The clinician’s responsibility is to conserve sound tooth structure whenever possible. The introduction of adhesive dentistry dramatically empowered today’s clinician to provide more conservative restorative dentistry for patients, as retentive features needed for older materials are often not required. More recent attempts at conservative approaches to treatment have included preventive preparations with fissurotomy burs, air abrasion procedures, and proactive sealants of pits and fissures. Although effective, these approaches to conserve tooth structure typically only address caries and/or defects within the occlusal aspect of the teeth in question. Additionally, conservative attempts at conventional restorative treatment are often limited by the size of the bur head being utilized or by the access to the carious or defective lesion.
ULTRASONIC TIPS
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| Figure 1. The recently introduced SL Tips (surface lesion tips) come in a variety of angulations to aid in access for multiple intraoral locations. | Figure 2. A direct comparison of the relative size of the ultrasonic tip to the conventional handpiece and bur assembly. |
Recently, ultrasonic tips were developed to meet the need for microinstrumentation of small areas requiring restoration. The SL Ultrasonic Tips (surface lesion tips, Obtura Spartan) were designed to broaden the capability of a pre-existing instrumentation—the Spartan MTS Piezo-Electric Ultrasonic Unit— already in many dental offices. These ultrasonic tips not only provide the benefits of conservative preparations in nonenamel areas, but also enable the clinician to access formerly inaccessible areas, and provide an easier approach into the buccal and lingual aspects of the posterior teeth. Additionally, they have lower noise levels compared to conventional handpieces; ensure delicate handling around fixed restorations to prevent breakage of porcelain; and often do not require local anesthetic for the restorative procedure. These benefits are especially significant in the treatment of geriatric and pediatric patient populations (Figures 1 and 2).
Access to Formerly Inaccessible Areas
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| Figure 3. An intraoral view of the clinical challenge in conservatively addressing interproximal lesions. The ultrasonic tips create a more direct approach to the small inconveniently positioned lesion. |
Small interproximal lesions often require the unfortunate sacrifice of sound tooth structure in the preparation process when coronal access is required. The slender profile of the ultrasonic tips, in combination with angled designs, more predictably enables direct access into formerly difficult-to-treat areas (Figure 3).
Conservative Preparations
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| Figure 4. A magnified view of the 0.5-mm SL Tip 2, demonstrating the fine diamond cutting surface. |
The ultrasonic tips are coated with a fine layer of cutting diamond fragments, creating a 0.5-mm ball tip. The sonicating action of the ultrafine diamond tips conservatively removes the carious surface while also creating a prepared surface roughness ideal for bonding restorative procedures. These micropreparations are compatible with the new highly filled flowable composites for a minimally invasive procedure (Figure 4).
Easy Handling of Posterior Teeth
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| Figure 5. An often challenging access area in the mouth is the distal cervical region of molars. The varied angles provided a more direct approach with better visibility. |
The most challenging of restorative procedures are typically related to the inability to have physical or visual access. Clinicians often struggle with the treatment of the disto-buccal aspect of both the maxillary and mandibular molars, the distal furcas of maxillary second molars, and the lingual aspect of mandibular molars. The exaggerated cutback angles of the SL Tips provide a more direct and less cumbersome approach to these formerly “tight spots.” (Figure 5).
Lowered Noise Levels
The ultrasonic instrumentation is essentially a noise-free delivery system. The elimination of the high-pitched noise of the conventional dental handpiece is a soothing change to the overall dental experience for both the clinician and the patient alike. This can be a welcome treatment option for the dental phobic patient or for the young pediatric patient who requires minor restorative treatment.
Delicate Handling of Existing Restorations
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| Figure 6. The small head of the tip allows for access with minimal destruction around defective crown margins, or inaccessible areas such as this mesio-buccal lesion on a mandibular third molar. |
One common area for the recurrence of dental decay is at the marginal area of existing crowns. The small diameters of the SL Tips provide access into the defective margin crevice without damaging or destroying the restoration (Figure 6).
No Anesthetic
The sonicating action of the microtips creates a less invasive incremental form of tooth structure removal. This more conservative and slightly slower approach in combination with the water spray at the tips often eliminates the need for local anesthetic to the area being treated. The lack of a need for anesthesia can often reduce treatment time overall.
Synergistic Applications With Magnification
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| Figure 7. With the increasing popularity of the use of magnification in restorative dentistry there is an increasing need for the development of instrumentation that allows better visibility in hard-to-access areas. |
One of the greatest indirect benefits of these newly introduced restorative SL Tips is their application in microscopic dentistry. The slender design of the tip eliminates the potential for the obstruction of one’s view by the head of a conventional handpiece during the clinical procedure. These benefits especially hold true at the higher magnification levels or when the working field is additionally restricted by the mirror head (Figure 7).
CASE REPORTS
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| Figure 8. A frontal view of the patient’s maxillary and mandibular incisors with progressive caries into the dentinal anatomy of the incisal edges. | Figure 9. A 5X view of the central incisors demonstrating the discoloration created by the underlying decay. |
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| Figure 10. An occlusal view of the incisal lesions well confined to the enamel shell. | Figure 11. The preparation process utilizing the SL Tips. |
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| Figure 12. The completed restorations on the incisals of the maxillary right lateral, right central, and left central incisors. | Figure 13. A close-up view of the central incisors illustrating the preservation of the enamel surface and the aesthetic enhancement achieved through this conservative approach. |
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| Figure 14. The view of the patient’s lower central incisors treated in this same manner. |
The patient presented with the complaint of darkness in her maxillary and mandibular incisor teeth. Upon examination it was apparent that the parafunctional activity had worn the incisal enamel down to the dentin level. The dentin had decayed in a small vertical channel-like progressive defect, creating a visual and structural compromise (Figures 8 through 10). The patient’s desire was to restore the teeth in as conservative a manner as possible. However, the thinness of the incisal edges required that a vertical approach be very controlled and precise. The small diameter of the SL Tip (Figure 11) was well suited for a direct approach to the defect, while the diamond coating along the shank provided delicate simultaneous lateral decay removal. Figures 12 and 13 show the final maxillary restorations that were completed with a highly filled flowable composite (Kerr Point 4 Flowable). The same technique was used on the mandibular incisors for this patient (Figure 14).
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| Figure 15. Small lesion in a mandibular central incisor of a medically compromised geriatric male patient. | Figure 16. With the aid of ultrasonic preparation, a minimally invasive microprep was created without the need for local anesthetic. |
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| Figure 17. A 14X view through the operating microscope of the clinical bonding procedure. | Figure 18. The same view of Figures 16 and 17 of the etched surface highlights the conservative nature of the preparation prior to final restoration placement. |
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| Figure 19. Polishing of the completed restoration at 14X. | Figure 20. The final outcome of the restoration of the mandibular right central incisor. |
In another patient example, a small carious microlesion was present on the lower left central incisor in a medically compromised male geriatric patient (Figure 15). Without anesthesia, a small microprep was created with the SL Tip. The tip allowed the removal of the carious material as well as the creation of a caries-free enamel surface ready for the bonding procedure. This preparation choice was preferable to air abrasion, as there was a need to control the area of tooth removal to a well-defined, accurate micropreparation (Figure 16). Conventional composite restorative protocols were followed to restore the preparation (Figures 17 and 18). These restorations were restored and photographed through the operating microscope at 14X, demonstrating the additional visibility that the ultrasonic tip provides the clinician. Figures 19 and 20 show the final polishing and the final completed restoration as viewed through the operating microscope.
SUMMARY
The SL Ultrasonic Tips provide a new option for specific microlesion indications. New designs are continuing to be developed and refined to help enhance the clinician’s ability to provide quality treatment in a conservative way. With the increase in the use of aided vision for clinical dentistry, the need for alternative instrumentation that gives the dual benefit of visibility and preservation of tooth structure will become increasingly valuable.
Dr. Sheets maintains a full-time private practice in Newport Beach, Calif, emphasizing aesthetics, implants, and reconstructive dentistry. She lectures internationally and is currently involved in implant research. Dr. Sheets is a past president of the AAED and the American Association of Women Dentists. She is a professor of clinical dentistry at USC and associate clinical professor at the School of Medicine, University of California, Irvine. Dr. Sheets is the founder and director of the Newport Coast Oral Facial Institute, an international teaching facility for dentists and dental technologists in Newport Beach.
Disclosure: Dr. Sheets, in conjunction with the Newport Coast Oral Facial Institute, is codeveloper of the SL Ultrasonic Tip for Obtura Spartan. Any proceeds will be directed toward research and education at the nonprofit Institute.
Dr. Paquette is a prosthodontist specializing in aesthetic and implant dentistry, reconstructive dentistry, and the management of occlusion and temporomandibular disorders. She maintains a private practice in Newport Beach, Calif. Dr. Paquette is associate clinical professor at the USC School of Dentistry in the Department of Restorative Dentistry. She is a member of the International College of Dentists, the American College of Prosthodontists, Academy of Osseointegration, and is an associate member of the Pacific Coast Society of Prosthodontists. Dr. Paquette serves as coexecutive director for the Newport Coast Oral Facial Institute, an international teaching facility for dentists and dental technicians located in Newport Beach. She can be reached at (949) 760-6288 or jmpaquette@ncofi.org.
Disclosure: Dr. Paquette, in conjunction with the Newport Coast Oral Facial Institute, is codeveloper of the SL Ultrasonic Tip for Obtura Spartan. Any proceeds will be directed toward research and education at the nonprofit Institute.
