Mimicking Nature: a multidisciplinary case
An article by Giuseppe Marchetti
1)V.Z. female 34 years old. After a bad fall on roller-blades, she came to my attention for the crown fracture of 1.1 and the crown and root fracture of 1.2.
2)There were no pulp exposure and no mobility or signs of extrusive or intrusive luxation.
3) Unfortunately the root fracture of 1.2 ended about 3 mm subgingival, palatally.
4)A first x ray was done to see if there were other areas of impairment, not evident at the clinical level and other root fractures. The diagnosis led to the development of a treatment plan which provided for the direct reconstruction of 1.1, the root canal therapy of 1.2, its subsequent extrusion with orthodontic therapy and sessions of fiberotomy, to accelerate the extrusion , the stabilization of the tooth extruded through a post orthodontic plaque, to prevent intrusions and promote bone regeneration of the apical alveolus, the reconstruction of the abutment by a fiberglass pin and composite, the remodeling of periodontal tissues, a temporary resin crown and a final ceramic crown.
5) After the protection of the dentinal tubules with a liner of light-curing calcium hydroxide, an impression was taken to build a first wax up of 1.1 and a silicon mask used as a guide for the reconstruction. A precise map of the tooth color was made in this session.
6)Details of the wax up.
7)Details of the silicon mask.
8)After the isolation with a rubber dam, the reconstruction of 1.1 was performed in the same session with the root canal therapy and of 1.2, that unfortunately was needed.
9)The enamel of 1.1 close to the fracture was beveled.
10)It was polished with a browny rubber.
11)Then the enamel was etched for 30 seconds and the dentin for 15.
12)The silicon mask was tested.
13) A very thin layer of enamel was positioned on the palatal surface of the mask and polymerized.
14)Then the mask was removed. A first hyperchromic dentine mass was placed palatally under the bevel.
15) With a second increment of dentin (A3) I made ??the central body of the tooth and the first shape of mamelons.
16)With the dentine the bevel was almost completely covered and the mammelons were defined better. The frame of enamel was completed successfully, too.
17)With an ochre stain, the apical dentine was painted, to obtain an effect of greater saturation. Then an opalescent-trasparent enamel was placed between the mammelons to create transparent areas in the enamel, as the original tooth.
18)At the end a thin layer of enamel, with a 0.5 mm of thickness, was positioned to cover all.
19)In the same session the root canal therapy of 1.2 was performed. The access of the cavity was sealed with composite to avoid infections because of the long treatment plan.
20) The shaping and polishing were postponed at the end of therapy, for the next day the orthodontic appliance was installed.
21)Ortho details. Periodic sessions of fiberotomy were performed to facilitate the extrusion.
22)After 5 months of orthodontic therapy and 3 months of post orthodontic retainer we could have started the pre-prosthetic phase, the surgical and the provisional phase
23)Detail of the extrusion
24)Detail of the palatal fracture after the extrusion.
25)Detail of the pre-prosthetic reconstruction. At the end it was done 9 months after the trauma.
26)The gingival tissues have undergone a substantial modification as a result of the orthodontic extrusion.
27) A new wax up(the second) was made by the laboratory, for define new and right tissue position and create a prototype for the provisional crown. A mask used to guide the perio-surgeon was made with it.
28)The mask in position.
30)Details of the gingivectomy and gingivoplasty from buccal side.