Non-ideal cases

Less-than-ideal cases may or may not be common in our practice now, but the truth is that they will arise on numerous occasions, and as good dentists we must expect them and seek to solve them in the best way.

As the name suggests, the fact that they are not ideal presents different challenges for the operator, and before starting treatment, the patient should be fully informed about the reality of the case and its prognosis, as well as the possibility of future failure.

Below you will find some of the most important points to keep in mind in these types of cases. The most important thing here is not the way I do it, but the reason why each step is applied and not being afraid of failure.

1. Radiographic Examination: A good dentist is one who makes the best diagnosis, and it's impossible to make a good diagnosis without the appropriate radiographic examination.

2. Use of Magnification: Hi, I'm Dr. Marvin, and I'm obsessed with magnification 😬. I talk about this topic every chance I get, so I'm just going to ask: How can you do good dentistry if you can't see what you're doing?

3. Absolute Isolation: In these types of cases, the lifespan is a big question mark, and that question mark directly depends on the quality of the adhesion. Good adhesion is directly related to fluid and moisture control. In these less-than-ideal cases, fractures are very often found subgingivally. The dentist should try to manage the soft tissues using retraction cords, Teflon tape, and, if necessary, consider performing gingivoplasty to properly apply absolute isolation.

4- Microabrasion: In extreme cases, we must use all available means to enhance adhesion. While there are debates about the effectiveness of microabrasion with aluminum oxide and its impact on adhesion, one undeniable truth is that its application not only increases micro-retentions on the tooth structure but also produces a deep cleaning of it. It is well known that the quality of adhesion is diminished when the tooth structure is contaminated.

5- Adhesive System: Extensive literature supports the use of adhesive systems that produce the best adhesion in cases where the predominant tissue is the biologically valuable dentin. Adhesive systems such as Optibond FL, Peak, and Clearfil SE Bond, among others, are some of the gold standards, and as my father says, "Forewarned is forearmed."

6- Contour Management: Achieving functional contours and strong contact points is not easy when our remaining tooth structure is minimal, but a mechanically ideal restoration is of little use if it becomes a food trap for our patient.

Strong contact points not only prevent food entrapment but also provide stability to our restoration. The use of metal bands, such as the well-known Tofflemire bands, offers a partial solution, as they allow us to obtain a good margin-resin bond, but result in a straight contour and high, small contact points. In these cases, it is ideal to use preformed matrix systems such as Nitin, Triodent V3, or Garrison's Composi-Tight. These preformed matrix systems offer different sizes and heights of matrices to be used on different teeth, achieving beautiful, curved, and natural contours.

A few years ago I had the opportunity to learn about a ring that took my less-than-ideal cases to another level. The Garrison FX600 Composi-Tight 3D ring was designed for use in large preparations because its active part is larger and manages to rest on the neighboring teeth to maintain the contour, unlike rings for small preparations that, when placed on teeth with little remaining tooth structure, tend to collapse on the tooth when applying pressure.

7- Resins: I've shared several Scientific Facts on this topic (you can find them in my IG highlights). The percentage and size of the filler in resins is reflected in their strength. Microhybrid or nanohybrid resins work well for cases where strength is the priority. Particularly for cases requiring extensive reconstructions, I like to use resins with Bulk Fill technology. It's a great advantage to know you can use thicker layers of resin while keeping shrinkage under control.

8- Reinforcing Fibers: I love this topic; in fact, I'm writing my undergraduate thesis on it. The performance of these materials when used correctly is impressive.

The dental structure is an exquisite blend of flexibility and rigidity, and when this balance is lost, catastrophes occur in the teeth. In less-than-ideal cases, and in each of our restorations, we must strive to mimic this perfect blend that nature provided. The placement of reinforcing fibers, such as Ribbond (polyethylene), reduces stress (C-Factor) in direct resin restorations. When placed near the pulp chamber, they produce an effect similar to that of the dentin-enamel junction. This junction between these two tissues is rich in collagen fibers and distributes stress axially. In addition to providing an energy absorption mechanism, it also provides anchorage between the walls of the restorations, offering resistance to fractures.

There are resins that have fibers of this type incorporated within their composition, such as the Everx Posterior from GC, which when used in conjunction with conventional resins can be used as a "substitute" for dentin.

9- Occlusion: This point applies to both non-ideal and ideal cases. Our restorations should aim for fluid function and a balance of forces. It is important that, when working in the posterior region, we allow freedom of movement for the restoration during lateral movements and that we seek centric contacts with balanced intensity. For this, I recommend using pressure-sensitive articulating papers that help us detect high contact points that could place more stress than desired on our restoration. Bausch articulating papers are among my favorites, in 80 or 100 microns for these types of cases.

Wow, it's great to talk about good dentistry! I hope you find this information very useful. Best regards! 🍻

Dr. Marvin