CDE0111

a dull ache in the buccal sulcus above the left central incisor. Intra-oral examination revealed poor contours of the composite fillings, with incorrect colour and texture. In addition, the patient’s oral hygiene was unsatisfactory, with extensive plaque and calculus deposits causing acute gingivitis. The left central incisor was sen- sitive to gentle percussion, as well as to hot and cold stimuli. Radiographs showed substantial defects be- tween the composite filling and remaining tooth substrate, allowing ingress of oral pathogens (Fig. 4). The periodontal ligament was intact, no root fractures were evident and a typical solid cortical bone appearance, consistent with an acute dental trauma, was apparent. _Initial therapy Before considering definitive treatment, the initial items requiring attention are the peri- odontal and endodontic status. Assessing the endodontic condition following acute trauma is essential for treatment planning. Following an accident, the patient is distressed, anxious and mentally traumatised. In addition, the shock of the physical trauma often results in a transient anaesthesia or paraesthesia of the pulpal neural fibres. For these reasons, assessing pulp vitality with thermal or electrical stimuli, which are highly subjective, yields unreliable results. In ad- dition, a false-negative result is often obtained with traumatised teeth owing to the transient paraesthesia of nerve fibres. Conversely, a false- positive result is elicited when necrosis of the pulpal vascular tissues has occurred, leaving vital nerve fibres, which are more resilient. This may delay diagnosis and treatment of the affected tooth, often leading to root absorp- tion. A reliable and objective method for deter- mining pulp vitality is pulse oximetry. Pulse oximetry measures the blood oxygen satura- tion levels or circulation within the pulp. The pulse oximeter consists of light-emitting diodes (LED) of two wavelengths (red light – 640 nm and infrared light – 940 nm) and a receptor for recording the spectral absorbance of the oxygenated and deoxygenated haemoglobin in the tooth pulp. A computer calculates the percentage of oxygen saturation levels, which is approximately 75 to 80 % for vital teeth, com- pared to values at the fingers or ear lobes of 98 %. The tooth oxygen saturation levels are lower than soft tissues of the body owing to the dentineandenamel,whichscatterstheLEDlight. A reading of 78 % was obtained for this pa- tient, indicating that there was adequate vas- cularity for eventual regeneration of the pulp. At this stage, root-canal therapy was not ne- cessary. In order to resolve the acute gingivitis, the teeth were scaled and polished, and the patient counselled about home oral-hygiene proce- dures. Impressions for the diagnostic wax-up were delayed until gingival health had im- proved. health and detachment of the defective composite build-up on the left central incisor. Notice the clearly visible dentine mamelons and incisal edge lobes of the reattached fragment on the right central incisor. Fig. 8_Dento-facial view with VITA Classic shade guide. Fig. 9_Dento-facial view with VITA 3D Shade Guide. Fig. 10_Photograph of patient before the sporting injury. Notice the blatant maxillary midline diastema. Fig. 11_A large overjet of 7 mm, making the maxillary incisors vulnerable to external trauma. Fig. 12_Facial view of pre-op plaster model. Fig. 13_Incisal view of pre-op plaster model. Fig. 9 Fig. 10Fig. 8 Fig. 12 Fig. 13Fig. 11 I 07 clinical technique _ fractured maxillary central incisors I cosmeticdentistry 1_2011