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Prosthetic Restoration of the Canine

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Prosthetic Restoration of the Canine D0l: 10.1051/odfen/2010202 J Dentofacial Anom Orthod 2010;13:112-132 Ó RODF / EDP Sciences Prosthetic restoration of the canine Pascal AUROY, Jean LECERF ABSTRACT There are many ways dentists can restore teeth prosthetically. Depending on its condition of relative integrity or more serious breakdown and the patient’s loss of other teeth, the practitioner can choose from a variety of quite different procedures ranging from the fabrication of a single ceramo-ceramic crown on a vital tooth to correction of considerable loss of teeth with an implant supported bridge. This paper will evaluate most of these treatment modalities and, in addition to purely prosthetic considerations, will discuss the integration into treatment of periodontal, implant, occlusal, and functional concepts. KEYWORDS Prosthesis Dental occlusion Oral rehabilitation Canine. Address for correspondence: P. AUROY, J. LECERF, 2 place Pasteur, 35000 Rennes. [email protected] 112 Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2010202 PROSTHETIC RESTORATION OF THE CANINE 1 - INTRODUCTION Dentists should view the prosthetic therapies pigeon-holed into the habi- restoration of a canine tooth as a tual subdivisions of our specialty but, process that is situated at the con- instead, to offer some thoughts de- fluence of occlusal, functional, me- voted to the canine tooth organised in chanical, aesthetic, periodontal, and relation to its deterioration, its ab- surgical imperatives. In this light we sence, and to the extent of the shall pass into the territories of related edentulousness that sometimes ac- specialties when certain specific companies those unhappy develop- points of their domain clearly have an ments. impact on the therapeutic success of We have prepared an abundant our prosthetic therapy. But the subject presentation of illustrations to vivify is vast and we have no intention of the concepts that have arisen from our covering it in an exhaustive fashion introspections. We hope that our because to that we should have had to colleagues in dento-facial orthopae- embrace the quasi-totality of prosthe- dics, whose interest in dental prosthe- tic dentistry. Nor have we planned to tics we share, will find in these pages present a catalogue of the traditional the synthesis they anticipated. 2 - RESTORATION OF A SINGLE BROKEN DOWN CANINE TOOTH Our first thoughts on the restoration the permanent crown that will indefi- of single deteriorated canine teeth nitely preserve all of the tooth’s focus on those that have managed to mechanical and biological potential56. remain vital despite the serious de- (fig. 1 and 2). In every case the predations caused by decay or trauma. temporary crown protects the pre- The protocols for the preparation pared crown during the indispensable of a fixed prosthesis placed on a several week rest period (fig. 3) vital tooth have been codified for needed before the permanent crown many years56. Dentists primarily make (fig. 4) can be cemented. their decision about a keeping a For experienced practitioners who canine tooth vital or treating it endo- follow the protocols we have outlined dontically before rehabilitating it pros- the failure rate, defined as inflamma- thetically on the basis of an evaluation tion or necrosis of the pulp that would of the health of the pulp and of a require endodontic intervention, is periapical X-ray. Dentists prepare the about the same as the failure rate of tooth under a water spray using sharp economic treatment itself. The new rotary instruments. They make endodontic of health care service the temporary crown by thoroughly indicate to us that no matter what cooling the thermally cured plastic, the precise failure rate of the two eventually taking advantage of the concepts may be, the practitioner who openings of dentinal tubules to gain routinely performs endodontic treat- its reliable retention as well as that of ment on all teeth that are candidates J Dentofacial Anom Orthod 2010;13:112-132. 113 PASCAL AUROY, JEAN LECERF Figures 1 and 2 Preparation of a maxillary canine for a ceramo-ceramic crown: in view of the considerable amount of dentine that must be removed in order to make room for the ceramo-ceramic crown and cosmetic cover, the clinician must follow protocol scrupulously in order to preserve the tooth’s vitality indefinitely. Figure 3 Figure 4 A temporary crown will protect the tooth View of the under-side of a ceramo-ceramic during the indispensable several week rest aluminum Vita Inceram. Note the cosmetic/ period while the permanent crown is being tooth periphery and the arrow indicating the fabricated. visible demarcation between the aluminum and the cosmetic ceramic covering it for crowns, whether they are vital or not, will, from the simple mathematics priate filling materials on vital teeth of the matter, extract more teeth when indicated. because of failure than a colleague But if the diagnosis shows that a who preserves the vitality of selected tooth’s vitality has already been com- teeth in preparing them for crowns. promised, or that the pulp is so large Let us remember that dentists should that the required reduction of the prepare affected teeth in accordance tooth’shardtissuetoaccommodatethe with accepted procedure, using appro- bulk of the restoration will endanger it, 114 Auroy P, Lecerf J. Prosthetic restoration of the canine PROSTHETIC RESTORATION OF THE CANINE endodontic treatment becomes neces- of elasticity, which is why dentists sary as well as a reconstruction of should not utilise zircon, oxide of crown and root. zirconium, whose module of elasticity At this point the dentist and patient is 60 times greater than that of must decide on the type of construc- dentine. tion of the crown. Should it be cast as In order to understand this problem is done for the traditional inlay-core well, we must consider the flow of procedure or milled? Indications for constraints at the interface of the this newer type of milled restoration prosthesis and the dentine: for a given are now also perfectly well codified1: amount of occlusal forces, the larger presence of the three elements of a the surface of the interface the more tooth’s hard structure of at least 1 mm widely and thus less densely, the in thickness and a height greater than forces are distributed. So the practi- half of the proposed prosthetic crown. tioner should increase the size of the The removal of tooth substance preparation in the root as much as should never enter into the sulcus possible thus increasing the amount space so that clinically the junction of dentine that will contact the in- between crown and tooth can be serted post. But this must be done by hidden in the sulcus and encircling making the preparation longer, not dentinal structure. Finally, more for wider, because that would reduce canines than for other teeth, the rule the thickness of the dentinal walls of dentists having have good accessi- and make them more fragile. Thus we bility in preparing it and maintaining it keep the bore of our preparations, in complete isolation from the fluids of and, accordingly the diameter of the the oral cavity in bonding or cementing posts that will fit into them, as narrow it is an indispensable requirement for as possible, but of lengths equal success1,5,8. to 2/3 to 3/4 of the depth of the With these points in mind, we alveolus in which the tooth’s root believe that milled crown-root rehabi- resides11,12,30,36. (fig. 5). litation is contra-indicated and that a We bond the inlay-core rather than cast reconstruction21,25,50 is re- cement it, thus reinforcing the attach- quired. No matter what material is ment of the prosthesis to the root and employed in fabrication the proper encouraging the diffusion of occlusal preparation for the root post will constraints1,10,11,12. All these modal- demand reduction of the root walls ities are particularly pertinent to canine to less than 1 mm in thickness and the teeth, in view of the heavy nature of removal of a considerable amount of the occlusal forces to which they are dentine. subjected. By carefully following the Because the modules of elasticity of preparationprotocolwehavesug- the metal making up the cast replace- gested, practitioners can reduce the ment crown and root are 10 to 30 risk of a prosthesis on a canine tooth times greater than those of the natural becoming uncemented or debonded dentine itself, occlusal constraints are or of the tooth’s root being fractured. transmitted almost in full force to the In order to make prosthetic crowns root structures. That is why it is best placed on canine teeth aesthetically to select materials with weak modules satisfactory the best materials for J Dentofacial Anom Orthod 2010;13:112-132. 115 PASCAL AUROY, JEAN LECERF they are set at a minimum distance .4 mm from leading edge cells of the epithelial attachment. Accordingly, prosthesis should never be set more deeply than .5 mm in a sulcus 1 mm in depth. There is today a strong consensus that with junctions of prosthesis to tooth of equal quality those that are placed more deeply in the dento-alveolar sulcus will provoke the most inflammatory reac- tions15,19,20,22,32,40,51,55. Preferably, dentists should make Figure 5 We believe that it is important for the the buccal aspect of a rehabilitated posts be narrow in diameter but long canine one of a ceramico-tooth junc- enough to equal 2/3 to 3/4 of the length tion rather than one that is metallic- of the root. tooth, for obvious aesthetic reasons. This is rapidly becoming the standard approach because modern well for- dentists to choose are ceramo-ceramic mulated techniques allow for an ex- for vital teeth and ceramo-metallic for cellent cervical adaptation, of less than endodontically treated canines whose 80 microns (cf.
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