Full adhesive restoration of subgingivally fractured teeth

4 Jun 2018 - 18004

Adhesive dentistry has been a revolution 30 years ago and has changed the mindset of the clinician. We went from a mechanical approach which required to adapt the tooth to the material, to a biological approach in which the chosen material has to adapt at the biology. 

Minimal invasive phylosophy started to lead and transform the clinical approach with a significant change in the preservation of the tooth structure. Biology became the most important pillar before esthetic and function.

Adhesion has changed not only the coronal reconstruction but the root anatomy as well. This is why fiber post reconstruction has become a perfect substitute of the metal post core esthetically and physically with a better stress distribution along the root. Combination of fiber glass and dual cure composite are the best dentin substitute.

If we think at the upper floor bonded glass ceramic restorations are the best enamel substitute  esthetically and biomechanically speaking

 

Fig. 1

A 22 years old patient has been assaulted in the street with a significant trauma in the mouth causing coronal fracture with a vestibular subgingival of 11 and 12. Root canal treatment was performed and coronal fragment bonded in proximal area to stabilize both teeth until the next appointment. 

Fig. 2

Palatal view of the two fracture.

Fig. 3

Second appointment. After digital anesthesia with the Wand, the dental coronal fragments of 11 and 12 were removed.

As you can see in the picture, the fractures go pretty far beyond the gingival margin.

Fig. 4

A mini flap was performed to visualize the exact level of the fracture and distance from the bone. A distance of 1,5 mm is observed between fracture and buccal bone and a slight osteoplasty is directly made to recreate a 3 mm distance and a mini shoulder simultaneously to identify the cervical  margin.

Fig. 5

During the surgery individual rubber dam was placed to isolate the tooth structure from the blood (212 clamp Hu Friedy) 

Fig. 6

Thanks to a fiber post reconstruction the core of the tooth is regenerated biomechanically and esthetically and is compatible with the use of glass ceramic crown (Emax press MO). To achieve this goal we need:

• dual cure adhesive (DMG LuxaBond – Total Etch)

• glass fiber post (DMG LuxaPost)

• core build up dual cure composite (DMG LuxaCore Z – Dual)

• Colibri mixer tip with metal tip to inject the composite precisely in the root anatomy (Pulpdent, Voco,  Danville, Itena, Tokuyama, Bisco)

Fig. 7

Core built : Dual Cure seringuable composite DMG Luxacore Z – Dual available in cartridge or smart seringue.

Note that a new type of smart universal all in one mixer tip are available too.

Fig. 8

Coronal preparation was finalized in the same appointment and impression directly taken for the final restoration.

Fig. 9

View of the temporaries after 2 months with a nice texture (DMG LuxaCrown)

Fig. 10

After 2 months we can appreciate the good physical stability of the resin because this material is supposed to be a semi permanent resin. 

Fig. 11

Individual dam is placed to make  the bonding procedure of the lithium disilicate crown (Emax press MO) safer. The basic protocol is applied:

– Sandblasting (Aquacare Velopex, Dentoprep Ronvig) with 50 micron aluminum oxyde particles)

– Etching with orthophosphoric acid 37% for 25 sec

– Universal adhesive (DMG Ecosite Bulk Fill) 

– Light curing for 45 sec

– Resin cement (DMG Vitique) B1 veneer

– n° 12 blade

Fig. 12

Final view of the restoration the day of the bonding protocol.

You can note the gum inflammation due to the placement of the rubber dam to push the gum in order to have the clamp beyond the deep margin.

Also the papilla between 11 and 12 is not complete because of the compression of the temporaries during the last 2 months.

Fig. 13

final view after the periodontal healing (3 months later)

 

ceramist (gerald UBASSY)

Fig. 14

Palatal view of the two bonded crowns

 

Conclusions

Thanks to adhesive dentistry the practitioner today has the choice, the protocol and the material to regenerate the tooth structure thanks to the mimicry of the material used.

The use of fiber post reconstruction is the ideal way to copy esthetically and biomechanically dentin body and offer the freedom to use a glass ceramic material to copy enamel body.

This approach is the real revolution in dentistry as it better distributes force thus reducing the risk of destructive failure of the residual tooth structure. 

Bibliography

• Lamichhane A, Xu C, Zhang FQ. Dental fiber-post resin base material: a review. J Adv Prosthodont. 2014 Feb; 6(1): 60–65.

• Hattory M, Takemoto S, Yoshinari M, Kawada E, Oda Y. Durability of fiber-post and resin core build-up systems. Dent Mater J. 2010 Mar;29(2):224-8

• Ozcan M, Valandro LF. Fracture strength of endodontically-treated teeth restored with post and cores and composite cores only. Oper Dent. 2009 Jul-Aug;34(4):429-36