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Case: DT17 – Save the Crown

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In this dental case, Dr. Ashraf Samir Refai provides a step-by-step guide showing how he saved a fractured palatal cusp on upper 2nd premolar.

Visit 1: Patient Profile & Diagnosis

A 70-year-old female patient came with a palatal cusp fracture of an old amalgam filling on tooth upper 2nd premolar( #4 ), which I had placed 20 years ago. The amalgam filling persisted.

Occlusal View of the fractured palatal cusp

Close up of the fractured palatal cusp

A temporary GI filling is placed and gave her an appointment for definitive treatment.

Visit 2: The Definitive Treatment:

The Temporary Filling

On the second visit, the treatment plan is as following:

  • Isolation Via Rubber Dam
  • Remove both the temporary filling and amalgam filling and Inlay Preparation.
  • Tissue retraction using cord and Teflon.
  • Digital impression.
  • Restoration Construction in Cerec (cad/cam) emax.

1. Rubber Dam Placement

Split Dam Application

2. Old Restoration Removal & Inlay Preparation.

The buccal cusp was thick at the base above 2mm and it isn’t the functional cusp. In Respect to the patient’s age (over 75 years old)  and wishes ( she didn’t want to go through a root canal, post and core and crown). If it was treated for a crown and I had reduced the buccal cusp there would be no retention at all, thus an Inlay was the preferred treatment.

After removal of the temp filling

removal of the amalgam fragments – a

removal of the amalgam fragments – b

3. Tissue retraction

Before tissue retraction

Occlusal view of retracted tissues

Palatal placement of Teflon for better retraction

4. Digital impression

Optispray is a powder used to spray on the teeth before taking a digital impression, which helps prevent light reflection for better details and accuracy.

Optispray is placed on prepared tooth for proper image scanning

5. Digital Designing of the Inlay

Design using Cerec software – Margin Outline

Design using Cerec software – Different views of the inlay with and without occlusion

Design using Cerec software – Position of restoration in the C14 Emax block

6. Milling of the Inlay

The Inlay after milling and before finish and polish

The Inlay: After Finishing / Polish

Visit 3: Restoration Placement & Cementation:

1. Tooth Isolation:

Rubber dam isolation

The use of rubber dam to offer proper isolation of the tooth surface before surface treatment.

2. Inlay Surface Treatment

The inlay fitting surface is etched via hydrofluoric acid etched, Silanation is done and finally bonding placement and light cured.

Fitting Surface: hydrofluoric Acid Etch

Fitting Surface: After etching

Fitting Surface: Silanation

Silanation: at the inner surface help promotes contact between resin cement and ceramic.*

Fitting Surface: Bonding agent placement

Fitting Surface: Curing

3. Tooth surface treatment

The Tooth surface is etched and then bonding is placed, then light cured.

Tooth surface: After Etching

Tooth surface: Light Curing of the bonding agent

4. Inlay Placement & Curing

A dual cure resin cement (G-Cem) is placed than cured.

Dual Cure resin cement is placed – View A

Dual Cure resin cement is placed – View B

Curing of the Dual Cure resin cement – View A

Curing of the Dual Cure resin cement – View B

5. Finishing

After the cement is placed and cured, it’s important to make sure the there is no excess cement ( especially in the proximal areas). Polishing is performed.

Removal of excess cement – View A

Removal of excess cement – View B1

Removal of excess cement – View B2

After removal of excess cement

After Polishing

6. Final View

The final restoration after finishing and polishing

Final Results

Special thanks to Dr. Ashraf Samir Refai for allowing us to post and publish his case.
Disclaimer: The patient had no objection to publishing this case as long as it didn’t identify her.


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About Author

Prof. Ashraf Samir Refai

An endodontic specialist and an Associate Professor of Endodontics. Proud to be lecturing full time at the Department of Endodontics at Al-Azhar University and have Lectured part-time in many other universities.

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