History: 60 year old man presents to you office with a fractured mesial lingual cusp of tooth number 30. The tooth is slightly sensitive to cold but not lingering. Patient has a history of bruxism. You old test it and it is testing 6 seconds and slightly more sensitive than 29 and 31. Bitewing radiograph shows decay on the distal also. Your patients esthetic demands are high and they do not want a silver filling or metal pins. Money is not a concern for this patient.

Notice the fracture on the Distal cups

WHAT WOULD YOU DO?

1) Options to restore the tooth

2) Your opinion as to what is best treatment based on patient concerns and your knowledge and opinion

3) what material?

4) Concerns about the treatment?

options MODBL Pin amalgam

MODBL composite

MODBL Onlay saving the MB and DL cusp

Bonded Crownlay with margin at height of contour on B and L (Emax)

full coverage bonded crown (no need for core because the crown is bonded) (Emax)

core buildup (to regain walls that are lost) and conventional cemented crown (FCZ, Gold or PFM)

Best Treatment (just an opinion)

Bonded Crownlay preserving facial and lingual enamel and breaking contact mesial and distal by dropping the finish line almost to the tissue.

Material The material of choice is e.max (lithium disilicate)

High translucency (to blend with tooth due to the high facial and lingual margins) I choose e.max due to the high strength (360MPa) and the ability to bond the ceramic on the tooth avoiding the need for long walls B and L like a traditional crown preparation. The preservation of B and L enamel will provide a strong bond, prevent aggressive tooth reduction which may avoid the need for endodontic treatment.

http://e.ma

Treatment Concerns Because it is bonded we have to have the ability to maintain

isolation during the bonding procedure

Due to lack of good retention it is important to have meticulous bonding protocol and use an adhesive resin cement (one that requires a sport bonding agent step on the tooth)

due to the need for adhesive resin cement, it is important to have attention to detail during cement cleanup to avoid a potential disaster of resin cement stuck everywhere.

have to have proper material thickness (1.5mm) to avoid fracture of the restoration

WHY I did not pick these? MODBL Pin amalgam (but does not want amalgam)

MODBL composite (difficult to place and at best considered a temporary patch and patient said he wanted the best)

MODBL Onlay saving the MB and DL cusp (Good option and was debating this but the remaining cusps looked a little fragile so I thought it best to cover them, he has a history of fracturing cusps off and the DB cusp already looks like it is about to go.

Bonded Crownlay with margin at height of contour on B and L (Emax) (My choice)

full coverage bonded crown (no need for core because the crown is bonded) (Emax) ( another good option but the facial and lingual had a lot of tooth structure that was healthy so may be a little too aggressive. Increase chance of endo when margins are placed near the tissue and need 1mm margin at the tissue level causes about 70% more reduction in tooth structure compared to a crownlay. Less enamel preserved to bond to. Takes longer to prep. harder to clean margins at the tissue.

core buildup (to regain walls that are lost) and conventional cemented crown (FCZ, Gold or PFM) Standard old school option, if you do a core you have to get a margin 2mm apical to the core. this will cause the margin to be very sub gingival on the mesial and distal and can be a violation of biological width (we will talk about this later) have to hide margins at or below the tissue on the facial, can cause a difficult final impression and a less accurate crown.