1. 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

2. Marginal Defect - Amalgam Restoration It is the second most common reasons given for replacing an amaglam restoration

3. 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%) Amalgam Tooth

4. 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? Amalgam Tooth

5. 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

6. 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.

7. 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 hypothesis supported by scientific facts? Amalgam Tooth

8. 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

9. 30 extracted teeth with occlusal amalgam restorations were sectioned. Caries were identified by imbibing the section in with quinoline and examined in polarized light

10. 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

11. 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). 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).

12. Contour Status  Proximal contact - open, rough, location  Axial contour - over/undercontour, location  Occlusion Diagnosis is based on visual, patient’s chief complain and radiographs

13. 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.

14. 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.

15. 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)

16. 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

17. Contour Replacement Decision and Options Occlusion Dx: usually based on patient’s complain Hyper-occlusion/interference - adjust Hypo-occlusion - replace

18. Biomechanical Form Status Tooth with bulk fracture or fracture line Restoration with bulk fracture or fracture line Diagnosis Visual, patient’s complain, differential loading

19. Differential loading using tooth slooth

20. 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

21. 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.

22. 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

23. 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

24. Tooth Fracture - Anterior Large -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

25. 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.

26. 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.

27. 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

28. 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

29. 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.

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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

36. Incomplete Tooth Fracture Case Report 3 cc “pain on chewing Dx - incomplete tooth fracture on MMR and DMR

37. Incomplete Tooth Fracture Case Report 3 Fracture line extended onto the pulpal floor. Tx - porcelain inlay using CAD/CAM technology Today - symptom is gone

38. 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

39. 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

40. 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

41. 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)

42. Esthetic Status  Poor color match  Poor contour Diagnosis  Should be based on patient’s complain

43. 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

44. 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