Transcript Dental Caries - University of Minnesota

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
patient’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%)
Tooth
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 margin- Survey 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).
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
Anteriors
Direct 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.
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, patient’s 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 patient’s 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,
patient’s 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.
Fractured Area
Why a full crown may
not be an option for
restoring a large
anterior fracture?
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 patient’s 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:
Patient’s 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
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
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 Options
Diagnosis
patient’s 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 patient’s complain
Esthetic
Replacement Decision
Listen to patient’s REAL concern, try to understand
EXACTLY what they want and expect
Choose 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 procedure
Important to understand the limitations of each of the
esthetic procedure; match patient’s 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