Contemporary Fixed Prosthodontics
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C H A P T E R 3 1 Postoperative Care After placement and cementation of a fixed dental pros- agent that may have been overlooked previously and that thesis (FDP), patient treatment continues with a care- all aspects of the occlusion remain satisfactory. fully structured sequence of postoperative appointments Radiolucent cements should be avoided because designed to monitor the patient’s dental health (Fig. detecting excess luting agent radiographically is impos- 31-1), ensure meticulous plaque control habits, identify sible if that material is effectively radiolucent. With luting any incipient disease, and introduce any corrective agents of greater radiopacity, excess cement is spotted treatment that may be needed before irreversible future more easily on routine radiographs; therefore, the dentist damage occurs. should choose a luting agent that is as radiopaque as Patients should be instructed in special plaque-control possible. In practice, luting agents are available in a measures, especially around pontics and connectors, and wide range of radiopacities.4-6 Figure 31-5 summarizes the use of special oral hygiene aids such as floss threaders data from these studies. (Fig. 31-2). If pontics are properly designed (see Chapter The presence of fremitus (see Chapter 1), or “pol- 20), floss can be looped through the embrasure spaces on ished” facets, on the occluding surfaces of cast restora- each side, and the loop can be pulled tightly against the tions at the postcementation appointment should prompt convex pontic tissue surface. A sliding motion is then a careful reassessment and correction of the occlusion. If used to remove dental plaque (Fig. 31-3). Flossing under any minor shift in tooth position has occurred, some pontics is essential for improving prosthesis longevity. occlusal adjustment may be necessary. If so, the patient When dental floss is used, the mucosa beneath pontics is rescheduled to visit the following week to confirm that remains healthy; without its use, mild or moderate no further correction is needed. inflammation results.1 Tissue response has been shown to be independent of the pontic material.2 Recall examinations are especially important for PERIODIC RECALL patients with extensive restorations and should be carried out by the dentist. Responsibility for follow-up care Patients with cast restorations should attend recall visits should not be delegated to auxiliary personnel (although at least every 6 months. If recall is less frequent, recurrent good cooperation with a dental hygienist is beneficial caries or the development of periodontal disease may go for success). undetected. Patients who have been provided with exten- Detecting disease around an FDP can be extremely sive FDPs (Fig. 31-6) need more frequent recall appoint- difficult at a stage when corrective treatment is still rela- ments, particularly when advanced periodontal disease is tively simple. For instance, partial dissolution of the present. The restorative dentist or the periodontist can luting agent may be difficult to diagnose with a subgin- coordinate these appointments. To ensure treatment con- gival margin. Caries is often detected only after irrevers- tinuity, it is imperative to establish in advance who will ible pulp involvement has resulted. Caries under a crown assume primary responsibility for coordinating recall is more difficult to detect radiographically, although appointments. bitewing images provide some interproximal informa- tion. Follow-up studies on patients with FDPs reveal that History and General Examination identifying risk factors and predicting the development of caries in any particular patient are complicated. The patient’s medical history should be reviewed and However, there is no indication that caries is more likely updated at least annually. The patient should be exam- to occur in association with prostheses than on unre- ined according to the principles introduced in Chapter 1. stored teeth.3 Particular attention is paid to the soft tissues because If caries is overlooked, disease may rapidly progress to early signs of oral cancer may be detected at a recall the point at which the fabrication of a new prosthesis appointment. becomes inevitable or, even worse, tooth loss results. Oral Hygiene, Diet, and Saliva POSTCEMENTATION APPOINTMENTS Patients tend to become somewhat less diligent in their plaque control efforts when the active phase of their To enable the dentist to monitor the function and comfort treatment is completed. The dentist should look carefully of the prosthesis and to verify that the patient has mas- for any signs of deterioration in oral hygiene and assess tered proper plaque control (Fig. 31-4), an appointment the general effectiveness of plaque control at every recall is generally scheduled within a week to 10 days after the with an objective index (Fig. 31-7). Deficiencies must cementation of an FDP. The dentist should check care- be identified early, and corrective therapy should be fully that the gingival sulcus is clear of any residual luting initiated. The dentist should ask about changes in diet, 792 31 Postoperative Care 793 FIGURE 31-4 ■ Postcementation monitoring of plaque control is necessary around recently cemented restorations. In this FIGURE 31-1 ■ Treatment after placement of multiple restora- patient, poor oral hygiene has led to gingival inflammation tions. To ensure tissue health and long-term success, proper (arrows). oral hygiene is mandatory. Saliva plays an important role in caries development. Patients with xerostomia can rapidly develop extensive carious lesions.7 Diagnosing the cause of reduced saliva is imperative; the origin is often a drug side effect.8 Patients with dry mouth should be on a more frequent recall schedule (e.g., every 3 months), and fluoride varnish may be applied. A protocol of a chlorhexidine 0.12% 10-mL rinse for 1 minute daily for one week each month, in combination with xylitol gum or candies and high- fluoride toothpaste, has been advocated.9 Dental Caries Dental caries (Fig. 31-8) is the most common cause of failure of a cast restoration.10-13 Detection can be very difficult,14 particularly where complete coverage is used. FIGURE 31-2 ■ Oral hygiene aids designed to maintain partial At each appointment, the teeth should be thoroughly fixed dental prostheses. dried and visually inspected (Fig. 31-9). The explorer must be used very carefully when early enamel lesions are assessed because a heavy-handed examination may damage the fragile demineralized enamel matrix. An intact enamel matrix is essential for procedures that induce remineralization15 (e.g., improved plaque control, dietary changes, topical fluoride applications). Conservative treatment of caries at the cavosurface margin is especially problematic. The lesion can spread rapidly, particularly if the restoration has a suboptimal marginal fit. Use of a small restoration made with amalgam, composite resin, or glass ionomer sometimes corrects the problem (Fig. 31-10). If the cast restoration is supported by an amalgam or composite resin core, the extent of the caries may be difficult to determine. When there is doubt that all carious dentin has been removed, replacing the entire restoration is recommended. FIGURE 31-3 ■ The patient should be instructed in the use of floss to clean partial fixed dental prostheses. Root Caries Caries of exposed root surfaces (Fig. 31-11) can be a severe problem in patients older than 50 (the age group particularly increased sugar consumption or “fad” diets. of patients who most commonly seek fixed prosthodontic Excessive weight loss or gain should also be investigated. care).16-18 In the classic Vipeholm study,19 root caries For instance, a patient who has recently stopped smoking accounted for more than 50% of new lesions in patients may start ingesting large amounts of candy, which can in that age group. Root caries incidence increased con- result in an increase in dental caries. siderably with age.20 In the caries examination from phase 794 PART IV Clinical Procedures: Section 2 Radiopacity Luting Agents mm/Al/4 mm 15 Glass Zinc Resins ionomers Polycarboxylates phosphates 12 Study: Akerboom et al Resin ionomer El-Mowafy et al 9 Matsumara Enamel 6 Increasing radiopacity Dentin 3 0 Tulux Estilux G-Cera Durelon GC Elite All-Bond Fuji Bond GC Carbo Dicor MGC 3M Indirect Ketac-Cem Clearfil Inlay Duo Cement Shofu Carbo Mirage Bond Dual Cement Vitrebond LC Porcelite Dual Shofu HY-Bond GI Shofu HY-Bond ZP Getz Zinc Phosphate FIGURE 31-5 ■ Radiopacity of luting agents. In three in vitro studies,4-6 investigators compared the radiographic appearance of various luting agents with that of aluminum. The data were normalized to account for different specimen thicknesses used by the investiga- tors. Excess luting agent is more difficult to detect if materials have lower radiopacity values. In addition, margin gaps and recurrent caries are more difficult to diagnose. or caused by medication or radiation treatment has been implicated in the origin of rampant caries.23-25 Other factors include the patient’s economic status, diet, oral hygiene, and ethnic background.26 Only a most vigorous effort on the part of the dentist and patient leads to resolution of the problem. Prevention is focused on diet counseling and fluoride treatment. Treatment often requires the placement of large cervical glass ionomer or amalgam restorations that wrap around the periphery of previously placed cast restorations. Such restorations are difficult to place. However, in view of the constraints, they are a preferred alternative to compre- hensive re-treatment with elaborate FDPs. Periodontal Disease FIGURE 31-6 ■ Patients who have received extensive treatment of this nature require frequent follow-up care. Unfortunately, periodontal disease often occurs after placement of FDPs,27 especially where the cavosurface margin has been placed subgingivally28-30 or if the pros- 1 of the Third National Health and Nutrition Examina- thesis is overcontoured.31 Inflammation is more severe tion Survey, root caries affected 22.5% of the dentate with poorly fitting restorations32 (Fig.