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CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 125-129

A judicious restorative approach for management of fractured anterior tooth: Report of three cases


Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication17-Nov-2014

Correspondence Address:
N B Nagaveni
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-0149.144857

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  Abstract 

Anterior crown fractures are common form of traumatic dental injuries that mainly affect the maxillary central incisors, in children and teenagers. During their first dental visit, these patients with trauma are quite apprehensive because of impaired functions, esthetics and phonetics. The advances in adhesive dentistry have allowed dentists to use the patient's own fragment to restore the fractured tooth if the fragment is available. Reattachment is such an ultraconservative technique which provides safe, fast, and esthetically pleasing results with immediate restoration of function and phonetics. This paper discusses three cases in which fragment reattachment was done using a different combination of techniques viz. simple reattachment, circumferential bevel and internal dentinal groove.

Keywords: Adhesive dentistry, anterior crown fractures, reattachment, tooth fragment


How to cite this article:
Nagaveni N B, Pathak S, Poornima P, Roshan N M. A judicious restorative approach for management of fractured anterior tooth: Report of three cases . Niger J Exp Clin Biosci 2014;2:125-9

How to cite this URL:
Nagaveni N B, Pathak S, Poornima P, Roshan N M. A judicious restorative approach for management of fractured anterior tooth: Report of three cases . Niger J Exp Clin Biosci [serial online] 2014 [cited 2021 May 12];2:125-9. Available from: https://www.njecbonline.org/text.asp?2014/2/2/125/144857


  Introduction Top


Traumatic tooth fractures are a common reason for seeking dental treatment. [1] It has long been estimated that at least 25% of those under the age of 18 years will present with at least one fractured anterior tooth due to trauma. [2] Dental injuries occur more frequently in boys than in girls because of their active participation in extracurricular activities. [1] Prevalence of trauma to maxillary incisors accounts for about 37% due to their anterior positioning and protrusion caused by the eruptive pattern. [2] Dental trauma, usually, affect only a single tooth; however, certain trauma types such as automobile accidents and sports injuries involve multiple tooth injuries. Anterior teeth trauma is a tragic experience, which requires immediate attention not only due to damage to the dentition, but also because of the psychological impact it may have on both patient and parents. [3]

Various methods and techniques have been employed to restore fractured teeth, which include pin retained resin, orthodontic bands, stainless steel crowns, porcelain jacket crowns, and complex ceramic restorations. However, all these techniques require significant tooth preparation and are not esthetically adequate; moreover, they cannot be used in an emergency aesthetic situation. [1]

One of the options for managing coronal tooth fractures, especially when there is no or minimal violation of the biological width, is the reattachment of the dental fragment when it is available. [4] This technique permits immediate treatment of the injured tooth, while avoiding wear on the remaining structure, affording greater durability by preserving the natural tooth's wear resistance, and maintaining shape, function, and surface texture. [2]

Presented here are three case reports in which the fracture segments were reattached using three different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.


  Case reports Top


Case 1

A 12-year-old boy, sustained trauma in his maxillary right center incisor due to hit on a friend's head 16 h back, had reported to our Department. No significant hard or soft tissue injury, other than tooth fracture, was observed. Clinical and radiographical examination revealed Ellis class III fracture (involvement of enamel and dentin compromising the pulp) [Figure 1]. After adequately anesthetizing and isolating the tooth, the fractured coronal fragment of the tooth was removed slowly [Figure 2]. Mild bleeding was observed, which was controlled with wet cotton pellets and manual pressure. An immediate endodontic intervention, followed by bonding of the fractured segment using the acid etch technique was decided. Single-visit endodontics was performed for the fractured tooth. An access cavity was prepared, and pulp extirpation was performed with the help of barbed broaches. After working length determination, biomechanical preparation was carried out with the help of K-files using the step-back technique. Copious irrigation of the root canal was intermittently done with sodium hypochlorite and normal saline. The canal was dried with absorbent point and was obturated with Gutta-percha points and Zinc oxide-eugenol sealer using the lateral condensation technique [Figure 3]. The pulp chamber was then partially filled with restorative glass ionomer cement. The tooth fragment and the remaining tooth structure were prepared for bonding. The tooth fragment was disinfected with sodium hypochlorite solution and then rinsed properly with water. An enamel bevel was prepared all around the remaining tooth structure as well as the fractured margin of the segment and the fragment was re-approximated to check its fit. Additional two internal dentinal grooves were prepared vertically within the dentine of the fractured fragment part using straight fissure carbide bur (#56), which approximated the access cavity prepared for endodontic therapy of the remaining tooth structure [Figure 2]. Acid etching of the access cavity and the approximating surface of the tooth segment was carried out for 15 s with 37% phosphoric acid (Scotchbond™; 3M ESPE) and thoroughly rinsed with air-water spray for 60 s. Excess water was removed with a brief jet of air and hence that the surface was left visibly wet. Bonding agent (Adper™ Single Bond 2; 3M ESPE) was then subsequently applied and light cured using an LED unit (Elipar™ 2500; 3M ESPE) with a 900 Mw/cm 2 output for 10 s. The access cavity was filled with composite resin (Filtek™ Supreme Ultra; 3M ESPE) in small increments and light-cured for 40 s for each increment. Then, flowable composite (Filtek™ Supreme Ultra; 3M ESPE) was applied into the dentinal groove and on the approximating surfaces of the fragment and the remaining tooth. Both the fragments were re-approximated and light-cured for 40 s each from the buccal and lingual aspects of the tooth. Flowable composite was applied over the bevel all around the tooth and was light cured appropriately. Final finishing and polishing was done 72 h after the restorative procedure using abrasive disks (Sof-Lex; 3M ESPE) and polishing paste (Prisma Gloss; Densply) [Figure 3]. The patient came for recall visit after 1, 3 and 6 months and the tooth was found to be intact and functional inside the oral cavity [Figure 8].
Figure 1: Preoperative records

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Figure 2: After removal of fractured fragment and groove placement

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Figure 3: Postoperative records

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Case 2

A 9-year-old girl reported to our Department with sustained trauma in her maxillary right center incisor due to fall while playing 20 h back. No significant hard or soft tissue injury, other than tooth fracture, was observed. Clinical and radiographic examination revealed fracture involving enamel and dentin compromising the pulp (Ellis class III fracture) [Figure 4]. The child brought the broken tooth fragment in handkerchief that was confirming adequately to the fractured right central incisor. Tooth fragment did not display any color difference compared with the remaining structure with only minor loss of tooth structure between remaining structure and fragment [Figure 4]. Single-visit endodontics was performed for the fractured tooth as described in case 1 [Figure 5]. The pulp chamber was then partially filled with restorative glass ionomer cement. The tooth fragment and the remaining tooth structure were prepared for bonding. The tooth fragment was disinfected with sodium hypochlorite solution and then rinsed properly with water. An enamel bevel was prepared all around the remaining tooth structure as well as the fractured margin of the segment and the fragment was re-approximated to check its fit. Acid etching of the access cavity and the approximating surface of the tooth segment was carried out for 15 s with 37% phosphoric acid (Scotchbond™; 3M ESPE) and thoroughly rinsed with air-water spray for 60 s. Excess water was removed with a brief jet of air so that the surface was left visibly wet. Bonding agent (Adper™ Single Bond 2; 3M ESPE) was then subsequently applied and light cured using an LED unit (Elipar™ 2500; 3M ESPE) with a 900 Mw/cm 2 output for 10 s. The access cavity was filled with composite resin (Filtek™ Supreme Ultra; 3M ESPE) in small increments and light-cured for 40 s for each increment. Then, flowable composite (Filtek™ Supreme Ultra; 3M ESPE) was applied on the approximating surfaces of the fragment and the remaining tooth. Both the fragments were re-approximated and light cured for 40 s each from the buccal and lingual aspects of the tooth. Flowable composite was applied over the bevel all around the tooth and was light cured appropriately. Final finishing and polishing was done 72 h after the restorative procedure using abrasive disks (Sof-Lex; 3M ESPE) and polishing paste (Prisma Gloss; Densply) [Figure 5]. The tooth was intact and functional inside the oral cavity when patient came for recall visit after 1, 3 and 6 months [Figure 8].
Figure 4: Pre-operative records

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Figure 5: Post-operative records

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Case 3

A 13-year-old boy reported to our Department with fracture of the maxillary left central incisor as the result of the fall from bicycle 24 h back. The tooth fragment was placed in a container of water shortly after the accident. Clinical and radiographic examination revealed the crown fracture involving enamel and dentin but had not compromised the pulp or periodontal tissue (Ellis class II fracture) [Figure 6]. No significant hard or soft tissue injury, other than tooth fracture, was observed. Tooth fragment did not display any color difference compared to the remaining structure with only minor loss of tooth structure between remaining structure and fragment [Figure 6]. Given the excellent state of the dental fragment, a decision was made to use the bonding procedure. The tooth fragment was disinfected with sodium hypochlorite solution and then rinsed properly with water. Acid etching of the access cavity and the approximating surface of the tooth segment was carried out for 15 s with 37% phosphoric acid (Scotchbond™; 3M ESPE) and thoroughly rinsed with air-water spray for 60 s. Excess water was removed with a brief jet of air so that the surface was left visibly wet. Bonding agent (Adper™ Single Bond 2; 3M ESPE) was then subsequently applied and light cured using an LED unit (Elipar™ 2500; 3M ESPE) with a 900 Mw/cm 2 output for 10 s. Then, flowable composite (Filtek™ Supreme Ultra; 3M ESPE) was applied on the approximating surfaces of the fragment and the remaining tooth. Both the fragments were re-approximated and light-cured for 40 s each from the buccal and lingual aspects of the tooth. Final finishing and polishing was done 72 h after the restorative procedure using abrasive disks (Sof-Lex; 3M ESPE) and polishing paste (Prisma Gloss; Densply) [Figure 7]. The patient came for follow up after 1, 3 and 6 months and the tooth was intact and functional inside the oral cavity [Figure 8].
Figure 6: Pre-operative records

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Figure 7: Post-operative records

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Figure 8: Follow-up after 6 months

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  Discussion Top


Functional, esthetic, and biologic restoration of the fractured anterior teeth is often a difficult task for the dentist. When an intact fragment is available, fragment reattachment may offer the most functional and esthetic treatment option. [3] Reattachment of fragment may offer the following advantages:

  1. Better esthetics, because shade match and translucency will be perfect.
  2. Incisal edge will wear at the same rate as the adjacent tooth.
  3. Replacement of fractured portion may be less time consuming than provisional restoration.
  4. A positive emotional and social response from the patient for preservation of natural tooth structure.


Various authors have recommended extra preparation of the fractured fragment and the remaining tooth structure to enhance the bonding between them. [4]

Reis et al. have shown that simple reattachment (without using any additional retentive technique) recovered only 37.1% of intact tooth fracture resistance, whereas the buccal chamfer recovered 60.6% and the overcontour and internal groove technique nearly reached intact tooth fracture strength recovering 97.2% and 90.5%, respectively. [5]

In addition to the variety of techniques used, some researchers have made the use of combinations of these. Simonsen used the association of a V-shaped internal groove and lingual enamel beveling, whereas Burke used a combination of an internal dentin groove and the circumferential beveling of enamel margins. [6],[7]

In case I, a combination of circumferential enamel bevel and internal dentin groove was given after performing the endodontic therapy of the tooth. The retention increases after beveling of the enamel rod ends which favors adhesion and provides better aesthetics. [8]

In the case of complicated crown fractures, where endodontic therapy is performed prior to the reattachment procedure, the pulp chamber can be used to give greater retention to the fragment. [9],[10] In this case, two internal dentin grooves were prepared in the fragment such that it opposes the pulp chamber. When the pulp chamber and groove were filled with composite and light cured, it simulated a short resin post extending into the fragment segment, thereby providing additional retention and support. [11]

In case II, circumferential enamel bevel was the only additional retentive feature incorporated in the attachment technique. Presence of circumferential bevel at the margins of the fragment increased the fracture resistance of the fragment as concluded in an animal study. Increased retention is attributed due to the higher bonding area obtained after preparing bevel at the enamel interface. [12] The only concern with the enamel bevel is the discoloration of composite at the junction, which may occur after some time. [4]

In case III, none of the additional retentive features was given to increase retention between tooth and the fragment. Few studies have concluded similar fracture resistance between tooth and the fragment, even when the fragment was only bonded to the remaining dental structure. [13],[14]

In our case series, the restored teeth were found to be in aesthetically and functionally good condition at all the recall visits, suggesting the clinical success of all the three different techniques.


  Conclusion Top


As with conventional restoration, fractured fragment reattachment success hinges on proper case selection and strict adherence to sound principles of periodontal-endodontic therapies, the techniques and materials for modern adhesive dentistry.

With the materials available today, in conjunction with an appropriate technique, aesthetic results can be achieved with predictable outcomes in less chair side time.

Thus, reattachment of a tooth fragment is a viable technique that restores function and esthetics with a very conservative approach, and should be considered when treating young patients with coronal fractures of the anterior teeth.

 
  References Top

1.
Vishwanath B, Faizudin U, Jayadev M, Shravani S. Reattachment of coronal tooth fragment: Regaining back to normal. Case Rep Dent 2013;2013:286186.  Back to cited text no. 1
    
2.
Kina M, Ribeiro LG, Monteiro S Jr, de Andrada MA. Fragment bonding of fractured anterior teeth: Case report. Quintessence Int 2010;41:459-61.  Back to cited text no. 2
    
3.
Patni P, Jain D, Goel G. A holistic approach to management of fractured teeth fragments: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e70-4.  Back to cited text no. 3
    
4.
Goenka P, Sarawgi A, Dutta S. A conservative approach toward restoration of fractured anterior tooth. Contemp Clin Dent 2012;3:S67-70.  Back to cited text no. 4
    
5.
Reis A, Francci C, Loguercio AD, Carrilho MR, Rodriques Filho LE. Re-attachment of anterior fractured teeth: Fracture strength using different techniques. Oper Dent 2001;26:287-94.  Back to cited text no. 5
    
6.
Simonsen RJ. Restoration of a fractured central incisor using original tooth fragment. J Am Dent Assoc 1982;105:646-8.  Back to cited text no. 6
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7.
Burke FJ. Reattachment of a fractured central incisor tooth fragment. Br Dent J 1991;170:223-5.  Back to cited text no. 7
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8.
Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured teeth: A review of literature regarding techniques and materials. Oper Dent 2004;29:226-33.  Back to cited text no. 8
    
9.
Amir E, Bar-Gil B, Sarnat H. Restoration of fractured immature maxillary central incisors using the crown fragments. Pediatr Dent 1986;8:285-8.  Back to cited text no. 9
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10.
Diangelis AJ, Jungbluth M. Reattaching fractured tooth segments: An esthetic alternative. J Am Dent Assoc 1992;123:58-63.  Back to cited text no. 10
    
11.
Goenka P, Dutta S, Marwah N. Biological approach for management of anterior tooth trauma: Triple case report. J Indian Soc Pedod Prev Dent 2011;29:180-6.  Back to cited text no. 11
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12.
Demarco FF, Fay RM, Pinzon LM, Powers JM. Fracture resistance of re-attached coronal fragments - Influence of different adhesive materials and bevel preparation. Dent Traumatol 2004;20:157-63.  Back to cited text no. 12
    
13.
Farik B, Munksgaard EC, Kreiborg S, Andreasen JO. Adhesive bonding of fragmented anterior teeth. Endod Dent Traumatol 1998;14:119-23.  Back to cited text no. 13
    
14.
Farik B, Munksgaard EC, Andreasen JO, Kreiborg S. Fractured teeth bonded with dentin adhesives with and without unfilled resin. Dent Traumatol 2002;18:66-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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