Dr. Rafeza Sultana
MS-
Resident, phase-B
Dept. of
Conservative Dentistry & Endodontics
Bangabandhu
Sheikh Mujib Medical University, Dhaka.
Abstract:
Dental
trauma is such a situation where in the patient is affected both socially and
psychologically. Such patients are quite apprehensive because of impaired
function, esthetics and phonetics. The prime objective while handling such
cases is immediate restoration of function, esthetics and phonetics as well.
The advances in adhesive dentistry have allowed dentist to use the patient’s
own fragment to restore the fractured tooth. Reattachment of tooth fragment is
such an ultraconservative technique which provides safe, fast &
esthetically pleasing results. This case report presents a 27 year male patient
with a complicated crown fracture of maxillary right central incisor tooth;
where fracture fragment luted with reattachment technique. The procedure used
to repair the fracture fragment included endodontic treatment & after root
canal obturation a glass fiber post is used for reinforcement and fragment was
luted with composite resin. On word assessment showed a stable reattachment,
good esthetic and periodontal health.
Key word: Coronal fracture, fragment reattachment,
Composite resin, fiber post.
Introduction:
Almost
every dental expert is familiar with the patient having traumatized tooth at
their regular practice. The most affected teeth are maxillary incisors due to
their anterior position and protrusion and the common etiological factor of
crown or crown root fracture in the permanent dentition are injuries caused by
fall, contact sports, automobile accident and foreign body striking the teeth.
Esthetic rehabilitation of crown fractures of the maxillary anterior teeth is
one of the greatest challenges to the dental specialist. The patients are very
conscious about their appearance where as the specialist has to consider long
term biological function of that tooth in addition to esthetic. Traditionally
such injuries have been restored with composite resin1, but they have some disadvantages of
colour match and variable wear.6
On the other hand reattachment of fractured fragment may offer following
advantages (1) Better esthetic and achievement of lifelike translucency (2)
Require less time (3) A positive emotional and social response from the
patient’s side5 (4) Relatively
inexpensive procedure.
Moreover
several factors influence the management of coronal tooth fracture including
extend of fracture, pattern of fracture and restorability of fractured tooth,
secondary trauma, presence/absence of fractured tooth fragment and it’s
condition for use, occlusion, esthetic, finances and prognosis.3,15,18 With the recent improvement in the
dental materials, resin based restorative materials with the use of tooth
coloured fiber reinforced polymer posts are of choice for such treatment
protocol. Because the biomechanical properties of fiber reinforced polymer post
are reported close to those of dentin8
like esthetic, bonding to tooth structure, modulus of elasticity and cause
fewer tooth fracture.20
If
a broken tooth fragment is available and in a good condition the restoration of
the tooth using its won fragment has been suggested.21
Case Report:
A
27 year old male patient reported to the Dept. of Conservative Dentistry and
Endodontics BSMMU with the chief complaint of broken upper front tooth
following trauma due to hard substance striking while taking food 7 days back.
His
medical history was all right. Clinical examination revealed a clean fracture
horizontally mesial to distal and angulated incisally from palatal to labial
with pulp exposure on the labial surface of right maxillary central incisor.
Fracture was not evident labially. There no apparent trauma to the adjacent
teeth and soft tissues. On radiographic examination revealed an oblique
fracture palato-labially. After routine history taking, examination and based
upon patient’s desire, a treatment plan was formulated that included endodontic
treatment and reattachment of fractured portion of tooth with composite resin
using a fiber reinforced post.
In
the first appointment a single visit endodontic treatment was performed. Under
local anesthesia, the pulp was extirpated and the working length was determined
by working length measuring X-ray. Then the root canal was prepared as standardized
technique at 17mm working length up to 70 H file and obturated with Gutta
Percha by lateral condensation technique.
The
fractured fragment was completely separated, dehydrated and chalky white in
appearance. In order to prevent dehydration and to get the natural appearance,
the fractured fragment was preserved in normal saline for 7 days. After 7 days,
in the next visit the GP was partially removed by pesos-reamer (No-1) leaving 5
mm GP at the apex to maintain a tight apical seal. A post hole was prepared
within the canal and a perfect diameter sized glass fiber composit
post(Glassix, Nordin) was cemented with the root canal using glass ionomer luting
cement (GC corporation). An internal groove was made both in fractured fragment
and the palatal aspect of the tooth where the fiber post and composite will
occupy. Acid etching was done on both the fragment and the tooth using 37%
orthofhosforic acid for 15 seconds and thoroughly rinse off. A bonding agent
(Beautibond, sofu) was applied to both the substrates and cured according to
manufacturer instruction.
Then the fragment was reattached with flowable
composite resin (Beautifil flow, Sofu). The excess resin was removed with an
excavator and light cured for 30 seconds from both buccal and palatal aspect.
Final finishing and polishing was done. Occlusion was cheeked and post
operating instructions were given and patient was recalled after 7 days for
evaluation. Clinical and radiological examination carried out after 1 month, 3
months, 6 months and 1 year to confirm the satisfactory esthetic and functional
outcome of the treatment with no associated endodontic or periodontal problem.
Discussion:
Up
to date, a lot of deferent approaches were proposed for treatment of fractured
tooth depending on location of the fracture such as (1) Reattachment of the
fractured fragment (2) Composite restoration (3) Orthodontic extrusion (4)
Surgical extrusion (5) Crown lengthening.11
In recent years due to
remarkable advancements of adhesive systems and resin composites, it is now
possible to achieve excellent results with reattachment of tooth fragments
provided that the biological factors, materials, and techniques are logically
assessed and managed.16 As with the conventional restoration, restorative success depends
on proper case selection, strict adherence to sound principles of periodontal
and endodontic therapies, and the techniques and materials for modern adhesive
dentistry.10,12,14
In the presented case of
complicated crown fracture requiring endodontic therapy, the fractured fragment
was available and reattachment of the fragment with fiber post is performed to
retain the fractured segment and reduce the stress on the luting material. The posts
interlock the two separate fragments and minimize the stress on the remaining
tooth structure. The use of the natural tooth substance offers a conservative,
esthetic, and economical option that provides good and long lasting esthetics,
restores function, results in a positive psychological response, and is
certainly a simple procedure. Adhesive post is used as it has the potential for
increased retention, is more flexible, and has modulus of elasticity
approximately same as dentin, and when bonded with resin cement it distributes
forces evenly along the root.17
The most common
complication of post and core system is debonding;4 another reason for
failure is root fracture.9 Restoration with cast metal posts can cause wedging forces
coronally that may result in irreversible failure because of fracture of an
already weakened root.2 Whereas fiber-reinforced composite resin post has demonstrated
negligible root fracture. Studies have indicated that dentin-bonded resin
post-core restorations provide significantly resistance to fracture than
cemented custom cast posts and cores.7,19 In addition; the
fiber-reinforced posts are used with minimal preparation because it uses the
undercuts and surface irregularities to increase the surface area for bonding,
thus reducing the possibility of tooth fracture during function or traumatic injury.13
Various studies reported
that sectional obturation of root canal (at the apex) and use of dual cure
resin play an important role in the successful treatment outcome of
reattachment technique. Use of a fiber post luted with dual cure resin increase
the retention of the segment and provides a monoblock effect by locking the
core material (fiber post) with the dentinal wall of root canal without leaving
any gaps.
Most concerns about
reattachment technique have been directed towards the fractured strength of the
restored tooth. There are several reinforcement techniques adapted to
strengthen the tooth structures like – i) Circumferential bevel, ii) External
chamfer, iii) ‘V’ shaped bevel, iv) Placement of internal grooves, v)
superficial over contour of restorative material over the fracture line and
pulp chamber, in case of complicated fracture.18
The clinician must
consider that a dry and clean working field and proper use of bonding protocols
and bonding materials is the key to achieve success in adhesive dentistry.
Conclusion:
Because of larger
incidence of trauma to dental tissues and their supporting structures, it is
important to have proper knowledge of the techniques available and their
indications, along with risk benefit ratio. The reattachment of the tooth
fragment is possible only when the fragment is available and can be improved
with different adhesive techniques and restorative materials. The main concern
is to educate the population to preserve the fractured fragment and seek immediate
dental care.
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Figures
of various steps of reattachment technique.
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| Fig: Pre-Operative photograph |
.png) |
| Fig: Fracture fragment (labial view) |
.png) |
| Fig: Fracture fragment (palatal view) |
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| Fig: Fiber reinforced post |
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| Fig: post placement |
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| Fig: post placement |
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| Fig: Groove preparation |
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| Fig: Trial of fragment reattachment |
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| Fig: Trial of fragment reattachment |
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| Fig: Check occlusion |
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| Fig: Light curing of composite resin |
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| Fig: Light curing of composite resin |
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| Fig: Post operative occlusion check |
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| Fig: After treatment |
Radiographic
assessment.
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| Fig: Pre-operative |
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| Fig: per-operative |
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| Fig: per-operative |
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| Fig: post-operative |
