Post Operative Care - Minia

BY

DR. MOHAMMED MOUSTAFASHALABY

LECTURER, CROWN & BRIDGEDEPARTMENT

MINIA UNIVERSITY

Post Operative Care

Introduction

After placement of the fixed dental restoration, patient

treatment continues with a carefully structured sequence

of postoperative recall appointments designed to

monitor the patient’s dental health, stimulating plaque

control habits ,identify any incipient disease,&

introduce any corrective treatment may be needed

before irreversible damage occurs.

Post Cementation Appointment

After the cementation of the fixed restoration , an appointment is scheduled within a week to 10 days to enable the dentist to monitor the function & comfort of the restoration & to verify that proper plaque control has been mastered by the patient

. A careful check is made to1- detect any remnants of cements in the sulcus2- Detect any occlusal problem. The presence of polished facets on the contacting surfaces of cast restoration , minor shift in tooth position denotes that some occlusaladjustment is necessary. If so, the patient is rescheduled for the next week to ensure that no further correction will be needed.

Monitoring the sulcus

depth & health of the

gingiva

Periodic Recall

It is recommended to recall patient every 6 monthsotherwise , incipient caries may be developedbeneath the restoration and unnoticed by thepatient . Also the patients with periodontallycompromised abutments & those having extensivefixed prostheses will need more frequent recallappointments.

Recall examinations should be carried out by thedentist personally.

History & General Examination

The patient medical history should be reviewed & updated annually ,oral sings of serious diseases may be captured through careful examination . The general aspects to be examined are :

1. Oral hygiene & shift in dietary habits.

2. Dental caries & root caries.

3. Periodontal disease.

4. Occlusal dysfunction.

5. Pulp & periapical area.

Oral hygiene & dietary habits

The dentist should insure the effectiveness of plaque control measures, especially around pontics and connectors, and the use of special oral hygiene aids such as tooth brushing, dental floss, oral irrigating devices, and mouth rinses

If pontics are appropriate in design, floss can be looped through the embrasure spaces on each side and the loop is pulled tightly against the convex pontic tissue surface. A sliding motion is used to remove dental plaque.

.Any indications of plaque accumulation should be identified and corrective therapy must be initiated.

Oral hygiene & dietary habits

There is an increasing interest toward the use of mouthrinses and chewing gum as vehicles for antiplaque agents.However chewing gum, sugarless or not, should be avoidedafter crown and bridge therapy. The great threat to oralhealth comes from the hydraulic pressures exerted onvarious confined areas of tooth structure by the chewinggum mass. These forces may drive plaque, & debris intodeeper invasion of the soft tissues.

Proper nutrition will help the fixed restoration to functionin an environment of healthy bone and soft tissues as itminimizes the formation of plaque on and near the crownsand bridges.

Oral hygiene & dietary habits

A most important goal to encourage the patient to reducehis intake of cariogenic sucrose especially between meals orto change it by non cariogenic sugars as in apples, nuts……

Patients should be warned about the harmful effect ofcarbonated beverages, as they contain large amounts ofrefined sugar & large quantities of phosphoric and citricacids, which etch and erode tooth enamel, challenge thesolubility of the cement line and the caries resistance of theremaning tooth structure.

Dental floss is

used to clean

beneath pontics

Plaque accumulation

Dental caries

Dental caries is the most common cause of failure of fixed restoration. Its detection is difficult, particularly when complete coverage is used .

Early enamel lesions can be detected by careful use of explorer.

It is sometimes possible to correct the problem with a filling material but when there is doubt that all carious dentin has been removed, it is wise to replace the entire restoration.

Root caries

Root surface caries is initiated by a plaque of differentcomposition (containing more anaerobic & gram-negativeorganisms) than that causing coronal caries.

The presence of Actinomycosis is thought to be of specialsignificance. These organisms seem to proliferate among thefiliform papillae of the tongue,& it has been suggested thatbrushing the tongue twice daily may be an effective means ofpreventing the root caries that is caused by them in elderlypatients. Similarly, xerostomia as a consequences of aging orcaused by medication or radiation is a cause of root caries. Itis treated by placing amalgam or glass ionomer restorationsthat wrap around the periphery of previously placed castrestorations.

Caries beneath the

crowns

New prosthesis

Root caries

Anaerobic ,gram –ve bacteria are the

causative organisms in addition to

xerostomia .

Periodontal problems

Inflammation and gingival rescission arecommonly seen after cementation specially if themargins are placed sub gingivally or therestorations are over contoured. Inflammation ismore severe with poorly fitting restorations. Atrecall appointments, swelling of interdentalpapillae & bleeding on propping, calculusformation is a sign of serious problems. Mobilitycan also be a sign of bone resorption .

Careful curettage and recontouring or replacing ofrestorations must be done.

Exposed metal rim of the restoration

and gingival recession.

PFM

Localized periodontal inflammation in

metal-ceramic crowns

PFM

Osseous defects

Mobility in the bridge & the

corresponding abutments

Occlusal examination

Any abnormal acquired occlusal habit must be monitored .

An examination of the occlusal surfaces may reveal abnormal wear facets. The canines, in particular, should be inspected because wear here will soon lead to excursive interfering contacts on the posterior teeth.

Articulated diagnostic casts should be periodically remade and compared with previous records, so any occlusal changes can be monitored and corrective treatment initiated.

Correction of interfering

contacts

Pulp & periapical area

At the recall appointments , any pain with temperature changes must be monitored .

Partial coverage restorations make the pulp vitality possible using either electric or thermal pulp testers.

Endodontic treatment may be performed through the crown without removal.

Radiographic examination is essential to examine the peri apical area.

Pulp tester Access cavity through

the crown

Closure by composite

Fractured root

Emergency Appointments

Patients should be taught to notice small changes in their oral health and to report them without delay. For instance, the porcelain veneer of a PFM restorations may be shielded from further fracture when a small chip is properly rounded off and the occlusion is adjusted immediately after it is first noticed. Postponing the corrective treatment can increase the cost of the treatment, as remaking of a complex prosthesis

Causes of emergency appointments can be:

Pain.

Loose Abutment or Retainer.

Fractured connector.

Fractured porcelain veneer.

Pain

Pain should be investigated in regard to its location,character, severity, timing, onset, precipitating or relievingfactors.

If the patient has several endodontically treated teeth thathave been restored with post and cores and fixedprostheses, the possibility of root fracture should beconsidered, especially for teeth that were internallyweakened as a result of endodontic treatment inconjunction with oversized posts of less than optimallength.

If a fracture has occurred, the tooth is lost, which cansignificantly complicate follow-up treatment, especially if itinvolves an abutment tooth for an FPD.

Loose abutment retainer

A loose retainer may not be easily perceived by the patient, especially if it is part of a fixed prosthesis supported by several abutment teeth. The patient may have noticed a bad taste or smell rather than been able to detect movement.

Poor cementation.

Bad preparation or bad design.

Caries in the abutments.

Bubbels of water or air in loose retainer

Fractured connector

Bad design.

Over loaded bridge.

Abnormal occlusal forces.

Fixed-fixed bridge in long span with pier abutments.

Fractured connector

Fractured porcelain veneer

Faulty metal framework design.

Excessive occlusal function or trauma.

Improper laboratory procedures.

When the fractured porcelain is not missing & there is little or no functional loading on the fracture site, it can sometimes be bonded in place with a porcelain repair system. But in most of the cases, composite resin is used to compensate for the broken veneering material.

Porcelain repair

Fractured porcelain

Although fixed prostheses do not last forever, withgood plaque removal, patient motivation, andaverage or above average resistance to disease, awell-designed and well-fabricated restoration cangive many years of service. With poor care andneglect, even the perfect prosthesis or restorationcan fail rapidly.