Direct composite crown replacing fractured Lithium Disilicate crown - With 8 month follow up

Posted on June 10 2020

Introduction:

Two factors set up this lithium disilicate crown for fracture:

1)    Endo asscess weakened it.

2)    Occlusal thickness not adequate.

 

Crown has fractured

Distal half of lithium disilicate crown has fractured. It was difficult for the dentist to achieve, needing occlusal clearance and still preserving a ferrule.

Buccal View

 

Rebuilding the crown

On a stone model, I rebuilt the crown in composite and made an occlusal stamp with Triad Gel. I had the model because the patient desired bleaching trays. I could have temporarily rebuilt the tooth and made the stamp directly in the normal fashion on the day of the appointment.

Occlusal view of the Triad Gel stamp

Stamping the composite will give me a head start on the occlusal adjustment.

Greater Curve Standard Band in place

Greater Curve Standard with a mesial contact opening surrounds the tooth. I reduced the occlusal further and was able to reduce the opposing tooth as well. I failed to take a prep photo to show the ferrule was now nearly non existent.

Seating the stamp

After some minor adjustments, the occlusal stamp fully seats inside the Greater Curve matrix.

 

Placing teflon tape over the stamp

This prevents the composite from sticking to the Triad Gel stamp.

Appearance of the restoration after the stamp has been removed

Sequence of of the buildup: Clean and Boost (Apex Dental), Futurabond U (Voco), Activa A2 (Pulpdent) provided the bottom 1/2 of the restoration. The base Activa was light cured. Filtek A2 was snowplowed into a thin layer of uncured Activa to finish out the top 1/2 of the restoration. The Triad Stamp was then pushed into the uncured Filtek. Stamp removed. Some excess composite smoothed away and the Filtek was cured. For isolation, I used a Saliva Ejector Holder which secured buccal and lingual NeoDrys.

Final direct composite crown

Most of the shaping was done after the matrix was removed.

Buccal view

 

Photo of tooth 8 months later

 

Conclusion:

Before attempting a similar case, make sure the crown margins are just supraginival in order to hold a tofflemire band.

Because there was no ferrule and lack of occlusal clearance, I felt another crown would succumb to the same fate as the previous crown. Also, maintaining isolation while bonding a new crown would be difficult.

I have had very good luck with full direct composite crowns has long as the composite does not extend across a wide interproximal space. Composite will chip if it is not supported. 

I realize this treatment may be controversial to some, however, I want to show what is possible. 

4 comments

  • KIM HENRY: June 15, 2020

    First of all, second molars need amalgam buildups or cast posts, not composite stuck down the access prep. Second of all, 2nd molars are not a good place for ceramic. Metal is ideal for this application, because metal has high tensile strength in low thicknesses. You need tensile strength on 2nd molars, as so often there are balancing contacts. The stress on the distal of 2nd molars is the highest of anywhere in the mouth.

    Good luck with that composite lasting over 2 years where a pressed crown failed. Hope the patient signed an agreement that she will pay again when it fails.

  • Nathan Mayo DDS: June 13, 2020

    I love your work and appreciate a guy who is gutsy enough to try alternative ideas, because I do the same every day. As long as the patient is on board with it and is prepared to pay in full for a zirconia or cast metal if it fails, then I say OK. If it works for 5 yrs you are a genius, and if it fails then you both know that it was not a good plan. I would never again use a disilicate crown on any posterior tooth on any patient for any reason. I have seen too many break and with zirconia around why would anybody in his/her right mind do that? At one time I thought the bonding factor was the reason, but I can usually keep a zirconia stuck on with a good parallel prep and glass ionomer.
    Hopefully you cut a big fat hole down into the pulp space to provide resistance and retention for your composite. Warm regards………….n

  • Chris Leishman: June 11, 2020

    Another (and much easier imo) option would be a One Visit Crown (OVC) combined with a Greater Curve band. OVC’s have a higher fracture resistance than lithium disilicate crowns and can be done in 45 minutes. However, I have problems using the OVC matrix bands so I use Greater Curve bands instead. The OVC and the Greater Curve band are a winning combo in my hands!

  • David Price: June 11, 2020

    Did you consider ribbond and new composite in endo access. My experience is that ALERT composite is less subject to chipping when unsupported marginal ridges are restored with composite.

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