32-Year Follow-up of a Class IV Central Incisor Restoration
A case report and resin-based composite retrospective
Theodore P. Croll, DDS | Steven R. Jefferies, MS, DDS, PhD
Often times articles in the dental literature detail step-by-step clinical procedures and depict the end result without showing any long-term follow-up, or perhaps present only 6 to 12 months of photographic documentation. The least informative of such reports are those that provide an immediate postoperative view but no follow-up images. A case report or clinical technique article that shows the results of treatment over many years can be a valuable contribution to the dental profession. This report documents a Class IV resin-based composite (RBC) restoration of a fractured central incisor in a 10-year-old girl, with photographs recorded at 2 years, 5.5 years, and 32 years after treatment. In addition, re-repair of the tooth is featured 32 years after initial repair.
In 1983, a 10-year-old girl sustained a Class IV disto-incisal corner fracture of her maxillary right central incisor (Figure 1). The patient struck the tooth on a brick wall at her school playground and was brought to the office for emergency treatment.
The tooth was not mobile and a radiograph confirmed that the root was neither fractured nor displaced. The coronal fracture penetrated into the dentin, but there was no pulp space exposure. A diagonal internal craze fracture across the crown was noted several millimeters from the detached fracture, extending from the mesio-incisal angle to midway up the distal surface (Figure 1). Exposed dentin was covered with Dycal® (DENTSPLY, www.dentsplysirona.com) calcium hydroxide liner, and the fracture site was repaired with an acid-etch–retained RBC insulating protective “bandage.”1 Two months later, the tooth was restored for the long term with Heliosit (Ivoclar Vivadent [originally Vivadent], www.ivoclarvivadent.com), a composite used in that time period (Figure 2). Helioseal (Vivadent), a bright white resin sealant, was applied as a surface coloration agent, to simulate the patient’s idiopathic generalized white enamel “dysmineralization”2 discoloration (Figure 3 and Figure 4). Both of these products were based on a UDMA (urethane dimethacrylate) formula, not BIS-GMA (bisphenol A glycidyl methacrylate).
A report of this tooth repair was published in 1984.3 The tooth was photographed again in 1988, 5.5 years after the injury and repair (Figure 5). The patient, then aged 16 years, was transferred by her parents to a family dental office for routine adult care.
In 2015, the patient’s younger sister, who was in the senior author’s office with her 2-year-old child, reported that her older sister’s “front-tooth filling had discolored.” She also provided her sister’s phone number and related that she still lived in the area. The patient from 1983 was called and an appointment made to evaluate her, 32 years after treatment of the central incisor.
32 Years Later
The patient, who was now aged 42 years, presented with the original restoration structurally intact. However, the white enamel surface sealant was absent, the RBC had turned yellow-brown, and resin/enamel margins had slight separation and some stain (Figure 6). No pathological changes were seen on a periapical radiograph except for a Class III caries lesion of the distal surface of the central incisor. The patient reported no discomfort and said there had been no need for additional treatment over the years, but she voiced displeasure with the color of the tooth. The clinician performed prophylaxis treatment and offered adamant encouragement about better brushing and flossing, and an appointment was made for renewed repair of the tooth.
The patient was anesthetized with local infiltration of articaine hydrogen chloride (HCl) 4%, with 1/200,000 epinephrine. The prior RBC material was cut away with a water-cooled high-speed diamond bur. No rubber dam was used. The mouth and throat were protected with a 4”x4” cotton gauze. Carious tooth structure in the distal caries lesion was debrided with slow-speed round burs. Peripheral enamel was roughened with a slow-speed diamond bur to enhance acid-etching, and preparation for RBC repair was completed (Figure 7 and Figure 8).
A dentin replacement liner (ACTIVA™ BioACTIVE-BASE/LINER™, Pulpdent, www.pulpdent.com) was used to cover exposed dentin,4 and a metal matrix strip was inserted and stabilized with a wooden wedge. A self-etching resin adhesive (Adper™ Prompt™ L-Pop™ Self-Etch Adhesive, 3M, www.3m.com) was painted on the peripheral enamel and within the preparation, and agitated for 30 seconds (Figure 9). The bonding agent was photopolymerized with 10 seconds of light-beam exposure. The disto-incisal corner of the incisor was then restored in a typical manner with three layers of shade A2B RBC (Filtek™ Supreme Ultra Universal Restorative, 3M); each layer was cured separately with 10 seconds of 1,200 mW cm2 light exposure (Figure 10). A 20-second light exposure from both the labial and then lingual aspects assured thorough resin polymerization. Finishing and polishing was completed in a typical manner.
Two months after re-repair of the tooth, when the tooth was air-dried the patient displayed white enamel dysmineralization of the adjacent surface of the tooth (Figure 11). Enamel microabrasion (PREMA®, Premier Dental, www.premusa.com) was used to remove the white discoloration and modify the enamel surface (Figure 12). Enamelon® Preventive Treatment Gel (Premier Dental) was applied and left in place for 5 minutes after microabrasion was completed (Figure 13), with the intention being that the stannous fluoride and amorphous calcium phosphate in the gel would have a beneficial effect on remineralization of the exposed enamel.
Nine months after re-restoration of the tooth (7 months after enamel microabrasion), the tooth had an improved appearance, whether air-dried or wet with saliva (Figure 14). A comparison of radiographs from 1983, 2015, and 2016 showed no pathological alterations of the root, periodontal ligament space, or associated alveolar bone (Figure 15).