Emergency treatment of a fractured molar

Accidents don’t ask for an appointment… they just happen! It’s very common, in a dental office, to have emergency sessions. Sometimes a prescription of an antibiotic, or an emergency pulpectomy can be enough to relieve pain, but sometimes you may need to find a solution for a more complex problem.
This young lady came to the office because of a fracture of her upper right first molar. Tooth 16 was root canal treated and it had been restored with a direct composite build-up. The mesio-palatal cusp was missing, and the fracture line was deep into the gingival sulcus. We decided to schedule a crown lengthening, a root canal retreatment, a fiber post restoration, and then a crown. Unfortunately we didn’t have the chance to arrange the procedure in a reasonable time, so we had to do something immediately, without the help of the lab technician for the temporary crown. That’s why having a self-curing resin to fabricate durable temporary restoration is mandatory in a dental office.

style italiano styleitaliano subgingival cusp fracture

Fig.1
A close-up picture of the fracture line. Probing depth was 3 mm.

style italiano styleitaliano pre-treatment build-up of palatal cusp

Fig.2
First of all, a composite direct “mock-up” was done to restore the shape of the molar, without putting any adhesive system. Then an alginate impression was taken.

style italiano styleitaliano flap elevation for crown lengthening

Fig.3
A flap was opened to perform a surgical crown lengthening.

style italiano styleitaliano rubber dam isolation of deep margin

Fig.4
After suturing, isolation was performed using the rubber dam.

style italiano styleitaliano access cavity for retreatment

Fig.5
The old restoration and some caries were removed.

style italiano styleitaliano endodontic access cavity of upper first molar

Fig.6
The old canal obturation was removed, and the retreatment was performed.

style italiano styleitaliano obturated canal orifices

Fig.7
After retreatment, the tooth was ready for a new build-up, this time with a fiber post restoration, in order to decrease the chances of a non restorable fracture. The dowel space was prepared with a calibrated bur at low speed, and the correctly sized fiber post (DMG LuxaPost) was chosen. It’s important to do so, because we need to have the less possible space in between the canal wall and the post, but we still need the post to be completely passive.

style italiano styleitaliano post core build up after retreatment

Fig.8
A dual-cure universal adhesive was used (DMG LuxaBond Universal). It is extremely important to have a chemical activation of the adhesive in the canal; even if the post is translucent, we can’t rely on a simple light activation. We also must pay attention in carefully applying the adhesive all over the tooth, so using specific small microbrushes is highly recommended. We have to remember that adhesion is the most crucial part, for an adhesive restoration! If the adhesive layer fails, the restoration fails.
A dual-cure composite material (DMG LuxaCore Z) was used to cement the post, and, at the same time, build-up the tooth. It’s essential to choose the ideal material to do so. We both need chemical activation, and light activation, so we can cure it and then we rely on the chemical process to complete the procedure. We also need a well mixed flowable material, with a practical and functional application tip, in order not to leave bubbles nor voids. At the same time, we need the cured material to be hard, strong and resistant, in order to support the future prosthetic crown.

dmg banner style italiano styleitaliano
dmg banner style italiano styleitaliano
style italiano styleitaliano abutment preparation after crown lengthening

Fig.9
After rubber dam removal, the tooth was vertically prepared into an abutment. I find it really important to have a restoration material with a dentin-like feel during preparation, to make final abutment precision easier to achieve.

style italiano styleitaliano alginate impression

Fig.10
A high-strength self-curing material (DMG LuxaCrown) was injected directly into the alginate impression, and the tray was positioned back in the mouth, after isolating the abutment with vaseline.

style italiano styleitaliano dmg luxacrown
style italiano styleitaliano dmg luxacrown
style italiano styleitaliano provisional resin crown

Fig.11
After waiting for the material to set, the tray was removed and the crown easily finished. Occlusion was checked, and then the temporary was polished.

style italiano styleitaliano provisional resin crown

Fig.12
Occlusal view.

style italiano styleitaliano provisional crown restoration after removal of stitches

Fig.13
One week later, stitches were removed.

style italiano styleitaliano palatal tissue healing after crown lengthening with provisional crown

Fig.14
The patient didn’t have the chance to come back for a couple of months. Here we can find the healing of the palatal tissues (where the fracture was) 10 weeks after the procedure. The patient was happy, and the tooth safe, because we could rely on a strong temporary crown, waiting for the final zirconia crown.

Conclusions

Emergency appointments are always unexpected, that’s clear. Having tools, materials and techniques to face them, is a great advantage. In case of extensive fractures of endodontically treated teeth, a complete crown preparation might be necessary, so it’s good to have the chance to rely on a simple and effective system for post and core restoration, and for an immediate, strong and resistant temporary crown.

Bibliography

1. Goracci C, Ferrari M. Current perspectives on post systems: a literature review. Aust Dent J. 2011 Jun;56 Suppl 1:77-83.
2. Monticelli F, Ferrari M, Toledano M. Cement system and surface treatment selection for fiber post luting. Patol Oral Cir Bucal. 2008 Mar 1;13(3):E214-21.
3. Grandini S, Chieffi N, Crysanti Cagidiaco M, Goracci C, Ferrari M. Fatigue resistance and structural integrity of different types of fiber posts. Dent Mater J. 2008 Sep;27(5):687-94.
4. Juloski J, Fadda GM, Monticelli F, Fajó-Pascual M, Goracci C, Ferrari M. Fouryear Survival of Endodontically Treated Premolars Restored with Fiber Posts. Randomized controlled trial. J Dent Res. 2014 Jul;93(7 Suppl):52S-58S.
5. Juloski J, Apicella D, Ferrari M. The effect of ferrule height on stress distribution within a tooth restored with fibre posts and ceramic crown: a finite element analysis. Dent Mater. 2014 Dec;30(12):1304-15.

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