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Patrizia Lucchi

Simplexity in dental trauma: a new way to manage difficult cases in the long term.

18955 Views - Jan 2016

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Dental trauma involves about 15-20% of young patients and it is probably one of the main causes that lead to a first visit in dental office. It requires precise protocols in order to maximize prognosis and minimize the risk of severe sequel. In order to follow a perfect workflow of intervention, extremely helpful are the guidelines reported in www.iadt-dentaltrauma.org, the website of the International Association of Dental Traumatology. Essential part in dental trauma treatments are the follow up, that should be taken into account for at least two years from the first observation. In 1996 Kaste LM et AA. published an article that reports the first national overall and age-specific population-based prevalence of dental trauma among gender, racial, and ethnic groups in USA. They noticed that 80% of traumatized incisors had enamel involvement until 10 yrs age, but above all at 41-50 yrs 60% of the sample had pulp involvement. This mean long term high cost. How it is possible to minimize this cost? As already mentioned, following the recipes proposed by the IADT.
Sometimes this injuries are so complex that the sequelae may be several and serious. In order to demonstrated such kind of situation, a complex case is reported from the first observation, in 2002 to the final restoration in 2016.

Lara came at our observation in 2001 for a orthodontic evaluation. In january 2002 he had a skiing accident, that result in vertical extrusion of 1.1, 2.1 and 2.2, non complicated enamel-dentin fracture of 1.2 and root fracture type II on 1.1 and 2.1.
The first aid was done in hospital, were the extrusion of the coronal segment of 1.1 and 2.1 and the 2.2 were partially repositioned and stabilized with a surgical fixed splint.
15 days later she came to our office and the splint was replaced with a flexible splint for 6 weeks. Because of the negative response to cold pulp test and the presence of a fistula on the 1.2, pulpectomy on the four upper incisors was performed. The final endodontic treatment was complete for 1.1 e 2.1 and only for the coronal fragment and 1.2 and this after applying 2 times calcium hydroxide temporary filling in all the canals.
13 years later she came back for a second visit, asking for improving the smile esthetic. Due to presence of the apical fracture, no orthodontic treatment was possible, without the risk of root resorption. The patient rejected a prosthetic treatment plane, so as an alternative the use of preformed and prepolimerized resin shell has been proposed.
Due to the position of both lateral incisors and the lingual of the central ones, a direct restoration would cause a big dental sacrifice for the central incisors. For this reason, an indirect approach was decided on 1.1 e 2.1 and direct on 1.2 and 2.2. First phase started putting the two central incisor shells in ideal alignment on the cast using composite.
Using a bite rigid transparent silicon a re-positioning key was built, with all the shells inside on both vestibular and palatal sides.
Then, the key was removed out of the cast and cleaned the internal veneer sides from the uncured composite.
Using a plaster isolator, was so possible to reline the componeers on the cast with the dentin mass chosen, and curing them for 60 sec. A better conversion degree was achieved putting the EGR in a composite oven before finishing, texturing and polishing them.
After prep, with the total removal of the old restoration, rubber dam was placed.The upper central incisors were luted using flow composite, while the laterals were relined using preheated composite. Because the patient had also requested a teeth bleaching, a lighter shade of composite was used.
The final result before home bleaching with carbamide peroxide 10% for 15 days
Final Result 1 month after bleaching.
A successful integration between teeth and lips was achieved, both in occlusal and lateral view.

Conclusions

This new method of semindirect restoration represent a simple way to improve esthetic in frontal area, as long as as some aspects, as rubber dam isolation, minimally surface prep and careful refine and respect of gingival close margins, are respected. The use of such kind of restorations has a wide range of applications in all treatment plans and it must be offered daily to our patients. Especially in patients in whom the aesthetic and economic demands must be reconciled. The main advantages that will surely make this new therapeutic option a high effectiveness and efficiency systematic are represented by minimal prep of the tissues, treatment in a single session and the ability to make changes of shape even after the luting. The direct use, even if simple, requires a learning curve. Where the complexity of the case imply a more important intervention on hard tissue, with the need to prepare much more the tooth surface, the use of an indirect technique could make the method equally simple.If on one hand this implies the inclusion of the technician, on the other side simplicity of management during luting phase may represent a big benefit in complex cases, in which manual ability of the clinician could represent a limit.
 

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