- Email: [email protected]
The Mutilated Dentition: An Alternative Approach
Oil
C L I NI C AL R E P O R T S
The mutilated dentition: an alternative approach Henry Hurwitz, DDS
To provide esthetic yet inexpensive restoration of severely carious anterior teeth, stainless steel posts with composite resin cores for crowns were used as interim substitutes for more costly crowns.
the population. The patient with a mutilated anterior dentition who cannot at that time afford the cost of crowns is often faced with the possi bility of extractions followed by some type of removable appliance. An alternate, intermediate solution is presented.
c a r ie s to th e g in g iv a l m a rg in s , w ith o n ly s h e lls o f e n a m e l r e m a in in g . In th e p o s te r io r se g m e n ts w e re m is s in g te e th , se v e ra l lo n g -te rm p e r ia p ic a l a b s c e s s e s , a n d r e s id u a l r o o ts fr o m b r o k e n a n d c a r io u s te e th .
Treatm ent T r a d itio n a l s e q u e n c e o f tr e a tm e n t w a s to
R e p o rt o f c a s e
T
he problems of esthetics have traditionally taken a back seat to the desires of the dentist to obtain func tional and physiologic results in the area of restorative dentistry. This is evidenced by the fact that only one complete textbook1 has been pro duced on dental esthetics in the past ten years. However, to the patient, especially one without acute pain, the esthetic appearance is often the most important. Recent advances in dental mate rials enable the skilled dentist to beautify the dentition of even the m o s t c a r i e s - p r o n e p a t ie n t . Goldstein,1 in his textbook on esthe tics in dentistry, describes a mul titude of techniques for solving esthetic problems. Most of these techniques involve the use of acidetched composite resins (Nuva-Fil, N u v a -S e a l) or f u l l c o v e r a g e porcelain-fused-to-gold crowns. In the case of advanced caries of the an terior teeth, ceramo-metal crowns are generally the preferred restorations. The cost of ceramo-metal crowns is, unfortunately, beyond the finan cial capability of a large segment of
t a l l y ig n o r e d b e c a u s e o f th e u n u s u a l p s y c h o lo g ic a l p ro b le m s a n d b e c a u s e th e
A 2 1 -y e a r-o ld w o m a n w a s re fe rre d to th e
p a tie n t sa id th e r e w a s n o d is c o m fo rt. T o
o ffic e b e c a u s e o f h e r a p p e a ra n c e . S h e h ad
g a in th e c o n f id e n c e o f th e p a tie n t a n d to
n o t v is ite d a d e n tis t in at le a s t te n y e a rs.
g iv e h e r so m e e m o tio n a l r e a s s u r a n c e , a n
D u rin g th e in it ia l in te r v ie w a n d d u rin g
a tte m p t w a s m a d e to ra p id ly r e s to re th e
m a n y s u b s e q u e n t v is its , th e p a tie n t o fte n sp o k e w ith h e r rig h t h a n d c o v e r in g h e r
m a x illa r y i n c is o r s a n d c a n in e s . T h e r e w a s m in im a l in v o lv e m e n t o f th e m a n d ib u la r
m o u th a n d m u m b le d h e r w o rd s, e v e n in
a n te r io r te e th . A s a ll s ix m a x illa r y a n
c o h e r e n tly . T h e p a tie n t w a s em b a rra sse d b y th e a p p e a r a n c e o f h e r s e v e re ly m u ti
te rio r te e th w e re v ita l a n d a s y m p to m a tic , e n d o d o n t i c tr e a t m e n t w a s p e r fo r m e d ,
l a te d d e n t i t i o n ( F ig 1 ). I n i t i a l r a d io -
d u rin g a s in g le v is it, o n th e in c is o r s a n d
g r a p h ic e v a lu a tio n d is c lo s e d e x te n s iv e c a r ie s w ith p u lp a l in v o lv e m e n t (F ig 2 ,
c a n in e s w ith u s e o f a c o n v e n tio n a l
to p ). T h e r e w a s , h o w e v e r, m in im a l d a m a g e to th e s u r r o u n d in g p e r io d o n tiu m . M o st o f th e m a x illa r y a n te r io r te e th h ad
g u tta - p e r c h a t e c h n i q u e .2 T h is w a s a c c o m p lis h e d q u ic k ly a n d a t a g r e a tly r e d u c e d c o s t to th e p a tie n t. N e x t, a ll c a r ie s
Fig 1 ■ Appearance of severely mutilated denti tion in 21-year-old pa tient.
JADA, Vol. 100, May 1980 ■ 703
CLIN ICA L
REPORTS
Fig 2 ■ Top, initial radiographic evaluation disclosed extensive caries with pulpal involvement. Bot tom, radiographic appearance of six maxillary teeth after endodontic treatment was performed, caries and undermined enamel were removed, and stainless steel posts were fitted into four canals with zinc phosphate cement. Remaining two teeth were supported by tapered stainless steel posts with ac cessory threaded pins.
a n d u n d e rm in e d e n a m e l w e re re m o v ed a n d s lig h t b e v e ls w e re p la c e d a ro u n d th e r e m a in in g e n a m e l. S ta in le s s s te e l p o sts (S ta r R a d ix A n c h o rs ) w e re fitte d an d c e m e n te d in to fo u r o f th e c a n a ls , u s in g z in c p h o s p h a te c e m e n t. T h e re m a in in g tw o t e e t h w e r e s u p p o r te d b y ta p e r e d s t a in le s s s te e l p o s ts w ith a c c e s s o r y th re a d e d p in s (F ig 2 , b o tto m ). C e llu lo id c r o w n fo rm e rs w e re a d a p te d to th e m a r g in s o f e a c h to o th . T h e s e c ro w n fo rm e rs w e re th e n fille d w ith a m ix o f c o m p o s ite r e s in (C o n c is e ) a n d s e a te d o v e r th e p re p a re d to o th . A fte r th e r e s in h a rd e n e d , th e c r o w n fo r m e rs w e r e re m o v e d a n d th e c o m p o s ite c o r e o f th e to o th w a s c a rv e d , u s i n g f i n e d ia m o n d s t o n e s , a n d th e n p o lis h e d . T h e o c c lu s a l c o n ta c t w a s a d ju s te d to e x e rt a m in im a l a m o u n t o f fo r c e o n th e s e te e th in b o th m a x im u m in te rc u s p a tio n (c e n tr ic o c c lu s io n ) an d e x c e n t r i c e x c u r s i o n s . F ig u r e 3 s h o w s p o s t o p e r a tiv e re s u lts a fte r a w e e k . R e s u lts a fte r 1 5 m o n th s a re s h o w n in F ig u re 4 . A fte r th e s u c c e s s fu l re s to ra tio n o f th e m a x i l l a r y s i x a n t e r i o r t e e t h , t h e im m e d ia te n e e d s o f th e p o s te rio r s e g m e n ts w e re s a tis fie d . T re a tm e n t c o n s is te d o f e x t r a c t io n o f re s id u a l ro o ts a n d n o n re sto ra b le te e th , e n d o d o n tic tr e a tm e n t as n e e d e d , a n d r e s to ra tio n o f c a rio u s le s io n s w ith a m a lg a m . T h e p o s te rio r re sto ra tio n s w e re a ll c o m p le te d a t th e e x is tin g v e rtic a l d im e n s io n .
D iscu ssio n The use of stainless steel posts with com posite resin as the core for crowns has been well documented in the literature.3'5 In this case, the use of such restorations was expanded to 704 ■ JADA, Vol. 100, May 1980
Fig 3 ■ Top, postopera tive facial view of maxil lary anterior teieth one week after completion of composite buildup. Mid dle, postoperative palatal view. Bottom, closeup palatal view.
that of an interim substitute for a more expensive crown. Additional skills are required to shape and finish the resin buildup into an esthetic res toration. Many practitioners would limit this type of treatment to those patients with a definite preference for cast crowns as a final restoration, but this may be an unfair restriction, as the economic situation of the pa tient may improve, thereby making possible further treatment and com pletion with ceramo-metal crowns. A complication of the use of the crow n s d escrib ed here is th at composite resin materials often de teriorate rapidly in the oral environ ment. Twenty months after the time of placement in this case, however, there has been minimal breakdown of the integrity of the composite. As a precaution, to help preserve the res
C LIN IC A L
torations, it was recommended that the patient: avoid stains caused by smoking or drinking coffee or tea, ex cessively; avoid breaking hard foods with anterior teeth; and be careful and thorou gh in bru sh in g and flossing. There are many criteria for select ing patients for this type of restora tion. Contraindications would in clude poor motivation of the patient, evidence of poor oral hygiene, mod erate to advanced periodontal dis ease, teeth with fragile or irregular root forms, an occlusion in which there is heavy anterior contact, and the presence of caries apical to the al veolar crest.
REPO RTS
Fig 4 ■ Top, appearance of teeth, facial view, 15 months postoperatively. Bottom, palatal view of teeth 15 months postoper atively.
S u m m a ry Econom ics often dictate a com promise in restoration of an esthetic appearance because of the high costs of ceramo-metal crowns. The tech nique described in this case can, with carefully selected patients, provide an alternative to immediate extrac tion and replacement with remov able partial dentures. The tooth with severe caries can be restored to fulfill the esthetic de mands of the patient as well as to satisfy functional requirements.
Dr. H urw itz is c lin ic a l a sso cia te, S ch o o l o f D ental M e d icin e , U n iv ersity of P en n sy lv a n ia , 4 0 0 1 S p ru ce S t, P h ila d e lp h ia , 1 9 1 0 4 . A d dress req u ests fo r re p rin ts to th e author.
3 . C apu to, A .A ., and S ta n d le e , J.P . P in s and posts— w h y , w h en and h ow . D en t C lin N orth
1. G o ld s te in , R .E . E s th e tic s in d e n tis try . P h ila d e lp h ia , J. B . L ip p in c o tt C o., 1 9 7 6 .
teeth . J P ro sth et D ent 3 8 ( 4 ) :4 0 5 - 4 1 2 ,1 9 7 7 .
2 . F ra n k , A .L .; A b ou -R ass, M .; and G lick , D.H . C h an g in g tren d s in en d o d o n tics. JAD A
A m 2 0 (2 ):2 9 9 -3 1 1 , 1 9 7 6 . 4 . K an to r, M .E ., and P in e s, M .S . A co m p a ra tiv e stud y o f restorativ e te ch n iq u e s fo r pu lp less 5 . L a u , V .M . R e in fo r c e m e n t o f e n d o d o n t i c a l l y tr e a te d te e th . D e n t C lin N o rth A m 2 0 (2 ):3 1 3 -3 2 8 , 1 9 7 6 .
9 6 (2 ):2 0 2 -2 1 0 , 1 9 7 8 .
Hurwitz : MUTILATED DENTITION ■ 705
C L I NI C AL R E P O R T S
The mutilated dentition: an alternative approach Henry Hurwitz, DDS
To provide esthetic yet inexpensive restoration of severely carious anterior teeth, stainless steel posts with composite resin cores for crowns were used as interim substitutes for more costly crowns.
the population. The patient with a mutilated anterior dentition who cannot at that time afford the cost of crowns is often faced with the possi bility of extractions followed by some type of removable appliance. An alternate, intermediate solution is presented.
c a r ie s to th e g in g iv a l m a rg in s , w ith o n ly s h e lls o f e n a m e l r e m a in in g . In th e p o s te r io r se g m e n ts w e re m is s in g te e th , se v e ra l lo n g -te rm p e r ia p ic a l a b s c e s s e s , a n d r e s id u a l r o o ts fr o m b r o k e n a n d c a r io u s te e th .
Treatm ent T r a d itio n a l s e q u e n c e o f tr e a tm e n t w a s to
R e p o rt o f c a s e
T
he problems of esthetics have traditionally taken a back seat to the desires of the dentist to obtain func tional and physiologic results in the area of restorative dentistry. This is evidenced by the fact that only one complete textbook1 has been pro duced on dental esthetics in the past ten years. However, to the patient, especially one without acute pain, the esthetic appearance is often the most important. Recent advances in dental mate rials enable the skilled dentist to beautify the dentition of even the m o s t c a r i e s - p r o n e p a t ie n t . Goldstein,1 in his textbook on esthe tics in dentistry, describes a mul titude of techniques for solving esthetic problems. Most of these techniques involve the use of acidetched composite resins (Nuva-Fil, N u v a -S e a l) or f u l l c o v e r a g e porcelain-fused-to-gold crowns. In the case of advanced caries of the an terior teeth, ceramo-metal crowns are generally the preferred restorations. The cost of ceramo-metal crowns is, unfortunately, beyond the finan cial capability of a large segment of
t a l l y ig n o r e d b e c a u s e o f th e u n u s u a l p s y c h o lo g ic a l p ro b le m s a n d b e c a u s e th e
A 2 1 -y e a r-o ld w o m a n w a s re fe rre d to th e
p a tie n t sa id th e r e w a s n o d is c o m fo rt. T o
o ffic e b e c a u s e o f h e r a p p e a ra n c e . S h e h ad
g a in th e c o n f id e n c e o f th e p a tie n t a n d to
n o t v is ite d a d e n tis t in at le a s t te n y e a rs.
g iv e h e r so m e e m o tio n a l r e a s s u r a n c e , a n
D u rin g th e in it ia l in te r v ie w a n d d u rin g
a tte m p t w a s m a d e to ra p id ly r e s to re th e
m a n y s u b s e q u e n t v is its , th e p a tie n t o fte n sp o k e w ith h e r rig h t h a n d c o v e r in g h e r
m a x illa r y i n c is o r s a n d c a n in e s . T h e r e w a s m in im a l in v o lv e m e n t o f th e m a n d ib u la r
m o u th a n d m u m b le d h e r w o rd s, e v e n in
a n te r io r te e th . A s a ll s ix m a x illa r y a n
c o h e r e n tly . T h e p a tie n t w a s em b a rra sse d b y th e a p p e a r a n c e o f h e r s e v e re ly m u ti
te rio r te e th w e re v ita l a n d a s y m p to m a tic , e n d o d o n t i c tr e a t m e n t w a s p e r fo r m e d ,
l a te d d e n t i t i o n ( F ig 1 ). I n i t i a l r a d io -
d u rin g a s in g le v is it, o n th e in c is o r s a n d
g r a p h ic e v a lu a tio n d is c lo s e d e x te n s iv e c a r ie s w ith p u lp a l in v o lv e m e n t (F ig 2 ,
c a n in e s w ith u s e o f a c o n v e n tio n a l
to p ). T h e r e w a s , h o w e v e r, m in im a l d a m a g e to th e s u r r o u n d in g p e r io d o n tiu m . M o st o f th e m a x illa r y a n te r io r te e th h ad
g u tta - p e r c h a t e c h n i q u e .2 T h is w a s a c c o m p lis h e d q u ic k ly a n d a t a g r e a tly r e d u c e d c o s t to th e p a tie n t. N e x t, a ll c a r ie s
Fig 1 ■ Appearance of severely mutilated denti tion in 21-year-old pa tient.
JADA, Vol. 100, May 1980 ■ 703
CLIN ICA L
REPORTS
Fig 2 ■ Top, initial radiographic evaluation disclosed extensive caries with pulpal involvement. Bot tom, radiographic appearance of six maxillary teeth after endodontic treatment was performed, caries and undermined enamel were removed, and stainless steel posts were fitted into four canals with zinc phosphate cement. Remaining two teeth were supported by tapered stainless steel posts with ac cessory threaded pins.
a n d u n d e rm in e d e n a m e l w e re re m o v ed a n d s lig h t b e v e ls w e re p la c e d a ro u n d th e r e m a in in g e n a m e l. S ta in le s s s te e l p o sts (S ta r R a d ix A n c h o rs ) w e re fitte d an d c e m e n te d in to fo u r o f th e c a n a ls , u s in g z in c p h o s p h a te c e m e n t. T h e re m a in in g tw o t e e t h w e r e s u p p o r te d b y ta p e r e d s t a in le s s s te e l p o s ts w ith a c c e s s o r y th re a d e d p in s (F ig 2 , b o tto m ). C e llu lo id c r o w n fo rm e rs w e re a d a p te d to th e m a r g in s o f e a c h to o th . T h e s e c ro w n fo rm e rs w e re th e n fille d w ith a m ix o f c o m p o s ite r e s in (C o n c is e ) a n d s e a te d o v e r th e p re p a re d to o th . A fte r th e r e s in h a rd e n e d , th e c r o w n fo r m e rs w e r e re m o v e d a n d th e c o m p o s ite c o r e o f th e to o th w a s c a rv e d , u s i n g f i n e d ia m o n d s t o n e s , a n d th e n p o lis h e d . T h e o c c lu s a l c o n ta c t w a s a d ju s te d to e x e rt a m in im a l a m o u n t o f fo r c e o n th e s e te e th in b o th m a x im u m in te rc u s p a tio n (c e n tr ic o c c lu s io n ) an d e x c e n t r i c e x c u r s i o n s . F ig u r e 3 s h o w s p o s t o p e r a tiv e re s u lts a fte r a w e e k . R e s u lts a fte r 1 5 m o n th s a re s h o w n in F ig u re 4 . A fte r th e s u c c e s s fu l re s to ra tio n o f th e m a x i l l a r y s i x a n t e r i o r t e e t h , t h e im m e d ia te n e e d s o f th e p o s te rio r s e g m e n ts w e re s a tis fie d . T re a tm e n t c o n s is te d o f e x t r a c t io n o f re s id u a l ro o ts a n d n o n re sto ra b le te e th , e n d o d o n tic tr e a tm e n t as n e e d e d , a n d r e s to ra tio n o f c a rio u s le s io n s w ith a m a lg a m . T h e p o s te rio r re sto ra tio n s w e re a ll c o m p le te d a t th e e x is tin g v e rtic a l d im e n s io n .
D iscu ssio n The use of stainless steel posts with com posite resin as the core for crowns has been well documented in the literature.3'5 In this case, the use of such restorations was expanded to 704 ■ JADA, Vol. 100, May 1980
Fig 3 ■ Top, postopera tive facial view of maxil lary anterior teieth one week after completion of composite buildup. Mid dle, postoperative palatal view. Bottom, closeup palatal view.
that of an interim substitute for a more expensive crown. Additional skills are required to shape and finish the resin buildup into an esthetic res toration. Many practitioners would limit this type of treatment to those patients with a definite preference for cast crowns as a final restoration, but this may be an unfair restriction, as the economic situation of the pa tient may improve, thereby making possible further treatment and com pletion with ceramo-metal crowns. A complication of the use of the crow n s d escrib ed here is th at composite resin materials often de teriorate rapidly in the oral environ ment. Twenty months after the time of placement in this case, however, there has been minimal breakdown of the integrity of the composite. As a precaution, to help preserve the res
C LIN IC A L
torations, it was recommended that the patient: avoid stains caused by smoking or drinking coffee or tea, ex cessively; avoid breaking hard foods with anterior teeth; and be careful and thorou gh in bru sh in g and flossing. There are many criteria for select ing patients for this type of restora tion. Contraindications would in clude poor motivation of the patient, evidence of poor oral hygiene, mod erate to advanced periodontal dis ease, teeth with fragile or irregular root forms, an occlusion in which there is heavy anterior contact, and the presence of caries apical to the al veolar crest.
REPO RTS
Fig 4 ■ Top, appearance of teeth, facial view, 15 months postoperatively. Bottom, palatal view of teeth 15 months postoper atively.
S u m m a ry Econom ics often dictate a com promise in restoration of an esthetic appearance because of the high costs of ceramo-metal crowns. The tech nique described in this case can, with carefully selected patients, provide an alternative to immediate extrac tion and replacement with remov able partial dentures. The tooth with severe caries can be restored to fulfill the esthetic de mands of the patient as well as to satisfy functional requirements.
Dr. H urw itz is c lin ic a l a sso cia te, S ch o o l o f D ental M e d icin e , U n iv ersity of P en n sy lv a n ia , 4 0 0 1 S p ru ce S t, P h ila d e lp h ia , 1 9 1 0 4 . A d dress req u ests fo r re p rin ts to th e author.
3 . C apu to, A .A ., and S ta n d le e , J.P . P in s and posts— w h y , w h en and h ow . D en t C lin N orth
1. G o ld s te in , R .E . E s th e tic s in d e n tis try . P h ila d e lp h ia , J. B . L ip p in c o tt C o., 1 9 7 6 .
teeth . J P ro sth et D ent 3 8 ( 4 ) :4 0 5 - 4 1 2 ,1 9 7 7 .
2 . F ra n k , A .L .; A b ou -R ass, M .; and G lick , D.H . C h an g in g tren d s in en d o d o n tics. JAD A
A m 2 0 (2 ):2 9 9 -3 1 1 , 1 9 7 6 . 4 . K an to r, M .E ., and P in e s, M .S . A co m p a ra tiv e stud y o f restorativ e te ch n iq u e s fo r pu lp less 5 . L a u , V .M . R e in fo r c e m e n t o f e n d o d o n t i c a l l y tr e a te d te e th . D e n t C lin N o rth A m 2 0 (2 ):3 1 3 -3 2 8 , 1 9 7 6 .
9 6 (2 ):2 0 2 -2 1 0 , 1 9 7 8 .
Hurwitz : MUTILATED DENTITION ■ 705