MANAGEMENT OF

GROSSLY MUTILATED
TEETH

Dr. Khushboo
JR III
DEFINITION

Mutilated tooth is that tooth which is grossly weakened

and badly broken down where the amount of
remaining tooth structure is less than the amount of
tooth loss.

Hanlin. The Mutilated Dentition--Management of the Debilitated Dentition. Ann R Australas Coll Dent Surg.
2012 Apr;21:49-50.
Lee et al. Fixed prosthodontic management of a mutilated dentition: A team approach. J prost dent 2009
A) Long standing caries

B) Traumatic fracture

C) Recurrent caries
A) Long standing caries:

Factors that increase Dental Caries Progression:

 Patients with poor oral habits (eating sweets, sticky food).

 Patients with poor oral hygiene.

B) Traumatic fracture

•Road traffic accident

•Blows to the face
•Chewing hard objects
•fall

c) Recurrent caries

It is considered the cause of mutilation to already placed

restoration
 Point 4 cross
checked

Lee et al. Fixed prosthodontic management of a mutilated dentition: A team approach. J Prosth dent 2009
1. Weakening of remaining tooth substance decrease
retention and resistance form

2. May endanger normal pulp physiology and

periodontal health.

3. Drifting or over eruption of teeth complicating

restoration and compromising success
• Slot retained restoration
• Pin retained restoration
Inlay are
• Onlay not
• Post and core included

• Endocrown
• Full coverage restoration
Roggenkamp CL, Cochran MA, Lund MR. The facial slot preparation: a non-occlusal option for Class 2 carious lesions.
Oper Dent 1982; 7(3):102–6.
- Slots are indicated in short clinical crown and in cases where
2-3 mm of reduced cusps is present.
- Slots can be prepared along the gingival floor using an inverted
cone bur.
- Slots are placed 0.5 mm pulpal of the DEJ.
- Slots are at least 0.5 mm in depth and 1 or more mm in length
depending on distance between the vertical walls. - sturdevant
Values
crosschecked
Ewoldse. Facial Slot Class II Restorations: A
Conservative Technique Revisited. Journal of the
Canadian Dental AssociationJanuary 2003, Vol.
69, No. 1.
 ADVANTAGES:

1. Slot-retained amalgam is more retentive

than pin-retained amalgam.
2. Slots are less likely to perforate the tooth.

DISADVANTAGE:

More tooth structure is removed preparing slots compared with

pins.

Ewoldse. Facial Slot Class II Restorations: A Conservative Technique Revisited. Journal of the Canadian Dental
AssociationJanuary 2003, Vol. 69, No. 1.
 PIN-RETAINED RESTORATION

Any restoration requiring the placement of one or more pins in

the dentin to provide adequate resistance and retention forms.

- sturdevant

Advantage

1- conservation of tooth structure in badly broken tooth

2- for resistance and retention means
3- economical

Disadvantage

1- dentinal microfractures
2- microleakage
3- perforation
 - Types of pins:
1.Cemented pins.
2. Self threading pins.
3. Friction locked pins.

Comparat
studies

Bailey et al. Retention design for amalgam restorations. The J ProsthDent Volume 65, Issue 1, January 1991, Pages 71-74

Barkmeier et al. Amalgam restoration of posterior teeth before endodontic treatment. J EndodVol 6, Issue 2, February 1980,
Pages 446-449
 Developed by Dr miles Markley in
1950

 Made of stainless steel

 Produce least stress

 Offer less resistance

 Diameter of pinhole preparation

is 0.0025 to 0.05mm larger than
that of pin.
- sturdevant

14
ADVANTAGES:
1.Require minimal access for insertion.
2.Available in 3 diameters.
3.No internal stresses upon placement.
4.Can be used in non vital tooth and vital tooth.

DISADVANTAGES:

1. Weak retention.
2. Retention of the pins in dentin is proportional to the strength of
Cement
 Developed by Dr. Going in 1966

 Most popular type among all, the different types

and most extensively used pin.

 Made of stainless steel or gold plated titanium

pins

 Provide maximum retention among all types of pins

 Cause craze lines

 Used in vital teeth

- sturdevant

16
-ADVANTAGES:
1.Strongest retention.
2.No cementation complications.
3.No pulp irritation.

-DISADVANTAGES:
1.Internal stresses.
2.Not used in non vital teeth.(Rely on dentin viscoelasticity.)
3.High cost.
 Developed by Dr. Goldstein in 1966

 Made of stainless steel

 More retentive than cemented pins

 Used in vital teeth .

 Cause craze lines or cracks

 They are smooth pins with continuous

spiral groove.

 Retain by resilience of dentin

 The pin diameter is 0.001” larger than

the twist drill.
- sturdevant

18
ADVANTAGES:
1.Strong retention.
2.No cement complications.
3.Quickest & easiest method.
4.Provided in a variety of precut lengths.

DISADVANTAGES:
1.Internal stresses.
2.Not used in non vital teeth.(Rely on dentin viscoelasticity.)
1. Type of pin.
2. Surface characteristics.
3. Orientation
4. Extention in dentin and amalgam.
5. Pin Diameter
1. They should be placed at different levels.
2. Interpin distance;
2mm for cemented pins
4mm for friction locked pins
3mm for the Minikin type
5mm for the Minim type.

ONE PIN PER MISSING AXIAL ANGLE

SHOULD BE USED
- sturdevant
An indirect restoration, which is partly intracoronal and partly
extracoronal that covers all the cusps of a posterior tooth, fabricated
outside the oral cavity and placed in the prepared cavity.
- marzouk

Indications:
1- MOD restoration with wide isthmuses.
2- Tooth at risk of fracture
3- Endodontically treated teeth
4- When there is a need to change the dimension, shape and
interrelationship of the occluding tooth surfaces
5- Abutment teeth for RPD & fixed prostheses
Contraindications:
•High caries rate
•Young patients
•Occlusal disharmony
•Dissimilar metal

Restorative materials :
A)
Gold alloys.
B)
Palladium based alloys.
C)
Base metal alloys.
D)
Sometimes for esthetic demands composite and ceramic onlays may be used

- marzouk
-“Capping” refers to the complete coverage of the cusp/ cusps of a
tooth with sufficient extension of the bevel onto the buccal and
lingual surfaces of the tooth to carry the margins of the restoration
into areas where stresses cannot be brought to bear directly into them.

-Needed when caries is extensive and when the lingual or facial

extension is two third from a primary groove toward the cusp tip.

- Functional cusps are reduced by 2mm minimum

- Non functional cusps are reduced by 1.5mm

- Sturdevant
• When capping cusps to protect and support them,
this type of bevel is used, opposite to an axial
cavity wall, on the facial and lingual surface of
the tooth, which will have a gingival inclination
facially or lingually.

• Extracoronal feature

• Relieved from opposing cuspal elements by at

least 1 mm in both static & functional occlusal
contact
- Sturdevant
 RETENTIVE FEATURES

• Grooves can be internal in an intracoronal preparation or externally

located in extracoronal preparation.

• This extension is indicated to provide additional retention form and

help in preventing lateral displacement of mesial, distal, facial or
lingual parts of restoration.

• Must be located completely in dentin.

• Should not exceed 2mm in depth.

- Sturdevant
• Thin extensions of the facial or lingual proximal margins of the
cast metal onlay that extend from the primary flare to a
termination just past the transitional line angle of the tooth.
• A skirt extension is a conservative method of improving both the
retention & resistance forms Relatively atraumatic to the health
of the tooth: removes very little (if any) dentin
• Usually the skirt extensions are prepared entirely in enamel
• Lingual wall missing: skirt extension on the facial wall
• Facial wall missing: skirt extension of the lingual surface
• When both the lingual and facial walls of a proximal boxing are
inadequate: skirt extensions on both the respective lingual & facial
margins

INDICATION
• Contact and contour areas of proximal surface
are to be changed.
• Teeth with missing or shortened opposing facial
or lingual walls.
• Tilted teeth to restore occlusal plane.

DISADVANTAGE

Increase the display of metal on

facial and lingual surfaces.
- Sturdevant
• To increase the retention and resistance forms when preparing a
weakened tooth for a MOD onlay capping all cusps, a facial or
lingual "collar," or both, may be provided.

• Depth 1.5-2mm, ends gingivally with a bevelled shoulder finish

line.

• Most reproducible surface extension and better marginal sealing.

Values - Sturdevant
checked
POST AND CORE
 DOWEL(POST):
It is a rigid restorative material placed in the radicular
portion of a non vital tooth when the crown structure is
compromised.

 CORE:
Restorative material placed in the coronal portion of tooth
which replaces missing coronal structure and retains the
final restoration.

 FERRULE(EISSMAN & RADKE): A 360 degree band of metal

that protectively encircles the remaining tooth structure.

- Cohen
Henry and Bower, 1977
 Indication of post
• Moderate to severe loss of tooth structure of more than 50%.

• Retention of complex restoration.

• Large cervical lesions

• Angles of core to be changed

• Extensive wear of teeth due to parafunctional habits.

Contraindication
• Minimal remaining dentin thickness available.

• Extreme curvature of root

• Fragile roots

• Teeth having questionable prognosis which require retreatment. - cohen

High strength

Custom fit to the root configuration

Minimal alteration of canal anatomy

Adaptable to large irregularly shaped canals and orifices

Changes in core angulation is possible

Henry and Bower, 1977 Christensen, 2004 Fredriksson et al., 1998

 Rigidity – Root fracture

 Tapered canals – wedging effect

 Two or more appointments

 Temporization between appointments necessary

 Risk of casting inaccuracies

 Unesthetic appearance

Martinez-Insua et al., 1998 Dean et al., 1998, Bateman et al., 2003

Simple to use

Requires less chair side time

Completed in one appointment

Easy to temporize

Pontius and Hunter, 2002 Qualtrough et al., 2003 Newmann et al., 2003
  Application is limited when considerable coronal tooth structure
is lost

 Galvanic reactions are possible when post and core are of

dissimilar metals

Teixeira at al., 2006, Robbertset al., 2004, Cormier et al., 2001, Christensen, 2004
 Standlee JP et al., 1978 & 1972

 Preserve 3 to 5mm of apical gutta percha to

maintain apical seal
Mattison CD et al., 1984, Kvist T et al., 1989

 Molars with short roots – Place more than one post

for Additional retention Hirshfeld Z et al., 1972
 Harper RH et al., 1976, Mondelli J et al., 1971, Goldrich N et al., 1970, Rosenberg
PA et al., 1971

 Longer than the crown Silverstein WH et al., 1964

 One-third of the crown length Dooley BS et., 1967

 Half the root length Baraban DJ., 1967, Jacoby WE 1976

 2/3rd of root length

Dewhirst RB et al., 1969, Hamilton AI 1959, Larato DC et al., 1966,
Christy JM et al., 1967, Bartlett SO., 1968
 Post preparation – molars – should be
limited to a depth of 7mm apical to the
canal orifice
Abou-Rass M et al., 1982

 Half the length of root in bone

Perel and Muroff 1972
 Mattison 1982, Trabert 1978)

Diameter increases –
stress increases – Fracture Resistance decreases

Dhalan. Prosthodontic management of endodontically treated teeth: factors determining post

selection, foundation restoration and review of success& failure data.
 greater than one third of the root width at its
narrowest dimension
Stern and Hirshfeld., 1973

 PRESERVATIONIST: Post should be

surrounded by a minimum of 1mm of
sound dentin Hall EB et al., 1984

 CONSERVATIONIST : Minimal canal preparation &

maintaining as much residual dentin as
possible
Pilo and Tamse., 2000
 than a smooth post Henry & Bower 1977

 Controlled grooving of the post and root canal – increases retention

of tapered post
 Roughening – Sandblasting
Dhalan. Prosthodontic management of endodontically treated teeth: factors determining post
selection, foundation restoration and review of success& failure data.

Joana Machado et al., 2017: Currently used systems of dental posts : Sci direct
Traditional cements – little effect

Commonly used : Zinc phosphate, polycarbboxylate, GIC,

RMGIC

 Recently, Adhesive resin luting cements – increased

retention
Dhalan. Prosthodontic management of endodontically treated teeth: factors determining post selection,
foundation restoration and review of success& failure data.

C Goracci et al., 2011: Current perspectives on post systems: a literature review:

Australian Dental Association
 Ash M jr.et al., 1993 and Smith TC et al., 1997

 Extensive preparation – Well adapted cast post and core restoration

 Funnel shaped canals – Prefabricated parallel sided posts

Cohen BI et al., 1996

 Tapered canals – Parallel post – fill remaining space with luting

agent
 Definition
The endo-crown is an onlay restoration on endo-donticaly treated teeth ,
which is more conservative than traditional post and core system and uses
the adhesive resin with mono-block technique

• Concept

To engage the large pulpal

chamber of root of treated molar
teeth with ceramic etched
restoration which provides cuspal
coverage.

Chaudhary. Restorative management of grossly mutilated molar teeth using endocrown: A novel concept. J rest dent 2016
• Succesfully root treated molar
with insufficient coronal tooth structure

• Excessive loss of coronal dental tissue

and limited inter-occlusal space

• Molar with Calcified Canals

Fages et al. The Endocrown: A Different Type of All-Ceramic Reconstruction for Molars. j can dent assoc 2013;79:d140
• Para Functional Habbits
• Can’t obtain adequate
isolation from saliva
• Depth of pulp chamber less
than 3mm

•Cervical Margin less than 2 mm

wide

•If adhesion can’t be assured

Fages et al. The Endocrown: A Different Type of All-Ceramic Reconstruction for Molars. j can dent assoc 2013;79:d140
• Less Complex , More practical and easier to perform

• Allow minimal tooth wear thus strengthens the tooth

• Preparation design is conservative and biological width is minimal

• Allows re-entery to canals if required without post removal

• Reduce patient cost and chairside time

• Risk of debonding
• Limitation maybe restricted to the ceramic material which must
be
acid etchable ceramics .
Making the guide grooves in an isolated
tooth and in situ

Axial preparation using a cylindro-

conical drill to make the coronal
pulp chamber continuous with the
access cavity
Cervical margin before (a) and after (b)
polishing.

Prepared tooth (a), endocrown (b) and final result after bonding
(c).
Full coverage restorations:

Full cast restoration rebuilding the prepared abutment teeth.

A) Full metal crown:
Full metallic restoration rebuilding the prepared abutment teeth.
B) veneered crown:
Full cast metal crown having the labial or buccal surface covered with
porcelain facing.
Indications of full coverage restoration:
1. Badly broken down teeth when no other type of restoration can be
used.
2. Mutilated teeth with short Occluso-gingival height.
3. Mutilated teeth which need splinting for periodontal disease.
4. Rotated , tilted and malposed teeth.
 Contraindications

• Primary posterior teeth- where conservative amalgam can

be placed.

• Partially erupted teeth

• Where conservative restorations can be placed

• Patient with high caries index and active periodontal

diseases.

Tooth preparation for full-coverage restorations—a literature review.  Clinical Oral Investigations 19(5) · March 2015
The management of a complete oral rehabilitation in patients
with severely worn dentition is often challenging due to loss of
vertical dimension, loss of tooth structure, uneven wear of teeth
creating an uneven plane of occlusion, poor esthetics, reduced
chewing efficiency and para-functional habits. So the treatment
not only restored function and esthetic, but also showed a
positive psychological impact and thereby improved perceived
quality of life.