Decision making in endo-perio-restorative cases of severely compromised teeth

Fig. 1

In this article, a clinical scenario would be presented regarding a patient living 400 km away from my dental practice, which happens to be in his hometown. He requested to treat his tooth once a month, when he comes to visit his relatives.

Diagnosis: Failure of a partial coronal restoration on tooth 2.5 due to marginal infiltration and fracture of the mesial portion. Distal caries on 2.4 and mesial caries on 2.6.

Therapy: Endodontic retreatment, clinical crown lengthening, core restoration with luting of fiber post, and prosthetic crown on tooth 2.5; direct composite restoration on the distal of 2.4 and mesial of 2.6.

In agreement with the patient and in the absence of acute symptoms, although tooth 2.5 requires retreatment, it has been decided to perform endo pre-treatment with surgery and definitive restoration of the peripheral walls of the tooth during the first session. 

Surgical treatment is indicated to restore periodontal health in the presence of subgingival carious lesions violating the tooth's attachment apparatus.

Fig. 2

First appointment: 

The old restoration and the carious lesion on tooth 2.5 are removed, and minimally invasive crown lengthening procedure is performed.

Fig. 3

After the surgery, a definitive pre-endodontic restoration is performed during the same session.

This is done to provide the patient with a more favorable aesthetic situation between clinical appointments.

The restoration was carried out using a cervical-stabilized ring matrix with two wedges. The peripheral walls were reconstructed to an adequate thickness with packable composite, and the central portion was closed with temporary material.

Fig. 4

The tooth is splinted to the adjacent teeth with two drops of high viscosity flowable composite. The restoration is under occlusion. The patient is instructed on the proper home oral hygiene practices. An agreement is made with him regarding the method for removing the sutures 10 days after the procedure, as he is unable to return.

Fig. 5

Second appointment (one month later): 

The endodontic retreatment is performed.

The old thermafil filling is removed, and the two canals are probed, which converge in the middle third and then become independent at the apical level. This is classified as Type VII according to Vertucci's classification.

Shaping is carried out with the final instrument 30.04, and a 5.25% NaCl solution is used throughout the shaping process to disinfect and remove debris.

Fig. 6

The root canals are filled using the coneless technique and warm vertical condensation. The filling is performed using a protocol that allows both canals to be closed “together", preventing the filling of one canal from interfering with the filling of the other, due to the presence of the confluence. This technique is useful in confluent canals and is particularly indicated when there is insufficient space to accommodate both gutta-percha cones together or when there are suspected canal, apical of the confluence, that cannot be probed with steel or shaping with mechanical NiTi instruments.

Fig. 7

Third appointment (one month later): 

Preparation of the post space using Largo drills sizes 1 and 2, cleaning with air flow and glycine powder, adhesive techniques and luting of two quartz fiber posts. 

In the same session, after removing the carious lesions on teeth 2.4 distal and 2.6 mesial, direct composite restorations are performed.

Fig. 8

Still in the same session, the vertical prosthetic preparation of the core is performed, and a relined, finished, and polished temporary crown is delivered.

Fig. 9

Fourth appointment, also one month later: 

After removing the temporary crown, intraoral scanning is performed, and the dental technician is instructed to fabricate the definitive crown in monolithic zirconia.

Fig. 10

Fifth monthly appointment: 

Luting the zirconia crown after performing fitting and aesthetic checks.

Fig. 11

Three years follow up.