Existing Restoration - Clinical Status Secondary Caries Marginal Integrity marginal defect overhang...

Existing Restoration - Clinical Status

Secondary CariesMarginal Integrity

marginal defectoverhangopen margin

Contourproximal contactaxial contourocclusion

Biomechanical Form

restoration fracturetooth fracture

Estheticpatient’s esthetic concern

Marginal Defect - Amalgam Restoration

It is the second most

common reasons

given for replacing an

amaglam restoration

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%)

AmalgamTooth

Reasons for replacing an existing restoration with defective marginReasons 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?

AmalgamTooth

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

Indirect/Empirical Evidence

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.

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.





More likely to find secondary caries on

the cavity wall below the defect

Is this hypothesis supported by

scientific facts?

AmalgamTooth

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

30 extracted teeth with occlusal amalgam restorations were sectioned.Caries were identified by imbibing the section in with quinoline and examined in polarized light

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

Replacement DecisionsReplacement Decisions

Risk Factors

Risk factors related to dental caries and periodontal diseases.

Presence of pulpal pathology (e.g. sensitivity to temperature change, sweet).

Patient’s complaint (esthetic concern).

Risk Factors

Risk factors related to dental caries and periodontal diseases.

Presence of pulpal pathology (e.g. sensitivity to temperature change, sweet).

Patient’s complaint (esthetic concern).

Contour

Status

Proximal contact - open, rough, location Axial contour - over/undercontour, location

Occlusion

Diagnosis is based on visual, patient’s chief complain and

radiographs

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.

No Proximal Contact - Treatment Options

AnteriorsDirect composite, indirect porcelain veneers, full veneer crowns. Choices depend on patient’s expectation/ability to pay and other clinical concerns (e.g. shade match problem, discolored tooth) and dentist skill.

PosteriorsDirect 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.

ContourReplacement Decision

Rough Proximal ContactSmooth 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, patient’s complain and esthetic concern)

ContourReplacement Decision and

OptionsAxial 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

ContourReplacement Decision and

Options

OcclusionDx: usually based on patient’s complain

Hyper-occlusion/interference - adjust

Hypo-occlusion - replace

Biomechanical Form

StatusTooth with bulk fracture or fracture

lineRestoration with bulk fracture or

fracture line

DiagnosisVisual, patient’s complain,

differential loading

Differential loading using tooth slooth

Tooth Fracture - AnteriorTreatment Options

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

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

ReasonThe 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.

Tooth Fracture - AnteriorModerate -Treatment OptionsDirect composite - Disadvantages: questionable prognosis due to the possibility of fracture; esthetic result? Advantages: cost, conservation of tooth structureFull crown - Disadvantages cost, not conservative; Advantages: good prognosis; good esthetic resultComposite veneers - Disadvantages: cost; no advantage over direct composite Porcelain veneers - Disadvantages: cost; Advantages good prognosis, conservation of tooth structure; good esthetic result

Tooth Fracture - AnteriorLarge -Treatment Options

Direct composite: Advantages: cost, conservation of tooth structure Disadvantages: very questionable prognosisFull crown: may not be an option due to inadequate retention and resistance formComposite/Porcelain veneers: may be your best option without involving RCTRCT/core buildup/crown: may be your best option depending on the amount of tooth structure left; Disadvantages: cost

Tooth Fracture - AnteriorLarge -Treatment Options

Why a full crown may not be an option for restoring a large anterior fracture?

Inadequate retention and resistance

Remaining tooth structure following crown prep.

Fractured Area

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 patient’s preference (esthetic); dentist clinical judgment on what is the best restoration in a specific clinical situation.


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.


Direct restoration - when indirect restoration is not an option for financial reason. Material of choice (amalgam vs composite) should be based on:

Patient’s preferences (cost, esthetic)Conservation of tooth structure Clinical expertise of the dentist to manipulate the material in a specific clinical situationClinical 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

Basic Principles in Determining What

Material/Procedure To UseThe 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 unpredictableIsolation (for bonding) may be a concern for certain patient and in the more posterior part of the mouth

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.

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.

Incomplete Tooth Fracture (fracture line) - Treatment

decision and OptionsDiagnosis

patient’s complain Sensitivity on function

Treatment OptionsDirect bonded restorationIndirect bonded restorationFull veneer crown

Incomplete Tooth Fracture

Case Report 11995cc “LR occasional sensitivity to chewing

2002cc “the sensitivity is getting worst”Dx - incomplete fracture on #30Tx - #30 full gold crown


Case Report 12003cc “ no improvement, still sensitive to chewingDx - evidence of fracture line on DMR of #31Tx - DO composite

2004Buccal fistula, gutta percha used to trace the lesion to the apex of the D root


Case Report 1#31 extractionFinal diagnosis - #31 DMR fracture line extended down onto the D rootPrognosis - unrestorableComplete relieve of symptom following the extraction


Case Report 2Undiagnosed 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


Case Report 3cc “pain on chewingDx - incomplete tooth fracture on MMR and DMR


Case Report 3Fracture line extended onto the pulpal floor.Tx - porcelain inlay using CAD/CAM technologyToday - symptom is gone


Case Report 441-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 doneReport to the clinic the very next day complaining the pain is becoming more intense; pain relieved by drinking cold waterRe-probe #31 and getting probing depth of at least 8 mmCareful exam reviewed a fracture line on MMRDx: Tooth fracture to apex of M root; confirmed by endodontist. Tooth was extracted

Restoration Fracture/Incomplete Fracture

Treatment decisions and Options

Treatment decisions and options similar to tooth fractureTry 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 againExceeding the physical properties of the material - should consider alternative procedure/material

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

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)

Esthetic

Status Poor color match

Poor contour

Diagnosis Should be based on patient’s

complain

EstheticReplacement Decision

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

EstheticTreatment Options

Recontour - least invasive, limited to minor alternationBleaching - non-invasive; unpredictable result; relatively inexpensiveComposite Veneer - limited ability to mask dark stain; longevity; technically more challengingPorcelain Veneer - more invasive, limited ability to mast dark stain; more expensive; better estheticPorcelain fused to metal crown - invasive, metal collarAll Porcelain crown - most invasive; most expensive; best color

Existing Restoration - Clinical Status Secondary Caries Marginal Integrity marginal defect overhang...

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