Treating the Class IV - a case of pediatric trauma!

Dr Priti Lamba was the Mentor of the DR Pronto Esthetic Challenge 3, 2021-2022 This is a case of a 7 year old boy who came to us with a fractured right central incisor. He had a fall 2 weeks ago, no pain on percussion, vitality test positive and slight sensitivity present on the exposed dentine.

Shade determination was done at the beginning of the appointment, prior to tooth preparation or even rubber dam placement.

In a typical clinical scenario, shade determination for direct and even indirect restorative work is usually not performed with a rubber dam in place. This is because isolation causes tooth dehydration which makes teeth appear whiter and lighter due to increasing enamel opacity, masking the underlying color of dentin. An accurate color match of the final restoration can only be expected if the shade was registered with the tooth in a hydrated state, and waiting for the tooth to get rehydrated once the restorative work is over.

The rubberdam was placed. In our practice, we usually do clampless dam from canine to canine and use wedjets to secure. However, this being a child in mixed dentition phase and this visit being his first dental visit, we isolated it just lateral to lateral and stabilised with the frame.

An infinity bevel was given for this case. An infinity bevel is basically a long bevel with smooth margins. The jagged margins of the tooth were smoothened (TR 25F bur) to create a smooth bevel at least 2 mm beyond the fracture line. This softens the edges and rounds off the fractured enamel prisms. The bevel was polished (3M coarse disc).

A buildup with Activa™ Pronto composite material was planned with tints. Being a fluoride releasing composite, we found this material to be the best option for the mixed dentition phase.

The initial palatal shell was made freehand with a Mylar strip, supporting the mylar with a finger.

Finishing was done (Red ring burs,Enhance cones from Dentsply and 3M coarse discs) and polishing was completed (Ivoclar eve twists with Sparkle polishing paste and buff). The final photo is the immediate post-op. We are yet to see the child for a review appointment.

As suggested earlier, an accurate color match of the final restoration can only be confirmed after waiting for the tooth to get rehydrated once the restorative work is over.

According to studies, in order to regain their original shade after dehydration caused by isolation procedures, teeth require more than 15 minutes of rehydration, sometimes close to 30 minutes. The child was instructed to drink a glass of water to hasten the rehydration process and confirm the shade match. 1

This was the post-operative view after rehydration.

Before & After at a glance!

References 1. Suliman, Sama & Sulaiman, Taiseer & Olafsson, Vilhelm & Delgado, Alex & Donovan, Terence & Heymann, Harald. (2019). Effect of time on tooth dehydration and rehydration. Journal of Esthetic and Restorative Dentistry. 31. 10.1111/jerd.12461