Table Of ContentAdvanced
OPERATIVE
DENTISTRY
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Advanced
OPERATIVE
DENTISTRY
A PRACTICAL APPROACH
Edited by
Professor David Ricketts
Professor of Cariology and Conservative Dentistry/Honorary Consultant in Restorative Dentistry
Leader of the Section of Operative Dentistry, Fixed Prosthodontics and Endodontology,
Dundee Dental School, University of Dundee, UK
Professor David Bartlett
Professor of Prosthodontics/Honorary Consultant in Restorative Dentistry
Head of Prosthodontics, Kings College London Dental Institute, Guy’s Hospital, London, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2011
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Contributors
ProfessorDavidBartlett DrAndrewHall
ProfessorofProsthodontics/HonoraryConsultantin SeniorLecturer/HonoraryConsultantinRestorativeDentistry,
RestorativeDentistry, DundeeDentalSchool,
HeadofProsthodontics,KingsCollegeLondonDentalInstitute, Dundee,UK
Guy’sHospital,London,UK
DrJohnRadford
ProfessorDavidRicketts SeniorLecturer/HonoraryConsultantinRestorativeDentistry,
DundeeDentalSchool,
ProfessorofCariologyandConservativeDentistry/Honorary
ConsultantinRestorativeDentistry, Dundee,UK
SectionLeader,
ProfessorWilliamSaunders
SectionofOperativeDentistry,FixedProsthodonticsand
ProfessorofEndodontology/HonoraryConsultantin
Endodontology,
RestorativeDentistry,
DundeeDentalSchool,
DundeeDentalSchool,
Dundee,UK
Dundee,UK
DrGrahamChadwick DrBrianStevenson
SeniorLecturer/HonoraryConsultantinRestorativeDentistry,
Lecturer/HonorarySpecialistRegistrarinRestorativeDentistry,
DundeeDentalSchool,
DundeeDentalSchool,
Dundee,UK
Dundee,UK
DrAngelaGilbert DrCarolTait
SeniorLecturerinRestorativeDentistry, SeniorClinicalTeachingFellow,
DundeeDentalSchool, DundeeDentalSchool,
Dundee,UK Dundee,UK
vii
Preface
Advancedoperativeproceduresindentistryencompassalldentalsubjectsanddisciplinessuchasoralsurgery,theplacement
andrestorationofdentalimplantsandendodonticstonameafew;however,thesesubjectsarecomprehensivelyaddressedin
othertexts.Thisbookthereforeconcentratesonfixedprosthodonticswhichinvolvesthepreparationofteethforlaboratory-
madeindirectrestorationssuchascrowns,bridges,veneers,inlaysandonlays.Wherealternative,moreconservativetreatments
arepossible–forexampletheplacementofdirectcompositetoaltertheshapeofteeth–thesearealsodescribed.
Thenecessityforadvancedindirectrestorationsistheresultofdiseaseorconditionswhichhavecompromisedthedenti-
tion.Itisimportanttoappreciatethatusingrestorationsdoesnottreatthediseasesorconditions,andtheiridentification
andpreventionunderpinsuccessfultreatment.Thefirstfivechaptersofthisbookthereforefocusonthemaindiseasesand
conditions(dentalcaries,periodontaldisease,endodonticproblems,toothwearandaestheticproblems)whichcanleadto
the need for advancedoperativetechniquesand addresses how these techniques can impacton theremaining dentition
andoralhealth.Intheensuingchaptersdetailsofmaterials,techniquesandtoothpreparationaredescribedwhichaimto
empowerthereadertoachieveahighstandardofcarefortheirpatients.
Indirectrestorationsaremadeinadentallaboratoryandclearcommunicationbetweendentistandlaboratorytech-
nicianisessential.Thistakestheformofaccurateimpressions,occlusalregistrationandaspectsofappearancesuchas
theshadeandcontourrequired,allofwhicharedevotedanindividualchapter.Clearprescriptionofrestorationdesign
andmaterial choiceis also requiredand theseare discussed inrelationtothe individual restorations. Inmanydental
schools little or no laboratory work is carried out by undergraduate dental students; however, an understanding of
howindirectrestorationsaremadeisimportantascertainaspectsoftoothpreparationhavetobefollowedtofacilitate
laboratoryconstruction.Laboratoryprocedurescanalsoimpactuponhowmaterialsandrestorationsarehandledatthe
chairside.Assuch,theseaspectsoflaboratoryworkaredescribedthroughoutthebook.
Theprovisionofadvancedindirectrestorationsiscostlyandcanoftenhaveanimpactontheremainingdentitionand
dentalhealth.Theadvantagesanddisadvantagesassociatedwiththeirprovisionhavetobebalancedforeachindividual
patientforthemtobeabletogiveinformedconsent.Theseprinciplesunderliesuccessfultreatmentplanning,execution
andhencepatientcare,andaretheprinciplesbehindthistext.
ix
Acknowledgements
Thistextbookwouldnothavebeenpossibleifitwerenotforthepatientswhoallowedtheirclinicalphotographstobe
used for medical education; the authors, undergraduate students, postgraduate students and clinical trainees who
allowedtheirclinicalworktobeincluded;thedentaltechnicianswhomadetheindirectrestorationsusedtoillustrate
this book, in particular John McLeish, Kevin Linklater, Donald Aitkenhead, Stewart Fairlie and Dave McMahon; and
clinicalphotographerSimonScottwhoseexpertiseinclinicalandlaboratoryimaginghasbeeninvaluable.Theauthors
wouldliketosincerelythankallthosewhohavebeeninvolvedandgiventheirtimegenerouslyandunreservedly.
xi
1
| |
Chapter
Management of dental caries
DavidRicketts,GrahamChadwick,AndrewHall
CHAPTERCONTENTS coveredinplaquedonotdevelopclinicallydetectablecar-
ies whereas other tooth surfaces covered with plaque in
Dentalcariesthedisease 1 the same mouth do. Many other factors, such as dietary
Therestorative cycle 2 habits, fluoride and saliva impact upon the disease pro-
cess which is complex and dynamic in nature. From the
Cariesdetection anddiagnosis 3
earlieststage,continueddemineralizationisnotinevitable
Cariesriskassessment 5
and lesion arrest is possible by simply disrupting the
Whatiscariesrisk? 5
plaquebiofilmonthesurfaceofthetoothatregularinter-
Cariesriskfactors 7 vals. Very early lesions which are not detected clinically
may therefore not progress to clinically detectable white
Socialdeprivation 7
spot lesions and the carious process is better represented
Pastcariesexperience 7
byFigure1.2.
Oralhygiene 7 It is often said that if an early white spot lesion devel-
Diet 8 ops, remineralization can take place. While complete
remineralization and resolution of the lesion is unlikely,
Fluoride 8
the clinically apparent remineralization of a white spot
Saliva 9
lesion may also be due to its surface abrasion following
Summaryandprinciplesoftreatment
improved oral hygiene procedures. Remineralization or
planningfor ahighcariesriskpatient 13
regrowthofpartiallydemineralizedapatitecrystalsinthe
surface zone of an enamel lesion (Figure 1.3) has been
DENTAL CARIES THE DISEASE reported.However,therelativelywell-mineralizedsurface
zoneactsalsoasadiffusionbarriertoions,makingitless
likelythat,intheunderlyingbodyofthelesion,supersat-
Dental caries is a disease that is common to all dentate urationwithrespecttoapatitewilloccurwithsubsequent
individuals. At the hydroxyapatite crystal level it could mineraldeposition.Preventionofthediseaseistherefore
beconsideredaubiquitousphenomenon.Fordentalcar- our primary aim. However, for many patients, this pri-
ies to occur a bacterial biofilm has to accumulate on a mary prevention fails and lesions develop. Caries risk
toothsurface.Thebacteriawithinthebiofilmmetabolize assessment and early caries detection are important so
dietarysugarsubstratesproducingacidswhich,overtime, that further prevention can be targeted to those patients
lead to demineralization of the tooth tissue. Thus the and lesions that are in need. In this situation a method
requirements for the carious process may be depicted by of monitoring the lesion is also important to determine
the Venn diagram seen in Figure 1.1. However, this dia- the outcome of our preventive approach; that is, has the
gramisoverlysimplisticandimpliesthatthediseasepro- lesionarrestedorprogressed.
cess and its progression are inevitable. Clinically, this is Primary prevention can fail for a number of reasons.
not the case. Some tooth surfaces that are frequently It may be due to the fact that the patient has not visited
©2011ElsevierLtd.
1
Advanced OperativeDentistry:APracticalApproach
Body of lesion Surface zone
Susceptible Bacterial
tooth surface biofilm
Dental
caries
Sugar
substrate Time
Figure1.1 Venndiagramdepictingtherequirementsfor
cariestooccur.
↑ Sugar intake
No fluoride
Poor OH Figure1.3 Highdefinitionmacroradiographofasectionof
atoothshowingtwoenamellesionsonthebilateralwalls
Demineralization ofafissure.Therelativelywell-mineralizedsurfacezoneand
bodyofthelesioncanclearlybeseen.
Lesion arrest
THE RESTORATIVE CYCLE
Improved OH
Fluoride
↓ Sugar intake
A significant proportion of a dentist’s work time is spent
replacingrestorationsandthemostcommonreasongiven
Figure1.2 Diagramdepictingthedynamicnatureofthe tojustifythisclinicaldecisionisthepresenceofsecondary
cariousprocessandhowitcanbeinfluencedbysomeexternal caries. This is caries that develops under or adjacent to a
factors.
restorationplacedtorepairacariouslesion.Thetermsec-
ondarycariesis,however,misleadingasitimpliesthatthe
a dentist to receive such advice or, worse still, they may restoration is somehow the cause. In certain situations
have attended a dentist or dental care professional and this is true when the restorative procedures have been
notbeengivenpreventiveadviceandtreatment.However, carried out incorrectly. For example, ledges create plaque
for some patients, regardless of their attendance pattern, stagnation areas, poor contact points allow food packing
the preventive advice is ignored or they are unable to andpooradaptationwithaninadequatebondofmateri-
follow it through no fault of their own. For example, an alstotoothtissueleadstomicroleakage(Figure1.4).Most
elderly patient may know that oral hygiene procedures ’secondary caries’ is actually new caries that has just
areimportantincariesprevention,buttheymaynothave formed adjacent to the restoration and is better termed
themanualdexterity,duetoaphysicaldisability,tocarry as such: caries adjacent to a restoration (CAR). The
themoutefficiently. appearance of caries, following restoration of a tooth,
When primary prevention fails, demineralization illustrates the continued high caries risk of the patient
within the carious lesion can progress to a stage that it and also shows that restoration alone does not change
becomes heavily infected with bacteria and no longer this.Inordertopreventrecurrenceitisfundamentalthat
manageable with preventive procedures alone. Indeed, thecariesriskbemanaged.Ifsuccessful,thismightavoid
thesurfaceofthelesioncanbreakdownandamicrocav- theneedformoreadvancedrestorativework,andensure
ityorfrankcavitycanresultwhichcannolongerbekept itspredictabilitywhencarriedout.
cleanofplaque.Inthesesituationscariesremovalandres- Unlike directly placed restorations, which are packed
toration with an appropriate dental material is required. andadaptedtocavitywallsandmargins,indirectrestora-
Thepatienthasnowenteredtherestorativecycle. tions are made on models from impressions taken of
2
Chapter |1| Management ofdentalcaries
A B
Figure1.4 Bitewingradiographsofahighcariesriskpatient.Theamalgamrestorationsplacedinthelowerrightsecond
premolartoothdistally,theupperrightsecondmolarmesiallyandthecompositerestorationupperleftfirstpremolardistally
haveledgesandarepoorlycontoured,encouragingfoodpackingandcariesadjacenttotherestorations.
tooth preparations. As such, discrepancies in the mar-
ginal fit, seating and hence the width of cement lute
exposedtotheoralcavitycanoccur.Marginaldiscrepan-
ciesintheorderof70mmhavebeenreportedinwell-fit-
tingrestorations.Whenfittinganindirectrestorationitis
important to assess its fit to ensure the marginal discre-
panciesarekepttoaminimum.Adentalprobeisuseful
for checking this and for ledges. Poor plaque control in
relationtoill-fittingandcontouredrestorationsnotonly
increasesthepatient’srisktonewcaries,butalsotoperi-
odontal disease if the margins are close to the gingival Figure1.5 Disclosedbiofilmonthebuccalsurfaceofthe
tissues. lowerleftsecondpremolartoothhaspartiallybeenremoved
exposingthewhitespotlesionbeneath.Thebiofilmonthe
CARIES DETECTION AND DIAGNOSIS mesialsurfaceofthefirstmolartoothcompletelyobscuresthe
detectionofthewhitespotlesionbeneath.
Itisimportantwhenexaminingapatientforprimarycar-
ies or caries adjacent to restorations that the teeth are refractiveindicesbetweenenamelandairresultsingreater
examined clean. The carious process initially takes place light scattering, enabling easier recognition of the white
inthebiofilmonthesurfaceofthetoothandtheproduct spotlesion.TheocclusallesioninFigure1.7clearlyillus-
ofthatprocessistheinitiallesioninthetooth.Toseethe tratesthisanditstandstoreasonthatalesionthatneeds
lesion and make a diagnosis the biofilm needs to be tobedriedtoenableitsdiagnosisislessseverethanone
removed (Figure 1.5). It is also essential that the teeth that is seen even on a wet surface. The examination of
areexaminedbothwetanddry.Theimportanceofdrying cleanteethunderbothwetanddryconditionsformsthe
isillustratedinFigure1.6.Whenlightilluminatesasound basis for a clinical visual classification system known as
tooth, the light can either be transmitted, or it can theInternationalCariesDetectionandAssessmentSystem
undergo refraction or reflection. Refraction is the ability (ICDASII).Thissystemcharacterizeslesionsofincreasing
ofatooth tobend (scatter) light and willvary according severitybycorrelatingthevisualappearanceofthelesions
to the refractive index of the material the light passes withtheirhistologicaldepth(Table1.1).TheICDASIIcri-
through.Theporositiescreatedinenamelduringthecari- teriacanalsobeappliedtocariesadjacenttorestorations.
ous process are normally filled with water (refractive For further information on the ICDAS, visit the website
index¼1.33)whichhasarefractiveindexclosetoenamel http://www.icdas.org/index.htm.
(1.66).Inthissituationlittlelightscatteringoccurs.Ifthe Anumberofcariesdetectiondeviceshavebeeninvented
lesionisdriedandthewaterisreplacedwithairwhichhas to aid detection and monitoring of early carious lesions;
a lower refractive index (1.0), the larger difference in however,theirusehasmainlyfocussedonprimarycaries.
3
