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Performance of Crowns and Bridges, Pan South London – Practical Study Day 11Th June 2015 EBD

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Performance of Crowns and Bridges, Pan South London – Practical Study Day 11Th June 2015 EBD Peter Briggs BDS(Hons) MSc MRD FDS RCS (Eng) Consultant in Restorative and Implant Dentistry, QMUL and Specialist Practitioner, Hodsoll House Dentistry. Performance of Crowns and Bridges, Pan South London – Practical Study Day 11th June 2015 EBD Experience Patient Evidence Needs Has the recent focus on direct and indirect adhesive dentistry and Dahl concept compounded our indecision when planning conventional crowns and bridges and being confident to prepare teeth well? Aesthetic restorations looking good comes at a biological price DBC prep = 63% off tooth PFM prep = 72% off tooth PFM prep 20% > FGC prep PFM prep x5 > Porcelain veneer (feathered) x3 > Porcelain veneer (butt joint) Edelhoff & Sorensen (2002). Tooth structure removal associated with various preparation designs for anterior teeth. J Prosthet Dent; 87: 503-9 Edelhoff & Sorensen (2002). Tooth structure removal associated with various preparation designs for posterior teeth. Int J Periodontics Restorative Dent; 22: 241–249 The problem is if you do something rarely – unless you have got ‘god-given’ talent or are lucky – when you need to do it you will not be able to execute it well Different types of failure Direct survives less well than indirect It’s about what options we have on failure and failure cycling It is being able to identify: • Do I need conventional luting or can I utilise resin bonding • What material will work best: aesthetically, functionally & cost? • What do I need to do to make it work well? I will struggle here with moisture control – conventional cementation You will see that Fixed Prosthodontics is very well represented within the major risk groups • 1 Endodontics • 2 Crown & Bridge 5 Implants 6 Orthodontics 7 Veneers 8 Oral Surgery • 3 Periodontics • 4 Nerve Damage Is this what we will all be reduced to? Pyramid of risk: Endodontics C & B Periodontology (or missed perio) Nerve Damage Implants Orthodontics Veneers Oral Surgery Where are the risks – C & B? • Abutment condition and prognosis • Static Jaw Registration / Occlusion • Impression quality & fit • Posts / Cores – as abutments • Aesthetics / shade / shape / margin etc. Why here today? Knowledge - Knowledge of skill – (early) Competence of skill – Proficiency of skill – Expertise of skill • Unconsciously Incompetent UI • Consciously Incompetent Proficient CI • Unconsciously Competent • Consciously Competent CC UC • Proficient (2000 hours) • Consciously competent (2,000 hours) CC CC • Proficient (3,000 hours) • Mono Specialist MasterMaster Proficient Proficient Competent (4,500 hours) Super specialist • Broad Specialist competent (7,500 hours) • Expert (10,000 hours) Expert SC • Master (20,000 hours) Expert SC Conventional Retention relates to: • Taper • Surface Area • Surface Roughness Jorgensen 1955 ‘Can you remind me how long you said my crown and / or bridge would last?....’ Mrs. Angry from Purley? I’ll just look it up! Survival of Fixed Space Fillers RBBs drop down to 65% at 10 years (cf to 89.2% for FDP) Evidence Based Dentistry All as it all it seems? Meta Analysis of 35 studies identified but only 8 could be included in the analysis. These 8 studies are very selective & how relevant are they to general dental practice? Only one study Scurria & Badia 1998 from UK (Reuter & Brose, 1984) How relevant are these studies to us? Scurria & Badia 1998 – looked at abutment survival Conclusions: Scurria and Bader meta analysis (re- published in BDJ evidence based practice 1998) 75% of abutments lasted 15 years 92% 10 years Most failures mechanical (rather than biological) Let’s look at the 8 studies used by Scurria et al 1998 – how relevant are they to you? Study Provider Pts Country Ericson UG DS Sweden Cheung Ug/staff DS HK Palmquist Pg/staff DS Sweden Reuter PP PP UK Karlsson GDP Ins Sweden Randow GDP Ins Sweden Valderhaug GDP DS Norway Leempoel GDP GDP Holland Evidence Based Dentistry - Is it all it seems? Scurria & Badia 1998 Excluded: Bridges of more than 8 units, those with predominantly partial coverage or cantilever design prostheses Evidence Based Dentistry - Is it all it seems? Conclusions: Headline findings - less than 15% of FPD needed replacement over 10 years. Actual results: at 10 & 15 years: 10 & 26% of FPD had been removed 13 & 31% had been removed or technically failed & replaced 4% of abutments had been lost at 10 years (but increasing fast) The ‘bath-tub’ curve of failure Failure = Success in the USA 80 70 60 % Failures 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Years of Service How long’s your bath? Much Variation in Survival 3% over 23 years - Scandinavia 20% over 3 years Main problems • caries • endodontic • periodontal Approx 80% remain in service at 10 years 1990 2012 However, there are some studies that suggest a much more depressing tale ‘Does it matter that the teeth supporting my future bridge are dead?...’ Miss Bunty Dogood, Glossop What do you think? endodontic status of abutment teeth - strongest variable on failure Dead teeth not good news under crowns let alone bridges They have enough trouble looking after themselves, let alone lost friends! British Dental Journal 2014; 216: E14 How much does it all cost? • Lumley et al.13 showed that the survival of root filled teeth in the general dental services in England and Wales was 74% over a ten-year period before re-treatment, apical surgery or extraction. knowledge Is our Endo going to work? Post-operative: Good coronal restoration (Eleven- fold increase in odds of success) Ng, Mann & Gulabivala - International Endodontic Journal, 2011 We must protect the investment Survival Comparison 38 Practical knowledge Ng et al (2008) Int Endod J 41: 6-31 2014 2004 2012 Reuter & Brose (1984) Post cementation endodontics dramatically increases bridge failure - they suggest elective RCT of questionable pulps prior to bridge manufacture The effect on crown retention from a palatal access cavity through an anterior crown Reduces in- vitro crown retention by 65% Why? ‘What are the chances that the nerves underneath my crown / bridge will die? ...’ Mrs. Concerned, Leicester Let’s have a look The size of the problem varies: • 10% over 15 years (Karlsson 1989) • 20% of non RCT’d teeth with apical pathology (Sanders & Saunders 1998) • 50% over 10 years - with bridges – much lower with single crowns (Cheung et al. 1990) Cheung et al. (1990) 70% of endodontic complications beneath bridges found in the anterior region (Cheung et al 1990) • 13.3% of full crowns lost vitality (in teeth previously restored) • 5.1% of partial veneers non vital at 5 years • Unrestored (controls) teeth that were crowned - only 0.5% non vital at 5 years Felton & Madison (1989) ‘Do single crowns have a better chance of surviving compared to bridges? – Yes ask Cheung’s team in Hong Kong...... What do you think? Agreed Team (Band) Standards E-max Monolith UR6 – single strategic RCT’d tooth Do we do posts well? Posteriorly you only need to use a post when there is inadequate coronal tooth structure to support & retain a coronal cuspal-protection restoration Parapost burs create signif greater deviations from the centre of canals than Gates Glidden (Gegauff et al 1988) Therefore safest to use of non-end cutting rotary instruments (e.g. GGs) first to remove (mostly by heat) the GP and then prepare / cut a post channel within the root Never use the post drill first In a multi-rooted tooth use only one root canal Metal or Glass-Fiber? Metal or Glass-Fiber? • The less tooth-tissue you have remaining – the more you need an indirect core • Survival better for glass fiber posts and all ceramic crowns if you have 3 or 4 remaining walls of tooth tissue • If you have less go for an indirect arrangement and optimise ferrule Creugers and Mentink Int J Prosthodont 2005 18: 34-39 The amount, height, thickness & ferrule of remaining tooth structure is the most important factor on outcome - much more so than the type & length of post and the type of core. Maximise Ferrule post to support one tooth not bridge Why is cementation and passive seating of posts so important? The ‘Moshonov’ Gap to be avoided Greater risk of periapical infection when there is a radiographic space between the root filling and the post (Moshonov et al 2005) No Gap - 83.3% PAH normal GAP 0-2mm - 53.6% PAH Normal GAP greater than 2mm - 29.4% PAH Normal 59 We need to get the cement right down the root and not just place on the post to wipe up coronally when you insert the post! The only time to safely use a spiral Filler 60 Crowns and Bridges are not for life! When they fail they will usually take one or more abutment(s), or at best, the pulps with them Worth a Read An important thing to get right Team Standards – Impression quality The Use of Gingival Retraction Cord Seems that we struggle Storey and Coward (2013) We as a team must know what is an acceptable / decent impression in 2015 – many C&B complaints relate to suboptimal marginal fit / recurrent caries and sensitivity – your nurse should be able to tell you yes or no – before it gets to your technician Plan A: Single Retained Gingival Retraction Cord • Pack dry cord apical to the preparation margins • Take the impression with cord in place • The impression then has to come out! Walton Dental Arts Plan A: Single Retained Gingival Retraction Cord / Injectable Expansion Matrix • Occasionally the cord will come out with the impression - it can be easily peeled out without problem • The cord can be left in after impression taking to facilitate construction of provisional restorations • Remember to remove the cord before patient leaves!
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