I got the idea for this post from teaching at the dental school. Different instructors seem to have different criteria for when its time to treatment plan a crown. I tend to crown teeth when there is sufficient tooth structure missing to put a tooth at greater risk for a future fracture. If such a tooth needs a replacement filling I usually recommend a crown instead since this will tend to protect the tooth from the forces involved with chewing and protect the tooth from future harm. While replacing a large restoration with a new filling may be tempting, usually, this is not optimal treatment. I believe that larger fillings fail more frequently than smaller fillings and when they do it places the tooth at additional risk for the need for endodontic treatment or tooth loss.
When treatment planning a tooth with a large failing restoration, I often find that the tooth structure will not be sufficiently supported by another possibly larger new filling. When this is the case, it’s best to restore the tooth with a crown (or an only). I often explain this to my patient and add that when it’s time to fix a restoration, it’s best to fix it right and choose the best option available.
Patients sometimes counter that they cannot afford to spend the money involved with having a crown made ( or would rather not). After hearing this I often point out that we can go ahead a place a large filling but if it may put the tooth at risk of developing a more significant problem. If their tooth later ends up needing a root canal or even needs to be extracted, a significantly greater sum will be required. I add this information because I need to confirm that my patient truly understands the reasons for my recommendation and that I have informed consent to proceed with the placement of a large filling. Often, after some back and forth conversation, my patient may change their mind and have a crown made instead of a filling, but if they don’t, I can often place the large filling, with a clear conscience!
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