Dental Health: Reattachment of fractured coronal tooth fragment of maxillary central incisor by using fiber reinforced post- Regaining back to normal.

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.