Balraj Sohal explains how he repaired a 54-year-old patient’s upper left first molar.
A 54-year-old patient broke a portion of her upper left first molar whilst having a meal. She attended an out of hours dentist who temporised the broken tooth with a filling. She had no symptoms or discomfort from the tooth although as it had broken, she wanted to ensure it was protected.
The upper left first molar had a GIC restoration filling the mesio-palatal region of the tooth. The tooth was not tender to palpation, non-mobile and upon radiographic assessment there were no signs of periapical pathology.
Due to the size of the pre-existing amalgam and the fact there was a fracture on the distal marginal ridge we decided to restore this tooth with cuspal coverage to help minimise further fracture.
The caries was removed with a rose-head bur until a caries free enamel-dentine junction was achieved. Note the fracture line running through the distal marginal ridge – manual pressure was applied with an excavator and unsurprisingly the disto-palatal cusp fractured off completely as it was undermined – only the buccal wall was left remaining.
A size 0 retraction cord was placed into the gingival sulcus to enable an accurate impression to be obtained.
The overlay was tried in on the preparation in order to assess the marginal fit and the occlusion. Once the fit and occlusion was approved, the fit surface of the overlay was air-abraded with 27-micron alumna oxide particles. The fit surface was then etched with hydrofluoric acid etch for 20 seconds (gently rubbing with a microbrush) – washed thoroughly and then dried. A drop of fresh silane (Monobond Plus, Ivoclar Vivadent) was applied to the etched fit surface and left for 60 seconds. After 60 seconds the silanated fit surface of the overlay was air-dried to remove the residual solvent. Next, Optibond FL bonding agent was applied to the silanised surface.
The tooth surface was air-abraded with 27-micron alumna oxide particles. And then it was etched for 30 seconds with 37% orthophosphoric acid – washed and dried. Optibond FL bond was then applied onto the tooth surface. Nexus (white) dual cure resin cement was used to bond the overlay in place.
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