This will be a “quick and dirty” case presentation. But, I’ll update it as the case progresses.
Patient is a 53 y.o. woman from China, who speaks a little English. Her boyfriend is a long-time patient in my practice. She first presented with a toothache… actually multiple toothaches.
She had full mouth crowns done by a dentist in China about a year ago. They are all splinted in segments. Each arch is three segments – right, anterior, and left sides. It was done for “cosmetic reasons.”
#’s 6 – 10 are splinted. #6 is blown out with recurrent caries.
Here’s the FMX:
(note the multiple apical lesions)
I made pre-op models and a Siltech matrix to help make the provisionals. Ultimately, the entire case needs to be re-done. But, the upper anterior segment was the most dire, so we started there. She will see an endodontist for the RCTs in the posteriors.
The first order of business was to remove the splinted crowns #’s 6- 10. They are porcelain fused to zirconia. So, you KNOW how much FUN that’s going to be. And, so it was…. not so much fun. I went through 6 diamond burs.
The first cut I made was between #8 and #9. Notice the residual cement bridging the gap between the teeth. Nice! Gingiva was NOT happy. I had removed some of the cement from the teeth at this point. The cement left on the mesial gives you an idea how thick it was. I did not put that hole there in #8. It was there under the cement. “Red paste” pulpotomy, I believe. Also notice the hyperplastic gingiva over #6. 🙁
The restorability of #6 is questionable. But, I hate to extract a canine. I went ahead and did the endo on it. I’ll build it up and prep it at the next visit and see what I think. Given that I believe there is a biologic width violation on #’s 8 and 9, I might send her for crown-lengthening and keep #6.
Occlusal view of #6 – 8, after removing crowns and some of the cement. Note the hyperplastic gingiva over #6.
Crowns #’s 9 – 10 removed. VERY thick cement left on #9. The color of #10 is… well… what it is before I touched it. I did not put the hole in the facial of #10. That was there… with nothing in it but “schmutz.”
Occlusal view of 9-10 after removing crowns.
The crowns after sectioning and removal. Note the lovely “schmutz” on the inside of some of them.
Getting things cleaned up. The hole in #9 was also already there. All of the “endo accesses” you see here were pre-existing. No instrumentation of the canals nor any canal filling (see x-rays above). I went through six diamond burs getting the five crowns off.
Occlusal view after “clean-up.”
Provisionals. It will be interesting to see how the tissue has responded at her next visit.
I worked on her from 9am to about 12:30pm. Next, I’ll do the RCTs on #’s 8, 9, and 10. I’ll also do a post and core and re-prep #6.
Update (April 2018):
We got the patient back to do the RCTs and build up #6. I think most of you will agree there is a perio issue. #6 will need crown lengthening surgery to provide some ferrule for the crown. I also believe there is a Biologic Width violation with the rest of the teeth secondary to the original crown preparations.
Endo time! Split dam isolation makes it easy. At the last visit, I used some blue block-out composite (used for bleach trays) to temporarily seal the previous “accesses.” Remember… these facial accesses were already there when I removed the crowns.
This is what came out of the canals.
I used some blue flowable composite to briefly “seal” around the gutta percha points, so I could remove the rubber dam for the final fill x-rays.
Final endo films.
Another view of the post in #6 and the other preps (not final preps).
I used a core former to give me a starting point for the build-up.
Preliminary prep of #6 and others.
Occlusal view of preliminary preps. Off to perio next!
Temps back on!
To be continued…
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