A patient presents with a high caries rate and a rather broken down dentitiion. The answer surely is to control the disease first by restoring all the lesions in a normal manner and controlling the disease. Once the disease is under control decisions can be made on which teeth should be crowned or inlayed and which spaces need to be restored with fixed C & B work. The patient is included in this discussion and decision making and is therefore encouraged to be part of the thinking on the decision. If they are not prepared to modify their dietary intake and hygiene routines then the final decision on C&B can be delayed until such time as they become sufficiently knowledgeable and responsible to care for the relatively expensive rehabilitation. The final decision is always the patient’s to make.
Diagnosis as to the etiology of the caries, and then oral disease control is the first step. If possible, the patient must be educated, brought to a level of understanding about the disease, and motivated to be engaged and take part in the treatment – “there’s nothing a dentist can do that will overcome what the patient will not do.” Included in this oral disease control phase may be interim restorations as a trial to see if the patient complies and can care for their dentition. Following this disease control phase the decision to place a crown vs a large restoration should be much clearer. My guide is if I cannot adequately isolate the tooth and place a matrix that will yield a well contoured and fitted direct restoration, then an indirect restoration (crown or inlay or onlay) is a better choice, because its contours can be controlled in the lab; and its fit in only dependent on me being able to isolate and make an impression of a well prepared margin on tooth structure. I have always believed that one of the indications for an indirect restoration is the inability to place a properly contoured matrix. Please feel free to contact me if this explanation is unclear.
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