JOURNAL CLUB

1. JOURNAL CLUB
BIOLOGICAL RESTORATION: A
4/5 CROWN
JISPPD| Oct-Dec 2013 |Vol 31| Issue 4 |
Monize Ferreira Figueiredo de Carvalho, Adriana M.
Botelho1, KarineT. A.Tavano1,Vanessa C.
S. fernandes
PRESENTED BY
KARUNA SHARMA

2. Introduction
Dental caries (tooth decay) is one of the most
prevalent conditions in humans throughout the
world, especially in childhood.
Sanches K, de Carvalho FK, Nelson-Filho P, Assed S, Silva
FW, de Queiroz AM. Biological restorations as a treatment
option for primary molars with extensive coronal
destruction –Report of two cases. Braz Dent J 2007;18:248-
52.

3.  According to 1999-2004 National Health and
Nutrition Examination Survey 42% of children in
the age group of 2 to 11 years have had dental
caries in their primary teeth.

4. The aim of restorative dentistry is to
 recreate the anatomy of the affected tooth
through the replacement of the lost tissue,
thereby reestablishing shape, chewing function,
speech and esthetics.
1. Sanches K, de Carvalho FK, Nelson-Filho P, Assed S, Silva
FW, de Queiroz AM. Biological restorations as a treatment
option for primary molars with extensive coronal destruction –
Report of two cases. Braz Dent J 2007;18:248-52.
2. Raghu R, Srinivasan R. Optimizing tooth form with direct
posterior composite restorations. J Conserv Dent 2011;14:330-
6.

5.  A variety of materials have been employed in the
restoration of teeth with considerable decay, such
as amalgam, composite resin, ceramic,
metalloplastic, metalloceramic and forged metal.
Reis A, Lourguercio AD.Tooth fragment reattachment current
treatment concepst. Pract Period Aesthet Dent 2004;16:739-40.

6. However, no synthetic material is capable
of replicating the esthetic characteristics
or color stability of natural teeth.
Grewal N, Seth R. Comparative in vivo evaluation of restoring
severely mutilated primary anterior teeth with biological post and
crown preparation and reinforced composite restoration. J Indian
Soc Pedod Prev Dent 2008;26:141-8

7. Thus, a number of researchers have suggested the
use of fragments from the natural teeth as an
effective restorative method.
Corrêa-Faria P, Alcântara CE, Caldas-Diniz MV, Botelho AM,
Tavano KT. “Biological restoration”: Root canal and coronal
reconstruction. J Esthet Restor Dent 2010;22:168-77.
This procedure is known as “biological restoration.”
Cavity preparation should be non-retentive and the
fragment is retained with adhesive materials.

8.  The expression “biological restoration” was
coined by Santos and Bianchi in 1991.
Santos J, Bianchi J. Restoration of severely damaged teeth
with resin bonding systems: case reports. Quintessence Int
1991;22:611-615.

9.  The concept of biological restoration is based on the
use of material from a tooth bank or a duly donated
tooth for the purposes of reconstruction.

10.  The aim is to ensure the best physical and
mechanical properties, such as shape, surface
texture, biocompatibility, resistance to wear and a
linear thermal expansion coefficient similar to that of
the sound dental tissue as well as an excellent
emotional response on the part of the patient to the
resulting esthetics.
Tavano KT, Botelho AM, MottaTP, PaesTM. Biological
restoration:Total crown anterior. DentTraumatol
2009;25:535-40.

11. Nonetheless, a number of limitations are inherent
to this technique, such as the difficulty in finding a
tooth with a similar color and shape to the
damaged tooth and the patient’s refusal to accept
a tooth from another individual.
Busato AL, Loguercio AD, Barbosa AN, Sanseverino Mdo
C, Macedo RP, Baldissera RA. Biological restorations using
tooth fragments. Am J Dent 1998;11:46-9.

12. The first paper reporting the use of fragments of
extracted teeth as dental restorative materials was
published in 1964 by Chosak and Eidelman .
Chosack ABDS, Eidelman EDO. Rehabilitation of a fractured
incisor using the patient’s natural crown - case report. J Dent
Child 1964;31:19-21.

13.  Ramires-Romito et al used teeth from the
human tooth bank of Sao Paulo University
Dental School to be used as natural posts and
crowns to fit into the roots and replace the
crowns as well .
Ramires Romito ACD.,Wanderley MT, Oliveira MDM, Imparto
JCP, Pires Correa MSN. Biologic restoration of primary anterior
teeth. Quint Int 2000; 31: 405-11.

14. This paper describes
 a clinical case demonstrating the quality and
functionality of a biological restoration
performed to reestablish function and esthetics
to a posterior tooth.

15. Case Report
 A 26-years-old female patient visited the dental
clinic of the Universidade Federal dosVales do
Jequitinhonha e Mucuri (Brazil) seeking
treatment for an esthetically compromised tooth
(#24).
 The clinical exam revealed fracture of the entire
vestibular face, terminating in the enamel of the
cervical face [Figure 1].

16. Figure 1: Clinical Exam and
prepared 4/5 crown

17.  The radiographic exam revealed that the tooth in
question exhibited satisfactory endodontic
treatment.
 The treatment options were then presented to
the patient and biological restoration was
selected as the procedure of choice.
 The patient then signed a statement of informed
consent.

18.  The technique consisted of the regularization of
the tooth and the subsequent creation of a filling
nucleus with photopolymerizable composite resin.
 The cavity was then prepared for an inverted 4/5
crown due to the involvement of the vestibular face
[Figure 1].

19.  A cast was made of the arches and the position
of the maxilla in maximum intercuspation was
recorded to facilitate the cutting and adjustment of
the tooth fragment.
 A temporary restoration was then performed.

20.  A duly donated extracted tooth 24 with similar
color and dimensions to the damaged tooth was
then selected and sterilized in an autoclave at
121°C for 15 min.
Corrêa-Faria P, Alcântara CE, Caldas-Diniz MV, Botelho AM,
Tavano KT. “Biological restoration”: Root canal and coronal
reconstruction. J Esthet Restor Dent 2010;22:168-77.
 With the aid of a thickness gauge, a number of
cuts were made to donated tooth with diamond-
tip burs under intense refrigeration until
achieving a fragment similar in shape to the
prepared cavity.

21. Figure 2: Extracted tooth
selected

22.  Once the fragment was adequately adapted
to the cast [Figure 3], the initial occlusal
adjustments were made on the articulated
model to facilitate the procedure [Figure 4].

23. Figure 3: Tooth fragment
adapted to the cast

24. Figure 4: Occlusal adjustments on
model and tested on oral cavity

25.  The dental fragment was then tested on the
prepared tooth in the oral cavity [Figure 4].
 Following absolute isolation of the operating fi
eld, the tooth and fragment were both etched
with a 37% phosphoric acid solution for 30 s on
the enamel and 15 s on the dentin.
 The etched regions were then rinsed and dried.
 The primer was applied to both substrates and
photopolymerized for 20 s.

26.  The fragment was then bonded using a duo resin
cement. Prior to photopolymerization, the
excess cement was removed and the final
occlusal adjustments were made.
 Further clinical and radiographic exams were
performed after a 12 months period [Figure 6].
 The restoration was stable, with no signs of
caries, migration of the fragment or marginal
infiltration.

27. Figure 5: Clinical and radiographic
immediately aspect

28. Figure 6: Clinical and radiographic
aspect after 12-months

29. Discussion
 The use of a donated tooth fragment for
biological restorations is often viable for teeth
with extensive crown damage.
Sanches K, de Carvalho FK, Nelson-Filho P, Assed S, Silva
FW, de Queiroz AM. Biological restorations as a
treatment option for primary molars with extensive
coronal destruction –Report of two cases. Braz Dent J
2007;18:248-52.

30. This method replaces the lost dental tissue and
reestablishes function, natural anatomic
characteristics and esthetics.
Kapur A, Chawla HS, Goyal A, Gaube K. An esthetic
point of view in very young children. J Clin Pediatr Dent
2005;30:99-103.
Moreover, the low cost allows the use of this
technique in public oral health-care.
Corrêa-Faria P, Alcântara CE, Caldas-Diniz MV, Botelho AM,
Tavano KT. “Biological restoration”: Root canal and coronal
reconstruction. J Esthet Restor Dent 2010;22:168-77.

31.  Biological restoration is an alternative to
complex restorations with amalgam, composite
resin and porcelain.
Santos JFF, Bianchi J. Restoration of severely damage teeth
a with resin bonding systems: Case Report. Oper Dent
1999;22:611-15.

32.  Although the synthetic restorative materials
have achieved a high degree of development and
stability, none completely satisfies the
requirements for the replacement of the lost
dental tissue in terms of function and esthetics.
Pegoraro CN, Domingues LA,Trassi PMMM. Biological
onlay: An alternative technique for restoration of severely
damaged posterior tooth. A case report. Rev Dent Press Estét
2006;3:114-5.

33. As biological restoration is a homogeneous
technique, changes are not expected as those
found in composite resin restorations, such as
discoloration of the restorative material over
time in comparison to the surrounding tooth.
Grewal N, Seth R. Comparative in vivo evaluation of restoring
severely mutilated primary anterior teeth with biological post
and crown preparation and reinforced composite restoration. J
Indian Soc Pedod Prev Dent 2008;26:141-8.

34.  The main difficulty regarding biological
restoration consists of selecting a tooth with
comparable color, shape and size to the tooth to
be restored. Compatible teeth can be acquired
from a tooth bank or a legally donated extracted
tooth that has been appropriately stored.
Reis A, KraulA, Francci C, AssisTGR, Crivelli DD, Oda M, Loguercio
AD. Re-attachment of anterior fractured teeth: Fracture strength
using different materials. Oper Dent 2002;27:621-7.

35. The donated tooth should be submitted to a
rigorous sterilization process to completely
eliminate the risk of contamination and the
transmission of diseases.
Cru E, Carpenter WM. Extracted teeth —
descontamination, disposal and use. J Cal Dent Assoc
1997;25:801-4.
A number of safe sterilization and storage
methods are currently available.

36. Sterilization can be performed with the use of an
autoclave, 10% formalin, thymol, ethylene oxide
and radiation and the tooth can be stored in 10%
formalin, thymol, sodium hypochlorite,
glutaraldehyde or sodium azide.
Kumar M, Sequeira P, Peter S, Bhat G. Sterilisation of extracted
human teeth for educational use. Ind J of Med Microb 2005;23:256-8.
Lolayekar NV, Bhat SS. Disinfection methods of extracted
human teeth. J Oral Health Comm Dent 2007;1:27-9.

37.  For the execution of a biological restoration in
posterior teeth, the cavity to be prepared must
be expulsive and must terminate in the enamel.
 Casting is necessary after the preparation of the
cavity.
 As with any indirect restoration, the laboratory
phase is a critical step.The cutting of the
fragment requires professional experience for
the adequate adaptation to the plaster model
and subsequent placement on the tooth to be
restored.

38. Several materials have been used for bonding
dental fragments to cavities, e.g., adhesive systems,
composite resins, glass ionomer cements and dual-
cure resin cements .
Busato ALS, Loguercio AD, Barbosa NA, Sanseverino MCS,
Macedo RP, Baldissera RA. Biological restorations using tooth
fragments. Am J Dent 1998;11:46-48.

39.  The use of fragments from extracted natural
teeth is viable for situations in which restorative
materials with adequate physical properties are
desired for the reestablishment of function and
esthetics in teeth having lost a large amount of
tissue.
 While, biological restorations have considerable
clinical applicability and offer the advantages of
a superior esthetic outcome as well as
indisputable psychological and social impacts,
such restorations do not replace existing
restorative techniques.

40.  Thus, biological restoration cannot be
considered the best option, only the most
biological option and should be well planned
considering each case on an individual basis.
Pegoraro CN, Domingues LA,Trassi PMMM. Biological onlay: An
alternative technique for restoration of severely damaged posterior
tooth. A case report. Rev Dent Press Estét 2006;3:114-5.

41. Conclusion
The purpose of this case report was to show
readers that biological restoration is a viable
alternative for reestablishing function and esthetics
to damaged/decayed teeth.

42. REFERENCES
1. Sanches K, de Carvalho FK, Nelson-Filho P, Assed S, Silva
FW, de Queiroz AM. Biological restorations as a treatment
option for primary molars with extensive coronal
destruction – Report of two cases. Braz Dent J 2007;18:248-
52.
2. Raghu R, Srinivasan R. Optimizing tooth form with direct
posterior composite restorations. J Conserv Dent
2011;14:330-6.
3. Reis A, Lourguercio AD.Tooth fragment reattachment
current treatment concepst. Pract Period Aesthet Dent
2004;16:739-40.

43. 4. Grewal N, Seth R. Comparative in vivo evaluation of
restoring severely mutilated primary anterior teeth with
biological post and crown preparation and reinforced
composite restoration. J Indian Soc Pedod Prev Dent
2008;26:141-8.
5. Corrêa-Faria P, Alcântara CE, Caldas-Diniz MV, Botelho
AM,Tavano KT. “Biological restoration”: Root canal and
coronal reconstruction. J Esthet Restor Dent
2010;22:168-77.
6.Tavano KT, Botelho AM, MottaTP, PaesTM. Biological
restoration: Total crown anterior. DentTraumatol
2009;25:535-40.

44. 7. Busato AL, Loguercio AD, Barbosa AN,
Sanseverino Mdo C, Macedo RP, Baldissera RA.
Biological restorations using tooth fragments. Am J
Dent 1998;11:46-9.
8. Kapur A, Chawla HS, Goyal A, Gaube K. An
Esthetic point of view in very young children. J Clin
Pediatr Dent 2005;30:99-103.
9. Santos JFF, Bianchi J. Restoration of severely
damage teeth a with resin bonding systems: Case
Report. Oper Dent 1999;22:611-15.

45. 10. Pegoraro CN, Domingues LA,Trassi PMMM.
Biological onlay: An alternative technique for
restoration of severely damaged posterior tooth. A
case report. Rev Dent Press Estét 2006;3:114-5.
11. Reis A, Kraul A, Francci C, AssisTGR, Crivelli DD,
Oda M, Loguercio AD. Re-attachment of anterior
Fractured teeth: Fracture strength using different
materials. Oper Dent 2002;27:621-7.
12. Cru E, Carpenter WM. Extracted teeth-
descontamination, disposal and use. J Cal Dent Assoc
1997;25:801-4.

46. 13. Kumar M, Sequeira P, Peter S, Bhat G. Sterilisation of
extracted human teeth for educational use. Ind J of Med
Microb 2005;23:256-8.
14. Lolayekar NV, Bhat SS. Disinfection methods of
extracted human teeth. J Oral Health Comm Dent
2007;1:27-9.
15. Imparato JCP, Bonecker MJS, Duarte DA, Guedes
Pinto AC. Restorations in anterior primary teeth: an
alternative technique

47. THANK YOU