Name: Ila B. Avenue
Occupation: Police woman
Reason for referral
The patient was referred to myself by a colleague to assess and treat the patients’12 after she attended the clinic on the same day with a fractured tooth caused by a “small” fall the previous evening. This patient was registered at an NHS clinic close by but attended our clinic on recommendation. She stated she had tripped and fallen onto her car when getting it to it, knocking her tooth on the metal edge at the top of the door frame. The patient retrieved the piece of broken tooth and I was informed that it fitted perfectly on the fracture line so it was seen to be inappropriate to send for a chest Radiograph. She had since lost the piece of fractured tooth.
The patient was not suffering from any pain. She complained of no sensitivity, just unsightly aesthetics. The event happened the previous evening.
The patient explained that she was nervous due to past dental experiences and also very nervous and upset about her present condition.
This was noted and special measures were taken to try to keep the patient calm, The patient was reassured and it was explained to her that we would achieve profound anaesthesia before we started and she would be in full control during the procedure, asking her to raise her left hand if she wanted the procedure to be halted at any time.
Relevant Dental History
The patient was a regular dental attender and visited her dentist every six months for routine examinations and every 3 months to the Hygienist. The patient had good oral hygiene and well-maintained dentition.
There was no relevant medical history and no allergies reported when asked.
There were no significant extra oral findings . No visible bruising or any other associated injuries resulting in trauma
Soft tissues: There were no significant intra oral findings.
Periodontal tissues: The patient attended regularly every 3 months to the hygienist to maintain her high standard of oral hygiene with only very small localised areas of gingivitis which is well maintained.
Teeth: The dentition was moderately restored but well maintained. The patient was an NHS patient at another practice. Restorations included reasonably small amalgams and composite restorations, all of which appeared sound. The patient was and is low risk for caries at the present time. There were no obvious signs of bruxism and the patient was not aware that she had a “grinding” problem The patient was seen to be low risk for periodontal disease.
Specific examination of the 12 area:
Vitality tests: The 12 and 11 both tested positively with endofrost. There was no discoloration. A shade was take for further reference at a later date to check the teeth for shade. Vita A2
Radiographic examination: Radiographic examination of the 12 11 area was consented . There was no associated pathology on the 12 with no further fractures visible . The 11 has slight enamel “crazing” but again no adverse pathology or detectable fractures. There was no widening of the PDL on the 12 but very slightly coronaly on the 11.
A diagnosis of complete coronal supra-gingival fracture due to blunt trauma ( an uncomplicated crown fracture) on the 12 was made, and enamel fracture due to blunt trauma. No endodontic diagnosis was made due to there being no endodontic pathology. A williams probe was used around the gingival margin to check for VRF but nothing remarkable was noted.
The treatment options were discussed with the patient and these included:
- An elective non-surgical orthograde endodontic procedure removing the pulp tissue in 12, and orthograde endodontic treatment of 12 , along with a post and core, followed by a suitable full coverage restoration.
- Extraction of 12 and replacement with prosthesis such as an Osseo-integrated dental implant
- Extraction and leave the area to heal.
- Direct composite build up. This was discussed with the patient and the consensus was to place a more permanent solution as the chamber was visible through the dentine
- Leave and do nothing. (not really an option and advised patient against this.)
A 90% success rate over 5 years was quoted due to it being a primary endodontic procedure in the 12 with no visible periapical radiolucency, it being asymptomatic and final restoration to be placed.
After discussion with the patient regarding the advantages and disadvantages of the above options, it was decided to attempt removal of any remaining pulp tissue in 12 and to electively root treat the tooth, with a view to placing a more suitable, more permanent restoration such as a glass fibre post cerec coronal coverage empress restoration, taking available ferrule, which was seen to be more than adequate, into account. This decision was not taken lightly.
The patient was very nervous so we decided to try and complete the procedure in one visit. It was explained that there was little evidence to suggest that the outcome would be compromised, however it was also explained that it might result in some increased post operative discomfort.
Fully informed verbal consent was given and written consent was obtained. Local anaesthetic was given in the form of an infiltration using 2.2ml cartridge of 2% lignocaine with 1/80000 adrenaline as a bucal infiltration adjacent to 12 The patient was reassured and checked after 5 minutes to see if anaesthesia had been achieved. During this time I assessed the anatomy of the 12 by using a Williams probe, which I found to be unremarkable.
The patient had never had rubber dam placed during previous treatments, so we placed very carefully with a metal anterior clamp as to fully isolate the tooth. Every care was taken to put the nervous patient at ease. The dam was modified by removing a section around the nose area as to let the patient breath more easily. The interproximal areas were flossed to ensure a good seal.
The access cavity in the 12 was prepared through what was left of the coronal dentine and the anatomy maintained as much as possible.
The orifice was accessed with a high speed fissure bur only and the pulp chamber irrigated with 3 % sodium hypochlorite. The canal was then explored with a size 10 K-Flexofile to open and flare the coronal part of the canal only, this was followed by exploration with a 15 and 20 K-Flexofile confined to the coronal 1/3, along with a pro-taper gold S1 file confined to the coronal 1/3 of the canal. A woodpecker apex locator reading was then obtained, with a size 10 K flexo–file and an initial working length obtained. A glide path was then made to this length with a Protaper Proglider. The canal was debrided and irrigated as much as possible to stop any debris being pushed down the canal. Working length were deemed to be 0.5 mms shorter than diagnostic zero reading. This protocol was followed to maintain uniformity.
Diagnostic length 18mm working length 17.5mm
The apical region was then cleaned and shaped using a single ONE Curve file after a glide path had been obtained by using a pro-taper pro-glider. The canal was cleaned, shaped and then irrigated with 3 % sodium hypochlorite (Henry Schein)
A cone fit radiograph demonstrated a good horizontal and vertical fit and following the form of the canal. Possitive tugback was achieved with a Protaper F1 GP point.
Working length radiograph 6.6.19 – grade 2 –
The point was removed and 17% EDTA was then used for 1 minute in the canal to remove the smear layer and then irrigated with the same aforementioned Sodium Hypochlorite as a final rinse and then dried with protaper F1 paper points. The GP point was then re-inserted into the canal to the working length with AH plus being used as the sealer. The point was cut using a heated amalgam packer and excess shaped and tidied using the residual heat.
Obturation radiograph 6.6.19
The fitment, position and form of the GP points was seen to be acceptable. The obturation followed the shape of the canal and no air voids were visible. There was no GP and minimal AH-plus extruded through the apical foramina and a good seal was found to be had. A good coronal seal was obtained and then the patient was allowed to relax in the waiting room for 30 mins. Allowing the epoxy-resin based cement to set.
The patient was then recalled, the GP was removed and canal prepared using a red post drill and then a red parapost glass fibre post was cemented in place after preparation, with a dentine bonding agent and composite.
The small “hole” in the core prep is the post . It was then decided to place the permanent cerec made “empress” full coverage ceramic crown, designed , milled and polished in surgery.
A scan was taken with a sirona omnicam and the images manipulated to design a suitable facsimile to match the mirrored tooth 22.
The tooth was designed to match the mirrored tooth and checked with the patient before being milled with a cerec empress c12 block (a2 shade). Please note slight design wrap around 11 to aid ferrule.
The crown was milled in surgery and then polished with differing pastes and goat hair brushes and then cemented in with Rely x. The occlusion was checked, excess cement removed and final pictures and radiographs taken. A slight “void” can be seen at the base of the post. This is the clear bonding resin.
The patient was released from care to be reviewed in 1 day and then 1 week , with a further view to discuss treatment on the 11, observing any pulpal changes on that tooth. All was uneventful and the patient was very content and full function restored from day 1.
It is understood that a full coronal build up could have been an option for treatment , but with the amount of traveling the patient does, she wanted a more permanent solution. It was discussed with the patient and the treatment plan devised.