CATEGORY 76 AUSTRALASIAN DENTIST CLINICAL Case description CASE HISTORY Reason for dental consultation A 37-year-old female patient came to the practice for a longitudinal mesiopalatal fracture with subgingival extension on her upper right rst molar (tooth 16) (Figs. 01 and 02). e endodontics specialist who had performed the prior root canal treatment had referred the patient for a post-endodontic reconstruction. Dental and medical history e patient had lost her upper right second molar (tooth 17) two years earlier, again due to a fracture. Her general medical history was unremarkable. Patient’s expectations e patient hoped that her tooth could be saved and restored with excellent aesthetic and functional results and requested a metal-free solution. FINDINGS AND DIAGNOSIS Clinical, radiological and instrumental findings In addition to the incomplete subgingival fracture on tooth 16, the pre-operative radiograph showed a periapical in ammatory process (Fig. 15a). Diagnosis Incomplete longitudinal fracture of tooth 16 with periapical granuloma. Therapy Treatment plan Based on the diagnosis, two possible courses of action were considered: 1. restoration with a berglass post and a metal-free crown or 2. a biomimetic approach consisting of deep margin elevation with composite, an adhesive build-up and a metal-free endo-overlay. As the buccal wall of the tooth was just 2 mm thick, removing an additional 1 mm for a crown preparation would have signi cantly weakened the remaining wall. Due to the low wall thickness, the biomimetic approach was chosen. Another essential decision was which material to use for the prosthetic restoration: ceramic or a CAD/CAM composite. It was decided to use a state-of-the-art nanoceramic hybrid material for high-quality CAD/CAM restorations (Grandio blocs, VOCO) because of its excellent mechanical stability, easy handling, and fast milling process. Timeline of treatment steps e incomplete fracture on tooth 16 was clinically visualised (Figs. 01 and 02). e fracture was unremarkable when using Caries Marker (VOCO), so that a nano-hybrid composite was used to directly seal it while performing the deep margin elevation. A rubber dam was placed and the tooth was etched (Fig. 03). After application of Futurabond U (VOCO) (Fig. 04), a deep margin elevation was performed (Fig. 05) using Grandioso (VOCO; shade A2), which was chosen for its favourable mechanical behaviour. e tooth was built up with the thermally controllable bulk- ll composite VisCalor bulk (VOCO) (Fig. 06), which was shaped, cured and grinded in the form of a retention cavity (Figs. 7b and c). As perfectly smooth preparations can present di culties during luting, it is preferable to provide them with an indentation to prevent incorrect seating of the restoration. erefore, a slight ring-shaped central depression was created (visible on Figs. 7b and c as a 0.5 mm deep occlusal box) to facilitate the positioning of the endooverlay and its adhesive cementation (Figs. 11 and 12). e residual cusps were prepared geometrically with bevelled margins using diamond instruments (820 und 859EF, JOTA; s. bur 820 in Fig. 07a). e amount of vertical reduction on the cusps was 1 mm (Figs. 09b and c) (1.5 mm on the supporting cusps) (Fig. 07). e resulting preparation was scanned (CEREC Omnicam, Dentsply Sirona), while the restoration was designed using exocad (Align Technology) (Fig. 08a) and then milled on a CEREC MC XL (Dentsply Sirona) from Grandio blocs (VOCO) (Figs. 08b and 09). FinalTouch (VOCO) in brown and orange shades was applied for the chromatic characterisation of enamel ssures (Fig. 10). Conditioning of the indirect restoration: Since the milled endo-overlay was made Dr. Lucas Echandia, DDS Composite-milled “Endo-Overlay” on thermo-viscous composite buildup following deep margin elevation By Dr. Lucas Echandia, DDS – Associate Professor, Clinical Prosthodontics II; Catholic University of Córdoba, Obispo Trejo 323, X5000 IYG, Córdoba, Argentina – Centro Odontológico Echandía-Meloni, José Otero 2090, X5009 HSX, Córdoba, Argentina Keywords Deep margin elevation, VisCalor, ermo-viscous composite, Build-ups, Grandio blocs, Milled composite blocks, Endo-Overlays Summary In this clinical case, the author presents a minimally invasive alternative to endocrowns, which he calls “endo-overlay”. He relies on the latest advances in nano-hybrid composites for CAD/CAM, particularly on the materials developed by VOCO, which allow for a thin design of indirect restorations. As a part of a post-endodontic reconstruction for a female patient with subgingival palatal fracture on tooth #16, who was referred by an endodontics specialist, the endooverlay was successfully applied. After deep margin elevation with GrandioSO (VOCO), followed by a core build-up with VisCalor bulk (VOCO), an endo-overlay made from Grandio blocs (VOCO) was designed and milled using CAD/CAM technology and nally adhesively luted with a bonded-in resin cement.
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