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Classification of Extensively Damaged Teeth to Evaluate Prognosis | JCDA | Essential Dental Knowledge

ClassificationofExtensivelyDamagedTeethtoEvaluatePrognosis
HelderEsteves,DMD,MDScAndrCorreia,DMD,PhDFilipeArajo,DMD,MDSc
PostedonSeptember29,2011
Tags:dentalcariesdiagnosisendodonticsrestorationstreatment

Citethisas:JCanDentAssoc201177:b105

ABSTRACT
Therestorationofteethwithextensivestructuraldamageisanimportantclinicalprocedureindentalpractice.However,despitetheavailabilityofavarietyofmaterials,techniquesand
studiesinthescientificliterature,thecriteriaforselectionofsuchteethforrestorationneedclarification.Theapproachtoseverelycompromisedteethshouldbebasedonconsistent
scientificevidencetoreducedentalerrorandimprovetheprognosis.Ifrestorationisindicated,itmustconserveandprotecttheremainingtoothstructure.Inthisarticle,wedevelopand
suggestclinicalcriteriaandguidelinesthatcliniciansmayusetoidentifyandclassifyextensivelydamagedteethtohelpinthediagnosis,treatmentplanandprognosis.

Introduction
Atoothwithextensivedamageisonethathaslostsubstantialstructureasaresultofcaries,previousrestorationfailures,fracturesorevenproceduresrelatedtoendodontictreatment.
Therestorationofsuchteethwithendodontictreatmentisanimportantclinicalprocedureindentalpracticehowever,variousstudieshavetakendifferentperspectivesonthisissue.1,2
Thelossofdentaltissueandtheweakeningoftheremainingstructurepresentachallengeintermsofprostheticrehabilitation.Althoughthecurrentsuccessrateofdentalimplantsis
high,3 the clinician must be able to assess the probability of restoring severely damaged teeth successfully.410 The dimensions of the remaining tooth tissues as well as several
biologicalandocclusalfactorsmustbeproperlyassessedtoestablishthecorrecttreatmentplan.
Theaimofthisarticleistopresentclinicalguidelinestohelptheclinicianeasilydiagnoseandestablishatreatmentplanfortherehabilitationofseverelydamagedteeth.

AssessingtheProbabilityofSuccessfulRestoration
RemainingToothTissues
Theextentoftheremainingtoothstructureisamongthemostimportantandcriticalfactorsindeterminingtheprognosisforrestorationofadamagedtooth.Evidenceindicatesthatthe
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dimensionsofthecrowndentinareimportant. Somestudies11,12agreethatadentinthickness<1mmincreasestheriskoffailure.Thisminimumthicknessismoreoftenachievedin
buccalorpalatal/lingualthaninterproximalareasafterendodontictreatmentandtoothpreparation.4,1315Theferruleeffecttheneedfora360collar2mminheight(1.5mmminimum)
wasdescribedbySorensenandEngelman11in1990.Smallerdimensionsareassociatedwithagreaterriskoffailure.4,6,9,1622
Apostshouldbeusedonlywhenthereisinsufficienttoothsubstanceremainingtosupportcorematerialorthefinalrestoration.Theheightofthepostshouldalwaysbethesameor
greaterthanthatofthefuturecrown,anditswidthshouldbeestablishedbythewidthofthecanalafterrootcanaltreatment.Increasingpostdiameterinanefforttoincreaseretentionis
notrecommended,asthiscreatesunnecessaryweakeningoftheremainingtoothstructure.1,9,2325
BiologicConsiderations
Caries,previousrestorationsandfracturescanaffectthebiologicwidthoftheremainingstructureandleadtoaccumulationofbacteria,inflammation,increasedprobingdepth,gingival
recessionoracombinationoftheseproblems.Whensulciarenormal(23mm)andhealthyandbandsofattachedgingivaareadequate,marginscanbeplacedupto0.5mminside
the sulcus. When tooth structure is insufficient to allow adequate soft tissue attachment, other procedures (such as surgical crown lengthening or orthodontic extrusion) may be
necessarytoachieveoptimalresults.2634
Inpreparingarootcanalforapost,themainbarrieragainstreinfectionoftheperiapicalregionistheendodonticobturationmaterial.Thelengthoftheremainingapicalsealafterpost
preparationcaninfluencethelongtermsuccessoftherestoration.4,5,10,3538Thereissomeevidenceforleaving35mmofundisturbedapicalendodonticobturationmaterialafterpost
preparation.Onlysometeethhavea1mmthicklayerofdentin5mmfromtheapex.Atdistanceslessthan3mmfromtheapex,thereisunlikelytobe1mmofsounddentinsurrounding
theapicalendofthepost.4,10,39
OcclusalFactors
Occlusalloadisalsoanimportantconsiderationinestimatingthechancesofsuccessfulrestorationofadamagedtooth.Inaretrospectivestudy,SorensenandMartinoff40foundthat,
althoughthesuccessrateforsingleunitcrownswas94.8%,itwas89.2%forfixedpartialdentureabutmentsandonly77.4%forremovablepartialdentureabutments.Nymanand
Lindhe41foundthatfracturesinabutmentteethoccurredmorefrequentlyinroottreatedteeth.Hatzikyriakosandcolleagues42 reportedafailurerateforendodonticallytreatedteethused
asabutmentsforfixedandremovablepartialdenturesthatwasmorethantwicethatforsuchteethnotusedasabutments.
Someconclusionscanbedrawnfromthesestudies.Extensivelydamagedteethcannotbeconsideredreliableasabutmentsforfixedorremovabledentures(especiallylongspanfixed
bridgesanddistalextensionsofremovabledentures)orcantileversorforpatientswithseverebruxismandclenchinghabits.4,8,9,11,41,42

ClinicalProtocolforDiagnosingExtensivelyDamagedTeeth
Foraseverelydamagedtooth,someelementsofatreatmentplanaremandatory:
Removalofallcariesandoldrestorationstoachieveaccesstotheremainingtoothstructure.
Eliminationofallperiodontalinfectionandcontrolofplaque.
Predeterminationofthevalueofthetooth,e.g.,isitimportantforocclusionoresthetics?
Thefollowingcriteriashouldthenbeassessedinthissequence:ferruleeffect,relationbetweenrootandcrownlength,endodonticcondition.
Criterion1FerruleEffect
Theferruleeffectisdeterminedfromverticalandhorizontalintraoralmeasurements.Theverticalmeasurementisfromthetopofthegingivalmargintothetopoftheremainingtoothwall
at4points:mesial,distal,buccalandlingualorpalatine.Thiscanbeeasilyassessedusingaperiodontalprobewithastopandanendodonticruler.Valuesarepositiveifthetopofthe
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remainingtoothisabovethegingivalmargin(Fig.1)ornegativeifitisbelow(Fig2).
Thehorizontalmeasurementisthethicknessoftheremainingtoothwallsatthelevelofthefuturecrownmarginat4points:mesial,distal,buccalandlingualorpalatine(Fig.3).Thiscan
beeasilymeasuredwithcalipers,whicharecommonlyusedtomeasureframeworkthicknessoffixedprosthodontics(Fig.4).Ifspacedoesnotpermittheuseofcalipers,aperiodontal
probe(withastop)canbeusedinstead(Fig.5).

Figure2:Measurementoftheremaining
buccalwalloftooth22withaperiodontal
probeandstop.Thevalueisnegativeasthe
toothwallisbelowthegingivalmargin.
Figure1:Measurementofthe
remainingbuccalwalloftooth
15withaperiodontalprobe
andstop.Thevalueispositive
asthetopoftheremaining
toothisabovethegingival
margin.

Figure3:Locationof
horizontalintraoral
measurements.

Figure4:Measurementoftheremainingbuccalwallofadamagedtoothwithcalipers
(1.4mm).

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Figure5:Measurementoftheremaining
distalwallofadamagedtoothusinga
periodontalprobe.

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Criterion2RelationofCrowntoRootLength
Thisfactorisimportantinpredictingtheretentionofthefuturerestoration.Asnotedabove,topromoteretentionofthecrown,apostshouldbeatleastthesamelengthasthefuture
crown.Futurecrownlengthmaybemeasuredfromthetopofthesupposedtoothtothehypotheticalmargin,intraorallyorusingamodel(Fig.6).
Rootlengthmaybemeasuredradiographically(Fig.7).
Ifneeded,onabuccal(Fig.8),palatineorlingualface,itispossibletomeasurethedistanceofthereferenceleveltothetopoftheremainingtoothandtransferthismeasuretothe
radiograph(seedonFig.8).Thenmeasuretherootlengthfromthisleveltotheapexontheradiograph(seeronFig.8).Usingtheratioofdtod,calculatetherealdimensionofthe
root,r,fromr.

Figure6:Measurementofanextensively
damagedtooth22fromthesupposedtopof
thetoothtothehypotheticalmarginwitha
periodontalprobe.

Figure7:Radiographshowing
crownandroot
measurements.

Figure8:Determinationofrootlengthatthe
buccalfaceoftooth12.

Criterion3EndodonticCondition
Theremainingtoothshouldbeevaluatedrelatedtotheextentofendodontictreatmentrequired:cantreatmentbeperformedwithoutpredictablecomplications,arecomplicationslikely
and,thus,treatmentoutcomeisuncertainorarecomplicationsirreversibleandcannotberesolvedwithendodontictreatment.

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ClassificationofTeethwithExtensiveEndodonticDamage
ClassI
Ferruleeffect:Heightofremainingtooth2mmat4locations(mesial,distal,buccal,palatineorlingual)andthicknessofremainingtoothwalls2.2mmforanestheticrestoration
or1.6mmfornonestheticrestorations
Remainingrootlength:Atleastaslongasthefuturecrownheightplus5mmfortheapicalseal
Endodonticcondition:Endodontictreatmentmaybeperformedwithoutpredictablecomplications
Prognosis:Good
ClassII
Ferruleeffect:Heightofremainingtooth0.52mmorwidthofremainingtoothwalls1.62.2mmwithvisiblemarginsor1.21.6mmwithnonvisiblemargins
Remainingrootlength:Lessthancrownheightplus5mmbutequalorgreaterthancrownheightplus3mm
Endodonticcondition:Withoutpredictablecomplicationsorwithuncertainresults
Prognosis:Moderate
Note:Atoothinthisclassshouldnotbeusedasanabutment.Anewevaluationshouldbeperformedafterendodontictreatmentincaseswherepretreatmentprognosisisuncertain.
ClassIII
Ferruleeffect:Heightofremainingtooth<0.5mmorwidthofremainingtoothwall<1.2mmatfuturemarginlevel
Remainingrootlength:Lessthancrownheightplus3mm
Endodonticcondition:Withirreversiblecomplications
Prognosis:Poor
Note:Atoothinthisclassisnotacandidatefortreatmentitshouldbeextractedandreplacedbyaprosthesis.
Theclinicalrecordform below may be used to evaluate severely damaged teeth using these criteria. Each parameter is evaluated and individually classified as I, II or III. Final
classificationisthehighestclassforanyparameter,i.e.,atoothratedI,II,Iforthe3parameters,isClassII.
Clinicalrecordformforscoringteethwithextensivedamage

ClassI,
prognosisgood

ClassII,
prognosismoderate
Height0,52mm

Height2mm
Ferruleeffect

Width2.2mm(esthetic)
1.6(nonesthetic)

ClassIII,
prognosispoor

Width1.62.2mm(visiblemargins)
1.21.6mm(nonvisiblemargins)

Height<0.5mm
Width<1.2mm

<crownheight+5mm
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Rootlength

crownheight+5mm

Endodonticcondition

Withoutpredictablecomplications

crownheight+3mm
Withoutpredictablecomplicationsoruncertaintreatmentresults

<crownlength+3mm

Withirreversiblecomplications

Finalclassification_________________________

AdditionalClinicalConsiderations
Preprosthetictreatmentmayaffecttheinitialclassification.
Concernaboutspecialstresspatterns(bruxism,abutmentsforaremovablepartialdenture,cantilevers,extensivebridgesorsecondaryabutments)raisestheclasslevelfromItoII
orfromIItoIII.
Classlevelalsoincreasesby1ifthereareestheticconcerns.
Incaseswherethereisnoantagonist,noocclusalissues,theantagonistisaremovabledentureorthereisclinicalevidenceofsmalltonoloadsovertheremainingtooth,theclass
leveldecreasesby1.
Forpatientswithpoororalhygiene,uncontrolledperiodontaldiseaseorcaries,anextensivelydamagedtoothshouldbeconsideredClassIII.

Conclusion
Clinicalguidelineshelpthedentistarriveatthecorrectdiagnosisandtreatmentplan,avoiderrors,increasethepredictabilityofdentaltreatmentandincreasethequalityofservice.
Although the literature describes the rehabilitation of teeth with extensive endodontic damage, no clinical guidelines have been published. Our goal in this article is to provide the
clinicianwithsuchguidelinesforselectionofextensivelydamagedteethforrehabilitation.

THEAUTHORS
Dr.Estevesisheadoffixedprosthodontics,SchoolofDentalMedicine,PortugueseCatholicUniversity,Viseu,Portugal.

Dr.Correiaisheadofdentalinformatics,SchoolofDentalMedicine,PortugueseCatholicUniversity,Viseu,Portugal.

Dr.ArajoisalecturerinfixedprosthodonticsSchoolofDentalMedicine,PortugueseCatholicUniversity,Viseu,Portugal.

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Correspondence to: Dr. Helder Esteves, rea Disciplinar de Prostodontia Fixa, Departamento de Cincias da Sade, Centro Regional das Beiras, Universidade Catlica
Portuguesa.EstradadaCircunvalao3504505Viseu.Email:hjme@sapo.pt
Theauthorshavenodeclaredfinancialinterests.
Thisarticlehasbeenpeerreviewed.

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