4 case reports regarding restorative treatment of badly broken teeth (2 posterior and 2 anterior)

1. Restoration of badly broken
teeth.
(4 Case Reports)
Belal N. Elmarhoumy

2. Case Report 1: (Badly broken Endodontically
treated tooth)
• An 18-year-old female reported to dental office with a complaint of
fractured endodontically treated maxillary central incisors.
• Clinical and radiographic examination revealed satisfactory
obturation of root canal and crown fracture extending till the junction
of the cervical and middle 1/3.

3. • All feasible treatment options were explained to the patient
depending upon the remaining tooth structure of respective tooth
• The proposed treatment plan included intra-radicular biologic post for
11 and custom made post for 21, and followed by porcelain fused to
metal crown fabrication.
• The post space was prepared using peeso reamers (Mani)
preserving a required apical seal.

4. • A direct wax impression of the post space was taken for fabrication of custom
post for 21 and for guide of shape, thickness & length of the biological/dentin
post for 11.
• The use of biological posts made from natural, extracted teeth represents a
feasible option for strengthening root canals.
• Thus presenting the potential advantages such as:
(1) Does not promote undue stress on dentinal walls,
(2) preserves the internal dentin walls of the root canal,
(3) presents total biocompatibility and adapts to conduct configuration, favoring greater
tooth strength and greater retention of these posts as compared to prefabricated posts.
(4) presents resilience comparable to the original tooth.
(5) offers excellent adhesion to the tooth structure and composite resin.
(6) at a low cost.

5. • A freshly extracted, intact maxillary anterior tooth was chosen and subjected
to autoclaving at 121c for 15 min (Ghosh and Chowdhury, 2013) Sterilization
and disinfection of extracted human teeth for institutional use
• The tooth was then sectioned Bucco-lingually along the long axis using a
diamond disc, The cementum was removed by abrasion, using diamond drills,
and each part of the root was cut in such a way as to form “biological post
• Contouring of the sectioned tooth into dentin post and core was done using
the wax impression.
• NB: The steps of biological post shown are related to other case.

6. Post were adapted to the master cast Application of 37% phosphoric acid in the post
Application of the adhesive system in the post Application of 37% phosphoric acid in the canal

7. Application of the adhesive system in the canal Application of the dual cure resin into the canal
Post were then inserted into the canals under constant
pressure until the end of the cement polymerization
Core build up, radiograph, crown preparation

8. • The satisfactory adaptation of custom and
dentin posts was verified radiographically as
well as clinically.
• The posts were cemented in the respective
root canal using dual cure Paracore
resin(Coltene, Germany) cement.
• Further core build-up and respective tooth
preparation was done followed by porcelain
fused to metal crowns cementation.

9. Case 2: (Restoration of badly broken,
endodontically treated posterior teeth)
• A 23 year-old patient reported to the Department of Conservative
Dentistry and Endodontics.
• On examination, it was found that tooth 36 had undergone root
canal treatment 8-10 months ago. However, tooth 36 was
asymptomatic and the clinical crown was <2 mm. The radiographic
examination of tooth 36 revealed straight root canals with well
condensed gutta percha filling extending 0.5 mm short of the
radiographic apex.
• No periapical changes were noted in relation to tooth 36.

10. • The preparation Steps:
1. The pulp chamber preparation included removal of any endodontic filling material
and blocking out the undercuts with type IX Glass Ionomer cement.
2. The root canal preparation included the post length in the posterior tooth, which was
dictated by the remaining bone support, root anatomy, root curvatures, and the apex
obturation.
3. Care was taken to ensure that the length of the post was 2/3 the length of the canal
and ½ the bone supported the length of the root.
4. The more coronally located the root curve, the shorter the post should be.
5. Thus, 1 mm of the surrounding dentin was preserved to maintain the strength of the
root.
6. A crown-lengthening procedure was carried out using the tissue recontouring system
to expose 2 mm of the tooth structure and to have the crown ferrule effect for better
retention.
7. A GG drill was used to remove the gutta percha. Post space was prepared in the distal
canal of tooth 36 with Peeso reamer. An H-file was used circumferentially to
smoothen the preparation of the post space.

11. 8. A slot or cloverleaf was prepared near the orifice region with a tapered carbide
bur. Also, tooth preparation was carried out for the full metal crown.
9. Orangewood stick (post) was selected and trimmed and shaped conically to fit
passively to full length into the prepared post space in the distal canal. The
orangewood stick was coated with adhesive and kept aside. Light-body, rubber-
based, impression material was injected into the prepared post space in the distal
canal and the orangewood stick was placed in the post space. Additional material
was then injected around the preparation and the tray loaded with the heavy-
body, rubber-based material was placed on the light-body material. The impression
of the post space was picked up along with the tooth preparation for the full crown
Clinical photograph showing the slot preparation

12. • The impression was poured in die material to obtain a master cast. Adjoining
teeth (the distal surface of the second premolar and the mesial surface of the
second molar) in the model were scraped to provide additional room for the wax
to ensure tight contact of the restoration. A wax pattern was made on the master
cast and the casting procedure was carried out.
• The final casting comprised of directly attaching the post to the crown which was
cemented using type I Glass Ionomer luting agent, the occlusion was then
checked.
• The case was followed for 16 months in which no root fracture, no loosening or
dislodgement of the post, and no secondary caries were reported.

13. Case 3: Restorative management of grossly mutilated
molar teeth using endo-crown:
• A 35-year-old female patient reported with extensively damaged tooth in the
upper right region of the mouth. She gave a history of previous pain and root
canal treatment 4 months back, but her symptoms resolved temporarily.
• There were no drug allergies or significant medical history.
• Clinical examination showed 16 to be badly destroyed with thin remaining walls.

14. • On analysis of all the factors, it was decided to retreat the tooth and plan for
endo-crown restoration. The access cavity was modified by means of Endo-Z bur
(Dentsply Maillefer, Ballaigues, Switzerland).
• Coronal flaring was accomplished with Gates-Glidden burs (sizes 3 and 4)
(Dentsply Maillefer)..

15. • Old gutta-percha and sealer was removed by means of rotary ProTaper
retreatment files and Endosolv E (Septodont, New Castle, DE, USA).
• The apical calcified portion of the root canal was negotiated using C-files
(Dentsply Maillefer, Ballaigues, Switzerland) and EDTA (Dentsply Maillefer,
Ballaigues, Switzerland).

16. • This was followed by usage of 10 and 15 K-files till the apical end. The working
length was estimated with an electronic apex locator (Root ZX, J Morita, Tokyo,
Japan) and confirmed with periapical radiograph.
• The canal was instrumented using rotary Pro-Taper treatment files up to master
apical file F3 under copious irrigation, with 5% sodium hypochlorite. After being
cleaned and shaped, the canal was dried and obturated by cold lateral
condensation of gutta-percha (Dentsply Maillefer) and sealer (AH Plus, Dentsply
DeTrey, Konstanz, Germany)

17. • As there was insufficient remaining coronal tooth structure, it was decided to
undertake a crown lengthening procedure.
• The patient was recalled after 1 week for preparation.
• After the removal of the provisional restorations, preparation for endocrowns
was initiated on tooth; the pulpal chamber floor was exposed, and appropriate
leveling of residual buccal and lingual walls was achieved.

18. • The cervical margins were supragingival; however, if
clinical factors or esthetics require, the margin can
follow the gingival margin.
• The step primarily involved eliminating undercuts in
the access cavity. With the bur orientated along the
long axis of the tooth, the preparation was carried out
without excessive pressure and without touching the
pulpal floor. Then, retraction cords were placed and an
impression made with a polyvinyl siloxane material.

19. • The final restoration was found to be esthetically good and the
margins were flushing well with the preparation. High points and
occlusion were checked, the patient was satisfied, and postoperative
radiograph was taken.
• The patient was recalled at 1, 6, 12, and 24 months for evaluation.

20. Diagram illustrates the endo-crown preparation and materials

21. Case 4: Pin Retained Restoration: A Case
Report
• A 24 year old Male patient came to University Dental College and
Hospital with a chief complaint of fracture of his front tooth.
• On examination there was an Ellis class II fracture of his maxillary left
central incisor.

22. • Also his left lateral incisor was missing.
• He was given the treatment options of
1) root canal therapy of the central incisor (fracture in proximity with pulp but not
involving it) followed by a fixed partial denture involving 21 22 23 or
2) a pin retained restoration for 21 and an implant placement for 22.
Patient agreed upon the second line of treatment to avoid tooth preparation on
undamaged 23.
Pre-operative picture

23. • Tooth Preparation:
• The incisal edge was made flat using a straight flat end diamond point.
• This made the table for the placement of the dentinal pins.
• The pin channel was prepared.
• The pin was then engaged to the driving device and threaded into the pin
channel until resistance was met by the pin channel floor.
• The desired length of the pin was then cut with a bur. The pins were screwed in
and tightened and then checked for stability.
Trijet pin system Retention pins in place

24. • For the buildup of the crown structure a layer of
flowable composite was used first and then B2 body
shade (Filtek 3M ESPE) was used according to the
patients natural teeth shade.
• The finishing and polishing was done using a –
composite polishing kit (Shofu).

25. • The patient was recalled for review at an interval of 1week, 1month, 6 months.
The patient did not report any history of pain and on clinical examination there
was no defect around the restored tooth. In addition to that, the pulp vitality test
revealed that the tooth was positive to thermal stimulation. The patient was
satisfied with the esthetics of the direct restoration.
post-operative picture

26. References:

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