The patient, a 30 y.o. male, came as an emergency to the office. He had lost his upper left central incisor, but his dentist was on holiday, so he came without an appointment asking for help.
Fig.1
It was immediately clear that the patient was not used to get his teeth checked on a regular basis. Plaque, calculus, a strong gingivitis and some caries were easily visible during the visual examination.
Fig.2
The fracture was clearly caused by caries. The tooth was root canal treated some years earlier, but the restoration was deeply infiltrated by caries.
Fig.3
From a palatal view we could better appreciate the situation. Also, a class III cavity at tooth 11 mesial was visible.
The x-ray showed an incomplete root canal filling.
Fig.4
The retrieved crown was completely infiltrated by caries, so it was useless.
Fig.5
Truth be told, we could find a use to the fractured crown, which is quite common in such cases. Putting it back in place with a little flowable composite allows for the on-the-spot fabrication of a wax-up, and hence, a temporary crown. We needed a fast and reliable solution, because the patient came as an emergency, so the office already had other scheduled patients and very little time to deal with this case. Yet, the aesthetic impact of a central incisor didn’t allow us to postpone this patient to another day.
Fig.7
The impression, ready to be used for the fabrication of the temporary crown.
Fig.8
Rubber dam isolation is always mandatory in endodontics, and when performing adhesive procedures.
Fig.9
It is always better to properly clean the mouth of a patient, but in this case we were on an emergency appointment, and there was the risk of getting a hardly-controllable bleeding, so we preferred to proceed without cleaning the neighboring teeth.
Fig.10
We started by removing the old filling material.
Fig.11
Then the root canal retreatment was completed.
Fig.12
The dowel space was prepared, paying attention just to remove gutta-percha, without cutting away sound dentin.
Fig.13
The most appropriately-sized fiber post was selected and verified (DMG LuxaPost 1.5 mm).
Fig.15
The core was easily restored with a dual cure material (DMGLuxaCore Z) with the help of a circumferential matrix.
Fig.16
Buccal view of the restoration after removing the matrix.
Fig.17
The abutment was prepared with vertical finishing area. In the x-ray we can appreciate the new root canal obturation.
Fig.18
At this moment we had to fabricate the provisional crown. We were in an emergency appointment, treating a central incisor in a deep-bite patient, so we needed a fast and reliable material, with high aesthetic properties and a very strong structure, because of the reduced occlusal available space. We also needed a long lasting material, as the patient said that the final crown would have been postponed for financial reasons. So a self-cure material designed for semi-permanent restorations was used (DMG LuxaCrown).
Fig.19
The impression was placed back into the mouth.
Fig.20
After the hardening time of the resin, the crown was removed from the impression. Intrasulcular margins were highlighted with a pencil, and the concavity between the blue line and the outer margin of the crown was filled with a flowable composite. The crown was then finished and polished.
Fig.21
At this moment it was possible to use the ultrasonic scaler to remove some calculus without worrying about the bleeding. The temporary crown was then cemented.
Fig.22
The situation 2 weeks after temporary crown cementation. Gums look healthier, the patient had no pain and was completely satisfied with this solution. Now he could focus on having all caries treated, relying on the semipermanent crown of tooth 21.
Fig.23
Before & after, the emergency solved.
Conclusions
Cases like this one are always a challenge. First of all, they come without any forewarning, and, second, we always need to be fast and effective from both a functional and an aesthetic point of view.
It’s important to have reliable techniques and materials to use every time we need to.
Having simple protocols is of great help to avoid mistakes and not to lose our grip when treating emergency cases.
Bibliography
1. C Goracci, M Ferrari. Current perspectives on post systems: a literature review. Aust Dent J 2011
2. Monticelli, Ferrari, Toledano. Cement system and surface treatment selection for fiber post luting. Patol Oral Cir Bucal
3. Grandini S, et al. Fatigue resistance and structural integrity of different types of fiber posts. Dent Mater J. 2008.
4. Juloski J, et al. J Dent Res. 2014.Four-year Survival of Endodontically Treated Premolars Restored with Fiber Posts. Randomized controlled trial
