Patient emergency calls during the course of the day bring added stress and can create havoc in the dentist’s work schedule. Such was the case with the following patient, who presented with a fractured lower incisor needing immediate attention on a Thursday morning. This case report will present a technique for the immediate insertion of a bonded, splinted bridge utilizing post-extraction laser hemostasis.
|Figure 1. Pretreatment view of fractured No. 25, partial denture in place.||
Figure 2. Pretreatment view.
|Figure 3. Pretreatment digital radiograph.|
A 74-year-old female presented with tooth No. 25 broken off at the gingiva (Figures 1 to 3). The tooth had fractured during mastication. Similar concerns existed on the strengths of the compromised adjoining dentition. The teeth were asymptomatic, and tooth No. 25 was not restorable. The patient was wearing a removable, mandibular Virginia Partial Denture (Lab One). Periodontal probing showed no measurements greater than 3 mm, and no periodontal or occlusal therapy was indicated. Tooth No. 24 had previously undergone endodontic therapy.
Treatment comprises extraction of tooth No. 25 and the subsequent fabrication and placement of a 4-unit bonded, splinted bridge. The retainers will be splinted, laboratory-fabricated, facial composite veneers. Appliance design will incorporate labial veneers as “abutments” to splint the anterior incisors and to support the pontic. The design will be done in such a way to be compatible with the fit of the existing removable partial denture.
|Figures 4a and 4b. Photos of temporization with tooth fragment after tooth preparation.|
A shade was taken, and tooth No. 24 was prepared for a labial veneer with an incisal wrap. The lateral incisors were also prepared using diamond burs from the Nixon Porcelain Veneer Kit II (Brasseler USA). Minimal facial and interproximal tooth reduction was needed, and the preparations were kept in enamel. No local anesthetic was needed. Undercuts were subsequently blocked out using a bonded composite resin system (Adper Prompt Bond, Filtek Supreme [3M ESPE]). A dual-arch final impression was then taken using a medium-body polyether (Impregum [3M ESPE]). The fractured tooth fragment was bonded back into place using a hybrid, light-cured composite resin (Filtek Supreme) and a self-etching dentin bonding agent (Adper Prompt Bond; Figures 4a and 4b). Finally, the temporized tooth (No. 25) was then taken out of occlusion to re-duce any possible excessive forces on it. The case was sent to the dental laboratory to construct a hybrid composite resin and glass-reinforced restoration (Sculpture Plus with FibreKor [Pentron Clinical Technologies]). The patient was scheduled to return to the office in 2 weeks for extraction of the remaining root fragment and insertion of the bonded bridge.
The patient returned after 14 days. She reported that the temporary fell out that morning; she knew that she didn’t have to be careful eating breakfast, since it was insertion day. Local anesthetic was administered for the extraction of tooth No. 25. One carpule of articaine HCl 4% with 1/200,000 epinephrine (Septocaine [Septodont]) was infiltrated surrounding tooth No. 25. The temporary materials were removed from the adjacent teeth and then cleaned with plain flour pumice and a rubber cup.
Figures 5a and 5b. Immediately following extraction and laser hemostasis, shows prepared teeth. Lingual view, post extraction and post laser.
The tooth was extracted using a straight elevator, and blood was allowed to pool in the extraction site. Hemostasis was then established using a Nd:YAG laser (PerioLase II Digital M.V.P. TruePulse [Millennium Dental Technologies]). Laser parameters were set at 4.0 W, 20 Hz, and the pulse width was set at 650 microseconds. This free-running, pulsed laser utilizes a contact fiber tip. The fiber was placed to the depth of the extraction site and fired as the fiber was slowly moved coronally. Observation showed color changes in the blood with the thermal clot forming; exposure time was less than 30 seconds (100 total joules). As a result, the site was immediately ready for restoration (Figures 5a and 5b).
Figures 6 and 7. Final restoration as returned from the laboratory (facial and lingual views.)
The bonded bridge, as returned from the dental laboratory, was tried in, and the occlusion was adjusted. This pontic was fabricated utilizing a highly polished bullet design that promotes gingival healing and allows for an aesthetic emergence profile (Figures 6 and 7). To condition the bridge, the internal surfaces were cleaned with air abrasion (50-µm alumina particles at low pressure), and a composite primer and bonding agent was applied (Clearfil Photo Bond [Kuraray Dental]).
Teeth Nos. 23, 24, and 26 were etched with 37% phosphoric acid gel for 30 seconds, rinsed thoroughly, and dried. The bridge was bonded into place using a dual-cured adhesive system (Panavia F2.0 [Kuraray Dental]). This cement includes a dual-cured dentin bonding agent (ED Primer) and dual-cured composite resin cement. Excessive cement was removed, followed by the light-curing of all surfaces with an LED light-curing unit.
|Figures 8a and 8b. Immediately post cementation and finish.|
|Figure 9. Lingual view, final restoration.||Figure 10. Final restoration.|
|Figure 11. Four months postoperatively.|
Finally, the bridge was adjusted to fit with the existing partial denture and polished (Figures 8a to 10). The patient was given oral hygiene instructions, which included the use of dental floss with floss threaders.
In 1999, we began the use of the Nd:YAG laser for hemostasis following extractions. The technique developed from periodontal laser training provided by Millennium Dental Technologies using a new Nd:YAG laser that had more than one pulse width. It has been instrumental in minimizing cases of alveolar osteitis and after-hour calls from patients with post-extraction bleeding.
In this case, immediate extraction with an immediate restoration technique minimized the time spent in the treatment of this challenging restorative case. The patient had satisfactory temporization and was presented with a long-term, aesthetic, and functional splinted bridge in a timely manner. The laser prevented the problems usually associated with a lack of hemostasis following extraction and during the try-in and insertion of the immediate appliance. Follow-up visits have shown that this treatment option is serving well as a solution for this patient’s restorative needs (Figure 11).
The author thanks Dental Arts Laboratory in Lincolnshire, Ill, for the excellent craftsmanship, fit, and aesthetics of this multiunit restoration. The author also thanks Millennium Dental Technologies and Drs. Del McCarthy and Robert Gregg for instruction at their Cerritos, Calif, training center as well as their willingness to be great mentors throughout these past 8 years.
Disclosure: Dr. Cranska has no financial interest in any laser company. He is compensated as a consultant for presenting and lecturing from Millennium Dental Technologies and as a Certified Clinical Trainer for the IALD.