|Year : 2016 | Volume
| Issue : 1 | Page : 64-67
Management of anterior tooth trauma: Two case reports
Suman Kaushik, Ritu Sharma, Vikram Sharma, Gaurav Setya, Garima Assudani, Anshul Arora
Department of Conservative and Endodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
|Date of Web Publication||21-Jun-2016|
Department of Conservative and Endodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Various treatment options may be employed for coronal fracture of anterior teeth and root, depending on the level of fracture. The following case reports highlight the anterior tooth trauma managed with reattachment of fractured segments using post and cores. In the first case, an easy and ultraconservative technique without any tooth preparation is used which involves intraradicular support, i.e., fiber post and core. In the second case, an interdisciplinary approach is used to treat the root fracture where biological width was encroached. The flap was raised to expose the fractured root with a small amount of osteoplasty so that the segments could be checked for exact fit and bonding can be done with proper isolation of the operating field. Successful esthetics and function were restored by conservative and economical means, and 6 months follow-up showed no failure of bonding or postoperative pain, indicating crown, and horizontal root fracture after trauma should not go for extraction.
Keywords: Fractured fragments; incisors; reattachment; trauma.
|How to cite this article:|
Kaushik S, Sharma R, Sharma V, Setya G, Assudani G, Arora A. Management of anterior tooth trauma: Two case reports. Endodontology 2016;28:64-7
| Introduction|| |
During any assault to the facial region, the incidence of maxillary anteriors, being injured, is 37% as they are most anteriorly placed in the arch and their protrusive eruptive pattern,  followed by maxillary laterals (16%) and mandibular central incisors. Coronal fractures can be classified as simple or complicated depending on the extent of fracture and involvement of the pulp. The incidence of complicated crown fractures ranges from 2% to 13% of all dental injuries.  An injury to the maxillary anterior region causes significant disfigurement of the patient's appearance as well as function which in turn imparts deep psychological impact. Such esthetically demanding critical scenarios require quick and logical clinical actions to restore the lost structures with most conservative and as natural as possible yet least time-consuming techniques.
Numerous techniques have been described in the literature for restoring coronal tooth fractures, majority of which are time-consuming and require extensive teeth preparations.  With the introduction of adhesion to restorative dentistry, reattachment of fractured teeth segments has become a popular technique provided the fractured fragments being available. The technique is much simpler, conservative, and time-saving while preserving the patient's own body parts and esthetics such as tooth contour and natural color and well-preserved incisal transparency.  This paper illustrates two such cases of coronal tooth fractures, managed conservatively by reattaching the fragments.
| Case Reports|| |
Case report 1
A 22-year-old young male patient reported to the Conservative and Endodontic Department with the history of trauma, the previous day, and complained of broken front teeth. After thorough clinical and radiographic examination, it was diagnosed as complicated crown-root fracture, extended subgingivally in palatal region with respect to 11 and 12 [Figure 1]a. The fractured fragments were intact and were attached subgingivally at palatal area.
|Figure 1: (a) Fractured 11, 12 extending subgingivally, (b) gingivectomy by electrocautery to expose fracture line palatally, (c) fiber posts luted, (d) intraoral periapical radiograph after segments attached with fiber post, (e) immediate postoperative, (f) 6 months postoperative|
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As the patient was young and conscious esthetically, he demanded immediate correction of the fractured teeth. The treatment options were explained to the patient, and reattachment of the fractured segments with fiber post after root canal treatment was planned with the consent of the patient.
After administration of local anesthesia, the fractured fragments were extracted atraumatically and were stored in physiological sterile saline solution to prevent dehydration. The pulp was removed with respect to both 11 and 12. One important finding of this case was the subgingival extension of the fractured margins on the palatal area of both teeth. Upon probing this area, it was determined that the biological width was not encroached, but the fracture lines were subgingival; hence, 1 mm of gingivectomy was done with electrocautery to expose the fracture lines [Figure 1]b. The root canals were prepared till 50 No. file size with 0.02 taper and using step back technique and were obturated at the apical 4 mm only (segmental obturation).
The rest of the radicular space (6 mm) was prepared for fiber post of size 2 (Radix Fiber post-DENTSPLY). The length of the post was adjusted accordingly and was 6 mm into the root. The corresponding coronal pulp chamber was prepared for the postattachment. The fiber post was luted using dual cure resin cement (Relyx-3M) and cured [Figure 1]c. The pulp chamber in the fractured segments was also etched and bonding agent was applied. The fractured segments were luted using the same resin cement and were finished and polished and radiograph captured [Figure 1]d. The occlusion was relieved w.r.t 11 and 12 in all eccentric movements. The patient was recalled for follow-up after 24 h and then after 1 week and after 1 month [Figure 1]e. At the 6 months follow-up, both teeth were esthetically functional and asymptomatic [Figure 1]f.
Case report 2
A 23-year-old young male patient reported to the Department of Conservative and Endodontics with the chief complaint of trauma and fractured upper front teeth for 24 h. On eliciting the chief complaint, it was found that the patient had a fall and had injured his front teeth. After thorough clinical and radiographic examination [Figure 2]a, diagnosis of horizontal root fracture below the cementoenamel junction with respect to 12 was made and complicated crown fracture w.r.t 11, 21. The fractured segment w.r.t 12 was intact and attached subgingivally at the palatal aspect [Figure 2]b.
|Figure 2: (a) Orthopantomogram showing horizontal root fracture with 11, (b) mobile fracture segment clinically, attached with soft tissue, (c) flap raised and osteoplasty done to expose fracture line, (d) postspace preparation in fractured segment, (e) bonding post to root stump, (f) fiber postluted, (g) fractured segment bonded, (h) site sutured, (i) intraoral periapical radiograph showing bonded segment|
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The fractured segment was removed atraumatically and was stored in normal saline to prevent dehydration. Upon probing the palatal aspect in this case, it was found that the biological width was encroached. After the bleeding had stopped, careful examination was done and was found that the fractured root piece was covered by the overlying flap and gingiva. To expose the remaining sound tooth structure and fracture line, flap technique or gingival flap displacement along with osteoplasty was planned.
Once the root piece was exposed, the fractured coronal portion was tried for its fit; excellent adaptation of the segments was observed, and immediate reattachment of the segment was planned [Figure 2]c. Immediate single sitting root canal treatment was done till 50 No. file size and step back technique after determining the length radiographically which was 9 mm. The canal was obturated only at apical 4 mm. Postspace of 5 mm was prepared to receive a fiber post of size 02 (Parapost).
The pulp chamber of corresponding fractured coronal portion was also prepared to receive the post [Figure 2]d. The root portion and the fractured segment both were etched using 37% phosphoric acid [Figure 2]e. The fiber post was cemented using resin cement [Figure 2]f; the cement was loaded into the fractured portion also and was placed exactly fitting the fractured counterpart and light cured for 2 s. After that, the excess cement was removed; complete light curing for 60 s was done on both the facial and palatal sites. The attachment was ensured by applying force so as to detach the fractured tooth segment but the segment adhered well [Figure 2]gThe patient was instructed not to bite very hard with the front teeth and was recalled after 24 h for follow-up [Figure 2]hThe healing was uneventful and fractured segment was secured in place ensuring successful reattachment procedure and radiograph was captured [Figure 2]i. Further prosthesis (Metal ceramic crown) was given after root canal treatment w.r.t 11 and 21.
Six months postoperative follow-up was done; the fractured line was not visible clinically and radiographically, and satisfactory periodontal health was exhibited with a pocket depth of only 3 mm palatally.
| Discussion|| |
Various techniques and materials have been suggested to manage the coronal tooth fractures, for example, stainless steel crowns, basket crowns, orthodontic bands, pin retained resin, porcelain-bonded crown, and composite resin.  All such historic techniques are least conservative and time-consuming. However, in today's era, immediate replacement of lost structures is demanded and practiced. One of such treatment options where immediate results are obtained is the reattachment of fractured teeth segments. Reattachment procedure using acid-etch technique was first reported by Tennery. Subsequently, Starkey and Simonsen  had also documented such cases. Reattachment of dental fragment has become possible due to the improvement of adhesive technique and restorative materials. With the current concepts of dentine hybridization, reattachment procedures have better prognosis with promising long-term results.
The advantages of reattachment procedure are as follows:
- Better esthetics as shade match and translucency will be perfect
- Incisal edge will wear at a rate similar to that of the adjacent teeth
- Replacement of fractured portion may take less time
- A positive emotional and social response from the patient for preservation of natural tooth structure
- Natural tooth contour and contacts with adjacent teeth are maintained
- It is an economical technique.
The treatment for coronal tooth fracture depends on various factors such as extent of fracture (biological width violation, endodontic involvement, alveolar bone fracture), pattern of fracture and restorability of fractured tooth (associated root fracture), secondary trauma injuries (soft-tissue status), presence/absence of fractured tooth fragment and its condition for use (fit between fragment and the remaining tooth structure), occlusion, esthetics, finances, and prognosis. 
The reattachment procedures should be considered in simpler cases of coronal tooth fracture, where the biological width is not involved and the fractured segments are available and preserved as naturally as possible, whereas for complex cases, meticulous planning and careful execution of the treatment planning should be done. Reattachment procedure restores the incisal function and surface anatomy perfectly and is probably less traumatic, simple, and low-cost method. Moreover, it provides superior esthetics, positive emotional and social response from the patient as his own natural tooth structures are preserved.
The main reasons for the loss of reattached tooth fragments are the fresh trauma to the same region causing debonding of the reattached tooth parts or due to parafunctional and excessive forces acting in the same region. To avoid such failures, stress is given upon the fracture strength of the restored teeth, and this strength is in turn depends on the bond strength of composite to tooth structure. To increase the fracture strength of reattached tooth fragment, the simple reattachment can be augmented with the use of additional retentive preparations such as bevel, chamfer, overcontour, or internal dentinal groove. Reis et al. have shown that a simple reattachment with no further preparation of the fragment or tooth was able to restore only 37.1% of the intact tooth's fracture resistance, whereas a buccal chamfer recovered 60.6% of that fracture resistance; bonding with an overcontour and placement of an internal groove nearly restored the intact tooth fracture strength, recovering 97.2% and 90.5% of it, respectively. 
In cases of complicated fractures, when endodontic therapy is required, the space provided by the pulp chamber can be utilized for inner reinforcement, thus avoiding further preparation of the fractured tooth. However, the pulpless teeth lose its natural translucency and color with time, and the esthetics can be hampered in a longer run. The use of the glass-fiber post is a favorable option for the retention of the fractured segment. Zorba and Ozcan  used a fiber-reinforced post to increase retention of the reattached crown fragment. Hence, in this paper, a similar technique is demonstrated for reattaching the fractured tooth fragment.
The fractured segments should be stored as naturally as possible to maintain the naturality of the fractured fragments. Improper storage of fractured fragments can lead to their dehydration. Therefore, to prevent such a loss, it is recommended that the fragment is kept in a medium such as physiologic saline. According to Toshihiro and Rintaro,  even though the fractured fragment that was reattached was dehydrated, the fragment recovered its original color and translucency without any marked change. In Case II, the typical esthetics of the tooth was recovered after a week.
The use of a post to attach the fractured segment increases the retention of the segment to the fractured root and in addition provides additional support and better prognosis without much preparation of the tooth, hence is conservative in nature. As the bonding interface is increased after using the post, microleakage and subsequent detachment can occur over time. Thus, accurate and careful bonding procedures are necessary through the course of treatment and can have a favorable long-term tooth prognosis.
| Conclusion|| |
With the materials available today, in conjunction with an appropriate technique, esthetic results can be achieved with predictable outcomes. Thus, the reattachment of a tooth fragment is a viable technique that restores function and esthetics with a very conservative approach, and it should be considered when treating patients with coronal fractures of the anterior teeth, especially younger patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]