CHIEF COMPLAINT:
Patient suffered an accidental trauma to the anterior area of the face, and wanted to “rebuild the broken teeth, as close as possible to their original shape“.
DIAGNOSIS:
Male patient, 29 years old, non-smoker. After hospital care, following facial trauma, the patient appeared in the consultation with extensive coronary fractures and pulp exposure on teeth 2.1 and 2.2. The fractures were at bone-level on the palatal level and the roots had marked mobility. Teeth 1.3, 1.2 and 1.1 were splinted with orthodontic wire. The splinting covered the vestibular and palatal surfaces. The three teeth also presented mobility. The lower lip was still sutured and oral hygiene was poor.
TREATMENT PLAN:
It was proposed to the patient to elaborate two treatment plans, one conservative and one more surgical. The two proposals could be tackled at first or become complementary, that is, if the more conservative plan proved insufficient, the more invasive approach would be followed.
A - Conservative Treatment Plan: Endodontic treatment on teeth 2.1 and 2.2. Gingivectomy with or without osteoplasty in the palatal area of teeth 2.1 and 2.2. Placement of a provisional bridge made in the laboratory. cast post and core fabrication for the fractured teeth. Placement of 2 elements bridge with Zr infrastructure coated with ceramic.
B - Surgical Treatment Plan: Construction of a provisional bridge with 2 elements bonded to teeth 1.1, 1.2 and 2.3. Extraction of teeth 2.1 and 2.2 and immediate placement of an implant at the site of 2.1. Guided tissue regeneration at the site to be intervened. Provisional 2 elements bridge screwed onto the implant. Definitive bridge with infrastructure in Zr coated ceramic screwed to the implant with metal interface.
These two plans were based on the assumption that teeth 1.3, 1.2 and 1.1 did not require intervention.
The patient, after being properly elucidated, opted for the conservative treatment plan.
TEAM PLAY “DENTIST – DENTAL TECHNICIAN” NOTES:
Endodontic treatment of the teeth 2.1 and 2.2 was performed immediately, as the patient's symptomatology so demanded. In the same consultation, an extensive gingivectomy was performed with the electric scalpel, in order to expose the cervical limits of the fracture. Composite resins were placed in the root remnants with the intention of reshaping the emergence of soft tissues. I carried out an impression of the remaining roots for laboratory production of a provisional bridge. The provisional bridge of 2 elements, presented a format that aimed in the future to accommodate the core of cast post and core that would be cemented in the remaining roots. It had a metallic palatal reinforcement and two supports for the adjacent teeth, one mesial and one distal. The remaining roots were prepared for the production of two cast post and core. The cervical finishing lines were defined and the root canals were prepared. Impression was done using plastic tutors with the double mixture technique. Gingival retraction was done using kaolin paste. The provisional bridge was relined with self-curing acrylic, cemented temporarily over the roots and the supports attached to adjacent teeth. In the laboratory, the cast post and core were made, being careful to preserve space for the definition in the dental re-preparation of the cervical finishing line. Once the provisional bridge was removed, the post and core castings were cemented with resin-reinforced glass ionomer cement. The provisional bridge had to be retouched to allow the accommodation of the cores and was simultaneously readapted to the redefined cervical finishing line. For 2 months, the provisional bridge followed the periodontal stabilization of the traumatized roots and simultaneously managed the maturation of the gingival architecture.
During this period, the splint of the teeth 1.3.1.2 and 1.1 was also removed in order to evaluate its stability. This removal was done very carefully so as not to damage the buccal surface of the teeth. Polishing discs were used sequentially with rubber cups. After repeated vitality tests, the necrosis of tooth 1.1 was verified, and the necessary endodontic treatment was performed. The definitive impression was made with the double mixture technique and the kaolin used as gingival retraction. The provisional bridge was relined once again. In the laboratory, using CAD-CAM technology, an infrastructure was made in Zr and later coated with ceramic. During this process, we felt the need to add composite resin of mesial of the tooth 2.3 with the objective of maintaining the mesio-distal diameters symmetrical to the teeth of 1.1 and 1.2. In this sense, a transparent silicone index was produce that would be used in the mouth to direct this addition. In the mesial portion of the palatal surface of tooth 2.1 of the bridge was made a small cavity that would be used to place a small wire splint in order to ensure the eventual opening of a diastema. A relative isolation was made in the mouth, followed by the addition of composite resin in the 2.3 with the help of the silicone índex. The bridge was cemented permanently with resin-reinforced glass ionomer cement. Finally, a small portion of wire was bonded between the bridge and tooth 1.1.