Re-restoration of Teeth

accounts for over 50% of dental work (Elderton et al.1985; Mjor and Toffenetti 1992)
caries rate declining worldwide (Downer, 1984; Rensen et al. 1985). All restorations have built in obsolescence.

Reasons for Failure of Restorations

recurrent caries (>50%) - most common reason
given by dentists

other technical failures

restoration fracture marginal breakdown cusp fracture defective contour (overhang, wear, open contact) poor appearance
Early Clinic

Early Clinic

When to replace existing restorations?

Recurrent (Secondary) Decay

Denition Microbiology and Histopathology Location Clinical diagnosis Examples
Early Clinic

Early Clinic

Denitions of recurrent caries

Spread of caries at the DEJ Failure to remove all diseased tissue Marginal defects of any sort Caries at new site on previously restored tooth Lesions at the margins of existing restorations
Early Clinic

Histology of Secondary Caries

Described as having two parts
Outer lesion Wall Lesion

Hals E. Andreassen BH. Bie T. Caries Research. 8(4):343-58, 1974. Early Clinic

Secondary Caries Process

Secondary Caries Process

Cannot visually assess wall lesion

Can visually assess wall lesion

microleakage Wall lesion - which forms as a result of leakage of bacteria, uids or hydrogen ions between restoration and cavity wall. This clinically undetectable leakage around a restoration is referred to as microleakage Early Clinic

Outer lesion - the enamel caries formed on the surface enamel as a result of new, primary attack. Related to plaque accumulation on the surface similar to primary caries Early Clinic

Secondary Caries Process

The Outer Lesion - Same characteristic features as early primary caries *Opaque white color early *Progresses through same characteristic histologic stages

Microscopic Features of Incipient Caries Dened Zones

Zone 1 Translucent Zone 2 Dark Zone 3 Body Zone 4 Surface
4 *Surface initially mineralized while subsurfaces demineralize *Stages based on pore sizes developing from demineralization *Later surface collapses and cavitates Early Clinic

3 cavitated incipient 1 Early Clinic 2

Secondary Caries Process

Presence of wall lesion questionable  Since caries process follows the enamel rods May just be in cases where enamel rods directed to restoration interface Or when microleakage is primary cause of secondary decay problem

Microbiology
Most researchers agree that secondary caries is the same as primary caries adjacent to a restoration. the pellicle that forms on materials may be different than the pellicle that forms on tooth the initial plaque colonization may be different
Early Clinic

Early Clinic

Location Of Secondary Caries Where is recurrent caries most likely to occur ?

It has been recognized by clinician for many years (GV Black 1908) and shown in numerous studies that secondary caries is more prevalent at the gingival margins of class II, III, IV and V restorations than other surfaces.

Early Clinic

Early Clinic

Frequency of secondary caries at cervical and interproximal .

94% of amalgams that fail from caries fail at these sites. Amalgams rarely fail at occlusal surface 62% of composites xed restorations - also would most likely be proximal areas.
Mjor IA. Operative Dentistry. 10(3):88-92, 1985 Early Clinic

Extension for Prevention

Recognition of rebeginning or recurrence of decay at cavity margins (GV Black: A Work on Operative Dentistry. 1908) Clinical observation led to idea of extension for prevention (Need to place
margins in areas accessible to inspection and mechanical oral hygiene measures)

Early Clinic

Location Of Secondary Caries

Relationship between proximal cavity design and recurrent caries. Otto and
Rule, J Am Dent Assoc 1988;116:867-870 Difcult to determine primary vs secondary in this particular area.

Factors that predispose the gingival areas

Clinical Techniques Materials Properties Patient factors

Early Clinic

Early Clinic

Patient Factors
Caries Risk (strep mutan count)
Oral hygiene Diet Genetic predisposition Fluorides

Technique Factors
Moisture control Access Technique
Condensation bonding

Early Clinic

Early Clinic

Materials Properties
Different materials have different potential to seal at restoration margins
Amalgam Composite Glass ionomers, resin modied GIs

Materials Properties Amalgam

Proper adaptation of amalgam at margins
Minimize voids and irregularities

Proximal contours and contacts (overhangs and open contacts) Some potential caries inhibition (corrosion products)

Early Clinic

Early Clinic

Materials Properties Composite

Contraction on polymerization Volume related All large composite restorations leak No ability to inhibit caries Seals well on enamel margins but poor on dentin and cementum margins

Materials Properties GI and RMGI

Ability to inhibit recurrent caries (some evidence but not denitive). Tend to have zero net shrinkage and seal well.

Early Clinic

Early Clinic

Methods of Diagnosing Recurrent Caries

Visual assessment of color Gap or defect size Hardness Bitewing radiographs

Appearance of Outer Lesion

Range from
white spot brown spot with or without softening of mineralized tissue frank cavity

Early Clinic

Early Clinic

Color Changes (amalgam)

particularly difcult to interpret adjacent to amalgam restorations gray or blue discolorations may indicate either a carious lesion or corrosion or light reecting from the amalgam itself
Early Clinic

Color Changes (composite)

more easily interpreted. discolorations adjacent to composite
may be a result of discolored demineralized dentin deep in the cavity wall or a line of stain at the junction of the lling and the tooth.
Early Clinic

Color Changes (composite)

The development of stain around a composite lling may indicate the onset of early secondary caries. Transillumination is helpful in the diagnosis of discolored dentin beneath a tooth-colored restoration.

Early Clinic

Early Clinic

Early Clinic

Early Clinic

Early Clinic

Early Clinic

Secondary caries and Margin defects

A ditched amalgam has long been regarded with suspicion by clinicians and are often replaced as a preventive measure to avoid plaque stagnation and secondary caries activity
Early Clinic Early Clinic

Marginal Gap or Defect Size

No good correlation between gap size and recurrent decay Larger gaps (>250 m) more likely to accumulate plaque Plaque accumulations may be decisive factor

A catch on a restoration interface is not synonymous with caries.

Early Clinic

Early Clinic

Hardness
The clinical parameters that correspond to heavily infected dentine was softness to probing, hard and medium-hard areas being very lightly infected with micro -organisms. Only frank cavitation was a good predictor of caries at the DEJ
Early Clinic

Bitewing Radiographs
limited value because of shadowing effect of restorative materials (amalgam)
restorative materials should therefore be same radiopacity as tooth to maximize detection

improve caries diagnosis signicantly compared to other methods

Poor sensitivity 30-50% Good specicity 90%+
Early Clinic

Decay can be more rapid under composite resin restorations

Conclusions: (recurrent caries)

Initiation and progression similar to primary caries Microbiology similar to primary caries Secondary caries rarely found in occlusal areas Most often found in gingival areas Margin gaps or ditching not good indicator of 2 caries

Early Clinic

Early Clinic

Conclusions: (recurrent caries)

Multiple modes of evaluation Frank cavitation, hardness, bitewings are considered best clinical indicators Color better for composite than amalgam Patient caries risk assessment counts

Replacing Amalgam Restorations

Early Clinic

Early Clinic

Amalgam Removal Technique

Isolation (rubber dam) High-vac suction Copius water spray Remove in chunks if possible
High-speed grinding releases mercury vapors (concern)

Mount Extracted Tooth

Early Clinic

Early Clinic

Mount Extracted Tooth

Mount Extracted Tooth

Early Clinic

Early Clinic

Amalgam removal
Use 330 carbide Other special designs just for rapid removal
34 330

Amalgam removal
Channel through the center of the isthmus from mesial fossa to distal fossa at the depth of the dentin or base of pulpal oor
Early Clinic

Early Clinic

Amalgam removal
Separate box from isthmus by extending to buccal and ling walls at depth of pulpal oor or base
Early Clinic

Amalgam Removal Technique

Try to remove in large pieces do not pry hard enough to break instrument-you pay)

Early Clinic

Amalgam Removal Technique

Amalgam Removal Technique

Boxes are generally locked in mechanically due to convergence of B-L walls

Early Clinic

Early Clinic

Amalgam Removal Technique

Section box portion in half

Amalgam Removal Technique

Remove pieces

Early Clinic

Early Clinic

Amalgam Removal Technique

Remove pieces

Amalgam Removal Technique

Determine where or if recurrent caries is present Base needed? Restore

Early Clinic

Early Clinic

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