CASE REPORT 1
Diagnosis and Treatment Planning
In my opinion, the age group of patients that has benefited the most by the development of durable and highly polishable composites is the pediatric group. Consider this patient: an 8-year-old was referred to our practice with a broken upper incisor (tooth No. 9) that had previous endodontic therapy and a temporary restoration placed (Figure 7). Notice the guarded and strained smile that she displayed when we photographed her presenting condition. The effect these conditions have on the psyche of patients can be emotionally disabling.
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Figure 7. Pretreatment photo (Case 1) shows patient with a guarded smile appearance after having previous root canal therapy and a temporary restoration placed in tooth No. 9. |
We considered the restorative treatment options available for this patient, knowing the dentition is in the developmental stage with lots of transitioning in the years ahead. It is obvious that this patient would likely endure multiple restorations over a lifetime for this tooth. What could we offer as a choice for the first restoration, and what were our considerations when making that choice? In a pretreatment photographic triage appointment, we consulted with our patient and her parent, showing photographs of the present condition along with photo examples of successes that had been achieved with other patients having similar conditions. This allowed the patient and parent to choose the treatment outcome, building trust in the doctor/patient relationship. In this case, it was decided that a direct bonded nanohybrid composite restoration would offer natural aesthetics to blend with the transitioning dentition while conserving maximum tooth structure while allowing flexibility if faced with future restorative needs.
Restorative Technique
We removed the temporary restoration along with any unsound tooth structure. The tissue was trimmed to allow proper access to the tooth area to be bonded (Figure 8). My preference for controlling tissue hemorrhaging to prevent contamination of the adhesive materials, and what we consider a must-have in adhesive dentistry, is Expasyl (Kerr). This proprietary putty-based material contains aluminum chloride (a hemostatic agent) which does not cause brown discoloration encountered with some other products used to control bleeding. Expasyl was placed with compression into the bleeding sulcus areas for up to 3 minutes, and then rinsed away. Using an effective hemostasis technique eliminated a great sabotager of long-term success in direct composite bonding and allowed us to proceed with confidence to completion of the restoration. The dentin was then etched with phosphoric acid gel, and the enamel was etched for 30 seconds, well past the anticipated restoration margin. After rinsing the acid etchant off the tooth with water, the tooth was dried and OptiBond FL primer component was applied 2 times and air-dried for 5 to 10 seconds after each application. The OptiBond FL bonding resin component was then painted over the dried primer and light-cured with a Demi LED curing light for 10 seconds. For this case we created an endodontic core and restoration with Premise (Kerr) nanohybrid composite (shade A1). With both Premise and Herculite Ultra, one shade is often sufficient to produce a natural restoration that blends with the surrounding dentition. Multiple applications and curing of composite placed in layers minimizes polymerization shrinkage effects, allowing for properly sealed dentin with margins that should not turn white or brown.
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Figure 8. The temporary restoration was removed, the tissue trimmed to create proper crown length appearance, and then Expasyl (Kerr) was applied to stop tissue bleeding. |
Figure 9. Photo taken at 4 years postoperatively shows a durable direct composite restoration constructed with Premise (Kerr) (Shade A1) that blends with surrounding natural teeth in appearance. The patient’s psyche was also greatly improved. |
Figure 9 shows the completed restoration at a 4-year post-treatment recall appointment. The patient was thrilled with a natural appearance of the restoration that also improved her psyche at a critical time in her emotional development.