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“Oh No You Didn't!” Why Patients Keep Breaking Restorations

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“Oh No You Didn't!” Why Patients Keep Breaking Restorations “Oh No You Didn’t!” Why Patients Keep Breaking Restorations John J. Maggio, DDS Clinical Assistant Professor Department of Restorative Dentistry SUNY at Buffalo, School of Dental Medicine [email protected] GUIDANCE AND INTERFERENCE The prognosis of any restorative therapy is heavily dependent on a consideration of all of aspects of the patient’s function. The ideal occlusion features only static posterior contacts in physiologic occlusion, with only anterior teeth functioning in protrusive and lateral protrusive movements. That means posterior teeth only touch in maximum intercuspation, and only the anteriors touch when the mandible moves. from Dawson, Functional Occlusion: From TMJ to Smile Design, 2006 Posterior teeth are designed to withstand compressive forces from the opposing teeth. Anterior teeth are designed to undergo shearing forces (or tension) from the opposing teeth in protrusive and lateral protrusive movements. THE CONFORMATIVE APPROACH “Conformative Occlusion” – placing a new restoration so that it does not alter the current occlusal contacts on all other teeth. 1 This is indicated when: - The patient has a stable maximum intercuspal position - The patient has no joint/muscular disease - The teeth are free of disease “Conformative” occlusion is not the easiest approach, but it is the SAFEST approach for the teeth, periodontium, muscles and TMJ’s. (Davies et al., 2001) SUMMARY - In the ideal occlusion posterior teeth contact only in maximum intercuspation. - In the ideal occlusion only anterior teeth contact in mandibular movements. - Posterior teeth are designed to withstand compressive forces. - Anterior teeth are designed to withstand tensile forces. - Occlusions that shift compressive forces to anterior teeth can cause chipping, wear and fremitus. - The conformative approach to restorative dentistry respects occlusal contacts of all teeth. - If a patient has a stable intercuspal occlusion, no pain and no TMJ disease, a non- ideal occlusion can be maintained. - Occlusal contacts should be observed BEFORE treating a tooth. - Articulating paper can identify static contacts and protrusive contacts. - Occlusion should also be observed visually. - Occlusion should be studied BEFORE anesthesia. - All mandibular movements a patient can perform should be considered when restoring a tooth. MISSING & TIPPED MOLARS The importance of a bilateral molar occlusion cannot be overstated. When molars are missing, the mandible advances to find a position of maximal contact of remaining (anterior) teeth. The anterior teeth are then subjected to compressive forces. The results of a lack of a bilateral molar occlusion are: - unhealthy stresses on the TMJ’s, - muscle strain, - excessive and inappropriate forces on anterior teeth (and even remaining premolars). Teeth in such a situation will BREAK, WEAR or FLARE. Therefore, it is very important for us to encourage patients to retain all of their teeth. When this is not possible, missing teeth should be replaced, to minimize forces on the remaining teeth. For patients who will not replace their missing teeth, restorations on the remaining teeth will have a weaker prognosis. 2 THREE TYPES OF SUPERERUPTION Craddock et al, 2007 Active Eruption involves loss of attachment, as seen in the presence of periodontal disease. The clinical crown increases in height. With Passive Eruption no additional tooth structure is exposed. - most common in: • younger patients • women • maxilla • premolars In Relative Wear, all teeth wear except the unopposed tooth. - most common in: • older patients • mandibular teeth Active Eruption was the most frequent mode seen, followed by Periodontal Growth, with Relative Wear much less frequently observed. So, we have a lot of information to rely on when planning with our patients... We know that: • Most unopposed teeth will supererupt. • Younger patients are very likely to have a supererupting tooth if they lose a tooth. • Maxillary teeth are more likely to supererupt than mandibular teeth. • Teeth on either side of a lost tooth are likely to tip toward the space. • Adjacent mandibular molars will tip the most. • Adjacent mandibular premolars and maxillary molars are most likely to rotate. • After ten years, or with periodontitis, teeth will actually erupt out of the tissue, exposing roots. • Opposing teeth with partial contact will most likely still supererupt (and to the same degree). • Opposing teeth with partial contact are more likely to tip. • Passive Eruption (Periodontal Growth) is common in young people, women, maxillary teeth, premolars and non-perio involved teeth. • Tipping and rotation of teeth adjacent to a space are more likely with a small 3 overbite. • Rotated, tipped and supererupted teeth cause occlusal disturbances and interferences. We can tell our patients: • tooth loss will have a lot of consequences, even if it’s “just one back tooth”. • lost teeth are best restored as soon as possible. • nutrition will be best with a fixed bridge or an implant. • TMD is likely following tooth loss, and will not necessarily improve by replacing the teeth. COMBINATION SYNDROME Combination Syndrome is commonly seen in patients who only have mandibular anteriors left. Severe anterior resorption of the maxilla results. Treatment with Complete Upper Denture and Mandibular RPD are not always successful, as the maxilla continues to be resorbed. The author suggests implants to retain the alveolar bone and end the destructive process. (Tosltunov, 2007) MISSING MOLAR SUMMARY - Lack of a bilateral molar occlusion can result in advancement of the mandible to maximum contact of anterior teeth. - Lack of a bilateral molar occlusion will cause wear, chipping and/or flaring of anterior teeth. - Restorations placed on remaining teeth have a weaker prognosis than with a complete dentition. - Loss of posterior teeth can lead to TMD. - Even single posterior tooth loss can cause major disturbances in the occlusal plane and excursions. - The ultimate disastrous result of loss of molars is Combination Syndrome. Fremitis is not always seen in these cases, because periodontal ligament proprioceptors will affect a change in the occlusion to achieve maximum intercuspation and spread forces among all remaining teeth. This change can bring a deviation from the midline in protrusion. Some patients (even with a full compliment of teeth) initially close in a centric position and then skid forward to a preferred anterior position. The causes of this unconscious adaptation could include: - a posterior prematurity in centric, - a diseased tooth (endo or perio lesion), - a diseased TMJ or TMJ’s, including disc disease, - muscular disease, - lack of a posterior position that provides maximal intercuspation. 4 Most people (even with full dentitions) deviate from the midline when protruding. This is an adaptation to achieve maximum contact and to avoid overloading one tooth. Teeth wear accordingly. Posterior interferences in protrusive and lateral protrusive excursions can: - interfere with proper anterior function, and - overload posterior teeth in function. Anterior guidance protects posterior teeth, and reduces stress on anterior teeth. In anterior guidance, posterior teeth disclude and the muscles of mastication shut down. THE NEUTRAL ZONE (from Dawson, Functional Occlusion: From TMJ to Smile Design, 2006) Teeth are positioned in the neutral zone, that area where the forces from the tongue are equal to the forces from the lips or cheeks. Teeth exist in their current position because the musculature wants them to be there. The teeth are positioned where the forces from facial muscles equal the lingual muscles. • The buccinator muscle is essentially one continuous band from left to right. • The neutral zone can explain why orthodontic cases, even those involving orthognathic surgery, often fail or relapse. • The neutral zone can also explain restorative failures, especially when a restoration extends beyond the neutral zone. • Crowded dentitions are the result of teeth that are larger than the neutral zone can tolerate. The musculature can tolerate an odd tooth out of place better than it could tolerate an arch form that violates it. 5 • The concept of the neutral zone also explains why inappropriately increasing the vertical dimension of occlusion can cause lingual tipping of anterior teeth, as the suddenly stretched buccinator seeks to return to its original length. • Unless the muscular cause of the position of a tooth is corrected, treatment will fail. • Attention to the neutral zone is a necessary prerequisite to restoring dentitions. Patients with small mouth openings and narrow smiles will have more powerful buccinator muscles. They will be most difficult to treat. Success will depend on respecting the neutral zone, or a successful effort to change it. Altering the neutral zone can be accomplished by several means: - orthodontics - elimination of noxious habits - myofunctional therapy - reduction of tongue size - surgical lengthening of the buccinators - vestibuloplasty Aside from changing the neutral zone, the arch form must be observed and obeyed in the course of restorative therapy. An overcontoured facial veneer can cause the buccinator muscle to put pressure on the veneer. This could result in: 1. DEBONDING AND LOSS OF THE VENEER 2. VENEER FRACTURE, AND LOSS OF ONE OR MORE FRAGMENTS 3. LINGUAL MOVEMENT OF THE TOOTH, WITH WEAR OF THE OPPOSING TOOTH. 6 PHONETICS & ENVELOPES Length of anterior teeth can be determined by observing the patient’s envelope of function. When
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