Fill and drill Technique: case report
Operative field isolation is a very important step in endodontic and restorative treatments. Hard-to-isolate teeth are no excuse for not using the rubber dam.
In complex cases the isolation ought to be carefully planned. Experience teaches us that the more difficult the tooth, the more the dentist will appreciate the advantages of using it.
Indeed, once the field has been isolated, a complex clinical case will become simple, with significant benefit for all subsequent procedures.
In this article I will describe a case where I applied the FILL and DRILL Technique, an approach to simplify the leakage control in complex cases.
The patient was a 37 year old man who had suffered anterior tooth trauma when he was a teenager. In 1999 he received from another colleague root canal treatment and restoration of his right maxillary central incisor due to external cervical resorption. In 2002, the treatment failed and the tooth was extracted and replaced with an adhesively cemented Maryland bridge in fiber-reinforced composite.
In 2010, he came to my observation after noticing a pink spot in the left maxillary central incisor, which was Maryland abutment.
The clinical examination revealed an erosive defect containing soft tissue on the vestibular surface of the incisor. Clinically the palatal surface was intact and a careful exploration of the defect with a probe confirmed that it involved only the vestibular aspect. There were no symptoms associated with the lesion. The tooth responded to the vitality tests and there was neither clinical nor radiographic evidence of periapical pathology.
Invasive Cervical Resorption (ICR) class II according Heithersay has been diagnosed. Regarding the prognosis, we know from the literature that the ICR class II according Heithersays classification, has positive outcomes close to 100% if the vitality of the pulp is maintained and if they are treated as a subgingival carious lesion. So, to ensure the highest chance of success, the therapeutic choice has been to preserve pulp vitality. Treatment plan therefore included: Removal of the Maryland, Surgical exposure of the defect, Removal of the soft granulation tissue, Isolation of the operating field, Cavity preparation, Obturation of the defect with direct adhesive composite resin and flap suture.
When I explained the treatment, the patient asked me whether it could be applied without removing or redoing the Maryland bridge, both for cost reasons and because he was pleased with its function and its aesthetic appearance. Considering that the defect affected only the vestibular aspect and that it did not involve the palatal aspect, where the wing of the Maryland was cemented, I tried to meet the request of the patient. This is why applying the rubber dam and sealing the operative field were the most difficult treatment stages. These stages were nevertheless critical to ensure the best possible seal in a critical area for adhesion such as the cervical area, where the risk of a microleakage is very high.
The isolation of the operating field was carefully planned and was achieved using two sheets of rubber dam that were previously disinfected by immersion in 0.2 chlorhexidine.
The sheets were perforated from first bicuspid to first bicuspid, excluding the hole at the level of the missing tooth. At the level of teeth 1.2 and 2.1, and perpendicular to them, the first sheet was cut in vestibular direction; these cuts were then joined through a third cut. The same cuts were also made in the second sheet, but in palatal direction, and another hole was made close to the free base of the newly-made dam peduncle.
After administration of local anesthesia the flap raising exposed the defect, then a aqueous solution of trichloracetic acid has been applied to induce coagulation necrosis of the granulation tissue.
CAVITY PREPARATION AND OSSEOUS RECONTOURING
After removing the granulation tissue, the deep cervical margins of the cavity has been prepared with a bur and the osseous recontouring has been performed.
Next, the first sheet of the rubber dam has been applied. The pedunculated portion of the rubber dam has been made slid under the Maryland, in labial direction.
Then the second sheet has been applied. Superfloss has been passed through the hole of the pedunculated section to ease sliding of the dam peduncle under the Maryland in palatal direction. When this has been done, the dam peduncle was moved towards tooth 2.1 by pulling the floss, and the traction was maintained by blocking the floss in the interproximal space between teeth 2.2 and 2.3.
OPERATING AREA EXPOSURE
The operative area has been exposed by applying as a retractor a sectioned 212 clamp, stabilized with a silicone for bite registration.
To seal easily, quickly and effectively the operative field, I used the FILL and DRILL Technique, that is merely a logical operating sequence that involves specific materials and allows operating in the easiest and most effective way, ensuring the best possible seal and the best possible comfort in complex situations such as the one of this patient.
In these cases to seal the operative field, I like to use a purple flowable composite because after polymerization its consistency is harder than that of a liquid dam and because of the strong contrast with tooth colour. The purple flow was applied quickly and abundantly without worrying if it FILL a little bit the cavity that we have not yet finished preparing because we can DRILL and remove the exceeding material with a bur during final cavity preparation.
It has been removed some purple flow apically to the cavity margin in order to perform the restoration in ideal conditions and to ensure better management of the emergence profile during composite layering.
At this stage, any pulp involvement requiring endodontic therapy was investigated. If treatment was required, the condition was ideal, because of a perfectly isolated surgical field. Fortunately, the pulp was not involved, so a glass-ionomer cement was applied to protect the pulp from cavity sandblasting that it has been done to maximize adhesion.
After having polished the enamel margin whit a brown silicone point, etching, adhesion and composite layering have been done.
Finally the rubber dam was removed and the restoration was polished.
After taking a control x ray, the flap has been replaced and sutured.
The suture has been removed after 1 week.
1 YEAR FOLLOW UP
Tooth vitality is evaluated at each control visit. The patient is not a floss and toothbrush lover, but reported feeling well.
3 YEARS FOLLOW-UP
At 3 years the tooth is still vital without clinical or radiographic evidence of periapical pathology.
After 5 years the tooth is still vital and the periodontal health seems good.