Temporising questionable teeth

Be very careful when managing the occlusion of questionably restorable teeth. The other day I had a strange appointment where I temporised an upper premolar with a deep carious lesion. the remaining cusps were thin but the tooth was an abutment to a partial denture. On checking the occlusion at the end of the appointment the patient bit down hard and there was a god almighty crack. The filling dislodged and the palatal cusp had fractured and was being held on by the palatal gingiva! Obviously there had been a very high spot in this case and all the force of the patient's (significant) bite had gone through the restoration and fractured the undermined cusp. One could argue that this would happen eventually through normal functioning but it did significantly reduce the longevity of the tooth. Before the fracture, she could consider a large cusp capped composite or a crown retrofitted to the partial denture. Both of these options can be considered very difficult or impossible now.

What I would suggest is to carefully gauge the restorability of a tooth before and after the preparation. In poorly restorable cases, ensure that the patient bites gently when checking the bite. You may even want to start to check the occlusion with a leaf gauge if you don't trust them to do so. You can consider reducing the cusps in the prep stage (as you would need to do this any way for cusp coverage) and temporise to this level. This would ensure that the restoration is out of the bite even before checking. You do have to be careful however in the central fissure area. This is a location that anatomyically dips down into the tooth. However, flowable materials such as GICs tend to form a flat surface layer due to their material characteristics and this area will inevitably need to be adjusted in the bite. Before checking, you can recontour the central fissure area to something that resembles natural anatomy. And of course, radiographs and preoperative discussion are important to manage patient's expectations and for a records point of view.

For this patient unfortunately it likely means an extraction and a new partial denture in the near future. Fortunately she is not happy with her current chrome so this may be something she was planning to do anyway.

PS: In adverse situations like this one it is also important to manage your own reaction. I had to take a minute after the crack to compose myself and formulate a plan for the rest of the appointment. In a clinical situation anything can be around the corner to take us by surprise and often the best way to proceed is to temporise the situation and take a moment to formulate a plan/ask for a second opinion/ inform the patient what has happened and their options and go from there. Honesty is the best policy in this case. You must balance your duty of care to inform them of the situations and their options with your obligation to protect yourself medicolegally. However, lying to patients is never the way to go as they can always seek a second opinion on the matter which will unravel your deceit. Explain in a calm and rational matter that this was an adverse outcome in a compromised initial situation but you will proceed onwards to the best course of action.Offering no charge for the appointment is an option to protect yourself from financial liability in the future.