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Special Issues
July/August 2021
Volume 42, Issue 1

Direct Resin Restorations for Caries Treatment and Maintaining Dentition in a Patient With Dementia

Gregori M. Kurtzman, DDS

Management of patients to preserve what dentition remains can be challenging when the patient has developed dementia issues. Homecare typically declines, and caries due to this and other factors such as dry mouth and high carbohydrate diets take a toll on the remaining dentition. An 84-year-old male patient, who was last seen in the practice 7 years prior, presented at his wife's insistence to address a broken mandibular anterior tooth. The wife indicated that her husband had developed increasing dementia since his last visit and had not seen another dentist over that time. The broken tooth was nonrestorable and caries was noted on adjacent teeth. A new partial denture was recommended to replace the existing poor-fitting flexible denture. Also recommended was restoration of the interproximal and cervical caries with restoration of incisal wear on adjacent teeth with a one-step fifth-generation bonding agent (DiaPlus™, DiaDent, diadent.com), flowable resin (DiaFil™ Flow, DiaDent), and nanohybrid composite (DiaFil™, DiaDent). These materials adapt well to the preparation and have minimal polymerization shrinkage and high fracture resistance with good wear properties, allowing their use in areas like the incisal edge or occlusal surface in patients with edge-to-edge anterior occlusion or parafunctional habits.

Key Takeaways

Sealing all enamel on the tooth during direct resin restoration with a fifth-generation adhesive helps prevent future caries due to demineralization, which is especially important in patients with poor oral hygiene.

Incisal wear presenting as "cupping" can be restored with a flowable resin with good wear and fracture resistance that possesses low polymerization shrinkage, minimizing postoperative sensitivity and marginal leakage.

DiaFil nanohybrid composite adapts well to the tooth without slumping, allowing anatomy to be shaped before light-curing without the material sticking to instruments for a strong, natural-looking esthetic restoration.

About the Author

Gregori M. Kurtzman, DDS
Master, Academy of General Dentistry; Diplomate, International Congress
of Oral Implantologists;
Private Practice, Silver Spring, Maryland

Fig 1. The patient presented after a 7-year absence from the practice with a flexible nylon lower partial denture, fractured tooth No. 25, caries on the adjacent anterior teeth, and heavy accumulation of plaque and food on the teeth and prosthesis.

Fig 1

Fig 2. Radiograph showed tooth No. 25 was fractured at the gingiva with periapical pathology and interproximal decay noted on the adjacent incisors.

Fig 2

Fig 3. Radiograph demonstrated interproximal caries on the incisors and tooth No. 22 with no apical pathology noted. The area on the distal of No. 21 was non-probable with an explorer, and all teeth tested negative to percussion and hot/cold.

Fig 3

Fig 4. After removal of the partial denture, the patient was instructed to occlude and an edge-to-edge occlusion was found on teeth Nos. 22 through 24 accounting for the “cupped” incisal presentation of the mandibular anterior teeth.

Fig 4

Fig 5. Caries was removed interproximally and cervically with a diamond in a high speed; gingival bleeding presented due to marginal gingival inflammation associated with the cervical caries, but pulpal exposure was not noted. The exposed dentin at the incisal of teeth Nos. 22 through 24 and 26 was prepared with a 330 carbide bur to allow composite placement to prevent or limit further incisal wear.

Fig 5

Fig 6. After the teeth to be restored with bonded resin restorations were acid-etched, rinsed, and dried, DiaPlus bonding agent was applied to all surfaces, including all unaffected enamel of the teeth being restored, to seal them and help prevent future caries due to the patient’s limited homecare. The bonding agent was air-thinned to remove the ethanol carrier and light-cured for 20 seconds.

Fig 6

Fig 7. The incisal preparations were filled with DiaFil Flow flowable composite to the level of the facial and lingual enamel surfaces and light-cured. DiaFil Flow provides good flow and adaption to the preparation with minimal polymerization shrinkage, excellent fracture toughness, and high tensile and compressive strengths that aids in preventing further incisal wear during normal functioning.

Fig 7

Fig 8. After placement of DiaFil Flow on the dentin surfaces, prior to light-curing, DiaFil nanohybrid composite was placed into the preparations and over the adjacent enamel surfaces and adapted with an instrument. A brush dipped into the DiaPlus bonding agent was used to smooth and shape the nanohybrid composite to minimize contouring with finishing burs and diamonds following curing of the composite. The underlaying flowable resin and overlaying composite were light-cured together to minimize potential interfaces between the materials. DiaFil adapts well with no slumping with high fracture resistance and wear ability.

Fig 8

Fig 9. The other preparations were filled in a similar manner with a DiaFil Flow liner and overlaying DiaFil nanohybrid composite prior to the restorations being lightcured.

Fig 9

Fig 10. The root tip at site No. 25 was extracted. The adjacent teeth were restored to full contour where caries and incisal wear had been present using direct resin restorations.

Fig 10

Fig 11. Full-contour restorations were accomplished with direct resin to replace the caries tooth structure interproximally and cervically and address the incisal wear using nanohybrid composite resin with a flowable that provided a good blend and natural-appearing esthetics.

Fig 11

Fig 12. A new cast partial denture, fabricated from an impression taken at the initial appointment, was inserted to complete treatment (Lasermet partial denture, Trident Dental Laboratories, tridentlab.com). Treatment was completed in two visits, including the initial appointment, which helped accommodate the patient’s dementia issues. The patient has been placed on 3-month recall prophy related to his inability to adequately perform homecare and will be monitored and modified as needed.

Fig 12

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