11 eval of existing restorations 2

8/3/2019 11 Eval of Existing Restorations 2

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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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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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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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Secondary Caries


overhang

open margin

Contourproximal contact

axial contour

occlusion

Biomechanical Form


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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No Proximal Contact - Treatment Options

AnteriorsDirect composite, indirect porcelain veneers, full veneercrowns.

Choices depend on patients expectation/ability to pay and

other clinical concerns (e.g. shade match problem,discolored tooth) and dentist skill.

PosteriorsDirect restoration - know the clinical and mechanicallimitations of the restorative materials; direct compositerestorative may be contra-indicated; deep gingival seat -clinical limitation.

Indirect restoration - may be the only viable option.


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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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Secondary Caries


overhang

open margin


axial contour

occlusion

Biomechanical Form


tooth fracture

Esthetic

patients esthetic

concern


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Biomechanical Form

Status

Tooth with bulk fracture or fracture line (incomplete

tooth fracture)Restoration with bulk fracture or fracture line

DiagnosisVisual, 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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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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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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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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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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Indirect Restorations

Gold, PFM - cement with traditional cement(RMGI); mechanical retention

All ceramic - e.g. Empress; castable; resincement (bond to tooth); need bulk (moreocclusal and axial reduction); no mechanicalretention

All ceramic with ceramic core - e.g. Lava;CAD/CAM core; reduction similar to PFM;cement with traditional cement; mechanicalretention; margin not as good as gold, PFM


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Decisions

Cement - what you are comfortable touse

Esthetic - metal collar, color match

Amount of tooth reduction

Retention


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History of a porcelain onlay


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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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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 t 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 occasional

sensitivity to chewing

2002

cc the sensitivity isgetting worst

Dx - incomplete fractureon #30

Tx - #30 full gold crown


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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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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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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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Case Report 341-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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Case Report 4

cc pain on chewing

Dx - incompletetooth fracture onMMR and DMR


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Case Report 4Fracture lineextended onto the

pulpal floor.Tx - porcelain inlayusing CAD/CAMtechnology

Today - symptom isgone


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CAD/CAM Porcelain Inlay

2004


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2008 - symptom came back


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Case Report 5

1996 2003

2006


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Case Report 5

2007


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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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Secondary Caries

Marginal Integrity

marginal defect

overhang

open margin


axial contour

occlusion

Biomechanical Form


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 patientsability 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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Final Written Exam

Thr, 4/301 pm in sim lab

easy Multiple choice, true/false

Review lecture materials.

No question on examples of past failure, Drs.Perdigao and Zieglers lectures.

Oper I and II manual:

Dr. Hildebrandt (3.C.3 - 3.C.7 Class II amalgamPrep; 4.A.5 -4.A.7 Cl III composite prep)

Dr. Phair (p 15-18, p21-24 Gold inlay/onlayprinciples and rationale)

Start Check


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Start CheckTalk to the instructor before you seat your patient if you have ANY

doubt in what you are doing.Seat patient, review medical history, explain the procedure to patient,fill out all the paper work (Operative Evaluation Form)

Place patient in operating position, confirm diagnosis and treatmentplan.

When you are ready, request starting check from instructor (turn redlight on).

ABSOLUTELY NO anesthetic should be given before starting check isgranted.

Review medical history, diagnosis and treatment plan with instructor

Introduce patient to the instructor

11 eval of existing restorations 2

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