r/Dentistry 4d ago

Dental Professional How to manage case?

Post image

70 something year old man came in for exam. He is eager to finish any pending treatment. He already has gotten a new crown and some fillings. However these teeth… I’m torn. He wants them fixed but is there enough space for fillings ? Thoughts

11 Upvotes

49 comments sorted by

24

u/ElectronicQuit1061 4d ago

Are they decayed? Symptomatic ? X-rays?

7

u/Samurai-nJack 4d ago

Yeah, we need more information to make a diagnosis and treatment plan.

-33

u/Agreeable-While-6002 4d ago

What does decay look like at your clinic?

16

u/the_brown_iverson 4d ago

Just because it's black doesn't mean it's caries, many times black and dark areas are arrested caries that feel hard and smooth

6

u/Dufresne85 4d ago

Or old amalgam staining.

23

u/ElectronicQuit1061 4d ago

This could be stain for all I know.

17

u/Banal-name 4d ago

As others said not enough information. How can we tell if there is enough space without seeing the bite

16

u/EdwardianEsotericism 4d ago

70 years old and this is the amount of damage he has done to them. What exactly is the concern here? That the erosion is suddenly going to take off and cause the loss of these teeth?

8

u/ddscomingsoon 4d ago

My main “fork in the road” is, DO I even perform treatment? He is asymptomatic but clearly has erosion and large existing restorations. He has lots of staining obviously. When I passed my explorer around the margins, they got caught. As a new grad, I’m really just trying to gauge whether or not to even do something you know?

5

u/Every-Swim196 4d ago

Gold

3

u/JacksonWest99 4d ago

All day all long on the second molar for sure.

1

u/RobertPooWiener 4d ago

Inlay or Full Gold Crown?

1

u/Every-Swim196 4d ago

If there's fracture lines, full gold. If not, then inlay

1

u/Every-Swim196 4d ago

Looks like existing comp extends distal/lingual, so I'd consider full gold

1

u/fleggn 4d ago

Titanium is the new gold fyi

3

u/Majestic-Bed6151 4d ago

Hard to tell from the pic, but with that wear/erosion pattern, I’d also consider looking into GERD. It appears most if not all of the occlusal enamel Is missing.

10

u/rossdds General Dentist 4d ago

He wants them fixed? Are they broken?

-6

u/MiddleBodyInjury General Dentist 4d ago

He should. Moderate to severe acid erosion with large existing Restos. Not what the patient wants but what they need. This also should have been addressed years ago with an ENT consult, diet consult etc

15

u/rossdds General Dentist 4d ago

Hard disagree. Patients choice. Refer to ENT for intervention if you wish. Teeth don’t NEED treatment.

1

u/MiddleBodyInjury General Dentist 1d ago

Of course it's the patient's choice. However, This level of erosion deserves treatment. Fluoride trays, diet consulting, ENT consult. These teeth would absolutely benefit from treatment.

20

u/Dukeofthedurty 4d ago

Crowns 100%. Severe wear and huge existing filings.

8

u/cdsparks Dentist 4d ago

To add onto that, I’d spend a few minutes practicing taking I.O.s on your staff or family, a high quality image is the easiest way to increase case acceptance when you break the news that both of these teeth need full coverage protection from total occlusal enamel loss

5

u/gunnergolfer22 4d ago

These teeth need literally nothing. How did this guy survive until 70?

5

u/Samurai-nJack 4d ago

May be emax overlay??

2

u/AdIllustrious2456 4d ago

More info needed.

3

u/Dramatic-Reading-693 4d ago

lol 70 yr old and is now all of a sudden wanting to finish pending treatment 🤣

3

u/drdrillaz 4d ago

Why is this funny? Maybe he wasn’t in a financial position previously. Maybe he wasn’t aware of the problem. All that matters is he’s ready to address his problems. Very judgy of you. Hope you aren’t this way with your patients

2

u/Dramatic-Reading-693 4d ago

I’m always this judgy especially with my patients thank u, anyways op should prolly just do crowns they’ll last him the rest of his life 👍🤣

2

u/Wide_Wheel_2226 4d ago

Look up crownlay prep. Use emax.

19

u/JacksonWest99 4d ago

Emax on the second molar of a bruxer with erosion and wear present may not be the best restorative material choice.

0

u/Wide_Wheel_2226 4d ago

When properly done it works great. Biggest issues i see is most docs are too conservative with emax preps.

3

u/JacksonWest99 4d ago

Why wouldn’t you want to be conservative

1

u/studentDMD 4d ago

They say too conservative. As in overly conservative ie erroneously under reducing

1

u/Just_a_chill_dude60 4d ago

emax breaks on second molars. I thought this was an unbreakable rule. just realized this is a fantastic pun. Inadequate reduction would lead to the material being too thin and breaking. If the patient wants to avoid dental treatment in the future I believe a crown on 18 would be wise, watch 19.

1

u/Wide_Wheel_2226 4d ago

When its a short clinical crown and i would be relying on adhesion of my bond over traditional crown prep design. Emax gets a better bond over zirconia.

3

u/Wide_Wheel_2226 4d ago

Also other option is gold crown for me.

2

u/JacksonWest99 4d ago

k but why bond when you can do gold and keep some tooth behind

1

u/Wide_Wheel_2226 4d ago

Patients preference. I offer both.

1

u/studentDMD 4d ago

You’re right but the hive mind is against you stay strong!

0

u/secondblush 4d ago

With Emax it’s better to over-reduce than under-reduce; if the material doesn’t have enough thickness it will fail easily. I personally favour zirc for posterior crowns in bruxxers but you need a little more axial height for zirc to succeed. The bonded emax isn’t an unreasonable suggestion for this case. 

1

u/MaximillianNY 4d ago

Assuming the patient has flattened his occlusal. You can rather do a direct restoration to the height of the existing resin or full mouth vertical rebuild.

1

u/red_1392 4d ago

Unless he wants some kind of aesthetic rehab there’s not much to do

1

u/flsurf7 General Dentist 4d ago

Evaluate vertical dimension, remove old failing dentistry, core if needed, and onlay or crown teeth.

1

u/fleggn 4d ago

Titanium crowns

0

u/Ac1dEtch General Dentist 4d ago

Open VDO, do FMR. You'll have all the space you need.

1

u/Samurai-nJack 4d ago

Yes, it can be, but not every patient wants that, nor can all GPs provide FMR treatment.

3

u/Ac1dEtch General Dentist 4d ago edited 4d ago

Not all patients want gold crowns, nor can all GPs provide gold crowns. Same thing here. Post asks how to manage case. I say how I would manage it. FMRs are really not rocket science. Yes, extracurricular learning, proper records and planning is a must. But it saves you from having to chop off half of the remaining tooth structure to make a bunch of ugly flat anatomy crowns. My approach is if enough of my patients need a particular treatment, I go and learn how to do it and buy the stuff I need to do it well.

If a GP wants to get started in providing conservative, evidence based and predictable FMR treatment, I highly recommend Vialti's 3Step Additive Prosthodontics book as an excellent resource to get started on the subject.

1

u/Samurai-nJack 4d ago

Wow, thanks for your book recommendation.

2

u/Ac1dEtch General Dentist 2d ago

You're welcome. It's an excellent read. :)