Restoration

To fill missing part of teeth

Indication

• Dental caries
• Fracture
• wasting diseases
• Esthetics

Restoration types

• amalgam
• composite
• porcelain
• metallic

class I and II Amalgam restoration

indication

• Class I and Class II caries or fractured restorations
• Large portions

Contraindication

• allergic to alloy components.
• esthetic areas
• if composite offer more conservatio
• -than Amalgam.

Advantages

I.Ease of use II. High compressive strength III. Excellent wear resistance IV. Favourable long-term clinical research results V. Lower cost than for composite restorations

Disadvantages

I.Non-insulating II. Nonesthetic III. Less conservative tooth preparation than for composite restorations (more removal of tooth structure during tooth preparation) IV. More difficult tooth preparation than for composite restorations.Initial marginal leakage.

Complex amalgam restorations06phlllllyyylllllybnl

Indications

Complex amalgams may be used as follows: I. Definitive (final) restorations Usually a weakened tooth is best restored with a properly designed indirect (usually cast) restoration that prevents tooth fracture caused by mastication forces (Chapter 23). In selected cases, amalgam preparations that improve the resistance form of a tooth may be designed (Fig. 14.2). When conventional retention features are not adequate because of insufficient remaining tooth structure, the retention form may be enhanced by using auxiliary features such as slots and pins. The type of retention features needed depends on the amount of tooth structure remaining and the tooth being restored. As more tooth structure is lost, more auxiliary retention is required. Slots and pins provide additional resistance and retention form to the tooth when remaining vertical walls are inadequate. II. Foundation restoration Although complex amalgam restorations are used occasionally as an alternative to indirect restorations, particularly due to cost savings, they are often used as foundations for full-coverage restorations. Abutment teeth for fixed prostheses may use a complex restoration as a foundation (Fig. 14.3). III. Control restorations in teeth that have a questionable pulpal or periodontal prognosis

A tooth with a severe caries lesion that may require endodontic therapy or crown lengthening or that has an uncertain periodontal prognosis is often treated initially with a control restoration. A control restoration helps i. protect the pulp from the oral cavity (i.e. fluids, thermal stresses, pH changes, bacteria); ii. provide an anatomic contour that is consistent with gingival health; iii. facilitate control of acidogenic biofilm and resultant caries risk; and iv. provide some resistance against tooth fracture (or propagation of an existing fracture). (See Chapter 2 for caries-control rationale and techniques.) Mesioocclusodistolingual (MODL) complex amalgam in a maxillary first molar. The status and prognosis of the tooth determine the size, number and placement of retention features. Larger restorations generally require more retention. The size, number and location of retention features demand greater care in smaller teeth. Carelessness may increase the risk of pulpal irritation or exposure. IV. Interim restoration Complex amalgam restorations are sometimes indicated as interim restorations for teeth that require elaborate occlusal alterations, ranging from vertical dimension changes to correcting occlusal plane discrepancies. When cost of indirect restorations is a major factor for the patient, the complex direct amalgam restoration may be an appropriate treatment option, provided that adequate resistance and retention forms are included (Fig. 14.4).2,3 For some older patients and/or those who are debilitated, complex amalgam restoration may be the treatment preferred over the more expensive and time-consuming indirect restoration.

Contraindications

I. if the tooth cannot be restored properly with direct restoration because of anatomic or functional considerations (or both); II.if the area to be restored has esthetic importance for the patient.

Advantages

Conservation of Tooth Structure The preparation for a complex amalgam restoration is usually more conservative than the preparation for an indirect restoration.

Appointment Time The complex restoration may be completed in one appointment. An indirect restoration generally requires at least two appointments unless it is done using a chairside computer-aided design/computer-assisted manufacturing (CAD/CAM) system.

Resistance and Retention Forms Amalgam restorations with cusp coverage significantly increase the fracture resistance of weakened teeth compared with amalgam restorations without cusp coverage.4 Resistance and retention forms may be significantly increased by the use of slots and pins (discussed in subsequent sections).

Reduced Cost The complex amalgam restoration may be utilized to reinforce and stabilize compromised posterior teeth at a much reduced cost to the patient. It may serve as a definitive final restoration or an intermediate-term restoration with a long-term goal of indirect, more costly restoration and protection of the tooth.

Disadvantages

Tooth Anatomy Proper contours and occlusal contacts and anatomy are sometimes difficult to achieve with large, complex restorations.

Resistance Form Resistance form is more difficult to develop with a complex amalgam as compared to the preparation of a tooth for a cusp-covering onlay (skirting axial line angles of the tooth or a full crown. The complex amalgam restoration does not protect the tooth from fracture as effectively as a full-coverage indirect restoration.

Direct Composite restoration

Indications

• Class I, II, III, IV, V and VI restorations.
• Sealants and preventive resin restorations (conservative composite restorations).
• Esthetic enhancement (anterior)
• Partial or full veneers
• Tooth contour modifications
• Diastema closures
• Temporary or provisional restorations
• Periodontal splinting.

contraindications

• Inability to obtain adequate isolation.
• Occlusal considerations related to wear and fracture of the composite material.
• Extension of the restoration on root surface.
• Operator factors.

advantages of composite restorations:

I.Esthetics II.Conservative tooth preparation (less extension, minimum depth not necessary, mechanical retention usually not necessary) III. Low thermal conductivity IV. Universal use V. Adhesion to the tooth VI. Repairability.

Disadvantages

I.May have poor marginal and internal cavity adaptation, usually occurring on root surfaces as a result of polymerization shrinkage stresses or improper insertion of the composite. II. May exhibit marginal deterioration over time in areas where no marginal enamel is available for bonding. III. Are more difficult and time consuming to place, and more costly (compared with amalgam restorations) because bonding usually requires multiple steps; insertion is more difficult; establishing proximal contacts, axial contours, embrasures and occlusal contacts may be more difficult and finishing and polishing procedures are more difficult. IV. Are more technique sensitive because the operating site must be appropriately isolated, incremental placement technique must be used for most materials and proper adhesive technique is absolutely mandatory. V. May exhibit greater occlusal wear in areas of high occlusal stress or when all of the tooth’s occlusal contacts are on the composite material.

Class II Cast Metal Restorations

Types

At present, four distinct groups of alloys are in use for cast restorations: I.Traditional high-gold alloys (ADA specification No. 5) II. Low-gold alloys III. Palladium–silver alloys IV. Base metal alloys (most commonly used).

indications

• Large Restorations
• When proximal surface caries is extensive, the cast metal inlay is an alternative to amalgam or composite when the higher strength of a casting alloy is needed.
• The cast metal onlay is often an excellent alternative to a crown for teeth that have been greatly weakened by caries or by large, failing restorations but where the facial and lingual tooth surfaces are relatively unaffected by disease or injury.

Superior Contact and Contour The indirect procedure used to develop the cast restoration allows more control of contours and contacts (proximal and occlusal).

Endodontically Treated Teeth A molar or premolar with endodontic treatment can be restored with a cast metal onlay, provided that the onlay has been thoughtfully designed to distribute occlusal loads in such a manner as to reduce the chance of tooth fracture

Dental Rehabilitation with Cast Metal Alloys When cast metal restorations have been used to restore adjacent or opposing teeth, the continued use of the same material may be considered to eliminate electrical and corrosive activity that sometimes occurs between dissimilar metals in the mouth, particularly when they come in contact with each other.

Posterior Diastema Closure and Occlusal Plane Correction I.The cast inlay or onlay is indicated when extension of the mesiodistal dimension of the tooth is necessary to form a contact with an adjacent tooth. II.Cast onlays also can be used to correct the occlusal plane of a slightly tilted tooth. Removable Prosthodontic Abutment

Teeth that are to serve as abutments for a removable partial denture can be restored with a cast metal restoration. The major advantages of a cast restoration are as follows I.The superior physical properties of the cast metal alloy allow it to better withstand the forces imparted by the partial denture. II.The rest seats, guiding planes and other aspects of contour relating to the partial denture are better controlled when the indirect technique is used

Endodontically Treated Teeth A molar or premolar with treatment root canal filling can be restored with a cast metal onlay, provided that the onlay has been thoughtfully designed to distribute occlusal loads in such a manner as to reduce the chance of tooth fracture.

Contraindications

High Caries Rate Facial and lingual (especially lingual) smooth-surface caries indicates a high caries activity that should be brought under control before expensive cast metal restorations are used. Young Patients With younger patients, direct restorative materials (e.g. composite or amalgam) are indicated, unless the tooth is severely broken or endodontically treated. An indirect procedure in a young patient has the following disadvantages: I. Treatment requires longer and more numerous appointments II. Access is more difficult III. Clinical crowns are shorter with larger pulp chambers IV. Younger patients may neglect oral hygiene, resulting in additional caries.

Esthetics The dentist must consider the esthetic impact (display of metal) of the cast metal restoration. This factor usually limits the use of cast metal restorations to tooth surfaces that are invisible at a conversational distance. Composite and porcelain restorations are alternatives in esthetically sensitive areas.

Small Restorations Amalgam and composites are the materials of choice for smaller restorations.

• Cast metal inlays are rarely done in small class I and II restorations.

Advantages

Strength The inherent strength of dental casting alloys allows them to restore large damaged or missing areas and be used in ways that protect the tooth from future fracture injury. Biocompatibility As previously mentioned, high-gold dental casting alloys are unreactive in the oral environment. This biocompatibility can be helpful for many patients who have allergies or sensitivities to other restorative materials. Low Wear Although individual casting alloys vary in their wear resistance, castings are able to withstand occlusal loads with minimal changes. This is especially important in large restorations that restore a large percentage of occlusal contacts. Control of Contours and Contacts Through the use of the indirect technique, the dentist has great control over contours and contacts. This control becomes especially important when the restoration is larger and more complex.

Disadvantages

Number of Appointments and Higher Chair Time The cast inlay or onlay requires at least two appointments and much more time than a direct restoration, such as amalgam or composite.

Temporary Restorations Patients must have temporary restorations between the preparation and delivery appointments. Temporaries occasionally loosen or break, requiring additional visits. Cost In some instances, cost to the patient becomes a major consideration in the decision to restore teeth with cast metal restorations. The cost of materials, laboratory bills and the time involved make indirect cast restorations more expensive than direct restorations. Technique Sensitivity Every step of the indirect procedure requires diligence and attention to detail. Errors at any part of the long, multistep process tend to be compounded, resulting in less than ideal fits. Splitting Forces Small inlays may produce a wedging effect on facial or lingual tooth structure and increase the potential for splitting the tooth. Onlays do not have this disadvantage.

Direct Gold Restorations

Types

Gold foil Powdered Goal

Indications

I. Class I direct gold restorations are one option for the treatment of small carious lesions in pits and fissures of most posterior teeth and the lingual surfaces of anterior teeth. II. Direct gold also is indicated for treatment of small, cavitated Class V carious lesions or for the restoration, when indicated, of abraded, eroded or abfraction areas on the facial surfaces of teeth (although access to the molars is a limiting factor). III. Class III direct gold restorations can be used on the proximal surfaces of anterior teeth where the lesions are small enough to be treated with esthetically pleasing results. IV. Class II direct gold restorations are an option for restoration of small cavitated proximal surface carious lesions in posterior teeth in which marginal ridges are not subjected to heavy occlusal forces (e.g. the mesial or distal surfaces of mandibular first premolars and the mesial surface of some maxillary premolars). Class VI direct gold restorations may be used on the incisal edges or cusp tips. VI. A defective margin of an otherwise acceptable cast gold restoration also may be repaired with direct gold.

Contraindications

Direct gold restorations are contraindicated in some patients whose teeth have: I. Very large pulp chambers II. Severely periodontally weakened teeth with questionable prognosis III. Patients for whom economics is a severely limiting factor IV. In handicapped patients who are unable to sit for the long dental appointments required for this procedure V. Root canal-filled teeth are generally not restored with direct gold.

Steps

Resin-bonded Splints and Bridges

Conservative bridges - natural tooth ponitic - denture tooth ponitic - porcelain metal fused ponitic - all porcelain ponitic

Class III and V Amalgam Restorations

indications

Few indications exist for a class III amalgam restoration. It is generally reserved for the distal surface of maxillary and mandibular canines if (i) the preparation is extensive with only minimal facial involvement, (ii) the gingival margin primarily involves cementum or (iii) moisture control is difficult. For esthetic reasons, amalgam rarely is indicated for the proximal surfaces of incisors and the mesial surface of canines. Class V amalgam restorations may be used anywhere in the mouth. As with class III amalgam restorations, they are generally reserved for non-esthetic areas, for areas where access and visibility are limited and where moisture control is difficult and for areas that are significantly deep gingivally. Because of limited access and visibility, many class V restorations are difficult and present special problems during the preparation and restorative procedures. One measure of clinical success of cervical amalgam restorations is the length of time the restoration serves without failing (Online Fig. 26.3). Properly placed class V amalgams have the potential to be clinically acceptable for many years. Some cervical amalgam restorations show evidence of failure, however, even after a short period. Inattention to tooth preparation principles, improper manipulation of the restorative material and moisture contamination contribute to early failure. Extended service depends on the operator’s care in following accepted treatment techniques and proper care by the patient. Amalgam may be used on partial denture abutment teeth because amalgam resists wear as clasps move over the restoration. Contours prepared in the restoration to retentive areas for the clasp tips may be achieved relatively easily and maintained when an amalgam restoration is used. Occasionally, amalgam is preferred when the caries lesion extends gingivally enough that a mucoperiosteal flap must be reflected for adequate access and visibility (Online Fig. 26.4). Proper surgical procedures must be followed, including sterile technique, careful soft tissue management and complete debridement of the surgical and operative site before closure.

Contraindications

Class III and V amalgam restorations usually are contraindicated in esthetically important areas because many patients object to metal restorations that are visible (Online Fig. 26.5). Generally, class V amalgams placed on the facial surface of mandibular canines, premolars and molars are not readily visible. Amalgams placed on maxillary premolars and first molars may be visible. The patient’s esthetic demands should be considered when planning treatment.

Advantages

Amalgam restorations are stronger than other class III and V direct restorations. In addition, they are generally easier to place and may be less expensive to the patient. Because of its metallic colour, amalgam is easily distinguished from the surrounding tooth structure. Amalgam restorations are usually easier to finish and polish without damage to the adjacent surfaces.

Disadvantages

The primary disadvantage of class III and V amalgam restorations is that they are metallic and unesthetic. In addition, the preparation for an amalgam restoration typically requires 90-degree cavosurface margins and specific axial depths that allow incorporation of secondary retentive features. These features result in a less conservative preparation than that required for most esthetic restorative materials.

Clinical operative procedures a step-by-step guide

7.1.1 Cavity/restoration classification 7.1.2 Restoration procedures 7.2 Fissure sealant - illustrated 7.3 Preventive resin restoration (PRR), type 3 DBA (enamel pre-etch) - illustrated 7.4 Posterior occlusal composite restoration (Class I)-illustrated 7.5 Posterior proximal adhesive restoration (Class II) 7.5.1 Type 3 DBA (enamel pre-etch)-illustrated 7.5.2 Type 2 DBA,'moist bonding'-illustrated 7.6 Buccal cervical resin composite restorations (Class V), type 2 DBA - illustrated 7.7 Anterior proximal adhesive restoration (Class III), type 2 DBA - illustrated 7.8 Anterior incisal edge/labial composite veneer (Class IV), type 3 DBA (enamel pre-etch) - illustrated 7.9 Large posterior amalgam restoration (bonded) illustrated 7.10 'Nayyar core' restoration 7.11 Direct fibre-post/composite core restoration 7.12 Dentine bonding agents - step-by-step practical guide 7.13 Checking the final restoration 7.14 Patient instructions

1. Recall, maintenance, and repair 140 8.1 Introduction 8.2 Restoration failure 8.2.1 Aetiology 8.2.2 Restorative material used 8.2.3 How may restoration outcome be assessed? 8.2.4 How long should restorations last? 8.3 Tooth failure 8.4 Monitoring the patient/course of the disease 8.4.1 Recall assessment and frequency 8.4.2 Points to consider (especially for a previously high caries risk patient) 8.4.3 Monitoring toothwear 8.5 Repairing/replacing restorations 8.5.1 Dental amalgam 8.5.2 Composites/GIC 8.6 Answers to self-test questions

Total ways

Indications with reasons

Class I and II Amalgam restoration
- Occlusal | conventional

Class III and IV Direct composite resin - Non-occlusal | conservation

Contraindications with reasons

direct gold alloy - Small - proximal |occlusal

statements

(Reasons, advantages ) Composite are weak Amalgam are strength

Composite are esthetic Amalgam are unesthetic

Composite= retention small anterior Amalgam= retention large posterior

Relationship

Posterior vs anterior Occlusal vs non occlusal Non esthetic vs esthetic

Posterior=>occlusal=>nonesthetic => class 1 and 2 Anterior=> non occlusal=> esthetic => class 3 and class 4

conclusion

Class I and II are amalgam Class I and II composite Class III and IV Amalgam Class III and IV are composite

Therefore, Indications Class I and II are amalgam Class III and IV are composite

Contraindications Class III and IV are amalgam Class I and II are composite

Attrition => occlusal and anterior => crowns

Decay and attrition

Chief complaint - food lodgement - pain - wearing of tooth - blackish discoloration

Examination - Dry air to remove

ICDAS - 0 - 1 - 2 - 3 - 4

Preventive resin Posterior Occlusal composite => class 1 Posterior proximal composite=> class 2 Periodontal Nayyar post-core Labial composite veener Dentine bonding agents Direct- core composite