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 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 marginSurvey of 124 dentists It is a plaque trap, thus increasing the chance of developing secondary caries (37%) Tooth More likely to find
secondary caries on the cavity wall below the defect (25%) Amalgam Reasons for replacing an existing restoration with defective margin It is a plaque trap, thus increasing the chance of developing secondary caries. Tooth Is this hypothesis
supported by scientific facts? Amalgam 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 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. Reasons for replacing an existing restoration with defective marginSurvey of 124 dentists More likely to find secondary caries on the cavity wall below the defect Tooth
Is this hypothesis supported by scientific facts? Amalgam 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 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). Contour Status
Proximal contact - open, rough, location Axial contour - over/undercontour, location Occlusion Diagnosis is based on visual, patients 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 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. Contour Replacement 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) Contour Replacement 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 Contour Replacement Decision and Options Occlusion Dx: usually based on patients complain Hyper-occlusion/interference
- adjust Hypo-occlusion - replace Biomechanical Form Status Tooth with bulk fracture or fracture line Restoration with bulk fracture or fracture line Diagnosis Visual,
patients complain, differential loading Differential loading using tooth slooth Tooth Fracture - Anterior Treatment 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 Tooth Fracture - Anterior Small -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. Tooth Fracture - Anterior Moderate -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 Tooth Fracture - Anterior Large -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 Tooth Fracture - Anterior Large -Treatment Options Remaining tooth structure following crown prep. Why a full crown may not be an option for
restoring a large anterior fracture? Fractured Area Inadequate retention and resistance Tooth Fracture - Posterior Treatment 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. Tooth Fracture - Posterior Treatment 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. Tooth Fracture - Posterior Treatment 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 Determining What Material/Procedure To The basic principle should be centered around - What is the most conservative way to restore the tooth to Use 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 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 buccallingual 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 Options Diagnosis patients complain
Sensitivity on function Treatment Options Direct bonded restoration Indirect bonded restoration Full veneer crown Incomplete Tooth Fracture Case 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 Incomplete Tooth Fracture Case 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 Incomplete Tooth Fracture Case 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 Incomplete Tooth Fracture Case 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 Incomplete Tooth Fracture Case Report 3 cc pain on chewing Dx - incomplete
tooth fracture on MMR and DMR Incomplete Tooth Fracture Case Report 3 Fracture line extended onto the pulpal floor. Tx - porcelain inlay using CAD/ CAM technology Today - symptom
is gone Incomplete Tooth Fracture Case 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 Restoration Fracture/Incomplete Fracture Treatment 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 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 patients complain Esthetic Replacement 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 Esthetic Treatment 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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