Existing Restoration - Clinical Status

1
Existing Restoration - Clinical Status

• Secondary Caries
• Marginal Integrity
• marginal defect
• overhang
• open margin
• Contour
• proximal contact
• axial contour
• occlusion

• Biomechanical Form
• restoration fracture
• tooth fracture
• Esthetic
• patients esthetic concern

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Marginal Defect - Amalgam Restoration
It is the second most common reasons given for
replacing an amaglam restoration
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Reasons for replacing an existing restoration
with defective margin- Survey of 124 dentists

• It is a plaque trap, thus increasing the chance
  of developing secondary caries (37)
• More likely to find secondary caries on the
  cavity wall below the defect (25)

Tooth
Amalgam
4
Reasons for replacing an existing restoration
with defective margin

• It is a plaque trap, thus increasing the chance
  of developing secondary caries.
• Is this hypothesis supported by scientific facts?

Tooth
Amalgam
5
Reasons for replacing an amalgam restoration with
defective margin
Are there direct scientific data showing a
relationship between marginal defect and the
development of secondary caries?
NO
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Indirect/Empirical Evidence

• We are seeing the majority of the disease in a
  small population of our patients therefore not
  everybody is equally susceptible to the disease.
• If physical barrier for oral hygiene is a
  problem, why do some pits and fissures never
  develop into lesions.
• Assuming these defects on the margin of an aging
  restoration has been there for years why no
  lesion has been developed in all these years.

7
Reasons for replacing an existing restoration
with defective margin- Survey of 124 dentists
More likely to find secondary caries on the
cavity wall below the defect Is this
hypothesis supported by scientific facts?
Tooth
Amalgam
8
Reasons for replacing a restoration with
defective margin

• There is scientific evidence showing that there
  is NO relationship between marginal defect and
  the presence of secondary caries on the cavity
  wall below the defect

9
30 extracted teeth with occlusal amalgam
restorations were sectioned. Caries were
identified by imbibing the section in with
quinoline and examined in polarized light
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How should we make the decision on when to
replace??

• Replacement decision should not be based on the
  quality of the margin ALONE
• Instead
• Replacement decision should be based on risks
  and/or the presence of pathology

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Replacement Decisions

• Risk Factors
• Risk factors related to dental caries and
  periodontal diseases.
• Presence of pulpal pathology (e.g. sensitivity to
  temperature change, sweet).
• Patients complaint (esthetic concern).

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Contour

• Status
• Proximal contact - open, rough, location
• Axial contour - over/undercontour, location
• Occlusion
• Diagnosis is based on visual, patients chief
  complain and radiographs

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No Proximal Contact - Treatment Decision

• No treatment indicated if it is physiologic (e.g.
  natural spacing between teeth)
• Replace if patient has esthetic concern or
  complain about food impaction, and/or in the
  presence of periodontal diseases.
• Grey area
• Complaining about food impaction between 2 teeth
  that have no existing restoration, no evidence of
  periodontal diseases.
• Complaining about food impaction - occlusal
  contact OK, but gingival embrasure area open
  because of gingival recession.

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No Proximal Contact - Treatment Options

• Anteriors
• Direct composite, indirect porcelain veneers,
  full veneer crowns.
• Choices depend on patients expectation/ability
  to pay and other clinical concerns (e.g. shade
  match problem, discolored tooth) and dentist
  skill.
• Posteriors
• Direct restoration - know the clinical and
  mechanical limitations of the restorative
  materials direct composite restorative may be
  contra-indicated deep gingival seat - clinical
  limitation.
• Indirect restoration - may be the only viable
  option.

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ContourReplacement Decision

• Rough Proximal Contact
• Smooth or replace only if patient complain about
  not being able to floss
• Proximal Contact at Non-physiologic Location
• Use the same criteria as no proximal contact (no
  treatment indicated in the absence of pathology,
  patients complain and esthetic concern)

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ContourReplacement Decision and Options

• Axial contour
• Undercontour - e.g. porcelain fracture from PFM
  crown
• Overcontour - e.g. buccal or lingual axial
  surfaces overcontour
• Recontour or replace if patient has esthetic or
  functional concern presence of periodontal
  pathology

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ContourReplacement Decision and Options

• Occlusion
• Dx usually based on patients complain
• Hyper-occlusion/interference - adjust
• Hypo-occlusion - replace

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Biomechanical Form

• Status
• Tooth with bulk fracture or fracture line
• Restoration with bulk fracture or fracture line
• Diagnosis
• Visual, patients complain, differential loading

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Differential loading using tooth slooth
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Tooth Fracture - AnteriorTreatment Options

• Based on the size of the fracture
• Small - recontour, direct composite
• Moderate - direct composite, composite/porcelain
  veneers full crown (PFM, all porcelain)
• Large - direct composite, composite/porcelain
  veneers, full crown, RCT/core buildup/crown

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Tooth Fracture - AnteriorSmall -Treatment Options

• Recontour or monitor - should be given as an
  option when the fracture is minor and only limit
  to the incisal edge area
• Reason
• The most common reason for patient fracturing the
  incisal edge (minor) is excessive bruxism. These
  patients usually grind the incisal edge of their
  Mx anteriors to thin edges and eventually part of
  the enamel will fracture off. The prognosis of
  restoring these fractures with composite is at
  best questionable (due to the limitation of the
  mechanical properties of the material). If you
  are going restore these lesion, you need to
  inform patient that the restoration is for
  cosmetic purpose only.

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Tooth Fracture - AnteriorModerate -Treatment
Options

• Direct composite - Disadvantages questionable
  prognosis due to the possibility of fracture
  esthetic result? Advantages cost, conservation
  of tooth structure
• Full crown - Disadvantages cost, not
  conservative Advantages good prognosis good
  esthetic result
• Composite veneers - Disadvantages cost no
  advantage over direct composite
• Porcelain veneers - Disadvantages cost
  Advantages good prognosis, conservation of tooth
  structure good esthetic result

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Tooth Fracture - AnteriorLarge -Treatment Options

• Direct composite Advantages cost, conservation
  of tooth structure Disadvantages very
  questionable prognosis
• Full crown may not be an option due to
  inadequate retention and resistance form
• Composite/Porcelain veneers may be your best
  option without involving RCT
• RCT/core buildup/crown may be your best option
  depending on the amount of tooth structure left
  Disadvantages cost

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Tooth Fracture - AnteriorLarge -Treatment Options
Remaining tooth structure following crown prep.

• Why a full crown may not be an option for
  restoring a large anterior fracture?
• Inadequate retention and resistance

Fractured Area
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Tooth Fracture - PosteriorTreatment Options

• Indirect restoration is the most common
  restorative options for restoring fractured
  posterior teeth.
• Different material/procedures are available each
  with their own characteristic, advantages and
  disadvantages partial veneer restorations (gold,
  composite, porcelain, CAD/CAM) full veneer
  restorations (gold, PFM, all porcelain).
• Choice should be based on patients preference
  (esthetic) dentist clinical judgment on what is
  the best restoration in a specific clinical
  situation.

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Tooth Fracture - PosteriorTreatment Options

• Repair - should no be overlooked as an option
  e.g. Patient presents with fractured DL cusp on
  tooth 14, which already has an extensive amalgam
  covering all the cusps except DL cusp. Patient
  cannot afford to have a crown.

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Tooth Fracture - PosteriorTreatment Options

• Direct restoration - when indirect restoration is
  not an option for financial reason. Material of
  choice (amalgam vs composite) should be based on
• Patients preferences (cost, esthetic)
• Conservation of tooth structure
• Clinical expertise of the dentist to manipulate
  the material in a specific clinical situation
• Clinical properties of the material that will
  allow the dentist to restore the tooth to a more
  ideal form e.g. amalgam will have an advantage
  over composite to establish proximal contact

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Basic Principles in Determining What
Material/Procedure To Use

• The basic principle should be centered around -
  What is the most conservative way to restore the
  tooth to its original (or as close to)
  biomechanical form.
• Some material needs bulk to resist fracture (e.g.
  amalgam, porcelain) - concern when dealing with a
  tooth with short clinical crown length.
• Mode of retention - mechanical vs bonding
  mechanical retention need more tooth reduction -
  concern when dealing with a tooth with extensive
  structural damage.
• Bonding to sclerotic/secondary dentin is somewhat
  unpredictable
• Rely on bonding to provide resistance form
  (prevent fracture of tooth structure) is somewhat
  unpredictable
• Isolation (for bonding) may be a concern for
  certain patient and in the more posterior part of
  the mouth

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Other Considerations in Restoring a Fractured
Tooth

• A fractured tooth or a tooth with a large
  existing restoration may need a foundation
  restoration before a crown can be fabricated.
• The need for a foundation restoration will depend
  on the depth of the pulpal floor of the existing
  restoration, and to a lesser extent the
  buccal-lingual width of the existing restoration.
• Retention of the crown will depend on the amount
  of tooth structure left around the pulpal area.

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What is your treatment recommendation?
Mn first molar with an existing Class I amalgam
restoration (pulpal depth of 2 mm). Fractured ML
cusp from mid MMR to Li groove area at the level
of the pulpal floor.
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Incomplete Tooth Fracture (fracture line) -
Treatment decision and Options

• Diagnosis
• patients complain
• Sensitivity on function
• Treatment Options
• Direct bonded restoration
• Indirect bonded restoration
• Full veneer crown

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Incomplete Tooth FractureCase Report 1

• 1995
• cc LR occasional sensitivity to chewing
• 2002
• cc the sensitivity is getting worst
• Dx - incomplete fracture on 30
• Tx - 30 full gold crown

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Incomplete Tooth FractureCase Report 1

• 2003
• cc no improvement, still sensitive to chewing
• Dx - evidence of fracture line on DMR of 31
• Tx - DO composite
• 2004
• Buccal fistula, gutta percha used to trace the
  lesion to the apex of the D root

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Incomplete Tooth FractureCase Report 1

• 31 extraction
• Final diagnosis - 31 DMR fracture line extended
  down onto the D root
• Prognosis - unrestorable
• Complete relieve of symptom following the
  extraction

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Incomplete Tooth FractureCase Report 2

• Undiagnosed fractured of the DMR extending to the
  apex of the D root (18)
• 19 (has an extensive MOD amalgam restoration) -
  was crowned along the way

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Incomplete Tooth FractureCase Report 3

• cc pain on chewing
• Dx - incomplete tooth fracture on MMR and DMR

37
Incomplete Tooth FractureCase Report 3

• Fracture line extended onto the pulpal floor.
• Tx - porcelain inlay using CAD/CAM technology
• Today - symptom is gone

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Incomplete Tooth FractureCase Report 4

• 41-yo male with cc low grade TA on LR
• No pathology found except 5 mm pocket on M of
  31. Patient is a bruxer with heavy wear facets
  on all teeth. Prophy was done
• Report to the clinic the very next day
  complaining the pain is becoming more intense
  pain relieved by drinking cold water
• Re-probe 31 and getting probing depth of at
  least 8 mm
• Careful exam reviewed a fracture line on MMR
• Dx Tooth fracture to apex of M root confirmed
  by endodontist. Tooth was extracted

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Restoration Fracture/Incomplete
FractureTreatment decisions and Options

• Treatment decisions and options similar to tooth
  fracture
• Try to identify the reason(s) for the fracture
• Inadequate bulk - most common reason for amalgam
  restoration need to correct the preparation if
  amalgam is used again
• Exceeding the physical properties of the material
  - should consider alternative procedure/material

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Replacement Decisions

• Start out with the least invasive option always
  ask yourself the question will the proposed
  option improve the health of the tissue/oral
  health?
• Will the new restoration improve
  function/esthetics?
• Will the new restoration addresses the chief
  complaint of the patient?
• Will the new restoration prevent further
  destruction of the surrounding hard/soft tissue

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Decision to repair/replace a cast gold
restoration with a perforation on the occlusal
surface
What rationale can you give to repair/replace a
cast gold restoration with a perforation on the
occlusal surface? (Assuming there is no complaint
from patient and you cannot find a cement line)
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Esthetic

• Status
• Poor color match
• Poor contour
• Diagnosis
• Should be based on patients complain

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EstheticReplacement Decision

• Listen to patients REAL concern, try to
  understand EXACTLY what they want and expect
• Choose a procedure(s) that has the potential of
  matching patients expectation (end result vs
  patients ability to pay), and satisfy our
  criteria of conservation and optimal oral health
  following the procedure
• Important to understand the limitations of each
  of the esthetic procedure match patients
  concern with the limitations of the procedure in
  mind

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EstheticTreatment Options

• Recontour - least invasive, limited to minor
  alternation
• Bleaching - non-invasive unpredictable result
  relatively inexpensive
• Composite Veneer - limited ability to mask dark
  stain longevity technically more challenging
• Porcelain Veneer - more invasive, limited ability
  to mast dark stain more expensive better
  esthetic
• Porcelain fused to metal crown - invasive, metal
  collar
• All Porcelain crown - most invasive most
  expensive best color