Restoration of fractured molars ...

[Shiko]

Hello doctors ...
I need to hear your opinions based on clinical experience concerning this case : 😕
It's a lower molar with a recent amalgam filling , the patient came with a fractured distolingual cusp , the fracture line is 0.5 mm above the gingival margin . What i did first was preparing a dove tail in the existing amalgam and building the missing cusp with Amalgam , two months later it breaks ..
Next , I replaced the amalgam by a direct composite filling and built the cusp again .. This time the patient also came with the same part fractured 😡
Well, I've always had this problem with fractured cusps , I wish i had amalgambond or something but i didn't at that time .. I thought of using pin retention , porcelain inlay , indirect composite inlay or full veneer ..
So what do you usually choose of all those treatment modalities ..
Hope to find the answer in your replies ..
Thanks a lot ..
Take care and have a great 2005

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[tinker bell]

I would rebuild it with composite, then do a FVC. Any other ideas?

 

[aphistis]

Yeah, it sounds like any direct restorations you do are going to end up failing, for whatever reason. Like Tink said, I'd go with a build-up & crown, though I'd probably go with amalgam for the b/u unless you're really concerned about secondary caries down the road; composite makes an expensive build-up, but the bonding would discourage recurrent decay.

Of course, this is all a pre-clinical D2's opinions. From the mouths of babes... 😉

 

[Sterichind69]

Hello doctors ...
I need to hear your opinions based on clinical experience concerning this case : 😕
It's a lower molar with a recent amalgam filling , the patient came with a fractured distolingual cusp , the fracture line is 0.5 mm above the gingival margin . What i did first was preparing a dove tail in the existing amalgam and building the missing cusp with Amalgam , two months later it breaks ..
Next , I replaced the amalgam by a direct composite filling and built the cusp again .. This time the patient also came with the same part fractured 😡
Well, I've always had this problem with fractured cusps , I wish i had amalgambond or something but i didn't at that time .. I thought of using pin retention , porcelain inlay , indirect composite inlay or full veneer ..
So what do you usually choose of all those treatment modalities ..
Hope to find the answer in your replies ..
Thanks a lot ..
Take care and have a great 2005

I had a friend of mine who fractured an amalgam cusp and I too made a dovetail, but I used ketac silver as my build-up and temporary repair. However, this effort was all for a tooth to eventually be extracted. In your case, it sounds like you tried bonding an old and new amalgam and tried bonding composite to the old amalgam. I say drop that idea. Depending on the amount of tooth structure left over, maybe you can do either an onlay or a crown prep for a 3/4th crown. Remove ALL the residual amalgam, refine your prep, make sure the site where the fracture is occurring is deep enough to support a bulk of amalgam 1.5 mm deep, use amalgabond, restore the prep and cusp with amalgam, prep for a 3/4th crown next visit keeping the buccal surface for esthetic reasons. Just my take... 😎

 

[organic]

new amalgam never bonds to old amalgam. In order to prevent secondary decay and crack, you should always remove the entire old amalgam and replace with a new restoration.

As for this case, I would first observe this patient's occlusion. Look for reasons or clues as to why he/ she keeps on fracturing this area ( supposing that you have followed the standard of retoration steps--- adequate depth, width, retention, resistence for amalgam restoration, and very very dry field for enamel bonding and wet bonding technique for dentin in case of composite restoration. Final occlusion was proper..etc.)

(1)Does he/she have bruxism? unusual eating habits, biting habit?
(2)DL cusp at lower molar is a non- functional cusp, normally, this cusp wouldn't be under too much force. Does this patient has cusp to cusp occlusion that the upper lingual hits onto the buccal slope of lower lingual cusp, instead of in the central cossa?
(3)Does the patient have lateral movement type of bruxism?
(4))working side interferences?
(5)upper lingual shapr plunging cusp?

Usually if you analyze the cause of the fracture, you could restore the tooth with a better and more predictable choice. Full veneer crown isn't always the answer and if you wish to save the tooth structure, you should use the most conservative restoration. Composite is usually quite strong when it is bonded to enamel.

Here are some solutions for the above conditions
( I suppose the patient is a " he")
(1) night guard, mouth guard, recommend patient to get rid of certain eating habits( biting hard food...chewy stuff) teach patient to be aware of relaxing his jaws. His teeth don't have to be in contact all the time.
(2) orthodontic treatment to improve occlusion. partial or full veneer crown protection. In this case, be aware that your reduction amount might differ depending on where the actual force is applied on the molar. Recommend patient to get a full casting crown instead of PFM ( definitely not full procelain crown) as the procelain might chip off if the reason is due to occlusion

(3) mouth guard, might guard, relaxation technique. Teach pt not to bite his teeth if not necessary. Functional splint.occlusal adjustment.
(4) occlusal adjustment ( must be used with caution)
(5) rounding and enameloplasty of upper lingual cusp ( or areas in contact)

If you want to use amlgam, use Tytin. It sets fast, so you need to be fast too. Do NOT use a amalgam carrier, stick the entire ball to the area and build up the entire cusp. IT is strong and solid like rock. I built up a few cusps with Tytin, some were even functional cusps, I was really amazed by how strong it is. But the key point is NOT to use a amalgam carrier.

If you prefer composite restoration, the best I think would be some type of extra-orally fabricated composite onlay. The reason is because your margin is quite close to gingiva and I suppose that is also where the enamel is very little or non. The sealing would be way better with an indirectly fabricated composite onlay at the marginal area. If direct technique is used, I would use GIC for base to cover dentin and build up the cusp with incremental layers, it is crucial for large composite filling. Make sure your bonding procedure is really really well executed( Isolation..etc), it is the key to the success of composite resin restoration.

Finally, if you wish to restore the tooth with casting restoration, gold onlay or full metal crown is preferred.

no matter what, I would treatment plan only after I find a possible reason to explain why restorations failed in this patients mouth. I would probably build a very light contact, carefully check lateral excursion to make sure there is no interferences, and finally round up the opposing cusp a bit to prevent any sharp or strong force on this lower molar. Advice patient to be careful with that tooth.

One last thing, if you do build up and full coverage crown, make sure you do not drop your margin a lot more, ( area where it is 0.5 mm from gingival margin) but definitely build your crown margin all around sound tooth structure, not on the build up. This ferrule effect would further protect this tooth and strength it.

 

[DrJeff]

Do the patient (and your own mental well being) a favor and get a full coverage crown on that tooth. Chances are as has been already hinted upon in this thread that their is some type of heavy occlussal forces on this cusp that is giving your direct restoration very little chance at long term survival.

What I do now(after taking a few years of watching full cusp direct restorations fracture) is that whenever a patient comes in with a fractured cusp, I tell them that it's going to need a crown. If they insist that they absolutely 100% can't do a crown, then I tell them that because of the cusp fracture and the very LARGE restoration that there is NO GUARENTEE as to how long this restoration lasts, and that WHEN IT LIKELY BREAKS in the future, be it a day, a week, a month or a year later, that I will be billing them fully again to replace that direct filling(if I can even get a new direct filling in place at all).

I have found that with this very blunt, direct approach at discussing cuspal fractures and their restorations with patients that I end up doing alot more "proper" dentistry with alot less "emergency phone calls" to repair direct fillings down the road! 😀

 

[Shiko]

Thank you tinker bell ,aphistis,Sterichind69,organic and DrJeff ..
Well , let me first correct a part that was misunderstood , I never tried to bond composite to old Amalgam , I know the bond strength would fall drastically . What I did was that I removed the whole restoration , refined the cavity preparation , I used GIC for base then I built the cusp .
It failed anyways ..
Second , concerning assessment of occlusion , "the patient is a 17 year old female by the way "
This molar is tilted lingually and study casts showed that the distobuccal cusp is out of occlusion !!
Let me quote what Organic wrote:
"1)Does he/she have bruxism? unusual eating habits, biting habit?
(2)DL cusp at lower molar is a non- functional cusp, normally, this cusp wouldn't be under too much force. Does this patient has cusp to cusp occlusion that the upper lingual hits onto the buccal slope of lower lingual cusp, instead of in the central fossa?
(3)Does the patient have lateral movement type of bruxism?
(4))working side interferences?
(5)upper lingual shape plunging cusp? "

Well .. There was no history of parafunctional habits , Could you please explain to me how you detect working side interference , lateral movement bruxism ??
I'd personally go for cast onlays or indirect composite onlays .. FVC would be too much destruction to remaining sound tooth structure especially that the rest of the molar is completely sound . I always think twice before I just go and throw the full veneer option ..
What I learned after 5 years of clinical trials , and a diploma in conservative dentistry and minimally invasive techniques is that tooth structure is just too precious to sacrifice just to do the patient (and my own mental well being) a favor 🙂
Thanks a lot for the fruitful discussion , I appreciate your help a lot

 

[organic]

our teeth are the most precious gem stones!
I agree with conservative approach, but I also have to admit that Dr. Jeff's approach sometimes is the most practical.

if the tooth is lingually tilted, how was the isolation during the restoration?


as for working side " interference" (ex) Put a full arch articulating paper between arches, ask patient to do to right lateral protrusive movement( very very small range). Check the right side -- the contact of buccal slope of linqual cusps of lowers and upper lingual side of lingual cusp. When patient does the sliding, does she feel a bump on certain teeth, does she only contact a tooth?

laterotrusive type of bruxism can be observed by at least 2 ways (as far as I know)
1. fabricate a functional splint, with even centric contract on every tooth. After sometime, you will start seeing wearing marks on the hard splint. ( more definite

2. Check for lateral movements,Check if there are wearing facets from multiple teeth opposing each other during lateral movements. ( less accurate)

voila

happy holidays

 

[Shiko]

our teeth are the most precious gem stones!
I agree with conservative approach, but I also have to admit that Dr. Jeff's approach sometimes is the most practical.

if the tooth is lingually tilted, how was the isolation during the restoration?


as for working side " interference" (ex) Put a full arch articulating paper between arches, ask patient to do to right lateral protrusive movement( very very small range). Check the right side -- the contact of buccal slope of linqual cusps of lowers and upper lingual side of lingual cusp. When patient does the sliding, does she feel a bump on certain teeth, does she only contact a tooth?

laterotrusive type of bruxism can be observed by at least 2 ways (as far as I know)
1. fabricate a functional splint, with even centric contract on every tooth. After sometime, you will start seeing wearing marks on the hard splint. ( more definite

2. Check for lateral movements,Check if there are wearing facets from multiple teeth opposing each other during lateral movements. ( less accurate)

voila

happy holidays

Thank you Organic ,your contribution has been of real benefit to me , I think I really need to work a lot on basics of occlusion, unfortunately our curriculum dealt very superficially with occlusal equilibriation .
As for the isolation ...I used cotton rolls !!! I know you must think i'm a terrible dentist , but it really worked (although the filling failed later on !! ). It was impossible to use a rubber dam with that type of fracture especially with lingual inclination of the molar .

 

[DrJeff]

Thank you Organic ,your contribution has been of real benefit to me , I think I really need to work a lot on basics of occlusion, unfortunately our curriculum dealt very superficially with occlusal equilibriation .
As for the isolation ...I used cotton rolls !!! I know you must think i'm a terrible dentist , but it really worked (although the filling failed later on !! ). It was impossible to use a rubber dam with that type of fracture especially with lingual inclination of the molar .

Just another way to think about things Shiko, how much chairtime did you spend on this tooth (so far??)And how much have you charged this patient for your valuable time (so far?) Verses how much chairtime would you have spent on a full coverage crown preparation and how much would you have charged for that?? 😕 I know that that may sound way too capitalistic but afterall we do have dental school loans, etc, etc, etc. Plus, I know that many of my patients start to get a bit skeptical of my clinical skills if something breaks a few times 😉 😀

That being said, I'm actually not a dentist that gleefully takes the diamond bur to excessive amounts of sound enamel and dentin. I spend more time nowadays doing ultra conservative direct composite restorations (where clinically appropriate) over the more invasive amalgams, so much so that many times after preparation of an interproximal lesion, I'll often need to "pre wedge" the teeth to stretch the PDL's just enough to get the matrix band around the tooth, and even with my full coverage crowns, my gingival margins are often closer to the cusp tip than the gingiva. Also, you should hear the education/lecture I give my patients if their seriously contemplating a 3 unit fixed bridge verses a single implant restoration. Enamel and dentin are "sacred" commodities, however so is/are "bulletproof", predictable restorations

 

[Shiko]

Thanks DrJeff , I never had to think of it that way as the case I was discussing here was part of my requirements in the diploma I was studying , the patient was charged Nothing and I wasn't so keen on the patient being skeptical of my clinical skills .
All I was focusing on was the best technique to obtain a durable restoration .
I was also kind of hoping (when I first started this thread ) that the discussion would be directed more to the scientific and operative techniques rather than discussing it buisiness wise , I know it's part of our profession after all and it has to be considered with great attention but that wasn't the aim of my question .. Thank you

 

[DrJeff]

Thanks DrJeff , I never had to think of it that way as the case I was discussing here was part of my requirements in the diploma I was studying , the patient was charged Nothing and I wasn't so keen on the patient being skeptical of my clinical skills .
All I was focusing on was the best technique to obtain a durable restoration .
I was also kind of hoping (when I first started this thread ) that the discussion would be directed more to the scientific and operative techniques rather than discussing it buisiness wise , I know it's part of our profession after all and it has to be considered with great attention but that wasn't the aim of my question .. Thank you

Now that I'm heading on 8 years out of dental school, I've found out that the EASIEST part of what we as dentists do on a daily basis is when we're working in someone's mouth. The HARDEST part of what we as dentists do is running a business 😱 Afterall, think about how many hours of dental instruction you get in dental school verses how many you get on practice management

Also, as much as some people may want to shy away from this idea, when you graduate are out practicing, it's okay to think about making money, afterall with all the years and years of education you've gone through to become a dentist(and often the large associated amounts of loans required to do this), you shouldn't feel nervous/ashamed/ uncomfortable about telling a patient what your fees are for a procedure, all your education has/will entitle you to this.

 

[Shiko]

Hey all ,
It's been 10 days now since I last "re-restored!! " that Molar ,and it seems to be doing good ... the trick was to remove all the old filling ( composite ) , I took the depth down 0.5 mm into dentin , I created a beveled finish line at the level of the fracture line , I used a layer of compomer first then I completed building the cusp with Z250 using small increments ..
I took the cusp slightly out of occlusion during finishing ..
I think I'd settle for a full crown if anything happens to that filling this time 🙁
Has any one tried this whole bunch of restorative materials/options ?
Ceromers , giomers, ormocers , Ceramic inserts , precured composite inserts ?
Back in college we only had two options : Amalgam & Composite ...
After 5 years I returned back to college and I found this huge list of options , so if anyone had to deal with any of those materials i'd appreciate sharing the experience ..
Peace