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26 I I case report _ composite restoration _Clinical case A64-year-oldfemalepresentedtotheendodon- tic office with an uneventful medical history. She complained of spontaneous pain on the lower left side of one week’s duration, which radiated up the ramus of the jaw and was causing headaches. She alsocomplainedofhotandcoldsensitivitywithpain on biting. Clinical tests revealed pain to cold, which lingered for five minutes and a sharp electric like pain when a tooth sleuth was placed over the DL cusp tip. A distal crack was visualised. There was no periodontalpocketing.Allothermandibularleftand maxillary left teeth tested vital and asymptomatic. The radiograph revealed a small shallow minimally invasiveamalgamrestoration(Fig.3).Thediagnosis was Cracked Tooth Syndrome with an irreversibly inflamed pulp. The patient was advised of the ques- tionablelongtermprognosiswithcrackedteethyet decidedtotryandretainitunderstandingthatifthe crack extends in the root proper and a periodontal pocket develops, then extraction with an implant replacement may be a viable solution. Due to the minimal invasiveness of the restora- tion, it is anticipated that after endodontic treat- ment,therewouldbeenoughcoronaltoothstructure left to allow for the preparation of a full coverage restoration with a fully circumferential ferrule of at least2+mminheight,aswellaswidth(Fig.4).Figure5 is a magnified view of the distal vertical crack, with thewearfacetonthelingualcuspindicatingawork- ing side contact interference. Endodontic therapy was initiated under the microscope and after a thor- ough debridement and shaping of the root canal spaces (Fig. 6), the roots were obturated with gutta percha using a continuous wave of condensation techniquetoalevel2mmbelowthepulpalfloor(Fig.7). Phosphoricacidetchingwasinitiatedwiththeplace- ment of Ultra-Etch Etchant (Ultradent) followed by microbrush agitation to work the etchant into the dentine,athoroughrinse,andlightairdrying(Fig.8). Figure9showstheapplicationofMPabondingagent (Clinical Research Dental) with a microbrush, which again was followed by agitation to facilitate deeper penetration of the bonding agent, followed by evap- oration of the solvent for ten seconds. The bonding agent was cured with a Valo Curing Light (Ultradent) fortensecondsutilisingaValoProxiballLens(Fig.10). The Macro-Lock X-RO segments are verified for fit over the three canal orifices, and then coated with MPabondingagent,whichwascuredfortenseconds (Fig. 11). Cosmecore (Cosmedent) A2 is injected into thepulpchamberonehalfwayuptheocclusalheight of the clinical crown (Fig. 12). The Macro-Lock X-RO segments are inserted into the Cosmecore followed bya10secondcurewiththeValo(Fig.13).Therestof theocclusalaccessopeningisfilledwiththeCosme- core and thoroughly cured with the Valo for 20 sec- onds.Figure14isthefinalpost-operativeradiograph showingtheplacementofthefibresegmentsintothe core. The final restoration of the occlusal access openingisshowninFigure15aftertrimmingandoc- clusal adjustment. The endodontically treated tooth is now ready for a final restoration. Thisarticlehasrecommendedrestoringtheteeth thatmeetthecriteriafornotneedingtheplacement of fibre posts because of sufficient remaining tooth structure, with the use of multiple fibre post seg- mentsplacedintothedual-curecompositecoresof endodonticallytreatedteethbasedontheaboveev- idence.Thiswilldecreasetheoverallpolymerisation contraction and stress formation, thereby reducing occlusalmicroleakage,whileatthesame,timedriv- ing the dual-cure composite to a better overall cure or conversion for better physical properties._ TheauthorswishtothankMrs.LauraDelellisforherwork increatingthefiguresusedinthisarticle. Editorial note: A complete list of references is available fromthepublisher. This article is reprinted with permission from Oral Health DentalJournal(May2014). Fig. 15_Occlusal view of the final restoration, trimmed and adjusted to the occlusion. The tooth is now ready for a full coverage crown or onlay to protect the clinical crack. roots1_2015 Dr Leendert (Len Boksman) DDS,BSc,FADI, FICD,is retired and a free lance consultant to various dental manufacturers.He can be reached at lenpat28@gmail.com Dr Gary Glassman DDS, FRCD(C)The author of numerous publications,Dr Glassman lectures glob- ally on endodontics,is on staff at the University of Toronto,Faculty of Dentistry in the graduate depart- ment of endodontics,and isAdjunct Professor of Dentistry and Director of Endodontic Programming for the University ofTechnology,Kingston,Jamaica. He can be reached at gary@rootcanals.ca. _about the authors roots Fig. 15