MANAGEMENT OF

MUTILATED TEETH
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.
Causes of Mutilation
A) Long standing caries

B) Traumatic fracture

C) Recurrent caries
Causes of Mutilation
A) Long standing caries:
Factors that increase Dental Caries Progression:

 Patients with enamel hypoplasia,

hypocalcification.
 Patients with bad oral habits
(eating sweets,sticky food,…).
 Patients with bad oral hygiene.
B) Traumatic fracture
Maybe due to
Traffic accident
Bicycle falls
Blows to the face
Chewing hard objects
c) Recurrent caries
It is considered the cause of
mutilation to already placed
restoration
Characteristics of
mutilated teeth

1. Partial or complete loss of cusps.

2. Loss of marginal ridges or crossing ridges.
3. Loss of axial angles.
4. Negative crown / root ratio, which is
normally 1:3.
Characteristics of
mutilated teeth

5. Partial or complete loss of

crown/root junction.
6. Multiple cracks with an unlimited
extent or appearance of signs
and symptoms of cracked tooth
syndrome.
 SEQUALAE OF
MUTILATION
 1. Weakening of remaining tooth
substance decrease
retention and resistance
 2. May endanger normal pulp
physiology , periodontal health and
restoration of esthetics
SEQUALAE OF
MUTILATION
3. Drifting or over eruption of teeth
complicating restoration and
compromising success
Examination and clinical
assessment of tooth
Patients with high caries
incidence
Amalgam or full coverage
2)Oral hygiene.
Bad oral hygiene (amalgam)
3) Periodontal status.
4)The amount of remaining tooth
structure
5) Amount of forces to which the
tooth is subjected.
6) Bad habits.
7) Mobility.
8) Cracks.
Restorative treatment
. Anterior teeth :
- Resin composite. (complex
fracture and horizontal)
- Porcelain laminate. (multiple
fracture)
- Ceramic or porcelain fused to
metal restorations.(loss of two incisal
angle together, multiple defect)
Restorative treatment

 II. Posterior teeth:

 Amalgam restoration
 Resin composite
 Inlays or Onlays
 Full coverage
restoration
CAVITY PREPARATION
FOR DIRECT
RESTORATIONS
GENERAL RULES:

1) Remove all carious dentin and

all undermined enamel.
2) The outline of all the cavity is
extended into smooth
cleansable enamel
 AMALGAM :
 Facial and lingual walls of the cavity
should converge occlusally with a C.S.A.
of 90 degrees .
 Additional resistance and
retention mean
 Capping cusps, Retention
locks, Slots, Dentin
chambers and Pins.
 CAPPING CUSPS:

 - 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

- Functional cusps are
reduced by 2mm
minimum
- Non functional
cusps are reduced by
1.5mm
 - Roundation of any sharp external
corners is a must to reduce stress
concentration in the amalgam.

 - Disadvantage:
 Reduction of the cusp significantly
reduce the retention form by decreasing
the length of the longitudinal walls.
 RETENTION LOCKS:

 - wherever
possible, retention
locks in dentin of
the axial walls are
are made by using
fissure bur.
 SLOTS:

 - 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.
 - 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.
DENTIN CHAMBER:
 - Called Amalgapin technique.
 - Dentin chambers are prepared in the
floor of the cavity with the bur parallel to
the external surface of the tooth.
 - Depth is 2mm.
 - The junction between the pulpal floor
and the walls of the chamber is beveled
with round bur.
 - DISADVANTAGES:
 1. The potential of tooth
perforation is greater than with
slots.
 2. Less retention than Slots and
Pins.
Definition of pin-retained restoration
It may be defined as any restoration requiring the
placement of one or more pins in the dentin to provide
adequate resistance and retention forms.

Advantage
1-conservation of tooth structure
2- resistance and retention means
3-economics
Disadvantage
1- dentinal microfractures
2- microleakage
3- perforation
PINS:

- Types of pins:
1.Cemented pins.
2. Self threading pins.
3.Friction locked pins.
1. Cemented pins:
 -They are serrated
 -They are cemented by dental luting
cement using lentulo spiral.
 -Diameter of pinhole preparation is
0.0025 to 0.05mm larger than that of pin.
 -Pinholes are prepared at a depth of 3-4
mm.
- ADVANTAGES:
- 1.Require minimal access for
insertion.
- 2.Can be measured, cut. bent.,
trial fitted before cementation.
- 3.Available in 3 diameters.
- 4.No internal stresses upon
placement.
- 5.Can be used in non vital tooth and
vital tooth.
DISADVANTAGES:
1. Weak retention.
2. ZPC is irritant.
3. Retention of the pins in dentin is
proportional to the strength of Cement
Used and the length of pin into holes.
2. Self threading
pins(TMS)
- Available in three types:
- 1.The regular type (3 lengths)
- Diameter 0.031”, Pinhole 0.027”
- 2.The Minim type (2 lengths)
- Diameter 0.024”, Pinhole 0.021”
- 3.The Minikin type
- Diameter 0.019”, Pinhole 0.017”
- ( anterior restoration)
-
 -ADVANTAGES:
 1.Strongest retention.
 2.No cementation complications.
 3.No pulp irritation.
 -DISADVANTAGES:
 1.Internal stresses.
 2.Restricted to available access cavity.
 3.Not used in non vital teeth.(Rely
on dentin viscoelasticity.)
 4.High cost.
3.Friction locked pins:

 -They are smooth pins with continuous

spiral groove.
 -The pin diameter is 0.001” larger than
the twist drill.
 -The pinhole dept is 2-3mm.
 -ADVANTAGES:
 1.Strong retention.
 2.No cement complications.
 3.Quiqest & easiest method.
 4.Provided in a variety of precut lengths.
 -DISADVANTAGES:
 1.Internal stresses.
 2.Its use is restricted to available access for
pin insertion cavity.
 3.Not used in non vital teeth.(Rely on
dentin viscoelasticity.)
 Factors affecting pin
retention in dentin &
amalgam
1. Type of pin.
2. 2. Surface characteristics.
3. 3. Orientation, Number and Diameter.
4. 4. Extention in dentin and amalgam.
Factors affecting pin
placement:
1. Pin size:
2. Factors affecting selection of size:
3. a. amount of dentin available.
4. b. amount of retention desired.
5. 2.Pin number:
6. Factors deciding the number:
7. a. amount of dentin available.
8. b. amount of retention desired
9. c. amount of missing tooth structure.
10. d. size of the pin.
11. ONE PIN PER MISSING AXIAL ANGLE
SHOULD BE USED
Consideration when placing
more than one pin:
1. They should be placed at different
levels.
2. 2. Interpin distance;
3. 3mm for the Minikin type
4. 5mm for the Minim type.
Possible problems when
using pins
1. Failure of restoration.
2. 2. Broken drills or pins.
3. 3. Loose pins.
4. 4. Penetration into the pulp &
perforation of the external tooth
surface.
PINS:
 - Indicated in anterior teeth but not
used any more due to the development
in the adhesive dentistry.
 - Teeth with little or no enamel to
etch that are ideally restored with
tooth colored crowns can be restored
with pins only for economics and time
restraints
Cast inlay/ onlays :
Indications:
1.It is the simplest of the cast restoration which is used to restore
occlusal, gingival and proximal lesions.
2. Restoration of teeth which need cusp coverage.
3. Proximo - occlusal inlays is indicated for premolars and molars.
4.Class I inlays can be used to restore a moderately sized occlusal lesion.
5.Class III inlay is used to restore the distal surface of canine.
6.Class V inlays is used to restore severe abrasion or erosion.

Contraindications of cast Inlays :

Patients with accumulation of plaque or recent history of caries here the
full coverage crown is the treatment of choice.
Cast onlays:-
Indications:
1-MOD
1-MOD restoration with wide isthmuses.
2- The use of inlay in mesio–occluso-distal lesions in premolars is questionable occlusal force on an inlay produces stresses along the sides of the restoration and at it’s base as the inlay pushes against the tooth structure surrounding it which could fracture the tooth so an inlay must be modified to distribute the load
evenly over a wide surface covering the occlusal surface with metal has minimized the damaging effect of stresses in an inter-coronal restoration.
Restorative materials used for cast restorations:
A) Gold alloys.
B) Base metal alloys.
C) Sometimes for esthetic demands composite inlays may be used
Full coverage restorations:
Full cast restoration rebuilding the prepared abuement teeth it’s either.
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
acrylic or 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.
Reinforcement of endodontically treated teeth
the pulpless teeth require different treatment from the tooth that still retains vitality.
l. The cast post and core:

1. Single rooted teeth

2. Multi rooted teeth:

A) Straight rooted
B) Divergent rooted teeth
ll. Prefabricated posts:
A) With amalgam core.
B) Prefabricated posts with composite core.
C. RESIN COMPOSITE:

 1. All enamel margins have to be

beveled to increase retention.
 2. Additional resistance and
retention means:
 Counter bevel, Reverse bevel,
Secondary flares, Skirts and Pins.
COUNTER BEVEL:

 - Prepared on non-functional
cusps.
 - The cusp is reduced 0.75mm.
 - A stone is placed with 30
degrees angle on the outer surface and
the counter bevel is placed.

 - Contraindicated in facial cusps of
upper premolars and first molars for
esthetics.
 So replaced by only blunting and
smoothing of the enamel margins.
REVERSE BEVEL

- Prepared on functional cusps.

- - Cusps are reduced by 1.5mm then
reverse bevel is placed with chamfered
margin on the external tooth surface.
SECONDARY FLARES:
 - Made on the proximo-facial and
proximo-lingual walls.
 - Approach from the lingual embrasure
moving the stone proximo-facially to place
the secondary lingual flare.
 - The same is done facially with
opposite direction to place the secondary
facial flare.
SKIRTS PREPARATION:
 - These are thin extentions of the
facial or lingual proximal margins
that extend from the secondary flare
to end just beyond the line angle of
the tooth.
 - Prepared entirely in enamel and
may involve very little dentin
ATRAUMATIC.
 - Never placed on the mesio-facial
wall of the upper premolars and first
molars for esthetics, so only
secondary flares are done.
 - It allows bonded composite to
brace the toothincrease
resistance to fracture.
PINS:
 - Indicated in anterior teeth but not
used anymore due to the development
in the adhesive dentistry.
 - Teeth with little or no enamel to
etch that are ideally restored with
tooth colored crowns can be restored
with pins only for economics and time
restraints