Modern adhesive dentistry has provided clinicians with simplify restorative procedures by opening new scenarios once unthinkable, thanks to the new adhesive techniques. To this end we nowadays have the possibility to perform partial restorations on anterior teeth, enabling us to get the best possible outcome.

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This is Italo, 32 years old, a few hours after a bicycle accident, coming from the hospital emergency room, on February 2006

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The patient has a pulp hemorrhage on tooth 2.1 suffering for a deep palatal fracture

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First of all it's removed the fractured fragment

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More than 5 mm fracture. Tooth 2.2 is still vital

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So, after the root canal treatment under the dam with correct pulp chamber opening, a cleaning of the cavity access and a root filling level control

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I performed an immediate dentin sealing on tooth 2.2 against bacterial leakage and sensitivity

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Due to the pulp hemorrhage tooth 2.1 has a discromy.

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In order to prevent the external root resorption caused by a not correct bleaching approach, I put a flow barrier on the gutta-percha

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Before performing an endo bleaching in office, under the dam, with 35% hydrogen peroxide and a composite stable temporary restoration with a coronal seal. Coronal seal is one of the most important factor of the clinical success during the time, because coronal bacterial infiltration are one of the main causes of failure after root canal treatment

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I performed an orthodontic extrusion for 6 months

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And then a wax up by my dental technician on model casts

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To prepare silicon keys to guide my build ups and preparations

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I decided to bond a fiber post for the build up retention, choosing the post on the basis of root canal shape and marking its correct hight with a pencil

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The post was also shaped to be covered by a uniform restorative material layer

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All the bonding post procedures with a dual composite cement were guided by the silicon key made on the wax up

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I used transparent matrices to protect the adiacent teeth during adhesion steps

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Layering was completed with a single shade dentin composite mass

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All the preparation came from a rational and not empirical project done by the wax up

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and guided by the silicon keys to respect the correct space for the restorative material

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Despite having experience with both ceramic and composite materials, I decided to treat this clinical case with indirect composite overlays for the cost and benefits of this materials

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After about a week I bonded the composite overlays one by one under the dam. First step was to perfectly clean the preparation sandblasting them with glycine powder

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Then using 37% phosphoric acid gel for 15 seconds

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Applying the bonding brushing 2 or 3 times

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I removed all the composite excess before curing for 60 seconds for each side with a high power led lamp

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I repeated the same steps on tooth 2.2

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Until the immediate final outcome

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Control one month check shows a natural smile

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And the vestibular

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and palatal tissue healing

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The control x-ray shows emergency profile modification on tooth 2.1 and restorations sealing even if composite overlays are quite radio transparent

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4 years check

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10 years check

Conclusions

The evolution of restorative materials has led dental companies to produce composite products with a predictable and long lasting result during the time, with a favorable cost performance ratio

Bibliography

Oper Dent. 2003 Nov-Dec 

Microhardness and color changes of human dentin with repeated intracoronal bleaching. 

Lai YL, Yang ML, Lee SY.

Torabinejad M., Ung B. et al.: “ in vitro bacterial penetration of coronally unsealed endodontically treated teeth”, J. Endodon., 1990, 16: 566-9

Tan et al, J Prosthet Dent 2005; 93:331-6. In vitro fracture resistance of endodontically treated central incisors with varying ferrule heights and configurations

Goto Y, Nicholls JI, Phillips KM, Junge T. Fatigue resistance of endodontically treated teeth restored with three dowel-and-core systems. J Prosthet Dent. 2005 Jan;93(1):45-50

Duke S. New directions for posts in restoring endodontically treated teeth. Compendium. 2002 23;2:116-122

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