Dental Demolition and Managing Failure in Tooth Wear Flashcards
What are the reasons for needing to carry out dental demolition?
As a result of high failure rates caused by:
Teeth already heavily restored
Affected by previous failure
Small teeth (short OG height)
High occlusal loads/bruxism
Vitality loss
Root fractures
What damage can wear patients cause in common restorations?
- Long span bridges (even with metal backings)- cycles of grinding has destroyed silver joints
- Porcelain in anterior regions can fail due to continuous bruxist load
- If amalgam has no cuspal protection we can get longitudinal root fractures
- Fractured restoration- can bring cusps with it (can leave tooth unrestorable)
What should be considered when carrying out dental demolition?
- Be clear on benefit- health or appearance
- Understand risk- think of appearance and health
- Should you be extracting or retaining tooth- risk assessment
- Valid consent- be clear about longevity and cycles of replacement (provide all info required)
- Whether this is beyond scope of practice
- Whether treatment is possible
How is operator safety achieved in dental demolition?
- Eye protection- beware of porcelain fragments, plaque, debris, infection
- Wear surgical gloves and consider handling- sharp edges
- Dispose of old restorations as for sharps
How is patient safety achieved in dental demolition?
Airway protection
-> Dam
-> Suction
Superfloss around pontics can be helpful if long span bridges
Eye protection
Examples of situations requiring dental demolition and what to do:
- Perforation and fractured instrument (symptom free)- monitor and extract when symptoms present
- Teeth with apical areas below a bridge (poor RCT)- access through bridge and ReRCT
- Double post retained crown with apical area with short root canal filling- refer to specialist endodontist or extract
- Periapical area with silver points in root canals- if corroded they can be difficult to remove, if they are not then RCT
What is the issue with radiographic washout when assessing whether a patient needs restorations removed?
Can make assessment of core or caries under crowns impossible
-> Warn patient that you may remove restoration and the tooth may be unrestorable
What instrument is used for cutting porcelain?
Tapered coarse diamond bur
*Zirconia may require multiple burs
What instrument is used for cutting metal restorations?
Gold cutting bur (cutting edges are at 90 degrees- vibration)
-> These only last once or twice
What is the basic technique for removing indirect restorations?
Drill up buccal surface Vertically and then use chisel to split (place in channel and twist clockwise)
-> Use high volume suction, stop periodically
What approaches may be used if a buccal section does not remove the restoration?
Go onto occlusal and palatal surface
Consider horizontal section
How is a sliding hammer used to remove problematic indirect restorations?
Place under margin and use weight to knock restoration off
- High risk of core fracture
- Consider airway- don’t lie patient flat
- Matrix band may be used to aid this (over tighten), use hammer to knock holder part
What should be done after removing an indirect restoration?
Critically appraise core and decide whether it needs redone
What are the considerations when removing long span bridge with only a few abutment teeth?
- Consider if patient needs temporary denture
- Consider what teeth you can keep and utilise (some teeth may have no future)
- Consider if you can keep any of the crowns from sectioned bridge as temporaries
Which factors would contraindicate repeat Endodontics in a failed indirectly restored tooth?
Subgingival caries
Insufficient dentine
Lack of tooth structure
-> do not spend time treating an unrestorable tooth
What should be assessed when carrying out repeat Endodontics?
Curvature of canal
Presence of disease
Material used (spad- eastern Europe- sets hard, won’t get it out)
What items can be helpful when carrying out repeat endo?
Eucalyptus oil and turpentine are good for softening and dissolving GP
GT files - greater taper
GG burs
Conventional small files
What can be used for complex repeat Endodontics cases?
- Magnification
- Ultrasonics- be careful with speed (higher frequency can result in instrument fracture)
*If unsuccessful- refer
What are the factors to consider when removing a post?
Length- longer is more difficult
Taper
Surface
Condition of remaining dentine
Other treatments- apicecectomy will complicate
What instruments can be used to remove posts?
Post puller or fine extraction forceps can be used (rotate out- difficult in mobile teeth)
What can done if core or posts fractures during removal?
Use ultrasonics and Stieglitz forceps
Masseran Kit- good for removing post inserted clockwise and it goes opposite direction
Likely require referral
What are the drawbacks of the masseran kit?
Removes dentine from tooth
-> If wide post and thin dentine it is unrestorable
High root fracture risk
Why is it important to take care of sockets in cases requiring multiple extractions?
Supporting tissue may be required for dentures or implants
-> Use Mattress sutures
-> Co-comfort lining in dentures to minimise trauma
What are the keys in successfully managing failure in tooth wear cases?
- Comprehensive history and examination (Information gathering)
- Thorough planning
- Seek advice if needed
- Prevention
- Avoid overambitious treatment
- Effective communication
- Decision-making and treatment planning around basic principles
- Keep plans simple
- Have an effective maintenance strategy and regularly reassess the situation
What are the preventative measures that all patients should receive before any complex treatment is carried out? (document in notes)
Basic Oral health messages
Individualised oral hygiene instruction
Individualised dietary advice
Individualised fluoride regime
Individualised habit advice
Management/referral to other health & social care professionals advice/safeguarding issues
What is the concept of herodontics?
Use of minimally invasive adhesive restorations to restore or maintain function or aesthetics (sometimes provisionally) on compromised teeth
What is the concept of superherodontics?
Attempting invasive and complex restorative treatment that is overambitious and has high failure rate on compromised teeth
What are the features of an effective management of failure through communication?
Effective listening
Being honest and transparent
Taking into account the patient’s wishes
-> avoid being patient led
-> give reality check if required
Seek advice when required
Being patient
Being assertive and compassionate
Having holistic approach to treatment
-> document any discussions
What are the steps in the SPIKES protocol for breaking bad news?
S- Set up an interview
-> mental/physical preparation
P- Perception
-> assess how much the patient knows about situation
I- Invitation
-> ask how much they want to know
K- Knowledge
-> give medical facts
E- Emotion
-> respond to patient emotion
S- Strategy and summary
-> Negotiate a concrete next step
