I did this last week and I just couldn't wait to show you. I know you see this all the time in your office: a patient comes in with decay on the distal of a crowned tooth #3. This is simple; you just replace the crown. Slam dunk. But what if #3 is the distal abutment to a 5-unit bridge? Not so easy. And in my office, it always seems that the patient with the 20-year-old bridge cannot afford to replace it; this patient was no different.
I thought it would be a sin it would be to have to replace this bridge because of a spot of decay. Was there any way I could save this bridge without replacing it? What the heck? I could cut a box in the crown like I would do on a non-crowned tooth and do a distal box prep.
Oh, by the way, I am basically making this stuff up as I go along. I told the patient that I had never done this before, but that I thought I might be able to save her close to $5,500. She, of course, was grateful.
So I decided I would treat this crown just like a natural tooth. I cut the box and got to the decay. It was deep, pulpally and axially. I put Vitrebond™ on the axial wall and then started to restore it. On a very deep box, I would use the Waterpik matrix in a Tofflemire, but because it was a bridge, I had to use a sectional matrix. (I found out the hard way that the interproximals are welded together.)
None of the matrices are deep enough for this. I ended up using the SmartDent matrix and it was just big enough. I used the whole DentiSmart system for this (we will go over this product at another date), and put porcelain etch on the porcelain. I used SE Protect as my bonding agent and began to fill Majesty Flow, Majesty ES until it was about 2mm from the top. This prep was a bit different because if I just used the Majesty all the way up, the translucency of the material would not look so good. It would end up too dark, like if I do an access filling through a crown. So I used Kolor + Plus® from Kerr as an opaquer. Then I filled up the rest of the box.
Wow. It turned out way better than I ever imagined! Here are the final photo and the final bitewing:
Yeah, I just lost $5,500 in revenue by not giving her a new bridge. But hope I now have a patient for life who will tell all her friends about me. And I can sleep well at knowing I did what I think was best for this patient.
John Gammichia, DMD, FAGD
Impressive, I feel I learn a lot via this blog. Exactly what they taught us in dental school.
ReplyDeleteIt looks like the over-contoured margin on #2 crown might be one of the reason for decay in that spot. However, that might not be case as we see a lot of other previous restorations in this patient.
It would be great to know what you think doc?