APPROACHES TO TREATMENT OPTION SEVEN
RE-RESTORE – WITH FIXED RESTORATIONS
Decisions are frequently made to re-restore some or all of a patient’s existing restorations.
It must be appreciated that the patient has demonstrated disease susceptibility, otherwise the initial work would presumably not have been provided. The existing restorations have now failed and caution must be exercised before re-restoring.
The following common diagnostic groupings may, or may not be complicated by facial arthromyalgia, caries and endodontic problems. They require the formulation of a logical treatment planning sequence.
Periodontitis Resistant (wear) Cases
- Conformative approach.
- Reorganised approach.
Periodontitis Susceptible Cases
- Conformative approach.
- Reorganised approach.
There are obviously patients who are periodontitis susceptible and exhibit wear, but the above mentioned conditions are the most common.
General Sequence of Treatment
There are essentially 11 stages, namely:
1) Initial contact, history, examination, diagnosis, preliminary treatment plan, correspondence.
2) Elimination of acute problems.
3) Reassess and re-treatment plan.
4) Treatment of chronic problems – Stage I.
5) Maintain, reassess and re-treatment plan.
6) Treatment of chronic problems – Stage II.
7) Maintain, reassess, decide upon further treatment, treatment plan accordingly.
8) Further preparation.
9) Maintenance and reassessment.
11) Maintenance therapy.
The techniques that would be used in these various stages have been described in Chapters 4 and 8-25.
Whenever extensive re-restoration is required, the clinician should develop a flow chart based on the foregoing stages, which will now be considered in greater detail.
1. Initial Contact, History, Examination, Diagnosis, Preliminary Treatment Plan, Correspondence
These stages have been described in Chapters 3, 4 and 5 and should be reviewed. It is important to remember that a commitment to emergency treatment should not necessarily be a commitment to re-restoration.
If necesary, initial correspondence should very clearly state that: ‘following treatment for the emergency problems, the situation must be re-evaluated and I cannot assure you that further treatment will be provided in this practice.’
2. Eliminate Acute Problems
The first stage of treatment is to eliminate acute problems in the form of pathological lesions (for example, acute periodontal or periapical abscess, see pages 429+447) or troublesome mechanical failure.
In failed bridgework, which requires urgent removal, the usual sequence of events would be (Chapter 8):
1) Remove existing bridgework.
2) Electrosurgical exposure of sound tooth structure, typically using a loop electrode and rectified current.
3) Prepare roughly or build up a sufficient number of abutments around the arch. Do not spend time at this stage in smoothing and refining the preparations.
5) Refine the preparations.
6) Insert the retraction cord, if essential – it is usually best to avoid this, if at all possible, since it will precipitate bleeding.
7) To produce better haemostasis and reduce serous exudate syringe reversible hydrocolloid around the preparations, or place a slip, made from a study cast filled with hydrocolloid over the preparations and leave for 10 minutes.
8) Remove the hydrocolloid and take a hydrocolloid impression for the temporary restoration. Hydrocolloid is preferred as an impression material, as it is haemostatic and absorbs moisture. The material itself and the cold water passing through the tray help to control haemorrhage from the inflammed tissue.
9) First impression for provisional restorations to provide individual dies, the haemostasis obtained with the initial hydrocolloid will result in a better impression for the provisional restorations.
10) Take a second impression for provisional restorations, if using hydrocolloid, to provide a solid cast (see Appendix).
11) Protect the preparations during fabrication of temporaries. A slip filled with a condensation cured silicone impression material, such as, Optosil (Bayer), is placed over the preparations. Following setting it is cemented to the teeth with temporary cement.
12) Try in the temporary restorations. Modify, shape and adjust them occlusally as necessary. Carry out any intraoral staining, using, for example, Minute Stain (George Taub & Co.) or Palaseal (Kulzer) mixed with porcelain stains.
13) Make jaw registations for the fabrication of provisional restorations.
14) Paint the outside of the temporary restoration with olive oil or Vaseline to facilitate later removal of surplus temporary cement.
15) Cement temporary restorations. To assist healing Tempbond (Kerr) into which is mixed aureomycin eye ointment 1%,1 is used.
16) Immediate attention by the hygienist is required to clean off temporary cement and initiate oral hygiene procedures.
17) Fabricate and fit a provisional restoration.
3. Reassess and Retreatment Plan
The Following should be Reassessed:
- Periodontium – bleeding on probing, pocket depth, attachment loss, muco-gingival involvements, tooth mobility, general oral hygiene.
- Caries – new cavities, dietary analysis, lactobacillus count (Dentocult – Orion Diagnostica; Vivocare – Ivoclar Vivodent), salivary buffering capacity (Dentobuf – Orion Diagnostica; Vivocare – Ivoclar Vivodent), salivary flow rate, streptococcus mutans count (Dentocult SM. – Orion Diagnostica; Vivocare – Ivoclar Vivodent).
- Pulp/Periapex – vitality testing where possible and applicable, radiographic appearance, presence of sinuses and fistulae, tenderness to percussion, periapical tenderness or swelling.
- Implants – radiographic appearance, presence of mobility, tenderness to percussion, sinuses, fistulae, marginal inflammation, pocketing.
- Neuromusculature – muscle tenderness, facial pain or discomfort, ease of mandibular manipulation, joint sounds, range of motion, joint tenderness, pantographic reproducibility index.
- Aesthetics – lipline, lip support, tooth length, incisal edges relative to the interpupillary line, subpontic ridge defects, vertical dimension, patient’s opinion. Possibly dentist, technician and patient to assess the provisional restorations compared with previous photographs.
Following the reassessment, time is set aside to evaluate the findings and to modify or replan the treatment, if indicated. Additional special tests, such as CT scans, may now be required.
4. Treatment of Chronic Problems – Stage I
Commence Periodontal Treatment
1) Oral hygiene instruction, scale and polish, root debridement, possibly root plane as appropriate, possibly mouthwash or antibiotic therapy, reshaping of poorly contoured restorations.
2) Determination of frequency and duration of the appointments for periodontal therapy.
3) Make appointments.
1) Replace restorations in teeth exhibiting carious lesions.
2) Commence dietary instruction and ensure the use of fluoride toothpaste.
3) Prescribe a 0.2% chlorhexidine mouthwash (Corsodyl–ICI) which should used at night for 16 days.
4) Prescribe a daily fluoride mouthrinse 0.05% (Fluorigard) to commence, following the 16 day chlorhexidine mouthwash.
5) Prescribe a xylitol containing chewing gum (Extra-Wrigleys) for patients without gastric ulceration. Two pieces should be chewed, three times daily.
Provide endodontic therapy.
Decide whether removal is required.
Implants, teeth or parts of teeth where treatment is hopeless should be removed as early in this stage of treatment as possible, to allow time for healing.
Institute occlusal stabilization appliance therapy, exercises, counselling, and medication as required.
Necessary Posts and Cores
Following endodontic therapy, necessary posts and cores (that is, those required to support temporary restorations) and temporary restorations are made.
5. Maintain, Reassess and Retreatment Plan
Maintenance is primarily by the dental hygienist but may also involve occlusal adjustment of any appliances. After two to three months a reassessment is made and the treatment plan modified, as necessary. It should be noted that when there are open carious lesions, Dentocult readings are probably inaccurate. It is only at this stage that such readings become meaningful. However, earlier Dentocult recording provides motivation for dietary control by the patient. Further special tests may be required.
6. Treatment of Chronic Problems – Stage II
New Attachment Procedures such as Guided Tissue Regeneration Techniques
If furcation lesions are obviously amenable to such treatment, it should now be provided.
Investigate Restored Teeth
Restorations still remaining in teeth to be re-restored are now removed to permit further investigation. Unless previously made, temporary and then provisional restorations are made.
Any further teeth requiring endodontic therapy are now treated.
Posts and Cores
Following endodontic therapy, posts and cores should be constructed within the provisional restorations, as required.
Commence aesthetic modification and assessment using provisional restorations or temporary composite additions.
Ridge Augmentation – see below
7. Maintain, Reassess, Decide upon Further Treatment, Treatment Plan
The frequency of appointments during maintenance therapy and the duration of the latter must be individually assessed and is based upon periodontal response, adaptation to the occlusion, discomfort. For example, a lack of gingival bleeding, good oral hygiene, and non-awareness of the occlusion, and a feeling of comfort with the restorations indicates that appointments may be made at two monthly intervals. Continued bleeding, poor compliance to oral hygiene instruction and occlusal awareness indicate the need for more frequent appointments – one to two weekly. Following this stage, a reassessment is made as outlined previously, after which the course of future treatment must be decided. The possibilities are, as described in Chapters 29–34 namely:
- Maintainance therapy.
- Complete dentures.
- Partial dentures with, or without crowns on abutment teeth.
- Osseointegrated prostheses.
- Re-restore with fixed restorations, with or without osseointegration.
After a decision has been made, a new treatment plan is drawn up.
In some cases the pathway of treatment is clear from the beginning. In others, the decision is less obvious.
If periodontal surgery is required because of periodontitis or to lengthen the clinical crown, it should, if possible, be performed at this stage. It is always helpful to remove provisional restorations prior to surgery, providing the periodontist with better access to the tissues.
Modified Provisional Restorations
Six weeks following surgery, crown margins may, if necessary, be extended further gingivally, to improve aesthetics. The patient must be warned of this delay previously, since during this time aesthetics may be adversely effected to a considerable degree and teeth may be sensitive.
This is often carried out at the time of periodontal surgery. If, however, it is obvious from the start of treatment that this will be required, then the earlier it is provided the better – to allow time for the tissues to heal and their form and contour to stabilize – in which case it will be in Stage II and separate from periodontal surgery.
Any remaining teeth for which endodontic therapy is indicated are now treated, although this will usually have been completed at an earlier stage.
Posts and Cores
These are built into the provisional restorations following any endodontic therapy.
The use of any occlusal stabilization appliance should now have ceased and any modifications to occlusal relationships carried out on the provisional restorations. These modifications may include changes in vertical dimension, anterior guidance, or antero-posterior jaw relationships.
Insertion of Osseointegrated Fixtures
Now that inflammatory lesions have been resolved, fixtures can be inserted.
9. Maintenance and Reassessment
If further preparation includes periodontal surgery, it is usually necessary to wait a further six months3 prior to re-restoration, to allow the tissues to heal and their form and contour to stabilize. If there are residual neuromuscular signs and symptoms elicited by pain to muscle palpation, difficulty in manipulation of the mandible to CRCP or a PRI indicating dysfunction, it must be decided whether to restore at this stage, or to prolong maintenance therapy in an attempt to resolve such signs and symptoms. The need for medication, in the form of tricyclic antidepressant therapy, during the re-restoration phase should be borne in mind. Periods of between three and six months are required for osseointegration following fixture placement.
The decision whether to restore in a conformative or reorganised fashion (Chapters 12 and 13), should have been made at previous reassessment stages.
11. Maintenance Therapy
Following re-restoration, a prescription must be made for subsequent maintenance. This is considered in Chapter 25.