A 7-year-old boy reported to our clinic with the chief complaint of decayed teeth. Clinical and radiographic examination revealed multiple carious lesions in all teeth with retained roots of 61, 62. Complete preventive care was provided, retained roots were extracted and all carious teeth were restored. Primary mandibular first molar (84) was grossly carious [] and a decision to place biologic shell crown was made.\nThe operative procedure is described below:\nStep 1: Biologic shell crown preparation: Primary mandibular right first molar (possibly extracted for serial extraction) was selected based on mesiodistal dimensions of the tooth to be restored. The selected tooth was sectioned approximately 1 mm occlusal to cemento-enamel junction. Any remaining pulp tissue was removed using sharp spoon excavator. All undercuts were removed and dentinal surfaces were prepared to diverge cervically. The cervical margin was prepared flat with rounded internal line angles so that it can be seated on prepared margin of primary mandibular first molar. Sterilization was performed as described previously.\nStep 2: Complete caries excavation was performed under local anesthesia with area isolated using rubber dam. After caries removal, a layer of GIC (GC Fuji II, Glass Ionomer Restorative, GC, USA) was placed. Circumferential shoulder margin with rounded internal line angles was placed using round end tapered diamond parallel to long axis of tooth []. Withdrawal form was established by rounding of all line and point angles and removing all undercuts.\nStep 3: Rubber dam was removed and occlusal clearance was checked using modeling wax sheet.\nStep 4: Trial fit of biologic shell crown was done and adjustments were done if needed [].\nStep 5: Etching of dentinal surfaces of prepared biologic shell crown and prepared tooth surfaces was done with 35% phosphoric acid (3M™/ESPE™ Dental Products, USA) for 15 s. Final cementation was performed using dual cure resin cement (RelyX™ U100 Self-Adhesive Resin Cement, 3M™/ESPE™ Dental Products, USA) following manufacturer's instructions.\nStep 6: Final check for occlusion in centric as well as eccentric positions to check for any functional interferences. Thin carbon paper was used and pre-maturities, if any were removed.\nStep 7: Finishing and polishing of margins was done with composite finishing and polishing tips (CompoSite™ Finishing Kit, CompoSite™ Polishing Kit, Shofu, USA).\nClinical examination [] at 1, 6, and 9 months showed the cemented biologic crown to be functioning well in the oral cavity.
A 23-year-old Indian female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of yellowish discoloration and poor appearance of her teeth with the rehabilitation of the same. Family history and medical history was non-contributory. Patient was unmarried, well qualified medical student and there was no history of similar condition in the family. Her parents and siblings were fine and no other family member presented with similar dental findings. Her past dental history disclosed that she underwent root canal treatment of 36 due to caries involvement. Extra-oral examination disclosed normal mouth opening and no temporomandibular joint problems. The patient was healthy with no co-morbidities.\nOn intraoral examination, the enamel thickness was highly thinned down and partially flaked off from few surfaces of teeth. Teeth revealed well defined pitted surfaces along with yellowish brown discoloration. Surfaces of teeth were rough with minimal enamel present. The teeth also revealed short clinical crowns with multiple spacing between teeth. The occlusal plane was uneven worn-down posterior teeth. On frontal view, the patient presented with deep bite with less horizontal overlap. Dentin which was exposed were brown in color. The periodontal examination revealed normal healthy gingiva with no abnormalities (Fig ).\nRadiographic examination included full mouth Orthopantomogram (OPG) and Intraoral periapical radiograph (IOPA) showed features of AI. (Fig ) Occlusion was assessed after obtaining the diagnostic casts. Based on clinical and radiological examination, it was diagnosed as hypoplastic type of amelogenesis imperfecta. Based on the arrived diagnosis, a full mouth rehabilitation was planned. A well formulated treatment plan involving endodontic, and prosthetic department was charted out to furnish a functional occlusion with good esthetics and further prevent the tooth loss. The entire treatment plan was explained to the patient and informed consent was obtained. The initial phase of the treatment consisted of endodontic therapy. Based on OPG reports, it was decided that pulp space therapies should be performed on 37, 46, 47, 16, 17, 26 followed with retreatment with respect to 36 and fixed prosthesis was planned for the entire dentition.\nTreatment protocol: Patient was asked to check her on diet to maintain oral hygiene. The mock presentation of full coverage prosthesis were executed on upper and lower casts and presented to the patient. She was contented with the anticipated outcome and prognosis of the overall treatment plan was satisfactory. The subsequent rehabilitation plan was formulated.\nDefinitive treatment plan:Patient motivation for the treatment and maintenance of oral hygiene, Endodontic treatments of #37, 47, 47, 16, 26, Providing temporary bridges on all posterior teeth for reconstruction of the lost occlusal vertical dimension, Trial of fixed partial dentures and, Periodic follow-ups at 1 year and 2 year intervals followed by augmentation of oral hygiene measures.\nEndodontic treatment was performed with respect to #37, 47, 47, 16, 26 under rubber dam and local anesthesia. 3% sodium hypochlorite (Vishal Dentocare Pvt Ltd, India) was used as irrigant in all the treated teeth. The working lengths for all teeth was obtained using hand K file (Dentsply Inc, Maillefer, Dentsply India), Root ZX II Apex locator (Morita, Irvine, CA), and finally confirmed using intraoral periapical radiograph. #16, 26 showed the presence of MB2. Cleaning and shaping of all the canals were performed with hand K files and Protaper rotary files (Dentsply Inc, Maillefer, Dentsply India) under copious irrigation with 3% sodium hypochlorite and enlarged upto F2 file size. Retreatment was performed with respect to #36. Three rounds of calcium hydroxide as intracanal medicament (CALCICURE, Voco) were placed for #36. All the access cavities were given temporary seal dressing (cotton pellet and intermediary restorative material, Cavit G, 3M ESPE GmbH, Neuss, Germany). All the obturation was completed using F2 protaper gutta percha cone (Dentsply, Maillefer, Dentsply India) with AH Plus sealer (Dentsply, Sirona, Dentsply India). The next stage of treatment was the restorative and prosthetic phase. Fixed partial dentures were planned.\nRestorative treatment included the Post endodontic restoration of # 37, 46, 47, 16, 17, 26 and 36 with composite restoration (Filtek Z 350 XT, 3M ESPE, St, Paul, MN, USA). As per radiographic findings, the impacted teeth was retained as the patient was not willing for any surgical extrusion procedure. The deciduous 63 was included in the tooth preparation. All third molars (#18, 28, 38, 48) were not extracted as they had not erupted.\nProsthetic treatment included the tooth preparation on #17, 16, 15, 14, 24, 25, 26, 27, 34, 35, 36, 37, and 44, 45, 46, 47 to receive metal ceramic crowns. Diagnostic impressions were made using alginate (3M ESPE Alginate Impression Material). The diagnostic casts were then mounted on semi adjustable articulator (Hanau Articulator, Teledyne Hanau Buffalo, NY, USA) using Hanau facebow. The tooth preparations were performed quadrant wise so that the patient was adjusted with the new occlusion. First the posterior teeth were prepared and the temporary acrylic bridges (Integrity™ Temporary Crown & Bridge Material, DENTSPLY, USA) were fixed to increase the occlusal height. Temporary acrylic crowns were placed for 1 month to assess the patient’s forbearance to the new occlusion. Once the patient was habituated to the new occlusal height, then final maxillary and mandibular impressions were prepared with poly vinyl polysiloxane impression material (Aquasil Ultra Putty Soft Regular and Aquasil Ultra LV, Dentsply USA). Interocclusal records in centric occlusion were taken and the working casts were mounted on semi-adjustable articulator (Hanau Articulator, Teledyne Hanau Buffalo, NY, USA). Trial with metal ceramic restorations was done and finally cemented with self-adhesive resin (RelyX Unicem 2 Clicker A2 Universal Self-Adhesive Universal Resin, 3M-ESPE, USA). Then the anterior teeth were prepared for metal ceramic restorations. The patient was regularly monitored at 1 week, 1 month, 3 months, 6 months and at 1 year and 2 years intervals using clinical and radiographic examinations (Figs. , and ). Patient was highly satisfied with the treatment outcome and the gingival condition was maintained, esthetic impairment and the dentinal sensitivity was resolved.