CASE 1
Severe loss of tooth structure in a molar (functional pre-endodontic build-up)
The patient, a 31-year-old female, came to our practice for dental treatment and prosthetic restoration of teeth 2.6 (#14), 2.7 (#15) and 2.8 (#16).The radiograph revealed that a very large amount of tooth structure was lost and an overhanging amalgam filling that irritates the gingiva on tooth 3.7 (Fig. 1). The patient was motivated to save the tooth, and after explanation of the treatment choices we decided to perform endodontic treatment and place a PFM crown. After cleaning the decay and the old amalgam filling (Fig. 2), it was clear that a pre-endodontic build-up was necessary due to functional reasons — the patient would experience discomfort during mastication, there is no way to temporize such a damaged tooth predictably, and the palatal gingiva would grow over the defect. A retraction cord (Ultrapak, Ultradent Products, Inc., USA) soaked with 20% ferric sulphate (Viscostat, Ultradent Products, Inc.) was placed in the sulcus to retract the soft tissues in order to be able to do the bonding procedures (Fig. 3). After a copious rinsing with water spray, a total-etch procedure was performed using 37% etching gel and a two-step bonding system with One Coat Self-etching bond (Coltene/Whaledent, Switzerland). The technique used to do the build-up was a version of the “Doughnut technique” that was modified for this case. Increments of flowable composite were placed and light cured for 20 sec. The remaining parts of the walls were built with Gradia AO3 (GC, Japan) (Figs. 4 & 5). After building the walls, they were finished using a sharp diamond bur and polishers. The final endodontic cavity was made and the endodontic treatment was initiated (Fig. 6). The cleaning and shaping was performed using ProTaper rotary files (Dentsply Maillefer, Switzerland) and the apical finishing was done with NiTi hand files (Fig. 7). After cleaning and shaping the root canal system, the canals were obturated using the squirting technique with the Beta device from B&L (Figs. 8 & 9). Then, a fiber post was placed and the final build-up was made using Gradia XBW so that the color of the pre-endodontic build-up will differ from the color of the final restoration (Figs. 10 & 11).
Photos
Figure 1. Preoperative radiograph of tooth 2.7 (#14).
Figure 2. Clinical photo of the prepared for the pre-en…
Figure 3. A retraction cord soaked with Viscostat is pl…
Figure 4. The first layer of flowable composite resin.
Figure 5. The finished build up.
Figure 6. The finished access cavity with reduction of …
Figure 7. After cleaning and shaping.
Figure 8. After obturatoin of the root canal system.
Figure 9. Postoperative radiograph.
Figure 10. The tooth is prepared for placing the fiber …
Figure 11. The final build up made with Gradia XBW.