Deep Margin Elevation
A case where there was deep interproximal decay. This was an example of deep margin management. The margin was placed on amalgam and the result was a nicely fitting crown. Apically some good healing at over 2 years.
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Patient Centered Endodontics: The Rehabilitation of Compromised Teeth
Deep Margin Management
Deep caries and the resulting deep margins can be a restorative problem especially when the patient has a history of interproximal caries or a “high caries hostility index”. Generally speaking it’s better to have a crown that fits and fits on a meticulously placed deep restoration than a crown that doesn’t fit. And when the margin is very deep, then that is when a poorly prepared and poorly captured margin is most likely. An alternative is DME or deep margin elevation. Dentists have unintentionally placed margins on amalgam for decades with success. It’s likely that the outcomes will be even more favorable when done intentionally under controlled circumstances, under magnification and with no overhangs. Attached is a 7 year outcome with the crown placed on amalgam. Also attached are two very long term outcomes. When placing margins on restorative material, it is probably best to choose amalgam over composite as it does not rely on bonding which is poor under such conditions. It’s also advisable to evaluate the emergence profile of the tooth, it’s contact with adjacent teeth, and potential plunger cusps that led to the problem to begin with. Managing these variable can prevent food impaction and decrease the probability of failure to recurrent caries.
Dual Entry Molar
Caries on the mesial and distal made this a dual caries leveraged access. We modified a UT4 to prepare under the truss. An old perio probe and shepard hook explorer was modified to be a plugger to adapt amalgam for the case.
Resorption Retreatment
This patient presented with pain associated with failing endo. The endodontic therapy was revised, and the tooth restored with a fiber post and palatal composite. The resorption would be classified as External Crestal Resorption, moderate/scooped. The resorption was removed, and restored with flowable composite. The almost 8 year followup shows healthy gingiva free of recession, and no black triangle formation. There was no bleeding on probing evident.
C Shape Retreatment
We ended up retreating both of these molars. Unfortunately there was a lot of tooth spent on the initial treatment the probably affects the long term prognosis. Intermediate term outcome, almost.
Resorption Repair
6 year followup on this case. CBCT imaging was used for determination of restorability. This type of resorption is crestal resorption. The resorption was determined to be less than two line angles by way of extent and located on the palatal. The endodontics was performed and a fiber post placed well below the level of the resorption. In this case we performed a burectomy to remove the ginigiva and visualize the cavosurvace once the the resorptive soft and hard tissues were removed A matrix band with a little Dycal was used for isiolation. A bulk fill of glass ionomer was placed and then vaneered with flowable composite. The restorative material approached the bone in the area of resorption, however, on followup there is no recession, and no bleeding on probing. We’re cautiously optimistic about a favorable long term outcome.
3 Rooted Premolar
We recently finished up this 3 rooted premolar. I considered using amalgam on this one due to the caries rate. Also considered deeper Markley wires. However, since the furcal floor was 3-4 mm below the bone level, I opted for a larger fiber post.
IGT of a Lateral
The porcelain crown attempted to correct the spacing caused by a peg lateral and as such the center of the canal was located pretty far distal to the crown. Using the imaging to guide the therapy (Image Guided Therapy or IGT) the access was planned for this particular tooth extending through the incisal edge along the long axis of the tooth. A thin fiber place was placed. The tooth was left in CaOH until there was evidence of radiographic healing.
Bridge Retreatment
The patient presented with pain on the distal abutment of the bridge. Clinical examination revealed caries and that the bridge was loose on the mesial abutment. The patient wasn’t interested in implant therapy due to a prior bad experience and chose to have the bridge remade. The premolar was retreated (Thermafill carrier removed with hedstroms) and the molar treated endodontically. Due to the wide short chamber present on the molar we chose to make a dual access leaving a dentin truss for support. The premolar was restored with a fiber post for rehabilitation purposes. We opted to use custom resin matrices for restorative purposes. The 1 year followup shows a good fitting bridge, and a functional asymptomatic restoration.
Management of Pulp Horns
Pulp horns recede with age and from pulpal insults resulting from caries, restorations, and trauma. Because of the patient population we care for, many of the teeth we treat as endodontists, don’t have prominent pulp horns. Thus, for the vast majority of our patients, a simple incisal based approach is appropriate for canal management, conservation of tooth structure, and post reinforcement. However, one subset of our population is trauma. More often, trauma affects younger patients. As a result endodontic management of teeth with pulp horns may be necessary. In this case, the patient was injured playing soccer. The tooth began discoloring and lost sensibility to cold. If the pulp horns aren’t managed, and a conservative approach is used, it’s possible to leave debris and or voids in this area. It’s possible that such a process centered outcome may predispose the tooth to an aesthetic failure if the tooth discolors over time. This is particularly true during apexification procedures if MTA is used and MTA (regardless of whether grey or white is used) ends up in this void. Access along the long axis of the tooth leaves a sharp angle of dentin adjacent to the pulp horn. This transition leads to void formation during the restorative procedure. Adjusting the dentin here with an internal axial groove allows air to vent and restorative materials to proceed without jumping over the sharp transition leaving a void. In order to prepare such a vent, adjusting the enamel in the apical aspect of the access can facilitate the use of small burs and/or ultrasonics. In the more rare situation that a shovel shaped incisor presents with the need to manage pulp horns, the risks and benefits must be carefully weighed if contemplating a buccal approach as a larger more demanding composite restoration may be necessary if the pulp horns are to be managed.
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