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Existing Restoration - Clinical Status
Secondary Caries
Marginal Integritymarginal 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 commonreasons 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%)
AmalgamTooth
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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?
AmalgamTooth
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Reasons for replacing an amalgam
restoration with defective margin
Are there direct scientific data showing a
relationship between marginal defectand the development of secondarycaries?
NO
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Indirect/Empirical Evidence
We are seeing the majority of the disease in a smallpopulation of our patients; therefore not everybody isequally susceptible to the disease.
If physical barrier for oral hygiene is a problem, whydo some pits and fissures never develop into lesions.
Assuming these defects on the margin of an agingrestoration has been there for years; why no lesion hasbeen developed in all these years.
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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 hypothesissupported by
scientific facts?
AmalgamTooth
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Reasons for replacing a restoration
with defective margin
There is scientific evidence showing thatthere is NO relationship between
marginal defect and the presence of
secondary caries on the cavity wall
below the defect
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30 extracted teeth with occlusal
amalgam restorations were
sectioned.
Caries were identified byimbibing 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 marginALONE
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 periodontaldiseases.
Presence of pulpal pathology (e.g. sensitivity totemperature change, sweet).
Patients complaint (esthetic concern).
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Existing Restoration - Clinical Status
Secondary Caries
Marginal Integritymarginal defect
overhang
open margin
Contourproximal contact
axial contour
occlusion
Biomechanical Form
restoration fracture
tooth fracture
Esthetic
patients 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 chiefcomplain 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 thepresence of periodontal diseases.
Grey area
Complaining about food impaction between 2 teeth that
have no existing restoration, no evidence of periodontaldiseases.
Complaining about food impaction - occlusal contactOK, but gingival embrasure area open because of
gingival recession.
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Contour
Replacement DecisionRough 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 estheticconcern)
C
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ContourReplacement Decision and
OptionsAxial contour
Undercontour - e.g. porcelain fracture from PFM
crownOvercontour - e.g. buccal or lingual axial surfaces
overcontour
Recontour or replace if patient has esthetic orfunctional 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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Existing Restoration - Clinical Status
Secondary Caries
Marginal Integritymarginal defect
overhang
open margin
Contourproximal contact
axial contour
occlusion
Biomechanical Form
restoration fracture
tooth fracture
Esthetic
patients esthetic
concern
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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 - Anterior
Treatment OptionsBased 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 - Anterior
Small -Treatment Options
Recontour or monitor - should be given as anoption when the fracture is minor and onlylimit to the incisal edge area
ReasonThe most common reason for patient fracturing theincisal edge (minor) is excessive bruxism. Thesepatients usually grind the incisal edge of their Mxanteriors to thin edges and eventually part of the
enamel will fracture off. The prognosis of restoringthese fractures with composite is at bestquestionable (due to the limitation of the mechanicalproperties of the material). If you are going restorethese lesion, you need to inform patient that the
restoration is for cosmetic purpose only.
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Tooth Fracture - Anterior
Moderate -Treatment Options
Direct composite -Disadvantages:questionable prognosis due to the possibilityof fracture; esthetic result? Advantages: cost,conservation of tooth structure
Full crown - Disadvantages cost, notconservative; 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 - Anterior
Large -Treatment Options
Direct composite:Advantages: cost,conservation of tooth structureDisadvantages: very questionable prognosis
Full crown: may not be an option due toinadequate retention and resistance form
Composite/Porcelain veneers: may be yourbest option without involving RCT
RCT/core buildup/crown: may be your bestoption depending on the amount of toothstructure left; Disadvantages: cost
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Tooth Fracture - Anterior
Large -Treatment Options
Why a full crown may
not be an option for
restoring a largeanterior fracture?
Inadequate retention
and resistance
Remaining tooth structure
following crown prep.
Fractured Area
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Tooth Fracture - Posterior
Treatment Options
Indirect restoration is the most commonrestorative options for restoring fractured posteriorteeth.
Different material/procedures are available; eachwith their own characteristic, advantages anddisadvantages: partial veneer restorations (gold,composite, porcelain, CAD/CAM); full veneerrestorations (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 - Posterior
Treatment Options
Repair -should not be overlooked asan option; e.g. Patient presents withfractured DL cusp on tooth #14, whichalready has an extensive amalgamcovering all the cusps except DL cusp.Patient cannot afford to have a crown.
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Tooth Fracture - Posterior
Treatment Options
Direct restoration -when indirect restorationis not an option for financial reason. Materialof 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 situationClinical properties of the material that will allow thedentist to restore the tooth to a more ideal form;e.g. amalgam will have an advantage over
composite to establish proximal contact
B i P i i l i D i i
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Basic Principles in Determining
What Material/Procedure To UseThe basic principle should be centered around - Whatis the most conservative way to restore the tooth to itsoriginal (or as close to) biomechanical form.
Some material needs bulk to resist fracture (e.g.amalgam, porcelain) - concern when dealing with atooth with short clinical crown length.
Mode of retention - mechanical vs bonding; mechanicalretention need more tooth reduction - concern whendealing with a tooth with extensive structural damage.
Bonding to sclerotic/secondary dentin is somewhatunpredictable
Rely on bonding to provide resistance form (preventfracture of tooth structure) is somewhat unpredictable
Isolation (for bonding) may be a concern for certainpatient and in the more posterior part of the mouth
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Other Considerations in Restoring a
Fractured ToothA fractured tooth or a toothwith a large existing restorationmay need a foundationrestoration before a crown can
be fabricated.The need for a foundationrestoration will depend on thedepth of the pulpal floor of theexisting restoration, and to a
lesser extent the buccal-lingualwidth of the existing restoration.
Retention of the crown willdepend on the amount of toothstructure 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 functionTreatment Options
Direct bonded restoration
Indirect bonded restoration
Full veneer crown
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Incomplete Tooth Fracture
Case Report 11995
cc LR occasionalsensitivity to chewing
2002
cc the sensitivity isgetting worst
Dx - incomplete fractureon #30
Tx - #30 full gold crown
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Incomplete Tooth Fracture
Case Report 12003
cc no improvement, stillsensitive to chewing
Dx - evidence of fractureline on DMR of #31
Tx - DO composite
2004Buccal fistula, gutta perchaused to trace the lesion tothe apex of the D root
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Incomplete Tooth Fracture
Case Report 1#31 extraction
Final diagnosis - #31
DMR fracture lineextended down onto theD root
Prognosis -
unrestorableComplete relieve ofsymptom following theextraction
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Incomplete Tooth Fracture
Case Report 2Undiagnosedfractured of theDMR extending to
the apex of the Droot (#18)
#19 (has anextensive MOD
amalgamrestoration) - wascrowned along theway
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Incomplete Tooth Fracture
Case Report 3
cc pain on chewing
Dx - incompletetooth fracture onMMR and DMR
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Incomplete Tooth Fracture
Case Report 3Fracture lineextended onto the
pulpal floor.Tx - porcelain inlayusing CAD/CAMtechnology
Today - symptom isgone
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Incomplete Tooth Fracture
Case Report 441-yo male with cc low gradeTA on LR
No pathology found except 5mm pocket on M of #31. Patient
is a bruxer with heavy wearfacets on all teeth. Prophy wasdone
Report to the clinic the very nextday complaining the pain isbecoming more intense; painrelieved by drinking cold water
Re-probe #31 and gettingprobing depth of at least 8 mm
Careful exam reviewed afracture line on MMR
Dx: Tooth fracture to apex of Mroot; confirmed by endodontist.Tooth was extracted
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Restoration Fracture/Incomplete Fracture
Treatment decisions and Options
Treatment decisions and options similar totooth fracture
Try to identify the reason(s) for the fractureInadequate bulk - most common reason foramalgam restoration; need to correct thepreparation 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 thehealth of the tissue/oral health?
Will the new restoration improve function/esthetics?Will the new restoration addresses the chiefcomplaint of the patient?
Will the new restoration prevent further destructionof the surrounding hard/soft tissue
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Decision to repair/replace a cast gold restorationwith a perforation on the occlusal surface
What rationale can you give to
repair/replace a cast gold restorationwith a perforation on the occlusalsurface? (Assuming there is no
complaint from patient and youcannot find a cement line)
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Existing Restoration - Clinical Status
Secondary Caries
Marginal Integrity
marginal defect
overhang
open margin
Contourproximal contact
axial contour
occlusion
Biomechanical Form
restoration fracture
tooth fracture
Esthetic
patients esthetic
concern
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Esthetic
Status
Poor color match
Poor contour
Diagnosis
Should be based on patients complain
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Esthetic
Replacement DecisionListen 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 thelimitations 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 tomast dark stain; more expensive; better esthetic
Porcelain fused to metal crown - invasive, metal collarAll Porcelain crown - most invasive; most expensive;best color
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