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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 31  |  Issue : 1  |  Page : 117-120

Fractured tooth reattachment: A series of two case reports


Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India

Date of Web Publication19-Jun-2019

Correspondence Address:
Dr. Ashtha Arya
B-8/9, Vijay Park, Najafgarh, New Delhi - 110 043
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_140_18

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  Abstract 

Trauma to the anterior teeth is relatively a common occurrence. There are several treatment modalities for such condition, one of which is the reattachment of fractured fragment itself. Reattachment of fractured fragment provides immediate treatment with better esthetics, restoration of function, and is a faster and less complicated procedure. Reattachment of tooth fragment should be the first choice and is a viable alternative to conventional approaches because of simplicity, natural esthetics, and conservation of tooth structure. Patient cooperation and understanding of the limitations of the treatment is of utmost importance for good prognosis. The manuscript presents two case reports describing the management of a complicated fracture of maxillary anterior teeth treated endodontically, followed by reattachment of the same fragment. Reattachment of fractured tooth fragment offers a viable restorative alternative, immediately restores tooth function and esthetics with the use of a very conservative and cost-effective approach.

Keywords: Complicated crown fracture, endodontic treatment, fragment reattachment, trauma


How to cite this article:
Thapak G, Arya A, Arora A. Fractured tooth reattachment: A series of two case reports. Endodontology 2019;31:117-20

How to cite this URL:
Thapak G, Arya A, Arora A. Fractured tooth reattachment: A series of two case reports. Endodontology [serial online] 2019 [cited 2019 Nov 20];31:117-20. Available from: http://www.endodontologyonweb.org/text.asp?2019/31/1/117/260520


  Introduction Top


Crown fractures are the most common consequences of traumatic injuries that mainly occur in the anterior teeth, especially the maxillary incisors (because of its position in the arch), whereas the mandibular central incisors are less frequently involved. It is estimated that a quarter of the population suffers from a minimum of one dental traumatic injury related to coronal fractures of the anterior teeth before the age of 18 years, the most common of which are attributed to falls, high-impact sports, and motor vehicle accidents.[1],[2]

Dental injuries usually affect only a single tooth; however, certain trauma types such as automobile accidents and sports injuries involve multiple tooth injuries.[3] One of the options for managing coronal tooth fractures when the tooth fragment is available and there is no or minimal violation of the biological width is the reattachment of the dental fragment. Reattachment of fractured tooth fragment can provide good and long-lasting esthetics because the tooth's original anatomic form, color, and surface texture are maintained. It also restores function, provides a positive psychological response, and is a relatively simple procedure. Patient cooperation and understanding of the limitations of the treatment is of utmost importance for good prognosis. This article reports two coronal tooth fracture cases that were successfully treated using tooth fragment reattachment.


  Case Reports Top


Case 1

A 17-year-old patient presented at the private clinic at Gurugram, Haryana, after sustaining a complicated crown fracture of the maxillary right central incisor during sports activities. The fractured tooth fragment was recovered by the patient at the site of the injury and maintained in a storage media (milk) for 2 h. Clinical and radiographic examination revealed a complicated oblique crown fracture that extended subgingivally on the mesiopalatal area [Figure 1]a and [Figure 1]b. On examination, the treatment options were presented to the patient and to her legal guardian, including (1)removal of fractured segment followed by restoration with post and core with crown and (2) reattachment of the tooth fragment. After some deliberation about the advantages, disadvantages, prognosis, and cost of every treatment option, the patient opted to have the tooth fragment reattached. It is important to note that the reattachment option was presented only after confirming that the fragment was in good condition [Figure 1]c and that it fits reasonably well on the fractured tooth. One important complication of this case was the subgingival extension of the fractured margin on the mesiopalatal area as mentioned earlier. Root canal treatment was carried out immediately, and obturation was done by sectional method maintaining 5-mm apical seal [Figure 1]d,[Figure 1]e,[Figure 1]f. After preparing the post space with Peeso Reamer, prefabricated glass fiber post was luted in the canal with resin cement (Calibra, Dentsply) [Figure 1]g and [Figure 1]h. A hole was prepared in the fractured tooth fragment and then etched with 37% phosphoric acid, rinsed, blot dried, and bonding agent (Prime and Bond NT, Dentsply) was applied. Subsequently, resin cement (Calibra, Dentsply) was used to fill the hole in the tooth and the prepared grooves into the coronal fragment. The fragment was carefully seated on the remaining tooth and light cured. During curing, firm and stable finger pressure was applied to the coronal fragment to closely oppose it to the tooth. After curing, excess composite was removed with a diamond finishing bur. Afterward, final polishing was done with Enhance (Dentsply) kit [Figure 1]i. Follow-up examinations were carried out at 10-month interval. The tooth remained normal in esthetics and function [Figure 1]j.
Figure 1: (a) Preoperative picture, (b) preoperative radiograph, (c) fractured fragment, (d) working length IOPA, (e) master cone IOPA, (f) postobturation radiograph, (g) post space preparation, (h) fiber post luted in the canal, (i) postoperative picture, and (j) IOPAR at 10-month follow-up

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Case 2

A 13-year-old boy reported to clinic with a history of fall from bicycle 2 days back. The child complained of sensitivity in the upper anterior teeth. Clinical and radiographic examination revealed Ellis class III fracture (involvement of enamel and dentin compromising the pulp) of the maxillary left lateral incisor [Figure 2]a and [Figure 2]b. No significant hard- or soft-tissue injury other than tooth fracture was observed. An intraoral periapical radiograph was taken, which showed the coronal fracture with no root fracture or any other periapical changes. The child was carrying the broken tooth fragment [Figure 2]c that was confirming adequately to the fractured left lateral incisor. The tooth fragment had been stored in water for 3 h and did not show any significant change in color. An immediate endodontic intervention followed by bonding of the fractured segment was planned. Single-visit endodontic therapy was performed for the fractured lateral incisor. An access cavity was prepared, working length determined [Figure 2]d, and biomechanical preparation was carried out with the help of ProTaper rotary file till F3 using the crown-down technique.
Figure 2: (a) Preoperative radiograph, (b) preoperative picture, (c) fractured coronal fragment, (d) working length IOPAR, (e) fiber post luted in the canal, (f) postoperative picture, and (g) IOPAR at 1-year follow-up

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Copious irrigation of the root canal was intermittently done during instrumentation with 1.3% sodium hypochlorite and normal saline. The canal was dried with absorbent point, and obturation was done by sectional method maintaining 5-mm apical seal. After preparing the post space with Peeso Reamer, prefabricated glass fiber post was luted in the canal with dual-cure resin cement (Calibra, Dentsply) [Figure 2]e. The tooth fragment was disinfected with sodium hypochlorite solution and then rinsed properly with water. Then, a hole was prepared in the coronal fractured tooth fragment so that it can be seated over the coronal portion of the fiber post. An enamel bevel was prepared all around the remaining tooth structure as well as the fractured margin of the segment and the fragment was approximated to check its fit. An additional internal dentinal groove was also prepared within the dentine of the fractured fragment part. Acid etching of the access cavity and the approximating surfaces of the two segments were carried out with 37% phosphoric acid. Bonding agent (Prime and Bond NT, Dentsply) was subsequently applied and light cured for 20 s. Then, resin cement was applied and both the fragments were reapproximated 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. Finishing and polishing of the tooth was done [Figure 2]f. The patient was recalled for follow-up after 1 year, and the tooth was in normal function and esthetics, and the patient was satisfied [Figure 2]g.


  Discussion Top


With advancement in dental bonding technology, it is now possible to achieve excellent results with reattachment of the dislocated tooth fragments provided that the biologic factors, materials, and techniques are logically assessed and managed. The use of natural tooth substance clearly eliminates the problems of differential wear of restorative material, unmatched shades, and difficulty of contour and texture reproduction associated with other techniques. Treatment plan can be made after evaluation of the periodontal, endodontic, coronal, and occlusal status.[4] Other factors that might influence the choice of the technique include the need for endodontic therapy, extension of fracture, quality of fit between fragments, and the fracture pattern.

Badami et al.[5] have shown neither the bevel nor the material used could obtain the original fracture resistance of the tooth. Specimens prepared with chamfer and bonded had a fracture resistance of 40%–60%, with internal dentin groove, and over contour, it reached around 90%. The highest fracture resistance was obtained by chemically cured composite followed by light-cured resin and least by only dentin-bonding agent.[6] The pulp chamber was used for increasing the surface area for composite bonding and without the use of post. Amir et al., in 1986, showed that the space provided by pulp chamber may be used as an inner reinforcement, thus avoiding any excess preparation of teeth.[7] The direction of the fracture line is an important aspect in rerestorability, and it has a direct bearing on the prognosis of teeth.[6] The fracture line was in a favorable direction in the cases undertaken. Extensive damage of the tooth structure and missing fragment warrants reinforcement using fiber posts followed by crown. However, in our case reports, the fractured fragment was in sound condition and exhibited good fit over the radicular portion, so reattachment using fiber post was considered to be the best treatment option. A bevel with flowable composite further improved the fracture strength. Conventionally, cast metal post and core were used for fracture reattachment. The newer variety of nonmetallic posts is made of either ceramic or fiber-reinforced materials such as carbon, quartz, or glass in an epoxy matrix. Tooth-colored fiber posts have several advantages. They are more esthetic, bonded to tooth tissue, modulus of elasticity similar to that of dentin, and have less chances of fracture. Using glass fiber post with composite core and with recent advances in adhesive techniques and materials, one can create a monoblock, a multilayered structure with no inherent weak interlayer interfaces. The unique advantage of this system is that it reinforces the teeth structure through this concept. Therefore, the integrity of the final endodontic restorative continuum monoblock approaches that of the original healthy tooth itself.[8] An additional use of fiber posts is that it helps to distribute the stress to remaining radicular dentin. Luting the fiber posts with resin cement not only reinforces the tooth but also helps in achieving higher bond strengths of the fractured segments. It also minimizes the inclusion of air voids are easy to use and predictable.[9],[10] In apical areas light-cured luting resin cement may result in incomplete polymerization; hence, dual curing systems prove to be the most suitable material as they would allow polymerization even in those areas which would otherwise have left uncured due to the inability of light to reach in deeper areas.[11] Resin-based sealers are used to obturate the teeth planned for restoration with glass fiber posts as eugenol-based sealers may inhibit the set of resin cements.

If the fracture line is supragingival, the procedure for reattachment will be straightforward. However, when the fracture site is subgingival or intraosseous, orthodontic extrusion with a post retained 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. It has been suggested that whenever the fracture site invades the biologic width, surgery should be performed with minimum osteotomy and osteoplasty.[12]

However, in cases with minimal biologic width invasion, the organism is able to restore the biologic width by itself provided assiduous plaque control is done. The prognosis of the reattached teeth would also depend on the fitness, contour, and surface finishing of the subgingival restoration. If the invasion of biologic width is minimal, satisfactory esthetics and function can be achieved, without conventional flap surgery, however, requiring long-term follow-up. In some cases, crown lengthening is required to keep the restorations on definite margins. The success rates of reattached fragments have been seen to be up to 90% based on the parameters of periodontal, pulpal, and color harmony for a follow-up period of up to 24 months.[13]


  Conclusion Top


Several aspects govern the choice of a technique or the association of materials for fragment reattachment. Reattachment proved to be a successful technique in the present case reports for restoring esthetics and function. However, because few long-term studies have been reported in the literature, the patient should be informed of possible interim nature of the treatment. For traumatized patients with broken teeth, pain relief and immediate esthetic restoration fragment reattachment fulfill the treatment goal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 1970;78:329-42.  Back to cited text no. 1
    
2.
Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Oxford, UK: Blackwell; 2007.  Back to cited text no. 2
    
3.
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. 3
    
4.
Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth fragments. Quintessence Int 2000;31:385-91.  Back to cited text no. 4
    
5.
Badami AA, Dunne SM, Scheer B. An in vitro investigation into the shear bond strengths of two dentine-bonding agents used in the reattachment of incisal edge fragments. Endod Dent Traumatol 1995;11:129-35.  Back to cited text no. 5
    
6.
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. 6
    
7.
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. 7
    
8.
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. 8
    
9.
Trope M, Maltz DO, Tronstad L. Resistance to fracture of restored endodontically treated teeth. Endod Dent Traumatol 1985;1:108-11.  Back to cited text no. 9
    
10.
Andreasen JO. Buonocore memorial lecture. Adhesive dentistry applied to the treatment of traumatic dental injuries. Oper Dent 2001;26:328-35.  Back to cited text no. 10
    
11.
Giachetti L, Grandini S, Calamai P, Fantini G, Scaminaci Russo D. Translucent fiber post cementation using light- and dual-curing adhesive techniques and a self-adhesive material: Push-out test. J Dent 2009;37:638-42.  Back to cited text no. 11
    
12.
Baratieri LN, Monteiro Júnior S, Cardoso AC, de Melo Filho JC. Coronal fracture with invasion of the biologic width: A case report. Quintessence Int 1993;24:85-91.  Back to cited text no. 12
    
13.
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. 13
    


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