Nicolas Coomber discusses the importance of treatment planning.
Loss of tooth structure can occur for a number of reasons. These may include bruxism, eating disorders, and dentinogenesis or amelogenesis imperfecta. Each of these can lead to the weakening and wearing of the teeth, which eventually leads to the decline of overall oral health, making the teeth more susceptible to infection and impacting on their function and aesthetics. When patients present with signs of erosion, it is important to act quickly, so that you are able to provide them with the most minimally invasive option, helping to preserve the health of as much tissue as possible. However, in some cases, there may be extensive tissue loss, meaning that further restorative treatment could be necessary.
Making the decision to provide a crown
When performing conservative dentistry, it is important to consider whether it is suitable to offer patients a crown in each individual case. A crown may be a valid option for many, but this will depend on the extent of tooth loss, and the risk to the remaining tissue and adjacent teeth if a crown is placed. Where possible, you should implement your most conservative option first, as this could postpone the need for more invasive treatment, and therefore slow down the restorative cycle.
As with any procedure, providing crowns comes with risks. This includes the potential to compromise the vitality of the tooth’s pulp. Additionally, overheating the tooth during the procedure could lead to pulp necrosis. If the pulp is compromised, it may be necessary to perform endodontic treatment. This could require a more extensive restoration and more invasive treatment. You should make patients aware of this risk, and plan accordingly to minimise it as much as possible.
Consider occlusion for a long-lasting, low-risk restoration
It is recommended to consider the end result before preparation begins. Take into account the patient’s occlusion, as it is likely that the loss of tissue has compromised this. This means considering the way that the final restoration will come into contact with its surrounding teeth. When providing a crown, it is essential to consider what precisely needs to be changed, or if extensive treatment is needed to optimise the patient’s occlusion. Clinicians should be careful here as, if the occlusion is incorrect, it could wear down the enamel of surrounding teeth, and put stress on the jaw joint, leading to temporomandibular disorder (TMD). By planning effectively, you reduce the risk of complications down the line, and ensure the crown will be long-lasting and comfortable for the patient. This is another important step for delaying the progression of the restorative cycle.
Accuracy in preparation, with consideration for surrounding teeth
It is important to use the appropriate instruments during crown preparation. This can help to avoid damage to neighbouring teeth and ensure you are able to remove tissue accurately and predictably. For this, it is recommended that a narrow, flame-shaped diamond bur is used to help avoid contact with other teeth. It is also important that you do not create sharp angles when preparing the tooth, as these can create areas of stress, which could eventually lead to fractures. Therefore, where appropriate, opt for burs with rounded ends, rather than flat. The quality of your instruments can also have an impact. If they wear down quickly, and produce irregular results, it will become difficult for you to plan the treatment outcome effectively.
Choice of instruments is essential for providing predictable treatment. The Diatech Multilayer Diamond range of instruments from Coltene have a uniform coverage of diamond on multiple different levels. This means that, as the outer layer wears, new diamond grits with sharp edges will be exposed, facilitating consistent and predictable treatment results. The instruments are high-quality, reusable and suitable for reprocessing – and are indicated across a range of clinical scenarios including preparation of crowns and cavities, removal of old fillings, fine adjustments, crown separation, and endodontic access. In addition, the Diatech Z-Rex diamond instruments make adjustments and removal of zirconia and high-performance ceramic restorations easy.
It can be challenging to create the ideal outcome for each patient, but with comprehensive planning and preparation, you will be able to accurately predict the outcome of the restoration, and achieve an excellent result for your patient. If a crown is necessary to restore the tooth, as opposed to less destructive options, it is important that treatment is planned carefully, to ensure the restoration is long lasting. This will mean that your patient will be more likely to enjoy their crown for many years, without needing additional restorative work in that time. Ensure you advise patients on appropriate oral hygiene measures too, to help them protect their investment, and recommend that they attend regular dental appointments to monitor the restoration and overall oral health.
References available on request.