Fractured Lateral Incisor
Here is a fun case I did today:
Patient came in with fractured lateral incisor (#7). Was a virgin tooth that he fractured on a peanut... It had exposed his pulp chamber and was painful
We went ahead and did endo on the tooth first:
He has a lot of lingual tooth structure left (plenty for ferrule and lingual is most important for tension forces):
We sandblasted the prep and bonded on his fractured tooth with total etch, Scotchbond Universal, and Rely X Ultimate (etched and applied Scotchbond to tooth as well):
We did a Biocopy and then prepped a full coverage crown on the tooth:
The final restoration was 3M2 Vita Trilux stained and glazed to match his existing teeth. I also show the contrasted picture so you can see the nice effect of the Trilux Block...
Mike...yes a fun case with great results... so by bonding the original tooth an prepping below the bond line, you feel there is enough strength with lateral and protrusive forces??? trying to stay away from P/C//?
Hi Catherine.
Yes, this is classic Pascal Magne Biomimetic approach as outlined in his book. He has a lot of research that states that posts make no difference in cases like this.
I will be very interested in the long term prognosis of this crown. I listened to Pascal's lecture weeks ago and I just can't get my old school head around not bonding a post in this situation. Please let us know how this works out for this patient.
Wow as well.... and equally impressed you had 3M2 triluxe in your inventory...I wonder if anyone in Scottsdale has that....?
Mark
Here is some anecdotal evidence that it works. I have done this many times...
5 year post op of a fracture (not quite as bad) on a 16 year old girl. Same tooth (#7). Not only did I not do endo OR a post/core crown... but all I did was bond the tooth back on with Optibond FL. I layered a little composite over the top to blend. I've seen her every 6 months since and it's perfect.
No ferrule, nothing...
Here is some references from Magne... He told me tonight he has a lot more in the works and is really doing a lot on this topic... He gave me a lot more... but all say really the same thing.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Operative Dentistry, 2014 39-6, 000-000 Influence of No-Ferrule and No-Post Buildup Design on the Fatigue Resistance of Endodontically Treated Molars Restored with Resin Nanoceramic CAD/CAM Crowns
Showed that they all survived with normal masticatory forces and the failure mode was more favorable with the 2mm buildup or endocrown (composite milled, not ceramic)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Operative Dentistry, 2016 41-1, 64-75 Composite Resin Core Buildups with and Without Post for the Restoration of Endodontically Treated Molars Without Ferrule
All groups with posts were affected by an initial failure phenomenon (wide gap at the margin between buildup/crown assembly and the root), High performance polymers with no posts have higher performance than with posts... and insertion of fiber reinforced post had no affect on performance or survival rate using all materials.
On 10/25/2016 at 7:10 pm, Grady Twohig said... I did that once by accident with an anterior crown that snapped off with tooth inside. After I did a root canal, I bonded a crown with the prep broken inside with Scotchbond/Rely-X Ultimate so I'd have something for biocopy. I thought it would easily come off but it didn't...so I cut off the crown off and the prep was still bonded underneath. I ended up not doing a post...I had some extra tooth to prep though as the old crown margin was not at the gingiva.
How long has it lasted? I have some in the mouth for 10 years now that are perfect and I cannot remember it not working... I never did what you said though :) That's pretty funny that you cut the crown off and the prep still stayed.
Mike,
That is a great!!!!!
You stated that you used Vita Triluxe. Could you show us how you positioned the crown in the block to get the translucency effect you show in your contrasted picture.
I think the most significant variables in a cases involving lateral incisors would be amount of palatal tooth structure remaining (pretty good in this case here) and the occlusion.... Looks like the laterals can be protected in protrusive by the centrals. A lateral that breaks off in "table top" fashion at the gingival margin I would think need to be handled differently. What do you think, Mike?
On 10/26/2016 at 5:48 am, Tyson Roe said...I think the most significant variables in a cases involving lateral incisors would be amount of palatal tooth structure remaining (pretty good in this case here) and the occlusion.... Looks like the laterals can be protected in protrusive by the centrals. A lateral that breaks off in "table top" fashion at the gingival margin I would think need to be handled differently. What do you think, Mike?
I would agree Tyson. In those cases, you have to generally extrude to make work and you don't have great tooth structure to bond to. As you can see on that second case I posted that has been solid for 5 years, that was more or less table top bonding, but there was a lot of enamel. This first case had excellent ferrule.
Mike,
Great case. How did you get that much translucency? Simply amazing! It's great when they save the fractured piece!
Carrie
Beautiful case Mike. I'd be thrilled to have this case look half as nice.
I haven't seen Pasal lecture in a while, but he's on the short list of people you don't miss when they come around. That being said I feel like his cases are always of college kids with perfect teeth. Never really seemed to show cases that look like what I see on a daily basis. It's been a while since I've seen him, so perhaps this is not the case anymore.
Awesome case to present Mike. Amazing what we can do now with our bonding protocols and materials. Never hurts to try the most conservative fix and you can always get more aggressive later!
Here is the Mill Preview:
I showed this to Pascal this morning and he said he would have done a slight "internal" composite resin ferrule in the canal and bonded the tooth like I did. He may not have even done a crown at all :) I told him the tooth was too dehydrated and it needed one...
mike, what staining kit did you use?
great post btw, my assistant and I are studying the esthetics of it. 
I guess I'm not getting something. You built up the prep with composite or something with no post/pin and it stayed there?
On 10/26/2016 at 11:04 am, Brian Chan said...mike, what staining kit did you use?
great post btw, my assistant and I are studying the esthetics of it.
Those are Empress Universal stains. I used A3, Khaki, and White. That is it. (with a thin layer of glaze applied first).
Also, it was stained and glazed directly in the mouth 
On 10/26/2016 at 11:15 am, Eric Prouty said...I guess I'm not getting something. You built up the prep with composite or something with no post/pin and it stayed there?
No buildup. I bonded back in the actual tooth that fractured off.... then prepped it.
On 10/26/2016 at 11:15 am, Mike Skramstad (Faculty) said...On 10/26/2016 at 11:04 am, Brian Chan said...mike, what staining kit did you use?
great post btw, my assistant and I are studying the esthetics of it.
Those are Empress Universal stains. I used A3, Khaki, and White. That is it. (with a thin layer of glaze applied first).
Also, it was stained and glazed directly in the mouth
Great case Mike...I think I may go slit my wrists now because I'm not worthy :)
Mike this is the BEST CASE EVER!!!!!!!!!hardest case to match I'm so Impressed!!!!!!!!!!not kidding the BEST!!!!! Would love to see how you did it!!!!
Mike this is the BEST CASE EVER!!!!!!!!!hardest case to match I'm so Impressed!!!!!!!!!!not kidding the BEST!!!!! Would love to see how you did it!!!!
On 10/26/2016 at 2:46 pm, Gene Messenger said...Mike this is the BEST CASE EVER!!!!!!!!!hardest case to match I'm so Impressed!!!!!!!!!!not kidding the BEST!!!!! Would love to see how you did it!!!!
Thank you Gene (twice...LOL)
Here are a few more details on how I did the case:
- Did the RCT first (was extremely fast and easy)
- Sandblasted the tooth structure thoroughly to clean off any debris and get a fresh surface for bonding
- Etched to tooth fragment that fell out and applied/cured adhesive
- Etched the tooth in the mouth and applied/cured adhesive
- Bonded the tooth back into the mouth. The fit was really perfect... just like a puzzle
- Biocopied the tooth in the software
- Prepped the tooth for a full coverage crown (more on that later)
- Designed and milled with Vita Tri 3m2
Now even with the 3m2 block, the tooth was really quite lighter than his other teeth. So I was going to have a bit of work to do to get a match. Here is how I did that
- Contoured the restoration to sharpen the line angles and also sharpen the wear facets and incisal anatomy that he naturally had. The milling process tends to round things off a bit and we needed more definition
- after contouring, I polished surface very slightly with green and blue (very light) Meisinger Twist Polisher
- isolated the area with cotton rolls and held the crown in firmly with my finger on the lingual surface
- I am going to stain and glaze this in the mouth directly. My assistant holds the staining well and I have one brush with a fairly thin tip that I use for intraoral staining and glazing.
- apply a very thin layer of glaze just to the facial surface
- apply sunset to the cervical and work it into the mid facial area (this took the most time)
- apply a little A3.5 shading and work it all the way to the incisal edge
- apply white in multiple areas and very finely worked it in so it wasn't super perceptible. Especially on the incisal edge (vertically to break up translucency).
- apply a little more glaze in areas that I wanted to dull out color (was too intense)
- gently moved the restoration off the tooth and grabbed it on the mesial and distal with a cotton pliers.... assistant applied putty to the inside and we transferred to pin and fired
- after firing, we polished the lingual and interproximal with all the twist polishers and the facial surface with the pink and yellow twist polisher.
- finally...bonded to place!
Hope that helps.
Also..looking back on what I would have done differently. I may have just tried NOT doing a full coverage crown on this case. Possibly just bonding old tooth back in and layering composite to match. I have had luck with that before and it would have been more conservative and less expensive for the patient. If it didn't work, I could have come back and done this.
Beautiful case, Mike. I agree, once the original tooth was bonded back together I may have just given it a bit of composite on the facial and sent him home. I'm not sure how much strength you gain by prepping for full coverage here.
