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Crowns and Implants (Restoring Extensively Damaged Teeth (Assessing of…

- - - - Static
        (teeth at rest)
      - Dynamic
        (teeth during function)
      - Increases from incisors to molars
        Incisal region (87-293 N)
        Molar region (650 N)
    - - Axial loading
        Loading closest to the fulcrum and force vectors
        Flatten cusps
        Control excursive guidance
        Flatten occlusal planes
        Strategical material use
    - - Cumulative bite force - ie parafunctional habits
        
        Result in =
        
        abfraction lesions
        
        Occ. Attrition
        
        Cusp fracture - Occl. Dimples
  - - - Loss of marginal integrity =
        greatest contributor to loss of tooth strength, as removal of mesial marginal ridge affects the stiffness of distal cusps
      - Cuspal Overlay
        Must protect the cusp = 2mm minimum
        Teeth restored with gold overlays were twice as strong
        selective cusp coverage ONLY protects the covered cusp but this reduces risk of fracture
  - - - Loss of strength in endo treated teeth
        loss of tooth structure
        restorative prognosis is critical
    - - Post length based on:
        
        Potential to minimise damage to the tooth
        
        Optimise post retention
        
        Maintain an adequate apical seal
      - Post diameter:
        
        Increased diameter does not increase retention
        
        Increased diameter increases risk (x6 every 1mm) of root fracture
        
        Post diameter should not exceed 1/3rd root diameter
- - - - HPC
        
        prev. restorative tx (endo?)
        
        Trauma date?
        
        duration of signs/symptoms
        
        Dental Hx
        
        when & whys for tx hx (prognosis of future tx?)
        
        Caries risk analysis
        
        Attitudes & Expectations
        
        Specific concerns, realistic achievable goals
      - E/O
        
        TMJ, muscles of mastication, open/closing path
        
        facial characteristics (symmetry, smile line, lip line, gingival display, skeletal pattern)
      - I/O
        
        Centric stops
        
        supporting teeth, range of movements, Initial tooth contact, slides from Centric Relation (CR) to Maximum Intercuspation (MI)
        
        OB/OJ
        
        Soft tissues, swelling, sinus
        
        Prosthesis (acceptable or failure?)
      - Teeth
        
        Caries Risk Analysis (needs to be controlled!)
        
        Assess coronal tooth structure and restorability
        (this will often involve removal of the current restoration)
        
        Special Tests
    - - Past heavily restored
        Erosion/wear
        Endodontic therapy
        Cracked tooth syndrome/fractures
        Aesthetic concerns
        Abutments.
      - MUST ASSESS RESTORABILITY
      - No crown is a valid tx decision
    - - Material Considerations
        Conservation of tooth structure
        Function
        Mechanical Integrity
        Aesthetics
      - Tooth Preparation Consideration
        Retention/Resistance form
        Pulp preservation
        Occlusal function
        Available tooth structure
        Material of choice
      - Risks
        
        Compromise to remaining tooth tissue
        
        Pulpal irritation
        
        Caries risk
        
        Fracture of tooth or root, fracture of restorative material
        
        Margin exposure (biotype)
      - Alternative Tx Options
        
        Endodontic therapy and PfM crown
        
        Extraction and implant therapy
        
        Adjunctive therapy
        
        Tooth movement/extrusion
        
        crown lengthening surgery
        
        Endodontic therapy
        
        As part of concurrent tx
        
        Bridge
        
        Implant
  - - - Tilting
        
        Drifting
        
        Recession
        
        Open Contacts
        
        Periodontal Pockets
        
        Over Eruption
        
        Residual Ridge Resorption
    - - Removable Appliances:
        Arcylic, CoCr, Root/Implant Over-Dentures
        Fixed Appliances:
        Bridges - Conventional, Resin-Bonded
        Implant - Screwed or Cemented
      - MUST ASSESS LONGEVITY of PERSON/PROSTHESIS for most appropriate tx solution
    - - Aesthetic Requirements
        
        Smile line
        Visibility of gingival margins
        Symmetry of gingival margins
      - Teeth/Root Prognosis
        
        Potential abutment support
        Preservation of alveolar ridge
        Useful roots
      - Missing tooth/teeth space
        
        Position within arch
        
        Space stability
        
        Arch integrity
        Inter/intra-arch integrity
        
        Patterns of bone resorption
        
        Ridge Form
        
        Tooth loss length/height
  - - - Saddle Area
        
        Need for replacing soft tissue defects
        
        aesthetic requirements
        
        Cleaning/OH
        
        Repair/ Maintenance
        
        Is further loss anticipated
    - - Periodontal Health - active or controlled disease, bone levels, mobility
        Past Hx of Rx - remaining dentine, ferrule, success/failure
        Endo Tx - Quality of root fill/coronal rx, potential abutments
- - - - Prevention of damage
        
        Conservation of tooth
        structure
        
        Impacts on OH (ie pulp)
        
        Periodontal health/biotype
        
        axial reduction, margin placement/adaptation
    - - Retention Form
        Resistance Form
        Occlusal relationship
        Guidance
    - - Smile line
        Lip line
        Position of teeth in the smile
  - - - Degree of taper
        Total surface area of cement film/under shear
        Roughness of the tooth surface
    - - Preparation width/length
        Taper (height:width)
        Path of Insertion
  - - - Shade guide
        Shade Prescription form
        Accessary shade guides
        Photograph or slides
        Daylight colour corrected fluorescent light OR Neutral environment
      - Qualities of enamel
        
        Translucence
        Halo effect at incisal edge
        Opalescence
        White opacities
    - - General description/design
        Specification of materials
        Die relief/venting
        Occlusal scheme – contacts of cusps in lateral slides y/n?
        Margin Design/Proximal Contacts
    - - Check:
        
        Margins and contours/form
        
        Marginal ridges
        
        Occlusal contacts/Fit
        
        Colour
- - - - Metal (GOLD)
        
        :check: strength, wear resistance, biocompatible, durability, conservative prep, CADCAM
        :forbidden: aesthetics, cost, lab handling
      - PFM
        
        :check: strength, wear resistance, biocompatible, durability, aesthetics, masking discoloutaion
        :forbidden: aesthetics, aggresive prep, lab handling
      - Ceramic
        
        :check: aesthetics, CADCAM, biocompatible
        :forbidden: strength, wear resistance, aggressive prep, wears opposing teeth, lab handling
    - - :check: Conservation off tooth structure Access to margins for OH Access for vitality testing, good for adequate crown height/no aesthetic concern
        :forbidden: Preparation difficult, Some metal display, not good for short crowns/poor OH/thin teeth
    - - :check: Covering exposed root surfaces, reduction of black triangles, improves aestehtics
        :forbidden: discoloration at margin, breakage, debonding