Operative Dentistry ‫ﻋﺒﺪﷲ اﻟﺸﻤﺎع‬.

‫د‬

Lecture (2)

Patient Evaluation, Diagnosis and Treatment Planning (Part II)

D. Evaluation of existing restorations
The following criteria are used to evaluate existing restoration:
1. Structural integrity: this evaluation involves determining whether it is
intact or whether portions of the restoration are partially or completely
fractured or missing. The presence of fracture line indicates replacement of
the restoration.
2. Marginal opening: for amalgam restorations the existence of marginal
ditching does not indicate the replacement of the restoration; because the
margins of amalgam restorations become relatively well sealed by the
accumulation of corrosion products, unless signs of recurrent caries are
present.
For composite restoration, the marginal gap should be considered for repair
or replacement of the restoration. The presence of marginal gap is less critical
for restorations with anticariogenic properties, e.g. glass ionomer cement.
Because studies have shown that tooth structure adjacent to GI cement
restorations is less susceptible to caries; replacement of the restoration is only
indicated when tooth structure adjacent to the marginal gap becomes carious or
when there is marginal staining (that is esthetically unacceptable) especially in
anterior teeth.
3. Caries: the dentist must use a combination of visual, tactile and
radiographic examinations to detect the presence of caries lesion. A
radiolucent area surrounding a radiopaque restoration or the presence of soft
tooth structure generally indicates caries and must be repaired or replaced.
4. Restoration-related periodontal health: examination of restorations must
include an assessment of the effect that existing restoration have on the
health of the adjacent periodontuim. Problems commonly encountered in
this area are:
a. Surface roughness.
b. Interproximal overhangs.
c. Impingement on the zone of attachment (called the biologic width) [the area
approximately 2-3mm in the apicocoronal dimension, occupied by the
junctional epithelium and the connective tissue attachment].

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 All three of these phenomena can cause inflammation within the
periodontium. Open or rough subgingival margins can harbor bacterial plaque to
generate an inflammatory response. Gingival inflammation around crown may
also due to an allergic reaction to material in the crown.

5. Occlusal and interproximal contacts: all interproximal contacts should be

assessed with thin dental floss by the dentist. Contacts should allow the
smooth passage of floss. Contacts that are open or excessively tight should
be evaluated to determine whether pathosis, food impaction or annoyance to
the patient has resulted.
The occlusal contacts of all restorations should be evaluated to
determine whether they are serving their masticatory function without creating
a symptomatic or pathogenic occlusion. Restorations whose occlusal contacts
are creating primary occlusal trauma should be altered or replaced to resolve
the problem. Restorations that are in significant infra-occlusal may permit the
super eruption of opposing teeth and should be considered for replacement.

6. Esthetics: some of the more common esthetic problems found in the

existing restoration are:
a. Display of metal.
b. Discoloration or poor shade match in tooth colored restoration.
c. Poor contour in tooth-colored restoration.
d. Poor periodontal tissue response in anterior restoration.

E. Evaluation of Occlusion and Occlusal Wear

The occlusion can have significant effects on the restorative treatment plan.
The following factors should be evaluated during occlusal examination:
1. Occlusal interferences between the occlusion of centric relation and that
of maximum intercuspation.
2. The number and position of occlusal contacts as well as the stress placed
on the occlusal contacts.
3. The amount and pattern of attrition of teeth and restorations resulting
from occlusal function.
4. The interarch space available for placement of needed restoration.

The number and position of occlusal contacts strongly influence the selection
of restorative materials as well as the design of the preparation and
restoration.
Attrition: excessive occlusal wear caused by occlusal parafunction (bruxism). In
these instances, facets on opposing teeth match well. Prevention is accomplished
with use an occlusal resin appliance (night guard, bite plane), and education of the
patients.

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 F. Evaluation of tooth integrity and fractures
Cracked-tooth syndrome: is a fairly common result of incomplete tooth
fracture. Patients suffering cracked tooth syndrome often experience cold
sensitivity and sharp pains of short duration while chewing. The cusps most
commonly fractured are the nonfunctional cusps. Often patients with
multiple cracked teeth have parafunctional habits or malocclusions. Cracked-
tooth syndrome is an age-related phenomenon, the greatest occurrence is
found among patients between 33-50 years of age.
This syndrome is often difficult to diagnose. The patient is unable to identify
the offending tooth and evaluation tools such as radiograph, visual
examination, percussion and pulp tests are typically non diagnostic.
The two most useful tests are:
Ø Transillumination: when a tooth with a crack is transilluminated
from either the facial or lingual direction, light transmission is
interrupted at the point of the crack. This results in the portion of the
tooth on the side away from the light appearing quite dark.
Ø Biting test: it is the most definitive means of localizing the crack, by
having the patient bite a wooden stick, rubber wheel; the dentist will
be able to reproduce the patient's symptom and identify the fractured
tooth.
In treatment of incomplete tooth fracture, the tooth sections are splinted
together with a cuspal coverage restoration. This may include the use of an
amalgam or composite restoration, a crown or indirectly fabricated onlay.

G. Esthetic Evaluation
In addition to an esthetic evaluation of existing restorations, an assessment of
the esthetics of the entire dentition should be completed. Commonly encountered
esthetic problems that are related to restorative dentistry include:
1. Stained or discolored anterior teeth.
2. Unaesthetic contours in anterior teeth (length, width, incisal edge shape or
axial contour).
3. Unaesthetic position or spacing of anterior teeth.
4. Carious lesions and unaesthetic restoration.
5. Unaesthetic color and/or contour of tissue adjacent to anterior restorations,
this includes: excessive gingival display occasionally referred to as the
(gummy smile).
The restorative treatment of esthetic problems may range from conservative
therapy such as micro abrasion or bleaching to more invasive care such as the
placement of resin veneers, ceramic veneers, or complete coverage crowns.
Additionally periodontal, endodontic or orthodontic procedures may be helpful
depending on the nature of the problem.

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2. EVALUATION OF THE PERIODONTIUM
From a restorative dentistry perspective, the periodontium must be evaluated for
two reasons:
Ø To determine the effect that the periodontal health of the teeth will have
on the restorative dentistry treatment plan.
Ø To determine the effect that planned and existing restorations will have
on the health of the periodontium.

Evaluation of periodontium consists of a clinical assessment of attachment

levels, bony support, tooth mobility, qualitative assessment of tissue health, and
radiographic evaluation of supporting bone.
The most consistent clinical indicator of inflammation is bleeding on probing.
Any bleeding by gentle probing should be noted.
The qualitative assessment of periodontal tissue health includes tissue color,
texture, contours, edema and sulcular exudates are noted. The presence of specific
local factors such as plaque, calculus and their relationship to tissue inflammation
should be noted.
During examination of periodontium, the dentist must estimate the location of
margins for future restorations and their potential to impinging on the biologic
width.

3. EVALUATION OF RADIOGRAPH
The radiographic examination is an essential component of the comprehensive
evaluation. Clinical situations for which radiograph may be indicated includes:
-Previous periodontal or root canal therapy.
-History of pain or trauma.
-Large or deep restorations.
-Deep carious cavity.
-Swelling and mobility of teeth, fistula or sinus tract infection.
-Abutment teeth for fixed or removable partial prosthesis.
-Unusual tooth morphology or color.
-Missing teeth with unknown reason.
In evaluating radiographic findings for restorative purposes, the dentist should
note open interproximal contacts, marginal openings, overhanging restoration,
periapical radiolucencies within the bone of the tooth.

The dentist must interpret abnormal radiographic finding with caution. For
example when the clinician evaluates radiolucencies that appear to represent
carious tooth structure but may in fact represent nonpathologic processes as in a
radiographic phenomenon known as (burnout) which is a radiolucency not cause by
caries, it occurs when x-ray beam traverses a portion of the tooth with less

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thickness than surrounding areas most commonly seen in cervical area of the tooth.
So the dentist must be careful not to mistakenly diagnose as demineralized tooth
structure. Also the dentist must be cautious in diagnosing caries beneath existing
restorations because certain radiolucent dental materials have a radiographic
appearance similar to that of carious tooth structure.

4. EVALUATION OF DIAGNOSTIC CASTS

The dentist can gain valuable information through an evaluation of diagnostic
casts. The dentist can see areas that are visually inaccessible during the clinical
examination. Facets and marginal openings that may be difficult to see
intraorally are readily visible on the diagnostic casts. Also cases involving
multiple missing teeth need the evaluation of casts mounted on a semi-
adjustable articulator. This enable dentist to assess the occlusal relationship and
to plan restorative treatment.

Treatment Plan
Having completed a comprehensive examination, the dentist lists the problem
related to restorative dentistry. Planning the restoration of individual teeth requires
the consideration of four factors:
1. The amount and form of remaining tooth structure.
2. The functional need of each tooth.
3. The esthetic needs of each tooth.
4. The final objective of the overall treatment plan.

Treatment Sequence
When the completed treatment has been visualized and the design of the
restorations required has been established the final step in establishing the
restorative dentistry treatment plan is sequencing the treatment.
Restorative treatment aimed at the control of active disease generally consists of
direct restorative procedures using amalgam, resin composite or glass ionomer
material. The sequence of treatment within the disease-control phase is dictated by
three considerations:
1. Severity of the disease process (i.e. the most symptomatic tooth, the tooth
with the deepest lesion, or the most debilitated tooth is restored).
2. Esthetic needs.
3. Effective use of time.
At each appointment, treatment is rendered in the area in most acute need of
restorative treatment. When possible the restorations should be completed quadrant
by quadrant to optimize the use of time.