Managing Restorative Emergencies, Part 1 of 2: Esthetic Emergencies (Fractures and Tooth Loss)

Transcription

1 SUPERVISED SELF-STUDY COURSES FROM BENCO DENTAL ACCEPTED NATIONAL PROGRAM PROVIDER FAGD/MAGD CREDIT Managing Restorative Emergencies, Part 1 of 2: Esthetic Emergencies (Fractures and Tooth Loss) These courses have been designed specifically to meet the needs of busy professionals like you, who demand efficiency, convenience and value. Begin your Benco educational experience with this course today and match the mail for live CE events in your area. Howard E. Strassler, D.M.D., F.A.D.M., F.A.G.D. Professor and Director of Operative Dentistry Department of Endodontics, Prosthodontics and Operative Dentistry University of Maryland Dental School 2 CONTINUING EDUCATION CREDITS COURSE OBJECTIVES Upon completion of this course, the participant will be able to: Understand what constitutes an esthetic emergency and the different types of emergencies including acute-urgent, subacute-not urgent, and esthetic. Develop a protocol for managing emergencies including the use of telephone screening Evaluate changes in the position and occlusion of the tooth, pulpal status and any trauma or changes to other teeth in the mouth due to the injury. Describe techniques for addressing various tooth fractures, fractured porcelain including how to achieve retention to metal when doing porcelain metal repairs, replacement of anterior teeth, and fiber splinting. COURSE SPONSOR Benco Dental is the course sponsor. Benco s ADA/CERP recognition runs from October 2006 through December Please direct all course questions to the director: Dr. Rick Adelstein, 3401 Richmond Rd., Suite 210, Beachwood, OH Fax: (216) Phone: (216) toothdoc@core.com SCORING & CREDITS Upon completion of the course, each participant scoring 80% or better (correctly answering 16 of the 20 questions) will receive a certificate of completion verifying two Continuing Dental Education Units. The formal continuing education program of this sponsor is accepted by the AGD for FAGD/MAGD credit. Term of acceptance: October 2006 through December Continuing education credits issued for participation in this CE activity may not apply toward license renewal in all states. It is the responsibility of participants to verify the requirements of their licensing boards. COURSE FEE/REFUNDS The fee for this course is $ If you are not completely satisfied with this course, you may obtain a full refund by contacting Benco Dental in writing: Benco Dental, Education Department, 360 N. Pennsylvania Ave., Wilkes-Barre, PA PARTICIPANT COMMENTS Any participant wishing to contact the author with feedback regarding this course may do so through the course director: Dr. Rick Adelstein, 3401 Richmond Rd., Suite 210, Beachwood, OH Fax: (216) Phone: (216) toothdoc@core.com RECORD KEEPING To obtain a report detailing your continuing education credits, mail your written request to: Dr. Rick Adelstein, 3401 Richmond Rd., Suite 210, Beachwood, OH Fax: (216) Phone: (216) toothdoc@core.com IMPORTANT INFORMATION Any and all statements regarding the efficacy or value of products or companies mentioned in the course text are strictly the opinion of the authors and do not necessarily reflect those of Benco Dental. This course is not intended to be a single, comprehensive source of information on the given topic. Rather, it is designed to be taken as part of a wide-ranging combination of courses and clinical experience with the objective being to develop broad-based knowledge of, and expertise in, the subject matter. COURSE ASSESSMENT Your feedback is important to us. Please complete the brief Course Evaluation survey at the end of your booklet. Your response will help us to better understand your needs so we can tailor future courses accordingly. WHY TAKE THIS COURSE? PATIENT CARE Offer your patients the fi nest emergency care while managing triage more effectively. CONVENIENCE Review the latest information on the management of esthetic emergencies in a concise and consolidated format. CE CREDITS Successful completion of this course earns you 2 Continuing Dental Education Units. HIGH VALUE Continue your education without traveling, taking time away from work and family, or paying high tuition, registration and materials costs. HIGH QUALITY Authored for dental professionals, by dental professionals, Dental U continuing education courses are engaging, concise and user-friendly. WHO SHOULD TAKE THIS COURSE? Dentists, Dental Assistants and Dental Hygienists. incisal edge 71

2 Managing Restorative Emergencies: Esthetic Emergencies (Fractures and Tooth Loss) It is not uncommon for busy general dental practices to see five to 10 dental emergency visits in any given week. These visits can range from minor (dentin hypersensitivity or a chipped tooth) to major (acute infection requiring antibiotic therapy and surgical intervention or perhaps 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 with a dental problem, the clinician and staff must respond by having a clear protocol for managing that emergency situation. The frontline in any dental office is the front desk staff. Even the chairside assistant and dental hygienist 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. I have found over the years that the use of a patient questionnaire for walkin emergencies provides important information for Fig. 1: Telephone emergency form. triaging the patient for an appropriate appointment in a timely manner based on the severity of the emergency condition. This form can be filled in by the patient or dictated to a trained staff member over the telephone. The Emergency Phone Call form (Fig. 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. 1 Once the information has been gathered, decisions can be made. The focus of this two-part series is the treatment of restorative emergencies as dental conditions that relate to teeth and do not require immediate endodontic treatment, oral surgery, or periodontal care. Restorative emergencies can be categorized as being acute-urgent, subacute-not urgent, and esthetic (usually urgent by their nature). Esthetic emergencies in most cases are not associated with pain, but in the patient s view, need immediate attention. These circumstances can include a lost anterior crown, fractured anterior tooth or restoration, an avulsed anterior tooth due Fig. 2: Fractured central incisor being etched. to trauma or the need for an immediate extraction of a tooth in the anterior zone due to periodontal disease or pulpal pathology. (Part 2 of this article will review other restorative emergencies that fall into the acute-urgent and subacute-not urgent categories including dentin sensitivity, fractured posterior teeth and restorations, crown and bridge emergencies and denture emergencies.) ESTHETIC EMERGENCIES 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 right after the trauma occurs. The fracture or loss of a tooth in the esthetic zone is an esthetic emergency that must be addressed. For esthetic emergencies, most patients want to be seen and treated within one or two days after the dental problem arises. Since there is no pain or swelling, triaging is different for esthetic concerns. Our patients do not want to be seen in public with a fractured or missing tooth in the esthetic zone. Your staff must understand the importance of understanding patients concerns and work with them to address their dental problem. This article will address several common esthetic emergencies. FRACTURED TOOTH One of the most common dental emergencies is a fractured tooth. A fractured tooth in the esthetic zone of the anterior region is especially urgent to the 72 incisal edge

3 SELF-STUDY COURSE patient. During the telephone triage by the staff, the type and location of fracture must be noted. An accidental fracture of an anterior tooth due to trauma should be seen immediately. Staff need 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 the type of trauma. These specific ques- currently needs only an adhesive Class 4 composite resin, this can be done in this emergency visit. For restoration of a traumatized fractured incisor, local anesthetic should be administered for patient comfort. The fractured site should have minimal tooth preparation. In the case of the Class 4 fracture, a 1-2 mm long bevel of the enamel is sufficient. Class 4 fractures should be restored using an etch and rinse Fig. 3: Restored Class 4 fracture with nanohybrid composite resin (Artiste, Pentron). Fig. 4: Traumatic fracture of mandibular incisor. Fig. 5: Patient brought in tooth segment from fracture. tions help the clinician prepare for the patient and expected emergency treatment. The traumatized tooth should be managed with a minimum amount of manipulation. 2 Pulp testing should be done as a baseline. At a later visit six to eight weeks later, vitality testing should be repeated. If a maxillary incisor has fractured, it is important to evaluate the type of fracture to determine whether it was tooth to tooth (opposing teeth to fracture) or due to a foreign object (teeth hitting a sidewalk, hit in the mouth with a bat or racket). If it is a tooth-to-tooth fracture, evaluate all teeth that were traumatized in both arches and not just the fractured tooth. Evaluate any changes in tooth alignment and condition of the supporting structures gingival tissues and alveolar bone). Evaluate the soft tissue for lacerations that may need suturing and refer appropriately. If the tooth was fractured but the segment not recovered, assess the soft tissue for the potential that the segment was embedded in a lip. Make radiographs of all teeth involved to evaluate any potential root fractures or even a fracture in the alveolus. A thorough evaluation should include the mobility of all traumatized teeth, occlusion, changes in occlusion or tooth position due to trauma, and condition of the supporting bone. When evaluating the tooth, evaluate the depth of the fracture and whether or not the pulp has been compromised. If the fractures of the teeth are small in size, it may only require smoothing of the teeth with finishing burs, disks and polishers. After the assessment, if it is determined that the tooth adhesive system. For this case, the enamel and dentin was etched for seconds with a phosphoric acid etchant (Fig. 2). After rinsing and drying, the bonding adhesive was applied and light cured. The final restoration (Fig. 3) was placed with a nanohybrid composite resin (Artiste, Pentron). When a patient s tooth is fractured and only dentin is involved (the pulp is not compromised), and the patient has retrieved the fractured tooth segment, it is important to evaluate if the segment has fractured cleanly and whether reattachment of the tooth segment is possible. 3,4 Using a patient s own segment affords the benefits of maintaining the tooth shape, form, texture, contour and color. 5 For this case, the patient fractured the mandibular incisor while playing racquetball. The racquet hit the patient in the face, frac- Fig. 6: Fractured incisor being etched. Fig. 7A & B: Incisor restored with tooth segment bonded to place with fl owable composite resin. incisal edge 73

4 Managing Restorative Emergencies: Esthetic Emergencies (Fractures and Tooth Loss) Table 1: Silane Ceramic Primers NAME RelyX Ceramic primer Clearfil Silane Monobond-S Silane Coupling Agent VersaLink Silane Porcelain Bond Silane bond enhancer CerinatePrime MANUFACTURER 3M ESPE Kuraray Ivoclar Vivadent Dentsply Caulk Sultan Healthcare Pulpdent Den-Mat turing the tooth (Fig. 4). The patient brought in the tooth piece. The tooth had fractured cleanly (Fig. 5). After a thorough assessment as described earlier, it was determined that the tooth segment could be bonded in place. A dental dam was placed and the tooth was cleaned for the bonding procedure. No tooth preparation was necessary. The surfaces to be bonded were etched for 30 seconds (Fig. 6), rinsed and dried. A 4th generation adhesive (Bond-It, Pentron) was used. Dentin primer was applied for 5 seconds and air dried to both tooth and tooth segment. Adhesive was painted on the etched FRACTURED PORCELAIN: CROWN AND BRIDGE REPAIR Nothing lasts forever. It is not uncommon for a patient to fracture porcelain on an existing porcelain-metal crown, ceramic crown, porcelain veneer or fixed 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, it may be necessary to remove the restoration, place a provisional restoration and remake the restoration. When porcelain chips in the anterior region, the patient wants to be seen right away and have the problem solved. Surface treatments of metal and porcelain for repair: Different surface treatments will be necessary to establish a bond between the existing crown or bridge and the type of repair material being used. These different treatments depend on the size and type of fracture and whether or not the repair is bonding to metal, metal/porcelain, or porcelain. Fig. 8: Porcelain fracture from maxillary lateral incisor pontic. Fig. 9: Tight occlusion contributed to porcelain fracture. surfaces of the tooth and tooth segment but not light cured. You do not light cure in this situation because the thickness of adhesive can interfere with seating the tooth segment back to place. A flowable composite resin (Artiste Flowable, Pentron) was placed on the tooth and tooth segment and the two joined together in the mouth. Excess flowable composite resin was removed using a brush wetted with adhesive and both facial and lingual surfaces were light cured for 20 seconds. Excess composite resin was finished away from the margins/fracture line with Soflex disks (3M ESPE) and the tooth was polished with a Superfine Softlex disk. The completed tooth restoration with the tooth segment is not distinguishable from the patients own intact natural teeth. (Fig. 7). Fig. 10: Mandibular canine reshaped to allow for room for the porcelain repair. Chemical metal bonding: Over the years, laboratories have used a wide variety of cast metals to fabricate crowns and fixed partial dentures. These metals may have high gold (noble) content, or they may be a base metal with high concentrations of nickel and chrome but no noble alloy present. It is almost impossible to know which metal has been used in an existing restoration that needs a repair. Bonding to high noble metal is very difficult while bonding to base metal is more readily accomplished. Bonding agents to base metal include the 4-meta resin cement, C&B Metabond (Parkell), and newer metal bonding agents such as M-Bond (J. Morita) and Metal Primer (GC America) have been introduced. 74 incisal edge

5 SELF-STUDY COURSE Chemical porcelain bonding: Dental porcelains are chemically very similar. The ability to adhere composite resin to porcelain is based upon the chemical coupling agent: ther a rubber dam or a light-cured resin-based paste. Typically, intraoral-use hydrofluoric acids are of low concentration generally in the 6%- 10% range, and in a gel formulation to allow for Fig. 11 A & B: Mechanical retention placed in the metal using a Great White Bur (SS White). Fig. 12: Metal bonding agent applied (GoldLink 2, Den-Mat). silane. Silane is available as a ceramic primer in all porcelain veneer bonding kits or can be purchased separately. (See Table 1) Surface roughening of metal and porcelain: The use of surface treatments with air abrasion for the purpose of microscopically roughening the surfaces to be repaired is beneficial. 6-8 Relatively inexpensive air abrasion units commonly referred to as microetchers (MicroEtcher II, Danville Engineering; MiniBlaster, Benco Dental) can be used to create a high velocity stream of aluminum oxide particles that microscopically roughen both metal and ceramic surfaces to prepare them for bonding. Recently, an air abrasion unit that can be used for crown and bridge repair as well as tooth preparation for preventive resin restorations was introduced. It is significantly less expensive than large stand alone air abrasion cavity preparation units. The RONDOflex (KaVo) fits on the Kavo coupler for their high speed handpiece and is a multiuse instrument. In the past, all air abrasive particles functioned similarly. 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 the repair using composite resin. 9 Another method for microscopically roughening porcelain is the use of hydrofluoric acid. 10, 11 Hydrofluoric acid (HF) for intraoral use should be used carefully in the oral cavity. When used, the soft tissues adjacent to the restoration being treated must be protected and isolated with ei- controlled placement. Typical etching of porcelain with an intraoral hydrofluoric acid gel is accomplished in 3-4 minutes, keeping the surface being etched moist with gel during that time. In most cases, air abrasion of the site is recommended over HF because of potential soft tissue damage. With the use of diamonds and burs, metal and porcelain can be roughened 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, it is important the site be enlarged by at least three to four times the original fracture surface area. 12 This increased surface area is critical for a more predictable, longer lasting repair. In the case of repairing only metal, composite resin retention can be enhanced further by creating mechanical undercuts in the Fig. 13: Opaquer applied. (TetraPaque, Den-Mat). Fig. 14: Dead soft stainless steel matrix placed to form tissue side of composite resin repair of pontic. Fig. 15: Pontic esthetically repaired with nanohybrid composite. (Filtek Supreme Plus, 3M ESPE). incisal edge 75

6 Managing Restorative Emergencies: Esthetic Emergencies (Fractures and Tooth Loss) Table 2: Resin Opaquers metal. Because adhesives are used to seal the composite resin repair, these NAME MANUFACTURER Kolor Plus Kerr undercuts can perforate TetraPaque Den-Mat through the metal portion of the crown into the Masking Agent 3M ESPE tooth without any ill effects. A new class of burs Opaquer Pulpdent Clearfil ST Opaquer Kuraray has been designed to cut even the hardest of crown and bridge metals. On example of these metal-cutting burs include the Great White series (SS White). Case report: The 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 that had been fabricated 18 months prior. Four months ago, porcelain fractured from the lateral incisor, leaving the metal exposed. A composite resin repair had been attempted, but at this visit it had fractured away (Fig. 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. Re-fabrication of the fixed partial denture would have led to remaking the removable partial denture. The patient was on a fixed income and asked that repair be attempted again. Evaluation of the site revealed a very tight occlusion that had contributed to the porcelain fracture and the subsequent composite resin repair fracture (Fig. 9). The opposing mandibular canine was reshaped to allow adequate room for a composite resin repair of the fractured site (Fig. 10). When the last repair was attempted, very little had been done to enhance retention of the composite resin to the metal. Without weakening the connectors of the fixed bridge, metal was air abraded with CoJet Sand (3M ESPE) using a RONDOFlex unit (KaVo). Additional retention was developed in the metal by placing undercuts in the incisal areas of the metal pontic (Fig. 11) using a Great White #1 metal cutting bur (SS White). One problem frequently seen when doing repairs of exposed metal is graying out of the composite resin repair. Avoiding this is best accomplished by using a composite resin that is opaque enough to mask the metal in a thinness that helps avoid overbulking of the composite resin repair. (See Table 2) The air abraded porcelain and metal was cleaned with a phosphoric acid etchant for 10 seconds, then rinsed and dried from the surface. A ceramic primer (3M ESPE) was applied to all exposed porcelain surfaces with a BendaBrush (Centrix) for 30 seconds and dried from the surface. The air-abraded and prepared metal was covered with a metal adhesive bonding agent (GoldLink 2, Den-Mat) (Fig. 12) Fig. 16: Periodontally involved mandibular incisor that was avulsed. Fig. 17: 12 hours after tooth loss, the site is healing satisfactorily. and an resin opaquer (TetraPaque, Den-Mat) using a BendaBrush Micro (Centrix) (Figure 13). The surfaces were light cured with a quartz halogen curing light for 10 seconds. For this case, another challenge was creating 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 dead-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 trapezoid was slid from facial to lingual under the pontic. The wider wings of the trapezoid are then stabilized into the gingival embrasures with wooden wedges (Fig. 14). The pontic was then restored with a nanohybrid composite (Filtek Supreme Plus, 3M ESPE). The composite resin was finished and polished using finishing burs (Safe-End, SS White) followed by a the use of silicone abrasive points and cups (Enhance Finishers, Dentsply Caulk) and composite resin polishing disks (Soflex Disks, 3M ESPE). The patient was told that the completed restoration (Fig.15) would probably last for several years. TOOTH LOSS DUE TO PERIODONTAL DISEASE OR FAILED ENDODONTIC TREATMENT There are times when a patient with severe periodontal disease loses an anterior tooth, or a patient must have a tooth extracted due to infection in the 76 incisal edge

7 SELF-STUDY COURSE Fig. 18: (A) Measuring the length of the natural tooth pontic needed with a periodontal probe. (B) Measuring tooth to verify length before cutting off the root. Fig. 19: Tooth pontic with channel prepared on lingual surface. Fig. 20: Dental dam placed leaving the pontic area with no hole punched. anterior region. For this patient, the diagnosis of severe periodontal disease in the mandibular anterior region had been made and the patient had not yet acted on treatment recommendations (Fig. 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 opening in the schedule. The patient had the tooth in hand and the site of the lost tooth was healing satisfactorily (Fig. 17). The decision was to replace the tooth using 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 provide a patient with a durable, single-visit tooth replacement in the anterior esthetic zone using 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 the incisal edge of the lateral incisor to the extraction site (Fig. 18). Some additional length was added so the pontic would be touching the gingival tissue as the extraction site healed. The tooth was measured with a periodontal probe to the length needed. The root was cut 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 gingival 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 reinforcement fiber ribbon, a channel with a width of 3-4 mm was cut in the lingual surface (Fig. 19). This was the same width as the 3 mm wide Ribbond THM Reinforcement Ribbon that was to be used for bonding and reinforcing the composite resin where the teeth were to be connected. A dental dam was placed. A hole was Fig. 21: (A) Pontic positioned before light curing with cotton pliers after etching adhesive and composite resin placed on facial. (B) Pontic stabilized with light curing. Fig. 22: Blockout of gingival embrasures after etching using a fast setting PVS iimpression material not punched for the tooth that was removed so bleeding would not contaminate the area being bridged during the bonding procedure (Fig. 20). The teeth were cleaned. To improve stabilization of these periodontally mobile teeth and minimize the thickness of the splint on the esthetic interproximal aspect of the facial surfaces of #22-27, a thin diamond (Pirana, SS White) and high-speed handpiece with water spray were used to barrel into the interproximal areas. Later, composite resin will be placed on these facial surfaces to improve cross stabilization of the teeth. The mesiolingual surface of the left caninie and mesiolingual surface of the left central incisor had Class 3 preparations made to further reinforce the bridge connectors and 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 between both ribbons provides additional strength and stability when placing a pontic by creating a laminated composite beam. 12 To determine the length of fiber ribbon to be used, a piece of dental floss was placed from distal of #23 to distal of #26 on the facial surface and cut. For incisal edge 77

8 Managing Restorative Emergencies: Esthetic Emergencies (Fractures and Tooth Loss) Fig. 23: Adhesive painted on all etched surfaces, composite applied to facial embrasures to create tooth stabilization for fi nal 180 wrap of teeth with bonding. Fig. 24: Composite resin applied to lingual surfaces. Fig. 25: Ribbond THM fi ber ribbon embedded into the composite resin. Fig. 26: Final immediate fi xed partial denture with natural tooth pontic. 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 Ribbond THM was cut into two pieces to match these lengths. The fiber ribbon was impregnated with resin adhesive (ScotchBond MP, 3M ESPE), then set aside and covered to protect it from light. The natural tooth pontic was 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. It was also set aside until it was time to bond it to place. The teeth #22-27 were etched for 30 seconds with a 32% phosphoric acid gel on the facial and lingual surfaces, then rinsed and dried. The resin adhesive was applied to teeth adjacent to the pontic and composite resin (Prisma TPH, Dentsply Caulk) placed on the facial surface. The pontic was placed into position with cotton pliers and then stabilized with light curing (Fig. 21). Gingival embrasure areas were then blocked out with a fast-setting, medium viscosity PVS impression material (Fig. 22). Adhesive was painted on the etched surfaces, composite resin applied to the facial interproximal surfaces, shaped (Fig. 23) and light cured. Composite resin was applied to the lingual surfaces including the channel in the pontic and the Class 3 preparations (Fig. 24) The shorter length of fiber ribbon was placed on the lingual surface into the channel and Class 3 preparations and adapted to the inner aspects of the tooth preparations. The second longer fiber ribbon was placed from #22-27 and embedded into the composite and adapted to the lingual surfaces of the teeth (Fig. 25). Excess composite was removed and the composite was light cured. Finishing and polishing of the composite resin was done after removal of the PVS blockout material. The patient was able to leave that day with the tooth and esthetics intact (Fig. 26). CONCLUSION The emergency created by a traumatically injured tooth in the esthetic zone is not an unusual occurrence in a dental practice. Clinicians and their staff should have a plan for the triage of emergency patients to provide them with treatment and also to address their dental and psychological need. This triage will allow the practitioner and staff to plan for the best course of action to manage the clinical circumstance. One excellent method for helping triage emergency patients is the use of a short questionnaire by the staff. The answers, which are obtained by interviewing the patient or responsible adult parent or guardian over the telephone, will help the clinician make an educated decision for management of the emergency. When the patient arrives, the course of treatment can begin and reach a successful result. Clinically, a traumatized anterior tooth that needs immediate attention should be evaluated for any changes in the position and occlusion of the tooth, pulpal status and any trauma or changes to other teeth in the mouth due to the injury. This article provides the dentist and staff a variety of techniques for the immediate, successful restorative treatment of an esthetic emergency. REFERENCES 1. Strassler HE, Gerhardt DE. Trouble shooting everyday restorative emergencies. Dent Clin North Amer. 1993; 37(3): Rauschenberger CR, Hovland EJ. Clinical management of crown fractures. Dent Clin North Amer. 1995; 39(1): Osborne JW, Lambert RL. Reattachment of fractured tooth segment. Gen Dent. 1985; 33: Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth fragments. Quintessence Int. 2000; 31: Strassler HE. Aesthetic management of traumatized anterior teeth. Dent Clin North Amer. 1995; 39(1): 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: el-sherif M, Shillingburg HT, Duncanson MG. Comparison of bond strength of resin-bonded retainers using two metal etching techniques. Quintessence Int. 1989; 20: 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: 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 Denehy G, Bouschlicher M, Vargas M. Intraoral repair of cosmetic restorations. Dent Clinic North Amer. 1998; 42(4): Stangel I, Nathanson D, Hsu CS. Shear strength of the composite bond to etched porcelain. J Dent Res. 1987; 66: Strassler HE. Achieving predictable crown and bridge repair. GP Insider. 1992; 1(5): Strassler HE, Taler D, Sensi LG. Fiber reinforcement for one-visit single tooth replacement. Dent Today. 2007; 26(6): Strassler HE. Serio CL. Esthetic considerations when splinting with fiber-reinforced composites. Dent Clin North Am. 2007; 51(2): incisal edge

9 SELF-TEST 1. Dental emergencies include patient requests to be seen because of all the following EXCEPT: a. dentin hypersensitivity b. fractured tooth c. broken denture d. acute infection e. All can be considered dental emergencies if the patient is concerned. 2. To help the staff manage a dental emergency, the office should use a form or questionnaire that can guide the clinician in making clinical decisions for the emergency. The form or questionnaire should include questions about the patient s chief concern, history of the problem, whether it is related to past dental treatment, what area or tooth is in pain, what relieves the pain, and whether there is there any swelling associated with the pain, among others. a. Both statements are true. b. The first statement is true, the second is false. c. The first statement is false, the second is true. d. Both statements are false. 3. TRUE or FALSE: According to this article, dental emergencies can be categorized as being acute-urgent, subacute-not urgent, and esthetic. a. True b. False 4. TRUE or FALSE: Fracture or loss of a tooth in the esthetic zone is a serious concern for our patients. Esthetic emergencies are unique as dental emergencies because a patient may want to be seen as soon as possible even though there is no pain or swelling associated with the emergency. a. True b. False 5. A fractured tooth in the anterior region is usually due to: a. endodontic treatment. b. trauma. c. caries. d. erosion. 6. When a tooth fractures due to trauma, it is important to bring the patient in for an evaluation. The health of the pulp must be considered as part of treatment. Therefore: a. The health of the pulp should be evaluated 2-3 weeks after the accident and again after restoration. b. The health of the pulp should be evaluated with pulp testing the day of the trauma and repeated 6-8 weeks after the incident. c. The health of the pulp should be evaluated the day of trauma and unless the patient is in pain, it can be assumed the pulp has maintained its vitality. d. If the tooth is not in pain, the pulp is healthy. 7. If a patient fractures a tooth due to trauma, it is important to: a. provide them with a prescription for antibiotic to avoid infection. b. avoid making radiographs until 1 week after the trauma to not further traumatize the tooth. c. make radiographs of the teeth traumatized to evaluate for fractures of the roots or bone. d. provide the patient with a prescription for analgesics so the tooth is not painful when the patient returns in one week for evaluation. 8. If a patient fractures an anterior tooth and they cannot find the tooth segment, then: a. it can be assumed everything is okay. b. have a flat plate chest film made at the hospital to rule out aspiration or swallowing of the tooth segment. c. an examination of any lacerations for the tooth segment being embedded in soft tissue should be done. d. perform b and c. 9. When an anterior tooth or teeth has been traumatized, the evaluation of the tooth or teeth should include: a. any changes in occlusion. b. any changes in tooth alignment and position. c. depth of fracture of tooth (teeth). d. changes in the supporting bone evaluate for fractures. e. All the above should be evaluated as part of the emergency appointment. 10. In most cases, managing a Class 4 fracture of an anterior tooth s incisal edge is accomplished with: a. a temporary crown. b. an extraction and fabrication of a temporary partial denture. c. an adhesive composite resin. d. initiation of endodontic treatment, saving the crown for a later date. 11. In some cases after the traumatic fracture of an anterior tooth, the patient may present carrying the piece of broken tooth with them. If the patient brings the tooth segment, you can: a. Throw it in the trash, it has become contaminated when out of the mouth. b. Take the piece of crown and match a composite resin to it. (cont d on next page) incisal edge 79

10 SELF-TEST c. Smooth the piece off, drill a hole in it and put it on a gold chain for all to see. d. Try-in the segment back on the tooth and if it matches up, bond it to place with a rinse-and etchadhesive technique. 12. When a tooth segment can be reattached to the natural tooth, as part of the adhesive procedure, the tooth is etched, rinsed and dried, and adhesive placed. When the adhesive is placed, it 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 the segment can be seated. c. Rinsed from the tooth with water spray and dried. d. Activated with a laser curing light to rapidly seal the tooth. 13. Fractured porcelain is a restorative dental emergency. If a patient fractures porcelain on a small area of posterior tooth with a porcelain-metal crown, this article recommends: a. adding a new piece of porcelain to be bonded to the fracture site. b. the crown be replaced but be taken out of occlusion to avoid it fracturing again. c. smoothing the porcelain and polishing it. d. adding composite resin to the fractured area using a enamel bonding technique. 14. Patients who present with fractured crown and bridge restorations should be presented with several options to treat the fracture. The options available for treatment include remaking the restoration, smoothing a small porcelain fracture and polishing it or repairing the fracture of the porcelain using an adhesive technique. a. The first statement is true, the second statement is true. b. The first statement is true, the second statement is false. c. The first statement is false, the second statement is true. d. The first statement is false, he second statement is false. 15. Methods to achieve retention to metal when doing porcelain-metal repairs with composite resin include: a. metal bonding agents. b. air abrasion of the metal. c. undercuts in the metal created with a diamond or bur. d. all the above. 16. Methods to achieve retention to porcelain when doing porcelain-metal repairs with composite resin include: 1. chemical bonding with silane coupling 2. air abrasion 3. etching porcelain with citric acid 4. etching porcelain with hydrofluoric acid 5. chemical bonding with siloxane a. 1, 2, and 4 only. b. 2, 3, and 5 only. c. 1, 2, and 5 only. d. all are acceptable methods to achieve porcelain adhesion. 17. The following clinical situations may necessitate immediate replacement of an anterior tooth EXCEPT: A. loss of the tooth due to severe periodontal disease. B. loss of the tooth due to endodontic failure. C. loss of the tooth due to orthodontic extraction. D. loss of the tooth due to trauma. 18. When doing a natural tooth pontic using the tooth crown of the extracted tooth, the length is determined by: A. cutting the crown at the CEJ for the final length. B. measuring the distance from incisal edge of the central incisor to the extraction site before placement of the dental dam. Additional length can be added so the pontic will be touching the gingival tissue when the extraction site heals. C. measuring the mesial-distal width and doubling it. D. measuring the length of the adjacent teeth. 19. The gingival interproximal areas are blocked out using a polysiloxane impression material to minimize excess composite resin in these areas when placing the fiber splint-bridge. The block-out is placed: A. after cleaning the teeth. B. after etching the teeth. C. after application of the bonding resin. D. after application of the composite but before placing the fiber ribbon. 20. A double thickness of fiber ribbon is embedded into the composite resin on the lingual surface of the pontic and into the Class 3 preparations to: a. create a beam effect to further strengthen the connector of the pontic to the adjacent teeth. b. create a more esthetic restoration. c. make polishing the composite resin easier. d. to create room for flowable composite. 80 incisal edge

11 SELF-STUDY COURSE Managing Restorative Emergencies: Part 1 of 2 Continuing Dental Education Course Order number [ ] NAME: TITLE: (CIRCLE ONE) DDS DMD RDH CDH RDA CDA EFDA E ADDRESS: CITY: STATE: ZIP: TELEPHONE: HOME ( ) OFFICE ( ) MAILING INSTRUCTIONS: When you finish reading the course text, use the form to submit your answers to the self test. Fill in the correct box for each question indicating your answer. Pen or pencil may be used. There should be only one correct answer for each question. Upon completion of the course, mail the answer sheet to: Dr. Rick Adelstein, 3401 Richmond Rd., Suite 210, Beachwood, OH NOTE: We recommend that you photocopy your answers before mailing this course. This will ensure that you have a record of your course completion in case of loss due to postal system error. COURSE EVALUATION: Please take a moment to answer the questions below. Your responses will help us in develop future course material. Your feedback is important in evaluating the content and value of our courses. Please indicate how well the course met the criteria below. Circle one number in each criteria: 1=Poor, 2=Average, 3=Good, 4=Excellent. The course provided clear information about the topic The course had relevance for my practice Overall rating The course evaluated my understanding of the topic through the post-course questions. How likely would you be to take a similar course on a different topic in the future? o highly unlikely o highly likely E On a scale of 1-5 (5=Excellent, 0=Poor), please rate the following: Course Objectives Course Content Author s Grasp of Topic References Overall Effectiveness Was the course clearly written and easy to understand? [] Yes [] No If no, please describe: Which additional continuing education topics would you be interested in? Additional Comments: PAYMENT OF $54 IS ENCLOSED (CREDIT CARDS & CHECKS ACCEPTED) Please charge to my Benco Account # If paying by credit card, please complete the following information: Visa Mastercard Discover American Express Account # Exp. Date Please direct all questions or requests for additional information pertaining to this course to: Dr. Rick Adelstein, 3401 Richmond Rd., Suite 210, Beachwood, OH This examination is graded manually. Upon completion of this course, a certificate will be mailed within 2-3 weeks of receipt of payment and completed examination. Please check if you would like to receive your score with your certificate of completion. incisal edge 81