Some of the most basic treatments are often never discussed in dentistry, such as the simple occlusal (or biting surface) restoration. In the images below, the dark staining in the occlusal (biting surface) grooves are clearly visible. Within this stain, there are perforations in the enamel allowing bacteria and the byproducts of bacterial activity to damage the inner dentin tooth structure. Once the dentin has been affected by decay, the tooth now requires repair in the form of a restoration.
The grooves of the tooth were "opened" with the necessary preparation to access the underlying decay. The decay was exacavated with a sharp carbide bur and then restored with Filtek resin (3M ESPE). A simple restoration like this can often be completed in less than 20 minutes. Timely treatment of decay such as this can save a patient money by not allowng the decay to progress to the point of becoming symptomatic and needing more extensive treatment, not to mention saving valable tooth structure!
This wondreful patient was tired of wearing a removable upper partial denture to replace a missing front tooth and decided a fixed option would be the right fit for her. She was also unhappy with the bonding and rotation of the adjacent front teeth.
A simple, single unit implant supported crown was placed to replace the missing fron tooth and the adjacent teeth were restored with the same ceramic as used for the implant restoration. A simple procedure with dramatic results!
Following a sports injury, this patient was left without a lower central incisor. Initially, the patient was using a removable prosthetic (partial denture) to replce this missing tooth. After wearing the appliance for a few years, the patient decided a fixed option was in order.
An implant fixture was placed with excellent inital stability. A temporary crown was fabricated so the patient no longer required the use of the denture. Once integration of the implant was complete, the patient was ready for the final prosthetic.
A scanpost was placed atop the implant fixture and a Cerec digital image was obtained. The Cerec software was used to create an Emax custom abutment as well as an Emax custom crown.
In the above images, the custom abutment has been delivered and torqued to 35Ncm. The access hole has been sealed with teflon.
The final crown was cemented and minor tissue recontouring completed with a Waterlase to sculpt the tissues into an esthetic emergence profile. With some additional restorative work (i.e. repair of the fractured canine and a full coverage crown for the adjacet central), the esthetics of this case would be complete.
What happens to a tooth once it has a cavity and subsequent restoration to repair this defect?
The life cycle of a tooth that has received a restoration is very predictable and has been well documented over the years.
The first area of decay for a tooth is usually the biting surface or proximal surface (i.e. between adjacent teeth). The initial restoration is small and usually free of sensitivity. As time goes by, the filling and surrounding tooth wear (from abrasion, acid erosion, thermal flexure, etc) and the filling fails. Moisture begins to penetrate the margins and recurrent decay develops. Most often, the restoration is not replaced in a timely manner because there are no symptoms with this process and the patient does not feel the treatment is necessary.
Once the patient decides they are ready for treatment, the old restoration is removed and a larger one placed to accomodate the damaged areas of the tooth. This means the width has increased, the depth has increased, the risk of sensitivity has increased (and the proximal surfaces are usually involved).
As the size of the resoration increases, so does the risk of fracture. Once recurrent decay develops around a filling of this stage, a fracture is inevitable. The fracture usually encompasses a large portion of the tooth and may encroach on the pulp tissue (nerve supply) of the tooth.
Further recurrent decay will develop with time and, when left untreated, will lead to even further fracture and risk for root canal therapy. As this point the only restorative option for the tooth will be a crown.
No restoration is permanent. Eventually the crown will require replacement. If the treatment has been delayed and even more tooth structure is lost, then the tooth may no longer be restorable and require extraction.
This doesn't sound very good, does it?! There are ways to prevent the progression from simple filling to extraction. The single most important thing is routine hygiene maintenance to keep restoration margins free of long-standing plaque and calculus debris. Routine radiographic and visual assessment of the restorations is necessary to detect failing restorations. Timely replacement of restorations can dramatically reduce the increase in size from one restoration to the next.
Choosing the right filling material can also improve the life-span of a restored tooth. Once the filling size has progressed to greater than 1/2 the intercuspal width or a cusp requires replacement, then a CEREC onlay, 3/4 crown or crown are the most durable and long-lasting options. They will reduce the risk of fracture dramatically!
If a tooth gets to the stage where root canal therapy, periodontal surgery and a new crown are required, one has to consider the long-term prognosis for the tooth. In some cases the prognosis will be good. In others, the prognosis may be guarded at best. At this point, replacement of the tooth with an implant-supported crown may be the best option. Implant treatment most closely resembles the original tooth and has an excellent pronosis - if cared for, they may last a lifetime.
One of the great many misconceptions people have about tooth decay is that it is an inherited trait. Many patients will often state, 'my Mom/Dad had bad teeth so I have bad teeth'. This is untrue. There are some genetic traits associated with teeth such as congenitally missing teeth, growth pattern of the jaw bones (Angles Class I, II and III), amelogenesis imperfecta to name a few.
Tooth decay is not inherited. It is 100% the result of the bacterial effects on our teeth. It is an infectious and contagious disease. In fact, it is the second most common disease in North America - second only to the common cold.
When we are born, we lack the bacterial flora in our mouths that are responsible for tooth decay. These bacteria are acquired following exposure; i.e. we become infected! This is most often caused by Mom or Dad sharing spoons with children. The longer we can delay exposure to these bacteria in young children, the lower the risk of developing tooth decay. Think about this before sharing utensils, food and cups with your children!
We can not blame our parents for tooth decay. Proper hygiene practices and diet can easily keep cavity causing bacteria in check and prevent decay!
Here are a some interesting dental myths:
1. My kids took all the Calcium from my teeth while I was pregnant and caused my teeth to decay.
Teeth are formed when we are children. They have a organic mineral matrix that once formed remains completely unchanged for our entire lives. Erosion, abrasion and attrition of the exterior surface of the tooth causes wear, but in no way can pregnancy remove Calcium from our teeth!
2. I inherited my bad teeth from my parents.
There are some dental traits that are genetic; e.g. congenitally missing teeth, genetic disorders like amelogenesis imperfecta, etc. Tooth decay is in no way genetic. It is caused by the metabolites produced by bacteria as they process sugars in our diet. We are not even born with cavity causing bacteria in our mouths, but rather acquire them once exposed (usually when sharing a spoon with our parents as babies). Every individual's teeth are as unique as finger-prints. Unfortunately, we can't blame our parents for this one!
3. Cavities in baby teeth are no big deal because they will just fall out anyway.
Baby teeth are the primary dentition and are just as important as our adult dentition. They are the only way for us to properly chew when we are children. They provide the space required for the eruption of the adult teeth when our jaws have grown to a sufficient size to accommodate them. If we do not treat baby teeth in a timely manner, children may experience pain that may reduce nutritional intake and affect growth and development. Early loss of baby teeth often leads to malpositioned adult teeth and costly orthodontic treatments!
Some fun dental facts:
1. Cavities are the second most common disease in North America - second only to the common cold!
2. Emergency dental treatments cost on average 10 x more than routine preventative dental care.
3. Someone dies of oral cancer every hour.
As of April 1, 2014, the Childrens Oral Health Program (MSI) will be increasing the age of eligible coverage to under 15. This means that children will have basic dental coverage until the end of the day on their 15th birthday.
It is important to note that this program is far from comprehensive and is designed to provide only basic coverage for dental treatment. The program will cover one examination, 2 bitewing radiographs and ONLY ONE PREVENTATIVE SERVICE per year. As usual, basic restorations (or fillings) are covered.
The problem with the program is that these coverages are generally far less than what the average individual requires to maintain their oral health; especially for teenagers! Changes in hormones and the continued eruption of the adult dentition in these years places teens at a high risk for dental problems. Crowding of teeth during eruption, poor oral hygiene techniques/ practices and diet are a few other additional risk factors. To reduce risk, most individuals will require at a minimum, TWO PREVENTATIVE SERVICES per year.
Many parents have been falsely informed and believe that this program is comprehensive meaning that all services will be covered. The purpose of examination is to not only identify dental problems (such as tooth decay), but to establish the patient's RISK. Each treatment plan is based on the individual's needs to reduce risk. Because the program is basic, it rarely covers the pateint's needs - this means there may be treatment required that is not covered by the program.
For more information on this program, please feel free to contact Dr. Luke Haslam and staff at Basinview Dental Centre or the Quickcard Nova Scotia Chilren's Oral Health Care Program.
When looking at this image, there are a few obvious problems:
The dark dark discoloration of the tooth is due to marginal leakage and subsequent recurrent decay beneath the old filling. There is a significant wear facet on the buccal cusp extending distally indicative of malocclusion and possibly parafunction (clenching/ grinding). There is a craze line in the enamel running from the buccal cusp tip distally through the isthmus, beneath the old restoration and ending on the lingual cusp. The proximal surfaces are overbulked with old amalgam giving the tooth poor contour and making hygiene difficult.
The patient was advised of the poor condition of this tooth but decided not to proceed with any treatment until there was a problem with the tooth. A discussion ensued that involved the malocclusion, occlusal wear, recurrent decay and risk of fracture. A full coverage restoration would be ideal to optimize occlusion, strength and gingival health. The patient indicated that he was not interested in treatment because the tooth has never given him problems.
A mere 4 months after our discussion regarding this tooth, the patient returned with a fractured filling. There was some discomfort when biting and the appearance of the tooth was highly suspicious for fracture.
The tooth was anesthetized and isolated with rubber dam for comprehensive assessment: the mesial portion of the amalgam was fractured and missing; there was a large gap in the cavosurface margin, the remaining filling material was mobile and the buccal cusp moved with light pressure.
The restoration was removed to reveal the source of the problem - a clear vertical fracture completely dividing the buccal and lingual segments of the tooth. Unfortunately, this type of fracture can not be repaired and the only course of treatment was immediate extraction of the tooth.
Timely care and maintenace of existing restorations are a crucial component of comprehensive dental care. As old fillings, crowns, etc. wear down, they dramatically increase the risk of fracture to the remaining tooth structure. Also, our bite will change with time such that even regular bite forces can lead to trauma to our teeth.
Don't let this situation happen to you. Waiting until there is a problem can often be too late and very costly - as in this case where the tooth was nonrestorable. A replacement for this tooth will cost the patient more than three times what the initial treatment proposal was. Being proactive with oral health care is the best way to save time, money and maintain your natural, healthy smile.
Contact Dr. Luke Haslam at Basinview Dental Centre to schedule your consultation today!
A patient presented with discomfort on the lower left side due to pulpitis of tooth 3-5. The tooth had been previously restored with a very large and deep composite restoration. The depth of the decay and trauma associated with removing it caused an irreversibe inflammatory response in the tooth known as pulpitis. This tooth required immediate endodontic treatment to remove the inflammed pulp tissue and resolve the discomfort.
Traditionally, this treatment is completed using chemical irrigation of the canal system to ensure the organic tissue and bacteria have been removed from the system. Some chemicals can be dangerous and difficult to use. Also, there is little guarantee that the chemicals introduced into the space can completely reach the apex of the tooth without passing beyond the tooth into the periapical tissues.
At Basinview Dental Centre, Dr. Luke Haslam does not use chemical irrigation to complete root canal disinfection, but rather uses laser energy applied by the Waterlase iPlus. With this system, root canals are cleaned and shaped using traditional instrumentation (hand and rotary endodontic files; stainless steel and/ or nickel titanium). The irrigatant used is simply distilled water - zero complication if any water passes beyond the tooth apex. Once the canal has been shaped as desired, a special laser tip is inserted into the canal space. Once the canal is shaped properly, this tip can be placed into position to allow laser energy to disinfect the tooth apex. Laser energy is applied in a series of passes throughout the canal system until the desired disinfection is achieved - for some teeth, this may merely take 30 seconds!
There is no discomfort or chemical smell. The laser will remove organic debris and bacteria 1000um laterally from the main canal. This means far greater penetration of disinfection than chemical systems into lateral canals, fins, isthmuses and apical deltas. These areas are a common cause of root canal failure - the chemical disinfection simply can not remove was it can not touch.
The root canal completed for this patient clearly shows a complex apical delta - there are at least 5 openings at the apex of this tooth. The laser disinfection allowed for these areas to be easily cleansed prior to obturation which allowed the gutta percha filling to flow into these areas. This will greatly improve the patient's chance of success with this treatment.
The patient noted no post-operative discomfort and has been symptom free since the treatment was completed 4 months ago. The patient has scheduled to have a full coverage crown placed on this tooth to complete the treatment for this tooth.
This patient presented for an emergency assessment of a fractured laterla incisor. The tooth had been previously endodontically treated (i.e. root canal) and had a large composite resin filling that encompassed all tooth surfaces. Due to the extent of these restorations, the tooth was in a highly compromised state and predisposed to fracture. (Sorry, the pre-operative photo did not save properly).
Luckily for this patient, there was enough tooth structure and healthy supporting tissues remaining to allow for a new restoration. The large amount of coronal tooth structure missing meant osseous crown lengthening was required achieve a stable crown margin that would not interfere with the biologic width (i.e. irritate the supporting tissues and bone causing chronic inflammation and premature failure of the restoration).
Crown lengthening was achieved using the Waterlase iPlus. The bone was moved apically 1-2mm as required and the soft tissues were recontoured. There was no need to delay placing the restoration 6-8 weeks as is normally required with traditional crown lengthening, because there is minimal risk of recession following this treatment with the Waterlase.
There is a video of this process at http://basinviewdental.com/dental-videos/
To increase retention, a Fiber Lux Parapost was placed into the root canal space of the tooth. This radiograph shows the post drill inserted into the canal as a reference to guage both the width and length of the canal space. The final post was placed 5mm from the root apex.
Once the post and resin core complex were completed, the final Cerec crown was fabricated using EMax (lithium disilicate) material. The crown was sintered in a ceramic furnace and stained to match the adjacent teeth. Two layers of glaze and polish were completed to stabilize this color.
Here is the post-operative view at two weeks following treatment.Other than minor healing still visible along the buccal margin, it is difficult to tell which tooth was restored. The disto-buccal tilt of the tooth is a product of the patient's occlusion and could not be corrected without significant alteration of the opposing lateral and canine teeth. The patient was happy to simply dupliacte the appearance of his tooth prior to the fracture. He is now going to return to have the same treatment completed for the upper left canine which currently has a large composite filling, 4 stainless steel pins and has been endodontically treated. The patient has chosen to proactively restore this tooth before it fractues
Thanks to the Cerec chairside system, the Waterlase iPlus and our Programat CS sintering furnace, this treatment was completed for this patient in a single appointment. No temporary crowns were required and there was no post-operative healing period following the minor crown lengthening. With traditional methods of treatment, this case would have taken months to complete. Crown lengthening would require 4-6 weeks of healing at a minimum while the patient wore a temporary crown. Once healing was complete, the temporary would be removed and a final impression fabricated to be sent to a dental laboratory. The temporary would be replaced and the patient would return in another 2 weeks for crown try-in. If the esthetics or fit were not acceptable, the crown would be sent back to the laboratory for adjustments while the patient wore the temporary for an additional week. In total, this could have taken 9+ weeks to complete!
At Basinview Dental Centre, Dr. Luke Haslam was able to complete this case in 2 hours! With these technolgies, we will not only see a reduction in treatment time, but also a reduction in treatment cost. In this case, the patient did not require referral to a periodontist to have the crown lengthening completed (as would be traditionally required). There was no commercial laboratory used to fabricate the restoration so there was no third party bill to pay. The patient was resposible for the treatment time and materials only which saved this patient close to $1000.00.
To learn more about our technology, please feel free to schedule a consultation with Dr, Luke Haslam at Basinview Dental Centre.