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Existing Restoration - Clinical Status

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Existing Restoration - Clinical Status Secondary Caries Marginal Integrity marginal defect overhang open margin Contour proximal contact axial contour – PowerPoint PPT presentation

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Title: 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

dr shabeel pn
2
Marginal Defect - Amalgam Restoration
It is the second most common reasons given for
replacing an amaglam restoration
3
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
6
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
10
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

11
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).

12
Contour
  • Status
  • Proximal contact - open, rough, location
  • Axial contour - over/undercontour, location
  • Occlusion
  • Diagnosis is based on visual, patients chief
    complain and radiographs

13
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.

14
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.

15
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)

16
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

17
ContourReplacement Decision and Options
  • Occlusion
  • Dx usually based on patients complain
  • Hyper-occlusion/interference - adjust
  • Hypo-occlusion - replace

18
Biomechanical Form
  • Status
  • Tooth with bulk fracture or fracture line
  • Restoration with bulk fracture or fracture line
  • Diagnosis
  • Visual, patients complain, differential loading

19
Differential loading using tooth slooth
20
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

21
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.

22
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

23
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

24
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
25
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.

26
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.

27
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

28
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

29
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.

30
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.
31
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

32
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

33
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

34
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

35
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

36
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

38
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

39
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

40
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

41
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)
42
Esthetic
  • Status
  • Poor color match
  • Poor contour
  • Diagnosis
  • Should be based on patients complain

43
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

44
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
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