Clinical case-stidies: Bonding back the clinical crown of an extracted tooth by Dr J Van Rensburg
Improving the aesthetic appearance of a periodontally compromised patient.
Patient
Female, 55 years
Case history
The patient was 55 years old and female. The patient had been treated for periodontal disease about 2 years ago. The treatment had been successful and the periodontal disease was under control. The lady was not satisfied with her aesthetic appearance (as is the case with many other patients who have had periodontal treatment.). One of the most common aesthetic complications of periodontal disease and the subsequent therapy is clinically long teeth due to recession and severe malposition of teeth due to pathologic migration and mobility. The upper central incisors were over-erupted; the upper left central more than the upper right central. A peri-apical X-ray of the upper left central revealed very little bone support. The patient was informed in detail what the different, available treatment options were. After a thorough discussion involving both the referring dentist and the oral hygienist the patient was referred to me for a consultation to discuss the possibility of a fibre reinforced Composite solution. Considering the amount of over eruption and the enormous amount of bone loss in the area a fibre reinforced composite splint and repositioning of the upper left central was chosen as an ideal treatment option. This treatment option was also really the only practical solution. The patient was well informed of the procedure and the importance of maintaining good oral hygiene was emphasized ( She was well motivated and oral hygiene was very good). Consent for the treatment was obtained.
Treatment
Initial planning: The occlusion of the patient was carefully examined by marking the occlusion contacts with articulation paper. The bite favoured the placement of a splint on the palatal side of the upper anterior teeth as the contacts with the lower teeth were very close to the incisal edges. The whole palatal surface could be used to bond the fibre splint. All lateral excursions were tested to check for premature contacts. The upper left incisor was removed under local anesthetic. Preparation of the extracted tooth: the majority of the apical root was removed by cutting it with a cylindrical diamond burr in the air rotor so that the remaining piece of root pushed into the socket of the extracted tooth, approximately 1 mm underneath the gingiva. This would compensate for the expected gingival recession in the area. The length of the upper right central was adjusted by reducing the incisal edge with a diamond burr and polished afterwards. Both the central incisors had to be reduced in the mesio-distal dimension to accommodate the extracted tooth in the more retro-clined position. The incisal edge of the tooth was lined up with the incisal edge of the upper right central. A small round bur in the contra angle hand piece was used to remove all the debris of the dead pulp from the pulp chamber. The pulp chamber was cleaned with sodiumhyperchlorite (Miltons), etched, bonded and filled with flowable composite. The access opening of the tooth was sealed off with flowable composite. The root was then shaped and polished to obtain a shiny surface. A groove was cut on the palatal surface of the tooth from mesial to distal just above the cingulum. The groove was approximately 1.5 mm wide with an undercut for extra mechanical retention. The prepared upper left central was now ready to be splinted into the arch. Preparation of the upper incisors to be splinted: it was decided to splint the upper incisors and to extend the splint to the stable upper right 3 and upper left 3. A groove to line up with the groove cut into the pontic tooth (extracted UL1) was prepared on the palatal surface of the upper anterior teeth mentioned to accommodate the everStick C&B fibres. The strong everStick C&B fibre was chosen to splint the teeth as the splint also had to function as a framework to support the extracted UL1 (pontic). Preparation of the fibre: 1. The desired length of the fibre was measured with a piece of ligature wire. The length of the fibre should be slightly longer (1mm) to compensate for the length that would be taken up by pushing the fibre into the interproximal areas. If the fibre is to long it can easily be cut off with a diamond bur and polished smoothly again. The fibres polish just as smooth as a composite restoration. 2. The desired length of fibre was stored under a light box to prevent unnecessary exposure to the overhead light. Everything was now ready to start with the procedure. The procedure: 1. After the extraction homeostasis was obtained by putting pressure to the extraction site. 2. Topical anesthetic gel was applied to the gum where the rubber dam clamps were to be fitted. 3. Rubber dam isolation was obtained. 4. The mesial interproximal surfaces of the UR1 and UL2 were etched with 37% phosphoric acid. Bonding agent was placed and light cured for 30 seconds. Flowable composite was used to tack the prepared tooth into position and to stay in that position. 5. The palatal side (with the groove preparation) of the upper anterior teeth were then etched and bonded. 6. The groove was partially filled with flowable composite and the fibre was bedded into the uncured flowable composite. 7. The Stepper instrument was used to push the fibres tightly into the interproximal areas and the fibre was spot cured for 3 seconds per tooth. 8. The fibres and the whole bonded palatal surfaces of the teeth were covered with composite restorative material. The uncured composite was sculptured and moulded to a smooth anatomical surface on the palatal side of the teeth. 9. All composite was then finished and polished to obtain the desired, aesthetic, smooth, patient-friendly end result. 10. The patient was given instructions on how to clean and maintain the splint. 11. A follow up appointment was arranged
Appearance
Over-erupted centrals
Extraction
Extracted tooth
Clinical crown
Palatal Perio fibre bonded and covered with composite
End Result
Peri-apical x-ray three years later
Result, three years later
Palatal view, three years later
