and 1998. He was appointed Professor at the University of Freiburg in 1981. In 1986, Prof Klaiber won the Walther-Engel Award of the Academy for Dental Studies, Karlsruhe. He has served as director of the Department of Operative Dentistry and Periodontology, University of WUrzburg, Germany, since 1987. Q: It is controversial to advocate the reproduction of pathologic phenomena in restorations. Why do you think it is important to know how to do it? A: The location and form of the restoration are, in my opinion, of outmost importance when we consider whether to mimic pathologic phenomena. Therefore, the imitation of stained fissures, opaque spots, or even caries in the functional zone may be regarded as irrelevant or overtreatment. However, we may take a different view in the esthetic area. In particular, when adjacent teeth reveal small aberrations such as opaqueness, staining, or enamel cracks, it is critical to imitate these characteristics in the restoration. In these situations, an immaculate and ideally reconstructed single tooth will always look artificial or unnatural. If crowns or veneers can be identified as restorations, and therefore as fake, we have failed to perform our job properly. 333 An Interesting Conversation In a course, during the hands-on demonstrations, participants generally are more relaxed. At one course, a participant came to me and asked me a very, very interesting question: "How would you stratify a tetracycline-stained tooth?" My answer was: "These are the most difficult cases. Masking tetracycline stains is difficult, because the grayish brown can be seen through the composite, especially if it is translucent. Therefore you must use opaque white composites ... " At that point she interrupted me: "Sorry. I did not explain myself correctly. I need to restore a fractured tooth in a patient with tetracycline staining. He does not want veneers or crowns." 334 I asked, "What have you done?" "Well, I have tried to restore it with very dark colors like a C4, but always with an unsatisfactory outcome." "Give me a couple of weeks to think about it. Remember that my answer may be unsatisfactory too. I have never done it before. We will keep in touch." Two weeks later, I sent her a photograph (1) with the following instructions: "Mix an A2 dentin with an orange stain and the same A2 dentin with a brown stain. Keep saturating both masses with the stains until you match the color. Try also to mix in a tiny amount of black stain if the tooth is very gray." The answer in 10 days was: "I have finally solved the case! I will send you pictures." I responded, "It was a great pleasure. It was a very interesting adventure; we should write a book ." Note: I am still awaiting those pictures! Note 2: the pictures came while this book was being finished. Pathologic features in teeth offer a wide range of colors rarely seen in healthy teeth. Stratifying these characteristics, not only to solve bizarre cases, but also to acquire a deep appreciation of dental color, increases our ability to identify color and become skilled in stratification and modeling. There are hundreds of artists in the entertainment world (theater, movies, photography) who are constantly manufacturing altered teeth , such as a vampire canines or rotten dentitions. These people have surprised us immensely with their ability to understand dental color in an amazing way. An ocher stain is placed in the center of the depression and extended to cover some of the white area. Before the enamel layer of a posterior tooth is placed, a car-ies lesion wi 11 be stratified on a proximal surface. A dark brown stain is placed ir-regularly, allowing some of the ocher stain to remain visible. An increment of a milky white composite is placed with a de-pression in the middle to house the stains. Final enamel placement should slightly dull the powerful effect of the stains. During the finishing stage, depending on how much enamel is removed, internal effects will become more visible, some even reaching the surface. 336 An increment of a milky white composite is placed with a de-pression in its center to house the stains. A dark brown stain is placed to characterize the center ir-regularly, allowing some of the ocher to remain visible. To highlight the effect, an opaque white stain is placed in some areas of the created circle. The final enamel layer will dull the effects of the stains slight-. ly. Normally these lesions are not reproduced in posterior teeth because they are hidden or, if by chance they are visible, they do not play a role in esthetic integration. However, some lesions of a complete different etiology are found in anterior teeth, and some of them must be reproduced to achieve successful integration of the restoration. The technique for their stratification is exactly the same as shown in these examples. An ocher stain is placed , slight-ly covering some of the areas of white characterization. Finishing and polishing can be used to make the effects emerge again or not, depend-ing on the needs of the par-ticular restoration. 337 .. 1 A recently stratified and pol-ished composite resin tooth will be transformed. 336 This type of characterization has only two applications, the artistic and the educational. However, these photographs are the ones that arouse the _most curiosity in lectures and courses because of the appar-ent complexity of the restora-tion. A No. 2 rounded diamond bur is used at low speed to create a cavity, leaving a thin layer of the facial enamel. An irregular shape is made to improve the natural appear-ance of the lesion. A milky white composite resin is placed inside the enamel wall for a decalcification effect. A high-Chroma dentin (A6) is placed as a liner in the floor of the cavity. Dark brown stain is used to fill most of the cavity and saturate the lesion body. An orange stain is also placed as a liner, to begin enhancing the Chroma to the maximum · level. A black stain is placed as the final chromatic layer. The mass used in this case was dark brown stain mixed with black ceramic powder. After polymerization is com -pleted, an ocher stain is placed in the same way, this time in-creasing the amount of mass and thus the inner volume. The cavity is closed with milky white and enam.el composite resins. This effect cannot be mechanically polished. 339 A root is constructed from a dentin composite mass modified with ocher stain. The palatal wall is formed with a high·Value enamel composite. A mixture of dentin, or· ange stain, and a small amount of brown is used to build the dentinal body. 340 We must learn to develop many intensities. In this case, less ocher stain and a small amount of brown stain were mixed with the dentin. An amber opalescent mass is used to place some characterizations in the incisal edge. This situation is probably where we find the strangest colors and the most complicated chromatic maps. It is important to know how to reproduce these stains for the following reasons: • It is highly probable that we will encounter a patient with such stains (depending on the country). • It helps us to understand dental color. • It improves our ability to stratify. The mixture of dentin, now saturated with dark brown, helps to create a band typical in these teeth. Corrections can be car-ried out to obtain thinner walls or structures. Between the amber spots, some white intensive is placed to create opaque enamel areas. Near the proximal area, intensive spots are mod-eled in a striped shape. Some natural opalescent is placed in the incisal area and proximal walls . For the final layer a high-value enamel composite is used to develop two white fissures. The same opalescent is used to develop a type 2 characterization to create a transparent band that wi II act as a filter. The finalized stratifica-tion reveals how every mass behaves under the enamel composite. An orange stain is used to make the division be-tween bands more evi-dent. The finishing and polish-ing make the internal characterization evident again. 341 Fluorosis Teeth that suffer this pathologic condition usually look similar to the tooth in the image (1). They show decalcifications, structural disarray, and accumulations of pigment. Generally these effects are found on the top layer, and therefore our clinical efforts should focus on their conservative removal. The color properties of these teeth are based on: • Power intensive features • Dark brown •Transparent brown • Opaque orange A composite mixture is not ideal , chemically speaking, and these masses are not commercially available. These techniques require long curing times and exhaustive polishing. A dentin core with a four-mamelon (type 2) opalescence (2a, 2b, 2c) is fabricated. This can vary, depending on the tooth that is being reproduced. Three kinds of inten· sive masses are used to "draw" the map of de· calcifications that must be reproduced. The stronger intensives are placed on top of the I ighter intensives (3a, 3b, 3c). Three types of mixture can be made with the natural opalescent and placed on the tooth ac· cording to the location and the shape of the ef · feet, which is usually ir· regular. Opalescent+ orange (4a) Opalescent+ ocher (4b) Opalescent+ brown (4c) The la.st enamel com· posite layer is placed (5a, 5b, 5c) overshad· owing the underlying effects. In some cases, where enamel is miss· ing, a modified dentin composite resin can be used as a final layer (5c). Mild fluorosis Strong fluorosis Severe fluorosis 3'13 346 Conclusions The study of pathologic conditions is essential to understanding normality. 2. These techniques provide us with self-confidence to tackle difficult cases. 3. Tooth defects are reproduced for artistic and educational purposes. 4. Learning the techniques for generating new composite colors avoids the need to have massive color systems. 5. Each stain has a different opacity; the darker the stain, the more opaque it should be. Stains also vary considerably from brand to brand. 347

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