|Year : 2010 | Volume
| Issue : 3 | Page : 223-229
Biological approach for management of anterior tooth trauma: Triple case report
P Goenka1, N Marwah2, S Dutta3
1 Department of Pedodontics and Preventive Dentistry, Post Graduate Student, Government Dental College, Rohtak, Haryana, India
2 Reader, Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan, India
3 Sr. Professor and Head, Government Dental College, Rohtak, Haryana, India
|Date of Web Publication||11-Dec-2010|
Department of Pedodontics and Preventive Dentistry, Post Graduate Student, Government Dental College, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Anterior crown fractures are a common form of injury that mainly affect children and adolescents. The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. In the pre-adhesive era, fractured teeth needed to be restored either with pin-retained inlays or cast restorations that sacrificed healthy tooth structure and were a challenge for clinicians to match with adjacent teeth. The development of adhesive dentistry has allowed dentists to use the patient's own fragment to restore the fractured tooth. Three cases are presented here with complicated crown fracture of maxillary central incisors; the reattachment of the fractured tooth segment in this case has been performed using different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.
Keywords: Anterior tooth fracture, biological restorations
|How to cite this article:|
Goenka P, Marwah N, Dutta S. Biological approach for management of anterior tooth trauma: Triple case report. J Indian Soc Pedod Prev Dent 2010;28:223-9
|How to cite this URL:|
Goenka P, Marwah N, Dutta S. Biological approach for management of anterior tooth trauma: Triple case report. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2020 Apr 3];28:223-9. Available from: http://www.jisppd.com/text.asp?2010/28/3/223/73791
| Introduction|| |
Uncomplicated and complicated crown fracture is the most common traumatic dental injury to permanent teeth,  and the teeth most commonly affected by trauma are the maxillary incisors, with a reported share of 96% of all the crown fractures (80% central incisors and 16% lateral incisors).  This is attributable to their anterior position and protrusion caused by the eruptive pattern.  This kind of injury mainly affects children and adolescents, with boys considered as being at a higher risk than girls mainly because of an increase in the participation of children in dangerous sports and activities.  In the past, fractured teeth were restored using acrylic resin or complex ceramic restorations associated with metals. These restorations did not promote adequate long-term esthetics and also required a significant tooth reduction during preparation. Because of difficulty in obtaining good retention, there were few attempts to reattach fractured fragments of the teeth. Chosack and Eildeman published the first case report on reattachment of a fractured incisor fragment in 1964 in which complicated tooth fracture was managed by endodontic treatment followed by a cast post and core. The post and core were fitted to the prepared tooth fragment and then cemented to the remaining tooth structure. 
Recently, with the advancement in the materials and bonding techniques, this new method of retaining fractured tooth segment is gaining popularity. Various techniques have been suggested to achieve the desired goal. This includes various methods employed to improve adhesion between the fractured and the remaining segments, using a circumferential bevel before reattaching, , placing a chamfer at the fracture line after bonding, , using a V-shaped enamel notch,  placing an internal groove , or a superficial overcontour over the fracture line. 
Presented here are three case reports of reattachment of the fractured tooth segment in which the fracture segments were reattached using three different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.
| Case Reports|| |
A 10-year-old boy reported with a history of fall from a swing 20 h back. The child complained of sensitivity in the upper anterior teeth. Complete history of events of trauma was recorded and no significant finding was observed. On examination, both the maxillary central incisors were found to be fractured. The right central incisor had undergone Ellis class II fracture whereas the left central incisor had undergone Ellis class III fracture [Figure 1]. No significant hard or soft tissue injury, other than tooth fracture, was observed. The patient presented with a piece of broken tooth fragment, which was confirming adequately to the fractured left central incisor [Figure 2].
|Figure 1: Clinical presentation of case I with Ellis class II fracture in the maxillary right central incisor and Ellis class III fracture in the maxillary left central incisor|
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An immediate single-visit endodontics was performed for the left central incisor [[Figure 3] a and b] and the remaining tooth structure was prepared for reattachment of the fractured tooth segment. The tooth fragment was disinfected with sodium hypochlorite solution and then rinsed properly with water. An enamel bevel was prepared all around the remaining tooth structure as well as the fractured margin of the segment. An additional internal dentinal groove was also prepared within the dentine of the fractured fragment part, which will approximate the access cavity prepared for endodontic therapy of the remaining tooth structure [Figure 4]. Acid etching of the access cavity and the approximating surfaces of the two segments was carried out for 20 s and the bonding agent was subsequently applied applied and light cured for 10 s. The access cavity was filled with composite resin in small increments and light cured for 40 s for each increment. As a next step, the dentin groove was also filled with composite and the two fragments were reapproximated and light cured for 40 s each from the buccal and lingual aspects of the tooth. Hybrid composite was applied over the bevel all around the tooth and was light cured appropriately. As the broken fragment of the right central incisor was not present, it was restored with composite resin. The teeth were polished and the patient was kept on recall of 1 month, 3 months and 1 year [Figure 5]. The tooth was found to be intact and functional inside the oral cavity in all the three visits till date and marginal integrity was intact with no crazing.
|Figure 3a: Pre-operative radiograph|
b: Radiograph after endodontic treatment
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|Figure 4: Placement of internal dentinal groove on the fractured fragment|
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An 11-year-old boy reported with broken upper anterior teeth due to a road traffic accident, which occurred around 36 h ago. The patient complained of no pain or sensitivity. On examination, it was found that the maxillary right central incisor had undergone Ellis class III fracture whereas the maxillary left central incisor had Ellis class II fracture [Figure 6]. The patient also carried the fractured segments of both the teeth with him (wrapped in a piece of paper), which, on examination, were found to be fitting well to the remaining tooth structure [Figure 7]. Single-visit endodontics was planned for the tooth having Ellis class III fracture and was carried out on the same appointment [Figure 8]. Now, both the fragments and the remaining tooth were prepared for reattachment of the fractured fragments. In this case, simple enamel bevels were prepared as the additional retentive feature on both the fragments and the recipient tooth structure. Acid etching of the access cavity and the approximating surfaces of the fractured segments was carried out for 20 s. A bonding agent was applied and light cured for 10 s. Then, the access cavity was filled with composite resin in small increments and light cured for 40 s for each increment. A thin layer of composite was applied over the apposing surfaces of the fragment and the remaining tooth structure. The tooth was cured from both buccal and lingual directions for 40 s each. Composite resin was applied over the bevel all around the tooth and was light cured appropriately. The same procedure was repeated for the other tooth also. Finishing and polishing was performed for both the teeth and the patient was kept on recall of 1 month, 3 months and 1 year. The restored teeth were found to be sound, both esthetically and functionally, at the commencement of all the three visits till date [Figure 9].
|Figure 6: Presentation of case II with Ellis class III fracture in the maxillary right central incisor and Ellis class II fracture in the maxillary left central incisor|
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A 10-year-old boy reported with broken, traumatized upper anterior teeth. On examination, both the maxillary central incisors were found to be fractured. Both the central incisors had undergone Ellis class III fracture [Figure 10]. The patient also presented with a fractured tooth fragment. The juxtapositioning of the fragment with the tooth showed that the margins of the fragment fitted well with that of the right central incisor and no inter-fragmentary space was present. Endodontic therapy was carried out for both the central incisors [Figure 11]. Now, the fragment was prepared for reattachment by disinfecting it with sodium hypochlorite solution. None of the additional retentive features were used in this case other than conventional bevel. Both the fragment and the tooth were acid etched with 37% phosphoric acid for 20 s and then rinsed with water adequately. Primer and adhesive were applied and light cured for 10 s. Composite resin was applied in a very thin layer on the approximating surfaces of both the segments and then the fragment was placed, checking its correct position. Excess composite extruding from the junction was removed using a probe. The composite was cured by keeping the light cure tip at the junction on both buccal and lingual surfaces for 40 s each. Because the fractured fragment for the left central incisor was missing, it was restored with composite resin [Figure 12]. Both the teeth were polished and the patient was kept on recall visits at 1 month, 3 months and 1 year. The patient reported after 3 months with loss of the reattached fragment as well as the composite restoration [Figure 13]. Both the teeth were planned to be restored with porcelain fused to metal crown as the patient was insistent on crown placement. For this, crown preparation was carried out [Figure 14] and then the porcelain fused to metal crowns was cemented on both the teeth [Figure 15].
|Figure 10: Clinical presentation of the case III with Ellis class III fracture in both maxillary central incisors|
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|Figure 13: Clinical presentation of patient with repeated fracture of both restorations on the 3-month recall visit|
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|Figure 14: Reduction of teeth after composite restoration for crown preparation|
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| Discussion|| |
Whenever possible, reattachment of the fractured tooth segment is one of the best techniques for the restoration of a fractured anterior tooth. It is esthetically more predictable for translucency, opalescence, fluorescence, characterizations and texture of the surface. , In addition, it is less time consuming compared with other direct and indirect restorations. The rate of wear and abrasiveness is the same as that for the intact tooth, while composite resin will be abraded more quickly than enamel by the opposing dentition.  Moreover, the technique also restores stress resistance comparable to intact tooth tissue and, thus, in case of further dental trauma, is preferable to composite restoration. , The technique also prevents the patient, especially children and young adolescent and their parents, from an emotional trauma of loss of a body part. They are at least satisfied of the original fragment being used in the restoration of their fractured tooth. 
Several aspects may govern the choice of a reattachment technique. The most important among them is the fracture strength of the attached fragment. Studies have shown that neither the different techniques nor the materials were able to attain the fracture resistance obtained from intact teeth. , Unfortunately, the amount of strength recovery needed to maintain the reattached fragment in function for long term is not known. However, recovery rates at 50-60% of the fracture resistance are likely to be sufficient.  Reis and others have shown that simple reattachment (not using any additional retentive technique) recovered only 37.1% of intact tooth fracture resistance, while the buccal chamfer recovered 60.6% and the overcontor and internal groove technique nearly reached intact tooth fracture strength, recovering 97.2% and 90.5%, respectively.  In addition to the variety of techniques used, some researchers have made the use of combinations of these. Simonsen  used the association of a V-shaped internal groove and lingual enamel beveling, whereas Bruke  has used a combination of an internal dentin groove and the circumferential beveling of enamel margins. In our case, we used three different techniques for three different patients of nearly the same age group so as to evaluate the best bond in similar body conditions. All the techniques used have met with moderate success with no definitive pattern.
In case I, a combination of circumferential enamel bevel and internal dentin groove has been used after performing the endodontic therapy of the tooth. The retention was due to the fact that beveling of the enamel edge increases the number of exposed enamel rod ends, which favors adhesion and provides better esthetics. , In the case of complicated crown fractures, where endodontic therapy is performed prior to the reattachment procedure, the pulp chamber can be used to give greater retention to the fragment. , In this case, an internal dentin groove was prepared in the fragment such that it opposes the pulp chamber. When the pulp chamber and the grove were filled with composite and cured, it simulated a short resin post extending into the fractured segment, thereby providing additional retention and support. The restored tooth was found to be in esthetically and functionally good condition at the first year recall visit, suggesting the clinical success of this technique.
In case II, circumferential enamel bevel is the only additional retentive feature incorporated in the attachment technique. One-year follow-up of the patient has showed this technique to be satisfactory in maintaining the tooth in function. An animal study conducted by Demarco et al.  has shown that presence of a circumferential bevel at the margins of the fragment increased the fracture resistance of the fragment when compared with the one without any bevel. This in turn increases the retention of the reattached fracture segment. The results of our study are inconcomitant with the above-mentioned study, and the increased retention can be attributed to the higher bonding area obtained after preparing bevel at the enamel interface. The only concern with the enamel bevel is the discoloration of the composite (at the junction), which may occur over a period of time. Although this technique appears to be clinically satisfactory, Reis et al.  have found other techniques like internal dentinal groove and overcontor to provide better fracture resistance.
In case III, none of the additional retentive features was used to enhance adhesion between the two segments and conventional retention feature was given. Studies have found similar resistance to fracture between intact teeth and reattached teeth, even when the fragment was only bonded to the remaining dental structure., Conversely, Reis et al.  have shown that simple reattachment technique recovered only 37.1% of the intact tooth fracture resistance. In our case, the patient reported back after 3 months with failure of the reattachment technique. The patient reported none of the non-functional events (trauma, bruxism, biting on very hard thing, etc.) that may lead to the failure of the technique. Thus, it can be said that the simple reattachment technique was not found to be satisfactory to retain the restoration in function for a long period of time.
Clinicians have used a variety of materials for the reattachment purpose, which include flowable composites,  hybrid and microfilled light-cured  and dual-cured  composites, chemically cured composites  and dual-cured,  chemically cured  and light-cured resin cements.  Most in vitro studies that have tested adhesive systems show that the kind of adhesive system used alters the fracture strength of the reattached teeth , and is in the range of 40-60% of the fracture strength of sound teeth. Conversely, Reis et al.  have shown, in a study, that the sole use of an adhesive system or its combination with higher mechanical property materials such as foldable resins, resin cements and resin composites have led to similar results when the fragment was reattached with no additional preparation. The study also tested the same materials with an additional preparation (buccal chamfer at the fracture line). Although no differences among the materials were detected, the fracture strength of the chamfer group was superior to that obtained when no additional preparation was performed. These results suggest that the technique employed for reattachment is more important than the association of the materials.
| Conclusion|| |
Reattachment of the fractured tooth fragment is the most conservative and biological method of restoring a fractured anterior tooth. It is advisable not to use the simple reattachment technique without additional preparation as this technique may not be able to restore sufficient fracture strength (not even half of the intact tooth [ 3] ). It is desirable to use any of the reinforcement techniques so as to increase the fracture strength of the reattached tooth fragment, thereby improving the longevity of the treated tooth.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
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