Big Indirect Adhesive Resto

Sometimes or often, in everyday clinical practice, it happens that we have to deal with complex cases like this. In this situation we are led to think that extraction could be the best option to just solve the problem at once.
This said, the path to reach the remaining sound structure, often leads to a situation suitable for less invasive solutions.

styleitaliano style italiano preoperative xray

Fig.1
Pre-operative x-ray. In this 2D-view you can only see the incomplete endodontic treatment, but not the coronal fracture.

styleitaliano style italiano open flap gingivectomy

Fig.2
As a first step, a flap was elevated to visualize the margin, and to try and achieve isolation for root canal retreatment.

styleitaliano style italiano isolation with rubber dam

Fig.3
If the margin is visible, and the gum is open, you can try to put the dam on and, of course, this is the result. The aim is to stabilize the dam below the margins.

styleitaliano style italiano achieving sub gingival isolation

Fig.4
Often, with an additional clamp and/or something like a spatula you can obtain the complete isolation of your field.

styleitaliano style italiano isolated molar with open endodontic cavity

Fig.5
A retraction cord may help to keep the dam down, to ensure a suitable setting to elevate the deep margins.

styleitaliano style italiano elevating deep margin before root canal retreatment

Fig.6
After achieving isolation, two matrices (Polydentia) were placed and propped with two liquid dam spots in order to achieve an anatomical margin elevation, and not just straight walls.

styleitaliano style italiano deep margin elevation

Fig.7
Composite Deep Margin Elevation before removing the matrices.

styleitaliano style italiano endodontic retreatment after margin elevation

Fig.8
After refining the peripheral margin elevation, full attention could be paid to the endodontic re-treatment and the following build up.

styleitaliano style italiano post space after canal retreatment

Fig.9
Space for the post can be left in the distal root when needed. The accesses to the mesial canals were marked with white flowable composite.

styleitaliano style italiano post-endodontic overlay build up

Fig.10
The build up was finished and prepared for an indirect overlay restoration.

styleitaliano style italiano digital impression for overlay restoration

Fig.11
Digital Impression.

styleitaliano style italiano overlay try in

Fig.12
Try-in of the overlay to evaluate the accuracy. The Condensa instrument (LM Arte by StyleItaliano) is very useful to keep restorations in place during try-in.

LM arte kit posterior cusp style italiano styleitaliano instruments
LM arte kit posterior cusp style italiano styleitaliano instruments
styleitaliano style italiano rubber dam retraction before overlay cementation

Fig.13
A retraction cord may be really helpful in improving isolation.

styleitaliano style italiano airflow cleaning of adhesion surface

Fig.14
Before starting the adhesive procedures it is mandatory to thoroughly clean the surface of the tooth by air flow, or by brushing it with pumice paste.

styleitaliano style italiano Selective enamel etching

Fig.15
Selective enamel etching

styleitaliano style italiano surface treatment of overlay restoration

Fig.16
These are the steps for overlay conditioning before cementation: etching, cleaning, bonding and warm composite placement.

styleitaliano style italiano cementation of overlay restoration

Fig.17
Overlay placement with the warm composite flowing out the entire margin to ensure filling of the whole cementation surface.

styleitaliano style italiano excess composite removal

Fig.18
The Fissura instrument from LM is very useful to remove the excess material while keeping full vision.

styleitaliano style italiano polishing of proximal margins

Fig.19
Polishing the interproximal margins is mandatory for the papilla’s healing after cementation. A reciprocating handpiece is a very precise and effective tool to achieve perfect proximal finishing.

styleitaliano style italiano cemented overlay restoration

Fig.20
Post-operative picture shows great integration of overlay restoration.

styleitaliano style italiano final xray after root canal retreatment and overlay cementation

Fig.21
Post-operative x-ray after root canal retreatment and overlay cementation.

styleitaliano style italiano post-op check up

Fig.22
Lateral view, color integration and gum healing after 7 days.

Conclusions

Some cases initially seem very complex, yet sometimes it is sufficient to be able to isolate with the rubber dam, even by elevating a simple surgical flap, which completely changes the initial perception of a clinical case.
Once the isolation is complete, adhesive protocols can ensure long term success.

Bibliography

  1. Zarow M, Devoto W, Saracinelli M. Reconstruction of endodontically treated posterior teeth with or without post. Guidelines for the dental practitioner. Eur J Esthet Dent. 2009 Winter;4(4):312-27
  2. Veneziani M. Posterior indirect adhesive restorations: updated indications and the Morphology Driven Preparation Technique, Int J Esthet Dent 2017, 12(2):204-230
  3. Magne P. Composite Resins and Bonded Porcelain: The Postamalgam Era. J Calif Dent Assoc 2006 34(2):135-147
  4. Duarte S et al. Adhesive Resin Cements for Bonding Esthetic Restorations: a Review. QDT 2011, 34:40-60
  5. Boeddinghaus M, Breloer ES, Rehmann P, Wöstmann B. Accuracy of singletooth restorations based on intraoral digital and conventional impressions in patients. Clin Oral Invest. 2015;19:2027–2034.
  6. D’Arcangelo C, Vanini L, Casinelli M, Frascaria M, De Angelis F, Vadini M, D’Amario M. Adhesive Cementation of Indirect Composite Inlays and Onlays: A Literature Review. Compend Contin Educ Dent. 2015;36(8):570-7.
style italiano styleitaliano Essential Dentistry kit online on demand course
style italiano styleitaliano Essential Dentistry kit online on demand course

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