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
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.
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.
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.
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