broken front tooth

Immediate provisional restoration of a complete crown fracture of a central incisor

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.

severely broken central incisor

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.

close view of a broken central tooth

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.

decayed and broken central upper incisor

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.

decayed tooth fragment

Fig.4

The retrieved crown was completely infiltrated by caries, so it was useless.

proximal multiple caries

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.

impression light body silicone

Fig.6

We need precision and stability to have a good shape of the provisional crown, and not to waste a lot of time in finishing it. So a high precision silicone material was used in two different viscosities (DMG Honigum Pro Light and DMG Honigum Pro Heavy).

double paste silicone impression

Fig.7

The impression, ready to be used for the fabrication of the temporary crown.

broken and decayed incisors

Fig.8

Rubber dam isolation is always mandatory in endodontics, and when performing adhesive procedures.

dirty teething broken central incisor with caries

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.

empty root canal

Fig.10

We started by removing the old filling material.

gutta-percha filling of root canal

Fig.11

Then the root canal retreatment was completed.

clean post space before restoration

Fig.12

The dowel space was prepared, paying attention just to remove gutta-percha, without cutting away sound dentin.

fiber post try in inside root cana

Fig.13

The most appropriately-sized fiber post was selected and verified (DMG LuxaPost 1.5 mm).

automatrix used for composite build-up

Fig.14

A universal adhesive (DMG LuxaBond Universal) was applied all over the tooth and on the fiber post in self-etch and dual-cure mode. Then the post was cemented with a dual-cure resin cement (DMG PermaCem Universal).

dual curing material build-up of abutment

Fig.15

The core was easily restored with a dual cure material (DMG LuxaCore Z) with the help of a circumferential matrix.

abutment build up with finer post

Fig.16

Buccal view of the restoration after removing the matrix.

central incisor abutmen

Fig.17

The abutment was prepared with vertical finishing area. In the x-ray we can appreciate the new root canal obturation.

fabrication of provisional crown inside silicone impression

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).

closed impression tray

Fig.19

The impression was placed back into the mouth.

resin provisional crown before finishing

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.

gingival bleeding due to scaling

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.

healthy gums and proximal caries on central incisor

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.

before and after provisional crown

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