Operative II- When Big Is Too Big

When big is too big. Fixed vs Operative. Doing what is best for your patient. Dr. Golda Erdfarb D.D.S Classification of Preparation Sites Class I – occlusal surfaces of premolars & molars Class II – proximal surfaces of premolars & molars Class III – proximal surfaces of incisors & ca...

When big is too big. Fixed vs Operative. Doing what is best for your patient. Dr. Golda Erdfarb D.D.S Classification of Preparation Sites Class I – occlusal surfaces of premolars & molars Class II – proximal surfaces of premolars & molars Class III – proximal surfaces of incisors & canines Class IV – incisal edge and a proximal surface of incisors and canines Class V – gingival third of buccal or lingual surfaces of the teeth Class VI – incisal edges of anterior teeth, or the occlusal cusp tips of posterior teeth https://pure.uva.nl/ws/files/2600600/171422_Scholtanus _digitale_versie_proefschrift_compleet.pdf https://jada.ada.org/article/S0002 -8177(14)61774 -8/pdf Restoration materials will dictate your preparation. Preparation Conventional Preparations Amalgam Modified Preparations Composite Crown Bridge Cast metals Glass Ionomer Direct Restorations Indirect Restorations Direct vs. Indirect Restorations • Direct Restorations - tooth is prepared and restoration is done and completed directly in the mouth • Example: composite or amalgam restoration s • Indirect Restorations - the tooth is prepared and then the final restoration is fabricated outside the mouth/indirectly. More than one visit is usually needed ** • Example: crown, veneer, inlay, onlay What are the other options? • Crowns • Inlays • Onla y Single unit crown NYC Smile Design How much tooth structure remains? • This will determine clinically the best care for your patient. • “When more than one -half of the cusp -tip to cusp -tip tooth structure is removed, the tooth has minimal strength remaining and a full -crown or onlay covering all of the remaining cusps is indicated .” (dentaleconomics.com) • What is clinically the best thing for your patient and what is practically best for your patient may be two different things. Why would you build up a tooth? • Age / health of patient • Elderly • Young • Special Needs • Time • Has the ability to sit, has the money to pay but doesn't have the time • Cost • Has the ability to sit, has the time, but doesn’t have the money to pay • To allow for further restorations/treatment To allow for further treatment • 1. definitive final restorations - if that is what is best for our patient • 2. foundations • 3. Provisional/control restorations in the teeth that have a questionable pulpal or periodontal prognosis • 4. Provisional/control restorations in teeth with acute or severe caries Foundations for other treatment • Large restoration s also are occasionally indicated in order to serve as foundations for other treatments such as crowns . Foundations for other treatment • Large restorations also are occasionally indicated in order to serve as foundations for other treatments such as crowns. www.mtedendentalsurgery.co.nz Evaluate your treatment plan • Your restorative treatment choice for a tooth is influenced by its role of that tooth in the overall treatment plan. • Sometimes complex direct restorations are used as an alternative to indirect restorations, but often they are used as foundations for full coverage restorations. Provisional Restorations • In selected cases, large composite restorations may be used where an interim restoration is indicated or where economics or other factors preclude a more definitive restoration such as a crown. • R estore it with light occlusion , since tooth structure is already weak. Control/Provisional Restoration • In cases where a patient may require endodontic treatment, crown lengthening, or has an uncertain periodontal prognosis they are often treated initially with a control restoration. • Why? • 1. to protect pulp from oral cavity • 2. provide anatomic contour to help with gingival health • 3. facilitate control of caries or plaque • 4. provide some resistance against tooth fracture, or propagation of existing fracture HOWEVER, a weakened tooth is best restored with a properly designed indirect restoration that prevents tooth fracture caused by mastication forces. (resistance and retention form) Reality is.. • That sometimes the gold standard is not the best for our patient. You have to work together to make the best plan for THEM. So what do I do if there is so little tooth structure remaining? • When conventional retention features are not adequate because of insufficient remaining tooth structure, added retention can be added. • Undercut • Retention grooves • Boxes • As more tooth structure is lost, more auxiliary retention is required. 33 ½ Resistance and Retention Form • No matter what you choose to do, undermined enamel or weak tooth structure subject to fracture must be removed. Iatrogenic • The status and prognosis of a tooth is determined by size/amount of remaining healthy tooth structure. Therefore the size, number, and placement of retention features have to be thought about. • Carelessness on behalf of the dentist can risk pulpal irritation and exposure or can weaken the tooth structure and cause fracture. Contraindication s • Isolation • Occlusal Force s Disadvantages • Tooth Anatomy • Resistance Form • Conservation of tooth structure • Appointment time • Economics Advantages • Conservation of tooth structure The Preparation - 30 MODL • Prepare a classic MOD on #30. • Level the mesiolingual cusp with the pulpal floor. • Make sure to raise the floor around the area of the pulpal horn so you do not end up with an iatrogenic pulp exposure. • Create a 1.5mm shoulder around the mesiolingual cusp. • This will increase resistance and retention form. • Bevel all internal line angles 1.5mm The Restoration • Place Tofflemire around tooth • Make sure you have adequate isolation!! • Why?! • Composite can not be contaminated. Otherwise it is compromising the composite’s integrity and bond • Place Wedge • You do not want overhang • Restore the proximal boxes and shoulder first. • Make sure you are packing tightly • Why? • To make sure your margins are sealed. • Make sure you are curing appropriately • Use your explorer to check once 20 second cure is complete. • Once you have restored up to the pulpal floor, restore as usual. Before you begin… • No matter what you would like to do for your patient, always start by discussing all possible treatment options with your patient. • Discuss the limitations of treatment. • Discuss the complications of the treatments. • Whatever you decide together make sure to always explain the procedure. • Make sure you have the same expectations and outcomes.