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References

Tjan AH, Miller GD, The JG Some esthetic factors in a smile. J Prosthet Dent. 1984; 51:24-28
Jotkowitz A, Samet N Rethinking ferrule – a new approach to an old dilemma. Br Dent J. 2010; 209:25-33
Samet N, Jotkowitz A Classification and prognosis evaluation of individual teeth – a comprehensive approach. Quintessence Int. 2009; 40:377-387
Dickie J, McCrosson J Post removal techniques part 1. Dent Update. 2014; 41:490-498
Wassell RW, St George G, Ingledew RP, Steele JG Crowns and other extra-coronal restorations: provisional restorations. Br Dent J. 2002; 192:619-630
Kurtzman GM, Strassler HE, Fadm F Provisional fixed restorations. Dent Econ. 2006; 3:1-12

Immediate temporization of a fractured endodontically-treated anterior tooth

From Volume 46, Issue 11, December 2019 | Pages 1083-1085

Authors

Ayman Jalal Al Oulabi

BDS, MFDS RCSEd, FRACDS

Postgraduate student, Prosthodontics Unit

Articles by Ayman Jalal Al Oulabi

Tahir Yusuf Noorani

DDS, MResDent, FRACDS, Lecturer

Senior Lecturer, Conservative Dentistry Unit, School of Dental Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kota Bharu, Kelantan, Malaysia.

Articles by Tahir Yusuf Noorani

Email Tahir Yusuf Noorani

Article

Traumatic injuries are not uncommon in dental practice. They are one of the principal causes of emergency treatment, especially when trauma is associated with anterior teeth. The consequences of dental trauma involves tooth structure loss that can be associated with pain, discomfort, appearance concern and a negative psychological impact on the patient. Management of patients with fractured endodontically-treated crowned teeth may require immediate temporary management. In cases when the tooth is restorable, the tooth may require further treatments, like re-endodontic treatment, crown lengthening or orthodontic extrusion, to expose the fractured margin and establish a ferrule. Hence, the described technique can be successfully applied to establish aesthetics and coronal seal during the course of treatment. Meanwhile, in cases when the tooth is non-salvageable, it will require extraction. However, the patient may hope to retain the tooth because, psychologically, he/she is not yet prepared to accept an extraction. Hence, appropriate temporization becomes important.

Here, a technique is presented to temporize an anterior tooth, where the tooth is compromised because of cervical fracture and the crown prosthesis is available.

Case report

A 60-year-old female patient attended complaining of a fractured UL1 while eating. She was keen to have the crown replaced. Medically she reported hypertension and hypercholesterolemia controlled by medication. History, clinical examination and investigations revealed that UL1 had undergone endodontic treatment with placement of a fibre post and porcelain-fused-to-metal (PFM) crown two years previously. Extra-oral examination was undertaken with no abnormality being detected. The patient had a low smile line according to Tjan and Miller,1 and intra-orally, the oral hygiene was good, with multiple edentulous spaces restored with removable chrome cobalt dentures. It was noticed that the root of UL1 was fractured cervically with small remnants of root fragments, which were removed by a probe from the gingival sulcus; the ferrule was category D according to Jotkowitz and Samet2 (Figure 1). The lingual and mesial walls were lost. A periapical x-ray revealed that the root was well obturated apically with a post and no periapical radiolucency. The fracture was associated with the cervical portion of the root, root length being estimated at around 11 mm. Based on Samet and Jotkowitz3 the tooth was non-salvageable (Class X), and indicated for extraction (Figure 1). However, the patient refused to have the tooth extracted initially, and psychologically she was not keen to lose a front tooth. Hence, a temporary measure was needed to temporize the tooth, maintain aesthetics and for the extraction to be considered and planned later.

Figure 1. Tooth UL1 with fractured crown root.

In this case, a simple technique is presented to restore a fractured crowned tooth temporarily and maintain aesthetics and function:

  • The tooth was cleaned from blood and debris.
  • Try in of the detached crown was carried out. Because of poor marginal integrity of the crown, flowable composite (Filtek™ 350ZXT (3M ESPE, Germany)) was used to fill the defect between the crown and the root.
  • Ensuring that the crown was placed on the tooth properly, with the position and inclination not altered, an alginate impression using a sectional tray was taken as an index (Figure 2).
  • A long neck round ISO size 006 bur (D205 LN bur, Dentsply Maillefer, Ballaigues, Switzerland) was used to remove the coronal one third of the fibre post.4
  • A temporary post from the Parapost® system (Coltene, USA) was fitted in the canal and adjusted using a carbide high speed bur.
  • Protemp™ 4 (3M ESPE, Germany) shade A3 was injected in the alginate index and reinserted in the patient's mouth.
  • The impression was removed once set and the whole crown was removed from the tooth (Figure 3).
  • Finishing and polishing was done using Sof-Lex™ discs (3M ESPE) using medium, fine and superfine discs according to manufacturer's instructions.
  • At try-in the occlusion was assessed in maximum intercuspation, lateral excursions and in protrusion to make sure that there was no interference.
  • Cementation of the post-crown was done using zinc polycarboxylate (Poly F® Plus, Dentsply, Germany) to enhance retention.5
  • Excess cement was removed and verification of the occlusion using articulator papers (Bausch, USA). The patient was advised to maintain good oral hygiene and avoid chewing on the tooth (Figure 4).
  • Arrangements were made for extraction of UL1, followed by immediate replacement with a denture.

    • Figure 2. Alginate impression after reseating the PFM crown using a sectional tray.
    Figure 3. Protemp™ temporary crown with temporary post attached to it.
    Figure 4. Labial view of the temporary crown (UL1) after cementation.

    Discussion

    A new temporary crown in this case was made because the fitting of the fractured crown was not optimal. To enhance fitting and prevent plaque accumulation by eliminating plaque retentive area, a new temporary was used rather than the existing PFM crown. If the marginal fit of the crown had been optimal, the core from the crown could have been removed, one third to a half of the post from the canal prepared, and temporary post and core done, together with the existing PFM crown, to increase the means of retention to dislodgment.

    There are many materials that can be used for index fabrication. These can vary from alginate and additional silicone, like polyvinylsiloxane (PVS) and polyether. Furthermore, there are many materials that can be used to fabricate a provisional crown or restoration as well. These can vary from polymethylmethacrylate, ethylmethacrylate and resin-based. Examples are listed in Table 1.6


    Type Brand Manufacturer Advantages Disadvantages
    Methylmethacrylate SNAP® Parkell, USA Good marginal fitGood transverse strengthGood polishabilityDurableDual curable High exothermic reactionLow abrasion resistanceFree monomer toxic to pulpHigh volumetric shrinkageSelf cure
    UNIFAST™ LC GC, Belgium
    Ethylmethacrylate Trim® Bosworth, USA Good polishabilityMinimal exothermic reactionGood stain resistanceLow shrinkage Surface hardnessTransverse strengthDurabilityFracture toughnessSelf cure
    Trim® II
    BIS-Acryl composite Protemp™ 3M, ESPE, Germany Good marginal fitLow exothermic reactionGood abrasion resistanceGood transverse strengthLow shrinkageDual curableExcellent polishability Surface hardnessLess stain resistanceBrittleThick oxygen-inhibited layerMore expensive than methacrylatesNot easy to repair
    Temphase™ Kerr, USA
    Bis-GMA composite TempSpan® Pentron Clinical Tech Good marginal fitGood polishabilityVery low exothermic reactionGood abrasion resistanceGood transverse strengthVery low shrinkageThin oxygen-inhibited layer on settingGood colour selection and stabilityRepairable with flowable or hybrid compositeDual curable

    Regarding cementation of the temporary post and crown, temporary cements, such as eugenol or non-eugenol zinc oxide cements, are the best choice for temporization. But when retention is questionable, stronger cements such as zinc polycarboxylate can be used to avoid premature decementation, as was used in this case.5