Sharing Passion for Fixing Teeth With Endo
This is the same patient as the prior post but contralateral side. She had extensive decay under the existing crown which didn’t leave much to work with. It was a pretty tough case to band and I couldn’t get it to stay on so I created a custom resin matrix out of Opaldam. Things still look good for this beat up tooth for almost a decade.
Terminal teeth are tough to band and keep rubber dam isolation. So we came up with an alternative- the custom resin matrix. Using green opaldam we make a custom matrix to pack amalgam with or place a controlled field resin. Often we use the technique subgingivaly on bone. For first iterations we used white Opaldam but found it hard to discern on bone. The green is easier to see and thus remove. Waiting 5 minutes or so for the amalgam to harden makes the green matrix easier to remove
The intersection of scopes, filters, composite, and light can lead to some confusion and possibly unsafe clinical habits. So lets get the whole story straight and make sure our working habits are healthy as well as productive.
Light cure composites set when they are exposed to a light energy at a set wavelength of light. The composite has a photo-initiator called camphorquinone and an accelerator. The activator present in light activated composite is diethyl-amino-ethyl-methacrylate (amine) or diketone. They interact when exposed to light at wavelength of 400-500 nm, i.e, blue region of the visible light spectrum and cause the composite to set.
Sunlight, ambient light, and all other white light have the entire spectrum. So in the operatory, the ambient light will have enough blue light to make composite eventually cure. And your scope light with all its fabulous power will totally cook your composite. Additionally, the blue light with its low wavelength and high energy has the potential to cause harm to your eyes. Macular degeneration, retinal problems, and possibly cataracts are on the table eye damage wise. In addition, blue light is believed to affect mood and sleep among other things. Fortunately, there are filters that filter out the blue light.
Looking at the color wheel which represents the colors (ROYGBIV) and their opposites, you can see the opposite of blue is orange. So these orange filters will filter out the blue light.
Which comes in super handy when working under the scope doing composite work:
We do all our bonding using the orange filter in the scope. And here’s where some people get bamboozled.
Awash in orange light it’s easy to think that your scope filter is protecting you during the cure process.
Oh contraire monfraire!
If you were to remove the light from the back of the scope, and hit a cure, you’ll notice there is no difference whether the filter is applied or not.
The filter isn’t in the column at all. Its where the fiberoptic/liquid cable enters the back of the scope.
It’s this little guy here…
So when it’s time to cure, either look away out of the scope or don some protective eye wear.
In the case of performing a custom resin matrix, its eye wear for the both of us. Routine composite work, I usually just close my eyes till I hear the beep.
This patient was in for another tooth so we grabbed a followup of this case we performed 6.5 years ago. Pretty extensive distal caries under the crown. The wide platform lended itself to a truss access. Root-form appropriate instrumentation was completed. We used some bent ultrasonics for chamber cleanup and some bent pluggers to manage the amalgam utilizing a custom resin matrix. We can see the results of deep margin management over time.
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This little guy caught a fly ball… in the mouth. The lateral was laterally luxated. The central was avulsed and replanted with a dry time of 15 minutes. The lateral was repositioned and splinted. I saw them the day after the injury. We made sure he was on an antibiotic and anti-inflammatory and saw him back in a week to start endodontic therapy as the apex of these teeth were completely deveoloped and the risk of resorption high. After what we thought was a sufficient time in both CaOH and splint therapy, we completed the endodontic therapy and placed fiber posts.
Over the next few years we saw resorption develop. According to the Resorption Classification for Clinicians, this resorption would be considered External Crestal Resorption, moderate scooping. We removed the invasive tissue and restored the root using composite. A custom resin matrix was used for isolation.
Over time, we could see that the central was subject to resorption as well; External Ankylotic Resorption. This was evident by the ankylotic tone when percussed. Radiographically, this was evident my the marked lack of periodontal ligament and lack of tooth root definition. Clinically, this was evident by the infraposition of the clinical crown relative to the other central.
In treatment planning the case, the orthodontist thought some initial leveling and aligning using the ankylosed tooth would be helpful before decoronation. After this was accomplished, the fiber post and root filling was removed and the crown was decoronated using the flapless decoronation approach as outlined by Jared Buck in Best Practices: A Desk Reference
A pontic was added to the orthodontic therapy.
We can see over time that bone developed over the tooth root and the the root is turned over in osseous regeneration. The alveolar ridge is preserved for future restorative replacement.
Here’s the 5 year followup.
Keeping the preparation conservative even in the last 2-3 mm helps in retaining the core. The shape of the access here is a frustum, or pyramid with the tip cut off. This providees a macro-retentive feature for the core. Terminal teeth can be difficult to place a band on so we used a custom resin matrix.
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