I industry report

Fig. 1_Single-tooth radiograph

showing fractured tooth #22.

Fig. 2_Thermoplastic root filling in

tooth #22.

Fig. 3_Radiograph of the orthograde

root filling, found to be lege artis.

Fig. 4_Crown-lengthening kit

(Acteon).

Fig. 5_Ultrasonic crown lengthening

of tooth #22 using minimally invasive

incisions.

Fig. 6_Microsurgical 8-0 suture.

_Introduction

Crown fractures frequently force the treatmentprovider to make a clear-cut treatment choice be-tween tooth preservation and dental implant treat-ment. Speakers at implantological congresses tend topresent impressive implant/prosthodontic solutionsfor anterior fracture cases, to the point where the au-dience could be tempted to believe that this was theonly appropriate treatment alternative. The followingcase report documents a tooth preservation optionthat is simple to perform, minimally invasive and suc-cessful.

A 66-year-old male patient presented at our officewith a fractured upper left lateral incisor (tooth #22).The clinical crown of this tooth had fractured in themarginal region, with the pulp of the tooth slightly

exposed in one location. The pulp tissue vitality testshowed a weak positive result. The patient was com-pletely free of pain symptoms. There was no root mo-bility. Available treatment options were discussedwith the patient based on a single-tooth radiograph(Fig. 1). The neighbouring teeth #21 and 23 had beenrestored with all-ceramic crowns two years previ-ously. However, a three-unit fixed prosthetic denturewas rejected by the patient, as was surgical treatmentwith immediate implant placement following extrac-tion.

Conservative tooth preservation was therefore thetreatment of choice for patient and treatmentprovider alike. The patient was informed that toothpreservation could only be successful if the requiredorthograde root-canal instrumentation was possible,the tooth was symptom free and biological widthcould be restored prior to the fabrication of a crownrestoration. If these requirements were not met, animplant/prosthodontic solution would have to be re-sorted to as an alternative.

_Treatment sequence

Following extensive patient education and pre-therapeutic discourse, the patient received localanaesthetic, and tooth #22 was instrumented. This

Minimally invasive crownlengthening as an alternativeto implant treatmentAuthor_Prof Marcel Wainwright, Germany

34 I implants1_2012

Fig. 5 Fig. 6

Fig. 3

Fig. 4

Fig. 1 Fig. 2

was initially difficult, as the root canal was slightly ob-turated. Following instrumentation to ISO 20, thetooth was prepared for a root filling. Instrumentationto more than ISO 20 did not appear advisable, as thereduced diameter of tooth #22 already constituted anincreased fracture hazard during preparation of theendodontic post or in the presence of lateral forces.

At the same visit, an orthograde endodontic fillingwas placed using a thermoplastic restorative tech-nique (Thermafil, DENTSPLY DeTrey) and Sealapex(SybronEndo; Fig. 2). The control radiograph showedthat the root-canal filling had been placed lege artis(Fig. 3).

Surgical crown lengthening was planned for fourweeks later. Like all surgical interventions at our clinic,this crown lengthening was performed using ultra-sonic surgical instruments (Acteon). In this protocol,the surgeon employs a surgical kit containing multi-ple calibrated diamond instruments (Fig. 4). A minimalcircumferential incision was performed under localanaesthesia, completely dispensing with extensiveflap elevation procedures or relieving incisions.

The marginal bone was prepared approximately 2 mm farther apically to provide sufficient biologicalwidth for a subsequent crown (Berglundh 1992). Theuse of ultrasonic surgical instruments allows the sur-geon to proceed quickly while protecting the tissue,as these instruments help reduce the risk of iatrogenicdamage to the root dentine, a risk that is elevatedwhen using conventional rotary instruments (Fig. 5).The site was sutured closed using a synthetic monofil-ament thread (8-0 Trofilene, Stoma; Fig. 6). Microsur-gical suturing is indispensable in the anterior region.If it is neglected, this will result in tissue recession andimpaired aesthetics.

The sutures were removed one week later. Woundhealing was uneventful, and the patient was com-pletely free of pain and other symptoms throughoutthe entire treatment. After an additional week, a post-and-core build-up was done using the Fibrapost andSealacore system (Produits Dentaires; Fig. 7). The rootcanal was prepared with reamers, which are availablein four different diameters (Fig. 8). The option to usethe depth stop to pre-calibrate the reamer to the de-sired length was helpful, not least as a precautionagainst excessive preparation depths (Figs. 9 & 10).The root canal was prepared under copious irrigationand conditioned with a self-etching bonding system(Sealacore; Fig. 11).

The UDMA-based resin cement (Sealacore) was in-troduced into the root canal with a syringe and appli-cation tip (Fig. 12). The Fibrapost is a fibreglass-rein-forced resin endodontic post (Fig. 13) with retention

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I industry report

Fig. 7_Fibrapost and Sealacore

system.

Fig. 8_Endodontic reamers.

Fig. 9_Defining preparation depth

using the adjustable stop.

Fig. 10_Endodontic preparation

using a reamer.

Fig. 11_Conditioning the lumen

of the root canal for accepting the

endodontic post.

Fig. 12_Applying the resin cement.

Fig. 13_Fibrapost with

retention grooves.

Fig. 14_Core placement and

preparation.

Fig. 15_All-ceramic crown in situ.

Note the healthy and complete

papillae and periodontal tissues.

grooves. Our clinic uses metal-free endodontic postsystems exclusively, as their biomechanical proper-ties are clearly superior to those of metal posts. Oneimportant aspect is the absorption of the vertical lat-eral masticatory forces, which is better for the resinposts than for the metal posts because the formerhave material characteristics resembling those ofnatural dentine. In addition, the optical properties ofthe system (translucency, transparency) facilitatehighly aesthetic anterior solutions while eliminatingthe risk of corrosive discoloration.

Following core shaping and preparation (Fig. 14), apolyether impression was taken for an all-ceramiccrown (IPS e.max, Ivoclar Vivadent). The definitivecrown was delivered a week after tooth preparationand cemented with a dual-curing self-adhesive ce-ment (RelyX Unicem, 3M ESPE; Fig. 15).

_Summary

When the clinical crown of a tooth is lost due tofracture, surgical crown lengthening and toothrestoration based on a post and core is a viable alter-

native to implant/prosthodontic treatment, providedthat the tooth is free of pain, that the preconditionsfor endodontic treatment are met, and that the rootis stable. Today’s post-and-core systems are expectedto be metal free and to offer easy handling and aes-thetic long-term results.

Our experience with the Fibrapost and Sealacoresystem has been positive throughout; it has producedexcellent results and suits our procedures well._

36 I implants1_2012

Fig. 11 Fig. 12

Fig. 8 Fig. 9

Fig. 10

Fig. 7

Fig. 14 Fig. 15Fig. 13

Prof Marcel WainwrightDentalSpecialists Kaiserswerther Markt 25 40489 Düsseldorf, Germany

www.dentalspecialists.de

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International annualcongress of the dgzi

FAX REPLY+49 341 48474-390Please send me further information on the42nd International annual congress of the DGZI October 5–6, 2012, in Hamburg, Germany.

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SpeakersProf. Dr. Dr. Kai-Olaf Henkel/DEProf. Dr. Dr. George Khoury/DEProf. Dr. Dr. Albert Mehl/CHProf. Dr. Herbert Deppe/DEProf. Dr. Werner Götz/DEProf. Dr. Shoji Hayashi/JPProf. Dr. Andrea Mombelli/CHProf. Dr. Dr. Frank Palm/DEProf. Dr. Suheil Boutros/USProf. Dr. Peter Rammelsberg/DEProf. Dr. Anton Sculean/CHProf. Dr. Dr. Jörg R. Strub/DEProf. Dr. Hans-Peter Weber/US

Prof. Dr. Thomas Weischer/DEPriv.-Doz. Dr. Andreas Bindl/CHDr. Tomohiro Ezaki/JPDr. Daniel Ferrari, MSc/DEDr. Sami Jade/LBDr. Ramy Fahmy Rezkallah/EGDr. Rolf Vollmer/DEDr. Osamu Yamashita/JPZTM Andreas Kunz/DEZTM Tom Lassen/DEZTM Christian Müller/DEMohamed Moataz M. KhamisB.D.S., M.S., Ph.D./EG

Quality driven implantology – On the way to long term success

October 5-6, 2012//Hamburg, Germany//Elysee Hotel

Congress President//Prof. Dr. Dr. Frank Palm/DEScientific Director//Dr. Roland Hille/DE