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Table of Contents
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 3  |  Page : 146-150

Conservative approach for natural restoration of fractured anterior teeth: A review and case series


Department of Conservative dentistry and Endodontics, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication7-Mar-2017

Correspondence Address:
Pradeep Gade
Department of Conservative dentistry and Endodontics, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.201653

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   Abstract 

Coronal tooth fractures are most common in anterior teeth, especially in maxillary teeth due to their anatomical position. They create serious esthetic and psychological problems for the patient. Esthetical rehabilitation of fractured anterior teeth is one of the greatest challenges to a dentist. Traditionally, such traumatized teeth are restored with composite resins, but the main disadvantage is variable wear and color mismatch. Reattachment of fractured fragments provides faster natural esthetics, positive psychological response, economical and is the relatively simple procedure. In the recent years, number of techniques and materials are evolved for reattaching the fractured fragments such as flowable composites, dual cure resin cements, fiber posts with self-etch adhesive cement. In this review and case series, different approaches for re-bonding the permanent incisors have been described. All the advantages are mentioned in the literature are summarized to provide a good clinical approach for this innovative procedure.
Clinical Relevance to Interdisciplinary Dentistry
Reattaching the fractured tooth fragments gives a viable conservative option for the clinician because it restores tooth function and esthetics with the use of a very conservative and cost-effective approach.

Keywords: Dual-cure resin cement, fiber post, reattachment


How to cite this article:
Gade P, Mandava J, Varma U L, Konagala RK. Conservative approach for natural restoration of fractured anterior teeth: A review and case series. J Interdiscip Dentistry 2016;6:146-50

How to cite this URL:
Gade P, Mandava J, Varma U L, Konagala RK. Conservative approach for natural restoration of fractured anterior teeth: A review and case series. J Interdiscip Dentistry [serial online] 2016 [cited 2019 Oct 15];6:146-50. Available from: http://www.jidonline.com/text.asp?2016/6/3/146/201653


   Introduction Top


Majority of dental injuries involves the anterior teeth, especially the maxillary incisors (because of its position in the arch), whereas the mandibular central incisors and the maxillary lateral incisors are less frequently involved. Dental injuries usually affect only a single tooth; however, certain trauma types such as automobile accidents and sports injuries involve multiple tooth injuries.[1]Traumatized anterior teeth require quick functional and esthetic repair. Traditionally, such injuries have been restored with composite resins. They have the primary disadvantage of color mismatch and variable wear. There is, however, no synthetic restorative material that can replicate the esthetic characteristics or color stability of the natural tooth structure.[2] Therefore, if a broken fragment is available, the restoration of the tooth using its own fragment has been suggested as an alternative.[3]

Several treatment options for fractured teeth include reattachment, fragment removal and immediate restoration, restoration after gingivectomy or osteotomy, forced orthodontic extrusion, forced surgical extrusion, ceramic crowns, and resin composite restoration with and without pins.[4],[5],[6],[7]

Although the reattachment procedure was there since many years, documentation was minimal due to lack of awareness or knowledge. The purpose of this article is to discuss the considerations for dental fragment reattachment techniques and to present different options available to treat such cases with clinical success.


   Case Reports Top


Case report 1

A 75-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, with the chief complaint of broken upper front tooth 2 hr back, following trauma while chewing hard food. Clinical examination revealed a fracture line with pulp exposure on the labial surface of the left maxillary central incisor and the fracture was not evident palatally [Figure 1]a. Radiographic examination revealed an oblique fracture labio-palatally [Figure 1]b. [Figure 1]c Preoperative radiograph reveals absence of periapical pathology. As the patient's medical history was noncontributory, root canal treatment followed by immediate reattachment of the dental fragment was planned. Patient received anesthesia using lignocaine 2% with adrenaline. The fracture segment was completely removed and preserved in normal saline to prevent dehydration of the tooth fragment [Figure 1]f. A single visit root canal treatment with sectional obturation was carried out [Figure 1]d. The root canal was then prepared with ParaPost Drill (3M). A corresponding prefabricated fiber post fit was checked for coronal fragment fixation. Circumferential bevels were placed on both the fractured fragment and tooth structure. Both the surfaces were etched with 37% phosphoric acid and after rinsing and drying a dentin bonding agent (Hellibond; 3M) was applied and cured. Dual-cure resin (Rely-X) was placed in the canal and a fiber post coated with resin was placed up to proper length. Simultaneously, the coronal tooth fragment was placed onto the post, with its bonding surface and pulp cavity loaded with dual cure resin composite. Tooth fragment was placed on to position and finger pressure was applied until the composite was light-cured. A check radiograph was taken to confirm close approximation of the two tooth portions [Figure 1]e. The occlusal corrections were done, and final clinical outcome showed more than satisfying results with restored esthetics and function [Figure 1]g and [Figure 1]h. The follow-up clinical and radiographic evaluation at 3 and 12 months revealed successful reattachment procedure.
Figure 1: Reattachment of the left central incisor crown using dual cure resin cement and fiber post. (a) Labial view of the maxillary left central incisor. (b) Palatal view of the maxillary left central incisor. (c) Radiograph showing preoperative view. (d) Post space prep x ray. (e) recall radiograph. (f) Tooth fragment. (g) Labial view of maxillary left central incisor after reattachment. (h) Palatal view of maxillary left central incisor after reattachment

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Case report 2

A 22-year-old male patient reported to the Department of Endodontics with a chief complaint of broken upper front teeth. He gave a history of fall 2 days back. On examination, the maxillary right and left central incisors Were fractured [Figure 2]a. Right central incisor showed a complicated crown-root fracture where fracture was extending from the incisal edge toward the subgingival area [Figure 2]b. In the maxillary left central incisor, fracture was present in the middle third of the crown, involving the pulp and fractured fragment was not available. No mobility was present in both the teeth. One important complication of this case was the subgingival extension of the fractured margin. On probing this area during the clinical examination, it was determined that the biological width was invaded minimally [Figure 2]a. To gain access to the subgingival area, a full thickness mucoperiosteal flap was raised with an intrasulcar incision [Figure 2]d. The fractured segment was removed and kept in saline mixed with docycycline [Figure 2]c. Conventional single visit root canal treatment was performed for both 11 and 21. An internal groove was prepared with a round diamond bur in both the tooth segment and the root portion of 11 to create space for placement of resin composites. The pulp chamber, dentin, and enamel were etched with a 37% phosphoric acid gel, rinsed, and coated with an ethanol-based adhesive system (Adper Single Bond Plus, 3M ESPE) and was light cured for 20 s. Then the fractured surface of the fragment was treated with 37% phosphoric acid gel, followed by delicate rinsing. The adhesive system was then applied to the etched surface and light cured. A dual cure resin cement (RelyX U200, 3MESPE, USA) was applied to both the fragments and tooth surfaces. The fractured segment was then accurately aligned, paying attention to the fit between the segments. When the original position had been re-established, excess resin was removed, and the area was light cured for 40 s for both surfaces [Figure 2]c. The interrupted sutures were given after flap approximation [Figure 2]e. One week later, the sutures were removed, and clinical examination revealed proper healing. The follow up radiographic evaluation at 6 months revealed successful reattachment procedure [Figure 2]f.
Figure 2: Surgical reattachment of fractured coronal fragment using resin cement. (a) Labial view of maxillary incisor. (b) Preoperative radiograph. (c) Tooth fragment. (d) Reattachment of fractured fragment done after raising labial flap. (e) Immediate postoperative after placing the sutures. (f) Postoperative radiograph

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Case report 3

A male patient aged 29 years reported to the department, with a chief complaint of pain and mobility of an upper front tooth since 3 days. Maxillary right lateral incisor was fractured in a labio-palatal direction with displacement of the fragment [Figure 3]a. Labial and palatal view of fractured tooth segment [Figure 3]b and [Figure 3]c. Intraoral periapical radiograph of maxillary lateral incisor revealed periapical pathology indicating existing pulpal necrosis of 12 [Figure 3]d. After administration of local anesthesia, single-visit root canal treatment was performed. The canal was obturated with gutta-percha and AH-Plus sealer [Figure 3]e. Grooves were placed on the tooth surface to be reattached and fracture tooth surface. Reattachment was done using dual cure resin cement (RelyX Ultimate Adhesive Resin Cement, 3MESPE, USA). The occlusion was carefully checked and adjusted. Instructions were given as to avoid heavy biting forces on these teeth and to follow regular oral hygiene practices. Recall visits at 12 months revealed clinical and radiographic good outcome [Figure 3]f and [Figure 3]g.
Figure 3: Reattachment of fractured crown using internal grooves and coronoradicular core. (a) Labial view of intact maxillary right lateral incisor. (b) Labial view of tooth fragment. (c) Palatal view of tooth fragment. (d) Preoperative radiograph. (e) Immediate postoperative radiograph. (f) Postoperative radiograph after 12 months follow-up. (g) 1-year follow-up photograph

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   Discussion Top


The reattachment technique was first described in 1964 by Chosack and Eildeman who considered it at that time as a provisional restoration, due to the low bond strength values achieved by the adhesive systems.[8] The techniques described in these case reports are reasonably simple, while restoring function and esthetics with a very conservative approach. However, the professional has to keep in mind that a dry and clean working field and the proper use of bonding protocol and resin cements is the key to achieve success in adhesive dentistry.[9]

With the fracture line extending below the alveolar crestal bone orthodontic extrusion or surgical extrusion is recommended before the restoration. But with the fracture lying above the alveolar bone crest, reattachment of the fractured fragment is a more viable option. Early retrospective studies indicate that the clinical performance of fiber post is promising and the failure rate recorded is 3.2% over a period of up to 4 years.[10]

In case 1, a fiber post extended into the pulp chamber of the coronal fragment was used for auxiliary retention. Fiber post was preferred over a metallic post because of their esthetic appearance and their modulus of elasticity is similar to that of root dentin. This results in less stress concentration on the root and thus reducing the incidence of root fracture. Using glass fiber post with composite core and with recent advances in adhesive techniques and materials one can create a monoblock, a multi-layered structure with no inherent weak interlayer interfaces. The unique advantage of this system is that it reinforces the teeth structure through this concept.[11]

Hence, in case 3, an external chamfer technique was used. Moreover, in this technique, a chamfer is placed after the fragment is reattached and thus there is minimal loss of fit as compared to techniques in which the fragment is manipulated before bonding.[12] Trope et al. in 1985 showed that endodontically treated teeth can be reinforced with the use of resin composite restoration. The flowable composite not only reinforces the tooth but also helps in achieving higher bond strengths of the fractured segments. Flowable composite also minimizes the inclusion of air voids. Several studies have shown that replacement of composite using dentin bonding agents provides strength to the root.[13] When they are used along with resin cement, there is decreased microleakage. The resin luting cements exhibits good bond strength to the tooth, easy to use and predictable. Resin based sealers are used to obturate the canals in teeth planned for restoration of light posts as eugenol based sealers may inhibit the set of resin cements.[14]

The successful reattachment depends on fragment's extent of dehydration. The longer the fragment remains dehydrated, poorer the tooth's strength will be. Performance of the technique becomes complicated when there is more than one fragment that must be connected to each other and then reattached to the tooth.[15]

If the fracture line is supragingival, the procedure for reattachment will be straight forward. However, when the fracture site is subgingival or intraosseous, orthodontic extrusion with a postretained crown may be necessary. Alternatively, surgical techniques such as electrosurgery, elevation of tissue flap, clinical crown lengthening surgery with removal of alveolar bone, and removal of gingival overgrowth for access to the fractured site are all viable methods for bonding fractured component.

In case report 2, a full-thickness buccolingual mucoperiosteal flap was raised by making an intrasulcular incision on the facial and lingual surfaces of the fractured teeth as well as half of the surfaces of the adjacent teeth. On direct inspection, we determined that the fracture line did not violate the alveolar bone, and thus osseous recontouring was not needed. Maintenance of the biological width is of utmost importance for a long lasting and predictable restorative treatment. Elevating a flap during the surgical procedure exposed the fracture line and improved access for removing the excess cement and finishing the area. The composite resin has a favorable subgingival reaction with the formation of junctional epithelium and connective tissue adjacent to subgingival restorative materials in humans. However, considering the proper contour and marginal adaptation of subgingival restoration is of prime importance, bonding of original fragment permits subgingival healing with long thick functional epithelium.

However, limitations of tooth reattachment include those associated with dental adhesion, in particular, control of operating field from contamination and force application, particularly indirect or shear forces working in directions where bonding forces are weakest.


   Conclusion Top


With advancement in dental bonding technology, it is now possible to achieve excellent results with reattachment of fractured tooth fragments, provided that the biologic factors and selection of materials are logically assessed and managed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Andreasen JO, Andreasen F, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. St. Louis, MO: Mosby; 1994.  Back to cited text no. 1
    
2.
Terry DA. Adhesive reattachment of a tooth fragment: The biological restoration. Pract Proced Aesthet Dent 2003;15:403-9.  Back to cited text no. 2
    
3.
Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of success in the reattachment of coronal fractures. Dent Traumatol 2008;24:151-8.  Back to cited text no. 3
    
4.
Ertugrul F, Eden E, Ilgenli T. Multidisciplinary treatment of complicated subgingivally fractured permanent central incisors: Two case reports. Dent Traumatol 2008;24:e61-6.  Back to cited text no. 4
    
5.
Eden E, Yanar SC, Sönmez S. Reattachment of subgingivally fractured central incisor with an open apex. Dent Traumatol 2007;23:184-9.  Back to cited text no. 5
    
6.
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. 6
    
7.
Durkan RK, Ozel MB, Celik D, Bagis B. The restoration of a maxillary central incisor fracture with the original crown fragment using a glass fiber-reinforced post: A clinical report. Dent Traumatol 2008;24:e71-5.  Back to cited text no. 7
    
8.
Chosack A, Eildeman E. Rehabilitation of fractured incisor using the patient's natural crown. Case report. J Dent Child 1964;31:19-21.  Back to cited text no. 8
    
9.
Macedo GV, Diaz PI, De O Fernandes CA, Ritter AV. Reattachment of anterior teeth fragments: A conservative approach. J Esthet Restor Dent 2008;20:5-18.  Back to cited text no. 9
    
10.
Ferrari M, Vichi A, Mannocci F, Mason PN. Retrospective study of the clinical performance of fiber posts. Am J Dent 2000;13:9B-13B.  Back to cited text no. 10
    
11.
Tay FR, Pashley DH. Monoblocks in root canals: A hypothetical or a tangible goal. J Endod 2007;33:391-8.  Back to cited text no. 11
    
12.
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. 12
    
13.
Andreasen JO. Adhesive dentistry applied to the treatment of traumatic dental injuries. Oper Dent 2001;26:328-35.  Back to cited text no. 13
    
14.
Trope M, Maltz DO, Tronstad L. Resistance to fracture of restored endodontically treated teeth. Endod Dent Traumatol 1985;1:163-8.  Back to cited text no. 14
    
15.
Hall DA. Restoration of a shattered tooth. J Am Dent Assoc 1998;129:105-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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