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Managing Restorative EmergenciesEsthetic emergencies - fractures and tooth lossBy Howard E. Strassler, DMD, FADM, FAGD

PART 1 OF 2

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EDUCATIONAL OBJECTIVES

The overall goal of this course is to provide the reader with infor-mation on the management of esthetic restorative emergencies. On completion of this article, the reader will be able to:

1. Describe and evaluate esthetic restorative emergencies

2. Review the steps involved in the evaluation of an esthetic restor-ative emergency

3. List and describe the protocols and options available for the treatment of a fractured incisor without pulpal involvement

4. Review the materials and protocols available for the treatment of patients presenting with fractured porcelain on all-porcelain or porcelain-fused-to-metal restorations

5. Provide an overview of the methodology involved in the treat-ment that can be provided to restore esthetics for a patient pre-senting with an avulsed periodontally-involved anterior incisor.

ABSTRACT

Esthetic restorative emergencies in the anterior esthetic zone can involve a fractured tooth, fracture of metal or ceramic material from fixed indirect restorations, or the avulsion or loss of a periodontally-involved incisor. While these are not acute emergencies from the per-spective of pain or discomfort, from the patient’s perspective these are emergencies due to the loss of esthetics. Triaging patients prior to the appointment is helpful in planning and optimizing treatment. A number of treatment options are available to provide these patients with single-visit solutions to these esthetic restorative emergencies.

ABOUT THE AUTHOR

Howard E. Strassler, DMD, FADM, FAGDDr. Howard E. Strassler is Professor, Division of Operative Dentistry at the University of Maryland Dental School in the Department of Endodontics, Prosth-odontics and Operative Dentistry. He has

presented over 450 continuing education programs both nation-ally and internationally on techniques and selection of dental materials in clinical use and esthetic restorative dentistry. For the twelve year in a row Dr. Strassler was honored as being one of the top CE presenters by Dentistry Today. He is a Fellow in the Acad-emy of Dental Materials and the Academy of General Dentistry. In 2000, Dr. Strassler received the Academy of General Dentistry’s highest honor, the Thaddeus W. Weclew Honorary Fellowship for contributions to the profession. He is on the editorial review board of a number of dental publications. Dr. Strassler is reviewer for many journals. He is a consultant and clinical evaluator to over 15 dental manufacturers. Dr. Strassler has been involved in funded research with restorative materials. Dr. Strassler is a regular con-tributor to many publications and has published over 500 articles and columns in the field of restorative dentistry and innovations in dental practice. Dr. Strassler’s focus in his over 30 years in dental education continues to be innovative teaching using technology. AUTHOR DISCLOSURE: Dr. Strassler does not have a leadership position or a commercial interest with any products that are men-tioned in this article, or with products and services discussed in this educational activity. Dr. Strassler can be contacted by emailing [email protected]

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Asso-ciation to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2016 - 1/31/2020. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. ORIGINAL RELEASE DATE: February 2012. REVIEW DATE: January 2015. EXPIRATION DATE: December 2017. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTIC-ITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Joe Riley, does not have a leadership or commercial interest in any products or services discussed in this educational activity. He can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC, in writing. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net take your course. © 2015

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Esthetic Restorative EmergenciesPart I. Esthetic emergencies - fractures and tooth lossIntroduction

It is not uncommon in any given week for a busy dental practice in general dentistry to expect at least 5 to 10 dental emergency visits from patients. These visits can

range from the need for treatment for conditions as minor as dentin hypersensitivity or a chipped tooth, to more ma-jor problems such as a patient with an acute infection that requires antibiotic therapy and surgical intervention or a patient with a tooth or teeth that require the fabrication of a provisional restoration as part of prosthodontic care. When a patient telephones the dental office or appears at the reception desk of the office with a dental problem, the clinician and staff must have a clear protocol for managing that emergency situation in order to be able to properly respond.

The front line in any dental office is the front desk staff; however, the chairside assistant and dental hygien-ist also need to be aware of the triage that is part of the process for screening dental emergencies. At any time any staff member can be answering the telephone or greeting a patient with a dental emergency. Using a patient question-naire for walk-in emergencies or to ask questions on the telephone provides important information for triaging the patient for an appropriate appointment in a timely manner for the severity of the emergency condition that that pa-tient has. This form can be filled in by the patient or on the telephone by a trained staff member. The Emergency Phone Call form (Figure 1) contains questions that elicit the patient’s chief concern, a history of the problem, whether or not it is associated with acute or chronic pain, and the need for immediate attention. From this form the clinician can make a determination for patient scheduling and the potential need for radiographs to assist in the assessment of the problem and decision-making.1

Esthetic restorative emergenciesThe focus of this article is the treatment of esthetic

restorative emergencies as dental conditions that relate to teeth that are not in need of immediate endodontic treatment, oral surgery, or periodontal care. Restorative emergencies can be categorized as acute-urgent, subacute-not urgent, and esthetic. Esthetic emergencies in most cases are not associated with pain; nonetheless, in the patient’s view these emergencies are urgent and require immediate attention. Such circumstances can include a lost ante-rior crown, a fractured anterior tooth or restoration, an avulsed anterior tooth due to trauma or the need for an

Patient Emergency Phone Call Form

Patient name:________________________________________________

If the patient can be reached by telephone, phone number the patient can be reached at and best time

to call: phone #:____________________ best time to call:__________

Date:_____________ Time:___________________ called back:________________

Is the patient in pain when making the phone call: (circle) YES NO

Date of last patient visit (get this from chart); _________________________________

What was done that visit:___________________________________________________

When did the problem occur?________________________________________________

Was there a cause the patient can describe?_____________________________________

Has the doctor previously mentioned anything special about this problem or area in a past dental

appointment:________________________________________________________

To staff member: If it is a toothache then ask the following questions:

• What is the problem?

• Does anything cause the tooth to hurt?

• Is there is pain, can you describe the type of pain- sharp, dull, throbbling, lingering,

short duration, long duration

• When did the tooth start hurting?

• Does anything relieve the pain? Is yes, what relieves the pain?

• How long does the pain last?

• Is the gum swollen around the tooth causing the pain?

• Is your face swollen?

• Do you have a temperature?

• Did the doctor recently work on that tooth?

• Have you had this pain before and it went away?

• What side of your mouth is the tooth on; top or bottom?

Side of mouth(circle) RIGHT LEFT TOP BOTTOM

Check patient chart:

Allergies to medication? YES NO If yes what medications?

Any other medical conditions? YES NO

If yes, what are they?

Before seeing the doctor, retrieve patient chart and attach this form to the patient chart.

Are radiographs needed? YES NO

If yes what kind and where?_____________________________________________

Figure 1. Emergency Phone Call Form

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immediate extraction of a tooth in the anterior zone due to periodontal disease or pulpal pathology. Fracture or tooth loss in the esthetic zone is a serious concern for our patients. This emergency is usually due to trauma. Either the patient contacts the dental office by telephone or in some cases will show up at the reception desk immediately after the trauma occurs. For esthetic emergencies, most patients want to be seen and treated within one or two days after the problem arises and as quickly as possible. Patients do not want to be seen in public with a fractured or missing tooth in the esthetic zone. Other restorative emergencies that fall into the acute-urgent and subacute-not urgent categories are addressed in a separate article and include dentin sensitivity, fractured posterior teeth and restorations, crown and bridge emergencies, and denture emergencies.

Fractured tooth One of the most common dental emergencies is a frac-

tured tooth. A fractured tooth in the anterior esthetic zone is especially urgent to the patient. During the telephone triage by the staff, the type and location of the fracture must be noted. An accidental fracture of an anterior tooth due to trauma should be seen immediately. It is important to find out if the patient has the tooth segment or has seen the tooth segment out of the mouth. Part of the questioning should determine if the tooth was avulsed due to trauma and, if so, the type of trauma. These specific questions help the clinician prepare for the patient and the expected emer-gency treatment.

The traumatized tooth should be managed with a minimum amount of manipulation.2 Pulp testing should be conducted as a baseline and, at a subsequent visit 6-8 weeks later, vitality testing should be repeated. If a maxil-lary incisor has fractured, it is important to evaluate the type of fracture – whether it was tooth-to-tooth (opposing teeth to the fractured tooth) or due to a foreign object (for example, teeth hitting a sidewalk during a fall or the im-pact of a bat or racket). If it is a tooth-to-tooth fracture, all teeth that were traumatized in both arches must be evalu-ated, not just the fractured tooth. The traumatized teeth must be examined and assessed for mobility, any changes

in tooth alignment or occlusion due to trauma, and the condition of the supporting gingival tissues and alveolar bone. The soft tissue must be evaluated for lacerations that may require suturing and appropriate referrals made as appropriate. If the tooth was fractured but the fractured segment was not recovered, it must be ascertained that the fractured segment is not embedded in a lip. Radiographs of all teeth involved should be taken to evaluate any potential root fractures or a fracture in the alveolus. When evaluating the tooth, the depth of a coronal fracture must be evaluated and a determination made as to whether or not the pulp has been compromised. If the fracture of the tooth is small, it may only require smoothing of the tooth with finishing burs, disks and polishers. After the assess-ment, if it is determined that the tooth currently needs only an adhesive Class IV bonded composite resin restoration, this can be performed at the emergency visit. For restora-tion of a traumatized fractured incisor, local anesthetic should be administered for patient comfort and the tooth should be only minimally prepared. In the case of the Class IV fracture, a 1-2 mm long bevel of the enamel is sufficient and the fracture should be restored using an etch-and-rinse adhesive system. In the case shown here, the enamel and dentin were etched for 15-30 seconds with a phosphoric acid etchant. (Figure 2) After rinsing and drying, the bond-ing adhesive was applied and light-cured, and the final restoration placed using a nanohybrid composite resin. (Figure 3)

When a patient’s tooth is fractured and only dentin is involved with no compromise to the pulp, if the patient has retrieved the fractured tooth segment and if this has fractured cleanly, it is possible to reattach the tooth seg-ment.3,4 This readily affords the benefits of maintaining the tooth shape, form, texture, contour and color.5 In the case shown below, the patient fractured his mandibular incisor while playing racquetball when the racquet hit the patient in the face. (Figure 4) The tooth had fractured cleanly and the patient brought in the tooth segment. (Figure 5) After a thorough assessment as described earlier in this article, it was determined that the tooth segment could be bonded to the tooth. A dental dam was placed and the tooth was cleaned for the bonding procedure. No tooth preparation

Managing Restorative EmergenciesEsthetic emergencies - fractures and tooth loss

5January 2015

was necessary. The tooth surfaces that were to be bonded, as well as the tooth segment, were etched for 30 seconds (Figure 6), rinsed and dried and a 4th generation adhesive was used. Dentin primer was applied to both the tooth and the tooth segment for 5 seconds and air-dried, after which the adhesive was painted on the etched surfaces of the tooth and tooth segment but not light- cured. It is impor-tant to not light- cure the adhesive because the thickness of adhesive can interfere with seating the tooth segment back into position. A flowable composite resin was placed on the tooth and tooth segment and the tooth segment was reattached to the fractured tooth. Excess flowable compos-ite resin was removed using a brush wetted with adhesive,

and both the facial and lingual surfaces were light-cured for 20 seconds. Excess composite resin was removed from the margins/fracture line with a finishing disk and the tooth was polished with a superfine disk. The completed result is indistinguishable from the patient’s intact natural teeth. (Figure 7)

Fractured porcelain: Crown and bridge repairNothing lasts forever, and it is relatively common for a

patient to fracture porcelain on an existing porcelain-fused-to-metal crown, ceramic crown, porcelain veneer or fixed

Figure 2. Fractured central incisor being etched

Figure 4. Traumatic fracture of the mandibular incisor

Figure 3. Class IV fracture restored with a nanohybrid composite resin Figure 6. Fractured incisor being etched

Figure 5. Tooth segment from fracture

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partial denture. In the posterior region, this is usually easily managed with smoothing and polishing of the fractured porcelain using finishing diamonds or stones with a dental handpiece and further polishing with rubber abrasives. When the fracture is large, however, it may be necessary to remove the restoration, place a provisional restoration and fabricate a new indirect restoration. When porcelain fractures in the anterior region, the patient wants to be seen immediately. There are a number of different surface treatments available that can be used to establish a bond between the existing restoration and the repair material being used. The selection of a surface treatment depends on the size and type of fracture and whether or not the repair is bonding to metal, metal/porcelain, or porcelain. These op-tions are their applications are discussed below.

Chemical metal bondingOver the years laboratories have used a wide variety of

cast metals to fabricate crowns and fixed partial dentures, ranging from metals with a high gold (noble) content to base metals with high concentrations of nickel and chrome and no noble alloy. It is almost impossible to know which specific alloy or metal has been used in an existing restora-tion, yet bonding to high noble metal is very difficult to achieve while bonding to base metal is more readily ac-complished. Bonding agents are available that are designed specifically for these purposes, and include a 4-meta resin cement (C&B Metabond, Parkell) and newer metal bond-ing agents that have been introduced (M-Bond, J Morita; Metal Primer, GC America).

Chemical porcelain bondingDental porcelains are chemically very similar, and the

ability to adhere composite resin to porcelain is based upon silane, a chemical coupling agent. Silane is available as a ceramic primer in all porcelain veneer bonding kits or can be purchased separately. (Table 1)

Surface roughening of metal and porcelainAir abrasion on the surface of metal and porcelain

microscopically roughens the surfaces to be repaired and is beneficial.6-8 This involves the use of an air abrasion unit to create a high velocity stream of aluminum oxide particles that microscopically roughen both metal and ceramic surfaces to prepare them for bonding. Recently introduced air abrasion units that can be used for crown and bridge repair and for tooth preparation for preventive resin restorations have been introduced that are significantly less expensive than large stand-alone air abrasion cavity preparation units. In the past all air abrasive particles func-tioned similarly, however some recent research has shown that a unique particle for air abrasion, CoJet Sand (3M-ESPE), contains a silanized silica coating on aluminum oxide particles that when used leaves a coating of silica on both metal and ceramic surfaces that enhances the bond of repair using composite resin.9

Table 1. Silane ceramic primers

Name Manufacturer

RelyX Ceramic primer 3M-ESPE

Clearfil Silane Kuraray

Monobond-S Ivoclar Vivadent

Silane Coupling Agent Dentsply Caulk

VersaLink Silane Porcelain Bond Sultan Healthcare

Silane bond enhancer Pulpdent

Bis-Sil BiscoFigure 7. Incisor restored with tooth segment bonded in place with flowable composite resin.


7January 2015

Another method to microscopically roughen porcelain to enhance micromechanical retention of composite resin to porcelain is the use of hydrofluoric acid.10,11 Hydroflu-oric acid (HF) should be used carefully in the oral cav-ity, and the soft tissues adjacent to the restoration being treated must be protected and isolated with either a rubber dam or a light-cured resin-based paste. Typically, only low concentration hydrofluoric acids are used (6%-10% range) and in a gel formulation to allow for controlled placement. Typically, the porcelain is etched with the hydrofluoric acid gel for 3-4 minutes while keeping the surface being etched moist with gel throughout the etching time. In most cases, however, air abrasion of the site to be repaired is recommended over HF due to the potential for soft tissue damage using HF.

Diamonds and burs can also be used to roughen the surface of metal and porcelain to enhance bonding. It is important that whenever porcelain is prepared with a diamond abrasive, copious water spray is used to cool the diamond. If the diamond heats the porcelain, it can cause heat-checking of the porcelain which initiates microcracks in the ceramic surface that can lead to further fractures of the porcelain. When preparing the fracture site for composite resin repair, for a more predictable long-lasting repair it is critical that the site be enlarged by at least three to four times the original fracture surface area.12 In the case of repairing only metal, composite resin retention can be enhanced further by creating mechanical undercuts in the metal. Since adhesives are used to seal the composite resin repair, these undercuts can be permitted to perforate through the metal portion of the crown into the tooth without any ill effects. The case bellows demonstrates the repair of a fractured lateral incisor porcelain-fused-to-metal crown.

Case reportThe patient presented with a 3-unit porcelain-metal fixed

partial denture that included a maxillary central incisor and canine abutment with a lateral incisor pontic. The fixed par-tial denture had been fabricated 18 months previously, and four months prior to the patient’s visit the porcelain frac-

tured from the lateral incisor, leaving the metal exposed. At the time, a composite resin repair had been attempted but had now fractured away. (Figure 8) The canine of the bridge was an abutment for a clasp and rest seat for a partial denture fabricated after the bridge was cemented. Refabrica-tion of the fixed partial denture would have necessitated a remake of the removable partial denture. As the patient was on a fixed income, this was not a preferred option and the patient wanted to try a repair again.

Evaluation of the site revealed a very tight occlusion that had contributed to the porcelain fracture and the subsequent composite resin repair fracture. (Figure 9) The opposing mandibular canine was reshaped to allow for ad-equate room for a composite resin repair of the fractured site. (Figure 1) Very little had been done, at the time of the prior repair, to enhance retention of the composite resin to the metal. For the new repair, without weakening the con-nectors of the fixed bridge, the metal was air-abraded with CoJet Sand and additional retention was developed in the metal by placing undercuts in the incisal areas of the metal pontic using a metal-cutting bur. (Figure 11) One challenge frequently encountered when repairing areas with exposed metal is how to avoid a graying out of the composite resin repair. This is best accomplished by using a composite resin opaquer that can mask the metal while being thin enough to avoid overbulking of the composite resin repair. (Table 2)

Figure 8. Porcelain fracture from maxillary lateral incisor pontic

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The air-abraded porcelain and metal was cleaned with a phosphoric acid etchant for 10 seconds, after which the etchant was rinsed from the surface and the surface dried. A ceramic primer was applied to all exposed porcelain surfaces with a disposable brush for 30 seconds and dried on the surface. The air-abraded and prepared metal was then covered with a metal adhesive bonding agent (Gold-Link 2, Den-Mat) (Figure 12) and a resin opaquer, using

a small disposable brush. (Figure 13) The surfaces were then light-cured with a quartz halogen curing light for 10 seconds. For this case, another challenge was the creation of the tissue surface side of the pontic when repairing it with composite resin. To control the contour of the pontic adjacent to the gingival tissue, a very soft stainless steel matrix strip (Fintrec Deadsoft Matrix, Pulpdent) was cut to form a trapezoidal shape. This trapezoidal shape was perfect for adapting the matrix under the pontic and into the embrasure spaces. The narrow portion of the trap-ezoid was slid from facial to lingual under the pontic, and the wider wings of the trapezoid then stabilized into the gingival embrasures with wooden wedges. (Figure 14) The pontic was then restored with a nanohybrid composite, which was finished and polished using finishing burs fol-lowed by silicone abrasive points and cups and composite resin polishing disks. The patient was informed that the completed restoration would probably last for several years. (Figure 15)

Tooth loss due to periodontal disease or failed endodontic treatment

There are times when a patient with severe periodon-tal disease loses an anterior tooth or has to have an anterior tooth extracted due to periodontal infection. For the patient in this case, a diagnosis of severe periodontal disease in the mandibular anterior region had been made and the patient had not yet acted on treatment recom-

Table 2. Resin opaquers

Name Manufacturer

Kolor Plus Kerr

TetraPaque Den-Mat

Masking Agent 3M-ESPE

Opaquer Pulpdent

Clearfil ST Opaquer Kuraray

Figure 9. Tight occlusion contributed to porcelain fracture

Figure 10. Mandibular canine reshaped to allow for room for the porcelain repair

Figure 11. Mechanical retention placed in the metal using a metal-cutting bur


9January 2015

mendations. (Figure 16) While eating the night before, the patient self-extracted the mandibular left lateral incisor. The patient called the office and was seen that day in a one-hour open time in the schedule. The patient had the tooth in hand and the site of the lost tooth was healing satisfactorily. (Figure 17) A decision was made to replace the tooth as a natural tooth pontic splinted to the adjacent teeth with fiber reinforcement ribbon (Ribbond THM, Ribbond) and to splint the periodontally mobile teeth (#22-27). Fiber reinforcement materials can be used successfully to splint periodontally mobile teeth and pro-vide a patient with a durable, single-visit tooth replace-ment in the anterior esthetic zone using either a natural tooth pontic, composite resin pontic or a denture tooth as a pontic.13,14

The length of the tooth pontic was determined by measuring the distance from incisal edge of the lateral incisor to the extraction site. (Figure 18) Some additional length was added so that the pontic would be touch-

ing the gingival tissue as the extraction site healed. The tooth length needed was measured with a periodontal probe, after which the root was sectioned from the crown and shaped with a flame-shaped finishing diamond. The opening in the root where the root canal was present was filled with a bonded composite resin and the gingi-val aspect of the tooth was smoothed and shaped to be rounded. To increase the bulk of composite resin at the connector area between the pontic and abutment teeth, and to create room for a double thickness of reinforce-ment fiber ribbon, a channel with a width of 3-4 mm was cut in the lingual surface. (Figure 19) This was the same width as the 3 mm wide fiber reinforcement ribbon that was to be used for bonding and reinforcing of the com-posite resin where the teeth were to be connected. A den-tal dam was placed, without a hole punched in the area where the tooth had been lost so that bleeding would not contaminate the area being bridged during the bonding procedure. (Figure 20)

Figure 13. Opaquer applied

Figure 14. Very soft stainless steel matrix placed to form tissue side of composite resin repair of pontic

Figure 12. Metal bonding agent applied

Figure 15. Pontic esthetically repaired with nanohybrid composite

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The teeth were cleaned and then a thin diamond was used with a high-speed handpiece and water spray to bar-rel into the interproximal areas, to improve stabilization of these periodontally mobile teeth and to minimize the thick-ness of the splint on the aesthetic interproximal aspect of the facial surfaces of #22-27. Later, composite resin would be placed on these facial surfaces to improve cross-stabili-zation of the teeth. Class III preparations were also made

on the mesiolingual surfaces of the left canine and left cen-tral incisor, to further reinforce the bridge connectors and to create room for a double piece of fiber reinforcement ribbon once the pontic was placed. A double piece of fiber ribbon with composite resin placed in between both rib-bons provides additional strength and stability when plac-ing a pontic, by creating a laminated composite beam.12

To determine the length of fiber ribbon to be used, a

Figure 16. Avulsed periodontally-involved mandibular incisor

Figure 17. 12 hours after tooth loss Figure 19. Tooth pontic with channel prepared on lingual surface

Figure 18a. Measuring the length required for the natural tooth pontic with a periodontal probe

Figure 20. Dental dam placed leaving the pontic area with no hole punched

Figure 18b. Measuring tooth to verify length before cutting off the root


11January 2015

piece of dental floss was placed from distal of #23 to distal of #26 on the facial surface and cut. For the second piece of ribbon a small piece of floss from the mesial of #22 to mesial of #24 on the facial was also cut. The fiber rib-bon was then cut into two pieces to match these lengths, impregnated with resin adhesive, put aside and covered to protect from light. The natural tooth pontic was then etched with a phosphoric acid etchant for 15 seconds, rinsed with water and dried. Adhesive was painted on the etched surfaces and into the prepared channel on the lingual surface. This was also put aside until it was time to bond it into place.

Teeth #22-27 were then etched for 30 seconds with a 32% phosphoric acid gel on the facial and lingual surfaces, rinsed and dried. The resin adhesive was ap-plied to teeth adjacent to the pontic and composite resin placed on the facial surface. The pontic was placed into position with cotton pliers and then stabilized by light

curing it. (Figure 21) Gingival embrasure areas were then blocked out with a fast-setting medium viscosity PVS impression material (Figure 22), after which adhesive was painted on the etched surfaces, composite resin applied to the facial interproximal surfaces, shaped and light-cured. (Figure 23) Composite resin was applied to the lingual surfaces, including the channel in the pontic and the Class III preparations. (Figure 24) The shorter length of fiber ribbon was placed on the lingual surface into the channel and Class III preparations, and adapted to the in-ner aspects of the preparations. The second (longer) fiber ribbon was then placed from teeth #22-#27, embedded into the composite and adapted to the lingual surfaces of the teeth. (Figure 25) Excess composite was removed and the composite light-cured and then finished and polished after removal of the PVS blockout material. The patient was able to leave that day with a tooth and esthetics intact. (Figure 26)

Figure 21a. Pontic positioned with cotton pliers after etching adhesive and composite resin placed facially before light curing

Figure 21b. Pontic stabilized with light-curing

Figure 22a. Facial view: Blockout of gingival embrasures after etching using a fast-setting PVS impression material

Figure 22b. Lingual view: Blockout of gingival embrasures after etching using a fast-setting PVS impression material

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ConclusionThe emergency presenting as a traumatically injured

tooth in the esthetic zone is not an unusual occurrence in a dental practice. The clinician and staff should have a plan for the triage of these patients to provide treatment that addresses their dental and psychological needs. One excellent method to help in the triage of the patient and to provide information to the clinician is the use of a short questionnaire when interviewing the patient or responsible adult over the telephone. With this information, when the patient arrives the course of treatment can begin and a suc-cessful result can be reached. Clinically, the traumatized anterior tooth that needs immediate attention should be evaluated for any changes in the position and occlusion of the tooth, pulpal status of the tooth and any trauma or changes to other teeth in the mouth due to the injury prior to determining care and providing treatment.

References1. Strassler HE, Gerhardt DE. Trouble shooting everyday restorative emergencies. Dent

Clin North Amer. 1993; 37(3):353-365.2. Rauschenberger CR, Hovland EJ. Clinical management of crown fractures. Dent Clin

North Amer. 1995; 39(1):25-52.3. Osborne JW, Lambert RL. Reattachment of fractured tooth segment. Gen Dent.

1985; 33:516-17.4. Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth frag-

ments. Quintessence Int. 2000; 31:385-91.5. Strassler HE. Aesthetic management of traumatized anterior teeth. Dent Clin North

Amer. 1995; 39(1):181-202.6. Suliman AH, Swift EJ, Perdigao J. Effects of surface treatment and bonding agents

on bond strength of composite resin to porcelain. J Prosthet Dent. 1993; 70:118-120.7. el-Sherif M, Shillingburg HT, Duncanson MG . Comparison of bond strength of

resin-bonded retainers using two metal etching techniques. Quintessence Int. 1989; 20:385-388.

8. el-Sherif MH, el-Messery A, Halhoul MN. The effects of alloy surface treatments and resins on the retention of resin bonded retainers. J Prosthet Dent. 1991; 65:782-786.

9. Boyer D, Armstrong S. Reinhardt J, Aunan D. Effect of surface treatment on porcelain repair with composite. J Dent Res (Special Issue). 1997; 76: 72, abstract no. 466.

10. Denehy G, Bouschlicher M, Vargas M. Intraoral repair of cosmetic restorations. Dent Clinic North Amer. 1998; 42(4):719-737.

11. Stangel I, Nathanson D, Hsu CS. Shear strength of the composite bond to etched porcelain. J Dent Res. 1987; 66:1460-1465.

12. Strassler HE. Achieving predictable crown and bridge repair. GP Insider. 1992; 1(5):71-74.

13. Strassler HE, Taler D, Sensi LG. Fiber reinforcement for one-visit single tooth replace-ment. Dent Today. 2007; 26(6):120-25.

14. Strassler HE. Serio CL. Esthetic considerations when splinting with fiber-reinforced composites. Dent Clin North Am. 2007; 51(2):507-24.

Figure 25. Fiber ribbon embedded into the composite resin

Figure 26. Final immediate fixed partial denture with natural tooth pontic

Figure 23. Adhesive painted on all etched surfaces, composite applied to facial embrasures to create for tooth stabilization for final 180 wrap of teeth with bonding

Figure 24. Composite resin applied to lingual surfaces


13January 2015

1. Dental emergencies include requests to be seen due to ____________.a. dentin hypersensitivityb. fractured teethc. broken denturesd. all of the above

2. To help manage a dental emergency, a form or questionnaire can be used that contains questions for the patient about ____________.a. the patient’s chief concern b. whether the problem is related to past dental treatmentc. whether the patient is in paind. all of the above

3. ____________ emergencies are unique because a patient may want to be seen as soon as possible even though there is no pain or swelling. a. Sub-actue b. Estheticc. Acuted. all of the above

4. A fractured anterior tooth usually occurs due to ____________.a. endodontic treatmentb. trauma c. cariesd. erosion

5. Pulpal health of a fractured tooth should be evaluated ____________.a. 2-3 weeks after the accident and after restorationb. the day of the trauma and 6-8 weeks after the incident c. the day of trauma and unless the patient is in pain, it can be as-

sumed the pulp has maintained its vitalityd. only if the tooth is painful

6. If a patient fractures a tooth, it is important to ____________.a. provide a prescription for antibiotics to avoid infectionb. avoid making radiographs until 1 week after the trauma to not

further traumatize the toothc. make radiographs to evaluate for fractures of the roots or boned. provide the patient with a prescription for analgesics so that the

tooth is not painful when the patient returns in one week for evaluation

7. When a tooth segment can be reattached to the natural tooth, as part of this procedure, the tooth is etched, rinsed and dried prior to placing the adhesive which is ____________.a. not light-cured until the tooth segment is placed with flowable

composite resin. b. light-cured and finished with a finishing bur so that the segment

can be seatedc. rinsed from the tooth with water spray and driedd. activated with a laser curing light to rapidly seal the tooth

8. In most cases, a Class IV anterior fracture is managed with ____________.a. a temporary crownb. an extraction and fabrication of a temporary partial denturec. an adhesive composite resind. endodontic treatment and a crown at a later date

9. The following clinical situations may be in need of an immediate replacement of an anterior tooth except the ____________.a. loss of a tooth due to severe periodontal diseaseb. loss of a tooth due to endodontic failurec. loss of a tooth due to orthodontic extractiond. loss of a tooth due to trauma

10. If a patient fractures an anterior tooth, cannot find the tooth segment, and is in the dental office ____________.a. it can be assumed that everything is okayb. a flat plate chest film must be made at the hospital to rule out

swallowing of the tooth segmentc. an examination for any lacerations due to the tooth segment

being embedded in soft tissues should be doned. b and c

11. According to this article, a dental emergencies can be categorized as being ____________. a. acute-urgent or esthetic b. subacute-not urgent or estheticc. acute-urgent, esthetic or subacute-not urgentd. none of the above

12. When an anterior tooth or teeth has been traumatized, evalua-tion of the tooth or teeth should include ____________. a. any changes in occlusionb. any changes in tooth alignment and positionc. depth of fracture of tooth (teeth)d. all of the above

13. In some cases after the traumatic fracture of an anterior tooth, the patient brings the piece of broken tooth with them, and if this occurs you can ____________.a. throw it away in the trash, it has become contaminated when out

of the mouthb. take the piece of crown and match a composite resin to it c. smoothe the piece off, drill a hole in it and put it on a gold chain

for all to seed. try-in the segment back on the tooth and if it matches up, bond it

in place with an etch-and-rinse adhesive technique

14. A double thickness of fiber ribbon embedded into composite on the lingual surface of a pontic and into Class 3 preparations ____________. a. creates a beam effect to further strengthen the repairb. creates a more esthetic restorationc. makes polishing the composite resin easierd. creates room for flowable composite

CEQuizTo complete this quiz online and immediately download your CE verification document, visit www.dentallearning.net/MRE1-ce, then log into your ac-count (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verification document. We accept Visa, MasterCard, Discover and American Express.

DENTAL LEARNING

14

15. If a patient fractures porcelain on a small area of a posterior PMC, the author recommends ____________.a. bonding a new piece of porcelain to the fracture siteb. replacing the crown but being sure to take it out of occlusion to

avoid it fracturing againc. smoothing the porcelain and polishing itd. adding composite resin to the fractured area using an enamel

bonding technique

16. If a patient presents with a fractured crown, this ____________.a. must always be remadeb. may be treated in some cases by smoothing itc. may be repaired in some cases using composite resind. all of the above

17. ____________ can be used to achieve retention to porcelain when doing porcelain-metal repairs with composite resin:a. chemical bonding with silane couplingb. etching porcelain with hydrofluoric acidc. air abrasiond. all of the above

18. Etching with citric acid can be used for ____________.a. porcelain veneers and crownsb. zirconiac. porcelain-fused-to-metal restorationsd. none of the above

19. For a natural tooth pontic, the length is determined by ____________.a. cutting the crown at the CEJ for the final lengthb. measuring the distance from the incisal edge of the central incisor

to the extraction sitec. measuring the mesial-distal width and doubling itd. measuring the length of the adjacent teeth

20. The gingival interproximal areas are blocked out using PVS impression material after ____________. a. cleaning the teethb. etching the teethc. application of the bonding resind. application of the composite but before placing the fiber ribbon.

21. The gingival interproximal areas are blocked out to ____________. a. minimize excess composite resin in these areasb. make the restoration longer lastingc. leave space for flossd. all of the above

22. The use of ____________ is a method to achieve retention when doing porcelain-metal repairs with composite resin:a. metal bonding agentsb. air abrasionc. undercuts in the metal created with a diamond or burd. all the above

23. A metal opaquer is used to ____________. a. avoid white outs of porcelainb. avoid a graying effect caused by the metalc. create a chameleon effectd. all the above

24. When blocking out gingival embrasures, ____________ impression material can be used.a. an alginateb. a green compoundc. a PVS d. all the above

25. A natural tooth pontic should be etched ____________.a. with chloric acid for 20 secondsb. with phosphoric acid for 15 secondsc. with phosphoric acid for 40 secondsd. all the above

26. Self-extraction of a tooth can occur due to _________.a. periodontal involvementb. orthodontic treatmentc. orthognathic therapyd. all of the above

27. A very soft stainless steel matrix can be cut into a _________ shape to control the countour of the pontic.a. squareb. ovalc. trapezoidald. hexagonal

28. If using hydrofluoric acid in the oral cavity, the soft tissues adjacent to the restoration _________.a. are unaffectedb. must be protected with a matrix band or a self-cured

glass ionomerc. must be protected and isolated with a rubber damd. all of the above

29. An air abrasion unit can be used on _________ to create a microsopically-roughened surface.a. porcelainb. etchantc. metald. a and c

30. One excellent method to help in the triage of the _________ is the use of a short questionnaire over the telephone. a. staffb. patientc. parentsd. all of the above

CE QUIZ


15January 2015

Managing Restorative Emergencies Esthetic emergencies - fractures and tooth losswww.dentallearning.net/MRE1-ceCE ANSWER FORM (E-mail address required for processing)

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

QUIZ ANSWERSFill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES1. Review the steps involved in the evaluation of an esthetic restorative emergency2. List and describe the protocols and options available for the treatment of a fractured incisor without

pulpal involvement3. Review the materials and protocols available for the treatment of patients presenting with fractured

porcelain on all-porcelain or porcelain-fused-to-metal restorations 4. Provide an overview of the methodology involved in the treatment that can be provided to restore

esthetics for a patient presenting with an avulsed periodontally-involved anterior incisor.

If you have any questions, please email Dental Learning at [email protected] or call 888-724-5230.

COURSE SUBMISSION: 1. Read the entire course.2. Complete this entire answer sheet in

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receive your CE verification certificate.

A score of 70% will earn your credits.

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2. Usefulness of content . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

3. Benefit to your clinical practice . . . . . . . . . . . . . . . . . . . . 3 2 1

4. Usefulness of the references . . . . . . . . . . . . . . . . . . . . . . 3 2 1

5. Quality of written presentation . . . . . . . . . . . . . . . . . . . . 3 2 1

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7. Clarity of quiz questions . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

8. Relevance of quiz questions . . . . . . . . . . . . . . . . . . . . . . 3 2 1

9. Rate your overall satisfaction with this course . . . . . . . . 3 2 1

10. Did this lesson achieve its educational objectives? Yes No

11. Are there any other topics you would like to see presented in the future? __________________________________________________________________________

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