biologic resto

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“Biological Restoration”: Root Canal and Coronal ReconstructionPATRÍCIA CORRÊA-FARIA, DDS* CARLOS EDUARDO PINTO DE ALCÂNTARA, DDS MARCUS VINÍCIUS CALDAS-DINIZ, DDS ADRIANA MARIA BOTELHO, MS, PhD § KARINE TAÍS AGUIAR TAVANO, MS ABSTRACT Anterior tooth fracture, as a result of traumatic injuries, frequently occurs in dentistry. Proper reconstruction of extensively damaged teeth can be achieved through the fragment reattachment procedure known as “Biological Restoration.” This case report refers to the esthetics and functional recovery of extensively damaged central maxillary incisors through the preparation and adhesive cementation of “Biological Posts and Crowns” in a young patient. Both biological posts and crowns—post and dental fragment obtained through natural, extracted teeth from another individual—represent a low-cost option and alternative technique for the morphofunctional recovery of extensively damaged anterior teeth. CLINICAL SIGNIFICANCE The biological restorations are an alternative technique for reconstruction of extensively damaged teeth that provides highly functional and esthetic outcomes. (J Esthet Restor Dent 22:168–178, 2010) INTRODUCTION A nterior tooth fracture, as a result of traumatic injuries, frequently occurs in dental clinics, with prevalence of 8.1 in 1,000 children examined. 1 This fact is commonly related to sports, leisure activities, and caries lesions, thus causing functional, esthetic, and psychosocial problems 2–4 in addition to reduc- ing the patient’s quality of life. 5 A satisfactory smile can be achieved by using several tech- niques and esthetic materials, such as resin and porcelain. Over the past decades, dentistry has achieved great scientific and tech- nological advances regarding restorative and adhesive materials. Nevertheless, to date, no restor- ative material has been more effective than the properties of the natural dental structures themselves. 6–8 Several authors have suggested the use of natural teeth fragments as an efficient method for restoring fractured anterior teeth. 4,6,9–21 When the patient *MSc student, Pediatric Dentistry, Federal University of the Valleys of Jequitinhonha and Mucuri, Diamantina, MG, Brazil MSc student, Dental Clinic, Federal University of the Valleys of Jequitinhonha and Mucuri, Diamantina, MG, Brazil Dentist, School of Dentistry, Federal University of the Valleys of Jequitinhonha and Mucuri, Diamantina, MG, Brazil § Professor, Department of Operative Dentistry, School of Dentistry, Federal University of the Valleys of Jequitinhonha and Mucuri, Diamantina, MG, Brazil PhD student, Bioengineering, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil © 2010, COPYRIGHT THE AUTHORS JOURNAL COMPILATION © 2010, WILEY PERIODICALS, INC. DOI 10.1111/j.1708-8240.2010.00331.x VOLUME 22, NUMBER 3, 2010 168

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Page 1: Biologic Resto

“Biological Restoration”: Root Canal andCoronal Reconstructionjerd_331 168..177

PATRÍCIA CORRÊA-FARIA, DDS*

CARLOS EDUARDO PINTO DE ALCÂNTARA, DDS†

MARCUS VINÍCIUS CALDAS-DINIZ, DDS‡

ADRIANA MARIA BOTELHO, MS, PhD§

KARINE TAÍS AGUIAR TAVANO, MS¶

ABSTRACTAnterior tooth fracture, as a result of traumatic injuries, frequently occurs in dentistry.Proper reconstruction of extensively damaged teeth can be achieved through the fragmentreattachment procedure known as “Biological Restoration.” This case report refers to theesthetics and functional recovery of extensively damaged central maxillary incisors through thepreparation and adhesive cementation of “Biological Posts and Crowns” in a young patient.Both biological posts and crowns—post and dental fragment obtained through natural,extracted teeth from another individual—represent a low-cost option and alternative techniquefor the morphofunctional recovery of extensively damaged anterior teeth.

CLINICAL SIGNIFICANCEThe biological restorations are an alternative technique for reconstruction of extensivelydamaged teeth that provides highly functional and esthetic outcomes.

(J Esthet Restor Dent 22:168–178, 2010)

I N T R O D U C T I O N

Anterior tooth fracture, as aresult of traumatic injuries,

frequently occurs in dental clinics,with prevalence of 8.1 in 1,000children examined.1 This fact iscommonly related to sports,leisure activities, and carieslesions, thus causing functional,esthetic, and psychosocial

problems2–4 in addition to reduc-ing the patient’s quality of life.5

A satisfactory smile can beachieved by using several tech-niques and esthetic materials, suchas resin and porcelain. Over thepast decades, dentistry hasachieved great scientific and tech-nological advances regarding

restorative and adhesive materials.Nevertheless, to date, no restor-ative material has been moreeffective than the properties ofthe natural dental structuresthemselves.6–8 Several authors havesuggested the use of natural teethfragments as an efficient methodfor restoring fractured anteriorteeth.4,6,9–21 When the patient

*MSc student, Pediatric Dentistry, Federal University of the Valleys of Jequitinhonha and Mucuri,Diamantina, MG, Brazil

†MSc student, Dental Clinic, Federal University of the Valleys of Jequitinhonha and Mucuri,Diamantina, MG, Brazil

‡Dentist, School of Dentistry, Federal University of the Valleys of Jequitinhonha and Mucuri,Diamantina, MG, Brazil

§Professor, Department of Operative Dentistry, School of Dentistry,Federal University of the Valleys of Jequitinhonha and Mucuri, Diamantina, MG, Brazil

¶PhD student, Bioengineering, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil

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presents the fragment in good con-dition, this procedure presentsoptimal results in the restorationof fractured teeth (autogenousbonding).6,11,12 However, whenthe patient does not present thefragment, or its use is not recom-mended, donated extracted teeth(homogeneous bonding) can beused. Fragment reattachment usingnatural teeth is a technique knownas “Biological Restoration” andprovides excellent results regardingsurface smoothness, esthetics, andthe maintenance of the incisalguide in dental structures thatcause physiological wear.4,7,9,12–17

The combination of dental frag-ments, adhesives, and restorativematerials that are commerciallyavailable today provides a goodfunctional and esthetic result,connecting these properties withinan alternative treatment in therestoration of extensivelydamaged fractured teeth.4,17,18

A proper coronary reconstructionthat produces satisfactory estheticand functional conditions for endo-dontically treated and extensivelydamaged teeth is still a challengefor restorative dentistry, consider-ing that, to achieve these condi-tions, the making of an intracanalretention, aimed at a better reten-tion and stability of the dentalfragments, becomes imperative.This retention can be performedby using posts made from severalmaterials,7,8,22,23 such as fiberglass,

carbon fiber, metal, and ceramic.However, no commercially avail-able premanufactured post meetsall ideal biological and mechanicalproperties.8 The use of biologicalposts made from natural, extractedteeth represents a feasible optionfor the strengthening of the rootcanal, thus presenting the potentialadvantages: (1) does not promotedentin stress, (2) preserves theinternal dentin walls of the rootcanal, (3) presents total biocompat-ibility and adapts to conduct con-figuration, favoring greater toothstrength and greater retention ofthese posts as compared to pre-manufactured posts, (4) presentsresilience comparable to the origi-nal tooth, and (5) offers excellentadhesion to the tooth structureand composite resin and at alow cost.7,8,21,23

The use of natural, extracted teeth(homogeneous bonding) for resto-rations does, however, present limi-tations, such as the difficulty offinding teeth with a similar colorand shape as that of the destroyedelement, or the patient may refuseto accept a tooth fragmentobtained from another patient,which prevents the executionof the restoration.6,10,14

The following study describes aclinical case performed by meansof “Biological Restoration” usinghomogeneous fragment bondingassociated with biological posts,

both obtained from natural,extracted teeth, aimed at theesthetic and functional recon-struction of extensivelydamaged and/or fracturedcentral maxillary incisors.

C A S E R E P O RT

A 23-year-old man was referred tothe Dentistry Clinic at Federal Uni-versity of the Valleys of Jequitin-honha and Mucuri—Diamantina,Brazil, presenting crown fracturesin right and left maxillary centralincisors due to a fall. The clinicaland radiographic examinationsrevealed that both fractured teethhad suffered a loss of tooth struc-ture extending to the cervical thirdas well as an exposure of the rootcanals and pulp necrosis (Figure 1).

Proposed treatment to restore bothmaxillary central incisors includedintraradicular biological postsmade from the roots cutting ofextracted and properly sterilizedcanines as well as the subsequentcrown adaptation of centralmaxillary incisors that had beenpreviously extracted and donated.The patient received instructionsregarding the advantages anddisadvantages of biological rest-oration as well as informationon other treatment options. Afteragreeing upon the proposed treat-ment, a consent form was dulysigned. In addition, it was madeclear to the patient that the postand the crown would be obtained

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from natural, extracted teeth thathad been previously sterilized byautoclaving in accordance withbiosecurity standards.

First, all carious tissues wereremoved, followed by endodontictreatment. The restoration tech-nique initially consisted of thepreparation of the root canals andtheir direct molding using additionsilicone (ADSIL, Vigodent SA,Rio de Janeiro, Brazil) (Figure 2).

The Making of Dentin PostsAfter having established theplaster model, the extracted,donated canines, after having beenautoclaved at 121°C for 15 min-utes,25 were selected to constructthe posts. Using a diamond disk,the crown portion was separatedfrom a portion of the root, andthe root was sectioned mesio-distally along the long axis of thetooth. The cement was removedby abrasion, using diamond drills,

and each part of the root wascut in such a way as to form“Biological Posts.” Previouslyacrylic resin molds (Duralay,Reliance Dental Mfg. Co., Worth,IL, USA) for each canal involvedwere obtained molding the plastermodel and used as references ori-enting shape, thickness, and lengthof the dentin post (Figure 3A–C).

Adaptation and Cementing ofPosts to Root CanalsAfter the intraradicular posts hadbeen cut and suitably adapted tothe plaster model; they were thenconditioned with 37% phosphoricacid for 30 seconds, followed bythe washing, drying, and appli-cation of the adhesive system(ADPER SINGLE BOND 2, 3MESPE, CA, USA). The posts weretaken to the plaster model, whichhad been previously isolated, alongwith self-cured resin cement (C &B Cement, Bisco, Schaumburg, IL,USA), so as to facilitate the angleof insertion as well as the adapta-tion of these posts within thecanal during the cementing stage

Figure 1. Initial clinical presentation of both maxillaryanterior fractured teeth.

Figure 2. A, Radiographic aspect of endodontic treatment. B, Preparation of canals. C, Anterior region mold withaddition-type silicone.

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(Figure 3D–G). A filling nucleuswas built on the portion of thepost located on the externalportion of the canal using aphotopolymerizable compositeresin (Z250, 3M ESPE, USA)(Figure 3H). After confirmingthe satisfactory adaptation of

the posts to the canals, throughclinical and radiographic analyses,the cementing stage was begun.The posts and the inner portionof the canals were conditionedwith 37% phosphoric acid for15 seconds. Next, the adhesivesystem (ADPER SINGLE BOND 2,

3M ESPE) was applied and thepost was polymerized. Theself-cured resin cement (C & BCement, Bisco) was applied to theinner portion of the canals withthe help of a lentulo spiral andlightly applied to the surface ofthe posts, which were then inserted

Figure 3. A, Selected canine teeth. B, Radicular sections after cement removal and acrylic resin molds (Duralay) fromeach canal involved. C, “Biological Posts” ready after cutting. D, Application of 37% phosphoric acid. E, Application ofadhesive system. F, Post taken to the plaster model with resin cement. G, Readapted post. H, Filling nucleus made up ofphotopolymerizable composite resin.

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into the canals under constantdigital pressure until the endof the cement polymerization.

Preparation and Molding ofthe Crown Portions andModel ConstructionThe crown portions were preparedpresenting a chamfered cervicalend (Figure 4A,B), mainly inenamel, and molded with addition

silicone (ADSIL, Vigodent). Later,provisionary restorations weremade using denture teeth and auto-polymerizable acrylic resin(Figure 4C,D). The special plastermodel with removable die and theantagonist region model were setup in a semi-adjustable articulatorserving as a guide to select andadjust the “Biological Crowns”obtained from extracted teeth.

The Making of“Biological Crowns”After having created the model, theteeth that were preselected to make“Biological Crowns” were auto-claved at 121°C for 15 minutesand worn, both internally as wellas on the cervical portion, using adiamond tip under intense coolinguntil adapting to the model(Figure 5A,B). To ensure a goodadaptation, the cut crowns under-went cervical re-adaptation using alight-cured hybrid composite resin(Z250, 3M ESPE) in the modelsafter applying the adhesive systemADPER SINGLE BOND 2,3M ESPE) (Figure 5C–F).

Cementation of“Biological Crowns”In the final clinical session, thecorrect adaptation of the biologicalcrowns on the remaining teeth waschecked and the necessaryadjustments were performed(Figure 6A,B). After the coronaryportion of the remaining tooth andthe inner part of the crown hadbeen conditioned with 37% phos-phoric acid for 30 seconds, washed,and dried, and the adhesive system(ADPER SINGLE BOND 2, 3MESPE) had been applied, the crownswere filled with the self-cured resincement (C & B Cement, Bisco),brought into position, and main-tained under digital pressure untilthe polymerization of the cementhad been completed (Figure 6C–G).Finally, occlusion interference

Figure 4. A and B, Crown portions prepared presenting a chamfered cervicalend; C, Mold of crown portions prepared with addition-type silicone.D, Provisionary restoration with autopolymerizable acrylic resin.

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checks, necessary adjustments, andinstructions to the patient regardinghygiene and diet were carried out(Figures 7 and 8). After 1 yearfollow-up, the clinical and radio-graphic findings showed that theadaptation of crowns and posts, theesthetics, and the tooth functionhave remained preserved (Figure 9).

D I S C U S S I O N

Fragment reattachment, as com-pared to conventional adhesive res-torations, is the technique preferredby clinicians when an anteriortooth fracture has occurred, as itpresents several advantages whenassessing the recovery of toothfunction and esthetics.3,4,6,16,17 This

report presents the restorations ofthe teeth 11 and 21 using biologicalposts and crowns made fromnatural, extracted teeth because thepatient had not found the originaltooth fragments. The teeth wereobtained from the Surgery Clinicof Federal University of the Valleysof Jequitinhonha and Mucuri

Figure 5. Vestibular (A) and palatine (B) adaptation aspect of Biological Crowns to the model. C,D,E and F, Re-adaptationof Biological Crown on plaster model: C, Application of 37% phosphoric acid; D, Application of adhesive system;E, Re-adaptation of resin cement; F, Cervical re-adaptation to model.

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(UFVJM) where patients donateteeth by signing a consent form anda term of donation. It is importantto note that, before the manipula-tion of any of these extracted dental

elements, the teeth were properlycleaned, stored, and sterilizedby autoclaving at 121°C for15 minutes, ensuring allbiosecurity standards.25

Nevertheless, selecting teeth with acolor and shape that is compatiblewith the dental elements to berestored presented a barrier to per-forming the biological restoration

G

FE

C D

A B

Figure 6. Vestibular (A) and palatine (B) aspect of the adaptation of biological crowns. Acid conditioning(C and D) and adhesive system application (E and F) of biological crowns and crown portions prepared inboth central incisors, respectively; G, Cementing.

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technique. This is due to the factthat the extraction of healthyanterior maxillary teeth is quiteuncommon. This, however, couldbe minimized by using ToothBanks—nonprofit institutions thatstore and provide teeth for didactic,clinical, and scientific use.25

In the present case study, since thecoronary destruction extended tothe cervical third, intraradicularreinforcement was deemed neces-sary to provide retention and

Figure 7. A, B, and C, Final clinical and radiographic presentation of crownsimmediately after cementing and adjustment of occlusion.

Figure 8. A, Initial aspect of smile. B, Final aspect of smile.

Figure 9. Control clinical (A, B, and C) and radiographic (D) aspect after 1 year.

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stability to the crowns. Dentinposts made from roots of extractedand donated canines were used, asthey allow for a juxtaposed adapta-tion to the root canals and do notcause stress to the dentin, since theycontain the same biomechanicalbehavior as the restored teeth.7,8,22,24

The adhesion provided among the“Biological Post,” the cementingagent, and the dental structureallows one to attain a sole biome-chanical system (monoblock) withmaterials that are compatibleamong themselves.8,24 The use ofposts in teeth with great compro-mise of the dental structure allowsthe occlusal forces that will placepressure on the tooth to be betterdistributed throughout the root.20

These facts call for a careful assess-ment of the patient’s occlusion inthe investigation of interference inprotrusion movements and thepresence of premature contacts,factors that can lead to the failureof the technique.

Although biological crowns returnexcellent esthetic and functionalresults to the fractured teeth (suchas the smoothness and shine of thesurface, anatomical contour,natural color, hardness, and resis-tance to wear), both the teeth andthe posts require that the patientpay special attention to hygieneand dental care so as to avoidexcessive pressure on the teeth,which could in turn cause frac-tures. Even if a longer period of

time is spent by the clinicianduring the preparation and adapta-tion of the fragments,12 these“Biological Restorations” take onspecial importance in restorativedentistry, especially since they areless expensive, which makes thispractice a feasible option withinSchools of Dentistry that attendmostly to people of a lowereconomic level.

The association between “Biolo-gical Crowns and Posts” offersexcellent esthetic, functional, andpsychosocial results, which justifiesthe use of this technique to achievethe morphofunctional recoveryof extensively damaged teeth.However, further studies are calledfor to assess adhesion, fractureresistance, and the long-termbehavior of the posts and crownsso as to better understand the ben-efits of the technique and make it amore acceptable practice amongdentists and patients.

D I S C L O S U R E

The authors do not have anyfinancial interest in the companieswhose materials are included inthis article.

R E F E R E N C E S

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4. Aguiar KCFM, Nascimento TN, CoronaSAM, Dibb RGP. Homogeneous bonding,alternative technique for anterior teethfracture. Rev Gaucha Odontol2000;48:153–4 (in Portuguese).

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7. Galindo VAC, Nogueira JSE, YamasakiE, Kós Miranda D. Biological posts andnatural crowns bonding—alternatives foranterior primary teeth restoration. J BrasOdontoped Odontol Bebe2000;16:513–20 (in Portuguese).

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Reprint requests: Adriana Maria Botelho,MS, PhD, Rua do Rosário, 113 Centro,Diamantina cep: 39100-000, MG, Brazil;Tel.: + 55-38-3531-3688; email:[email protected] article is accompanied by commentary,“ ‘Biological Restoration’: Root Canal andCoronal Reconstruction,” Martin Trope,DMD, DOI 10.1111/j.1708-8240.2010.00332.x

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