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CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 147-151
 

Autologous reattachment of complicated crown fractures using intra canal anchorage: Report of two cases


1 Department of Pedodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Pedodontics, Rishi Raj College of Dental Sciences, Bhopal, Madhya Pradesh, India

Date of Web Publication15-Apr-2015

Correspondence Address:
Dr. Kashetty Panchakshari Bharath
Department of Pedodontics, College of Dental Sciences, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.155131

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   Abstract 

Crown fractures are most common form of dental trauma sustained by children and adolescents. Major portion of these crown fractures are uncomplicated. Complicated crown fractures though infrequent and account only 4-16%, is an enigma to any clinician. Autologus reattachment of the tooth fragment is a simple and conservative procedure in managing such crown fractures. The present article intends to report the successful clinical management of Autologus tooth fragment reattachment in two complicated crown fractures.


Keywords: Autologous, crown fracture, reattachment


How to cite this article:
Bharath KP, Patil RU, Kambalimath HV, Alexander A. Autologous reattachment of complicated crown fractures using intra canal anchorage: Report of two cases. J Indian Soc Pedod Prev Dent 2015;33:147-51

How to cite this URL:
Bharath KP, Patil RU, Kambalimath HV, Alexander A. Autologous reattachment of complicated crown fractures using intra canal anchorage: Report of two cases. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Oct 17];33:147-51. Available from: http://www.jisppd.com/text.asp?2015/33/2/147/155131



   Introduction Top


Traumatic injuries to teeth and its supporting structures in children and adolescents involving the crown portion of anterior teeth has become fairly a common occurrence. [1],[2],[3] Roughly 1/4 th of school going children experience trauma to their teeth at some point of time. [4],[5] Children of two specific age groups 2-3yrs and 8-12yrs sustain dental trauma more often and boys suffer more than girls. [6],[7],[8] Epidemologic Studies indicate that Maxillary incisors account for 96% of crown fractures, out of which maxillary central incisors are involved in 80% of the cases. This could be due to their anterior position and protrusion caused by eruptive pattern. [5],[6],[7],[8],[9],[10]. Various predisposing factors such as Over jet, gender, race, age and ethnicity predispose maxillary anterior teeth for dental trauma. [4],[11],[12],[13],[14],[15],[16] Crown fractures can be broadly classified into two main variants such as complicated and uncomplicated. Un complicated crown fractures comprises the bulk of crown fractures where as Complicated crown fractures constitute only 4-16% of all traumatic injuries. [6],[17] Based on the extent of involvement un Complicated crown fractures can be effectively managed by enamel recontouring, composites and porcelain veneers along with reattachment. On the other hand complicated crown and crown root fractures pose major restorative dilemmas and challenges to clinician. [1],[4] Complicated fractures with extensive loss of tooth structure may necessitate the use of endodontic posts to strengthen the remaining tooth segment. [18],[19] Depending on clinical scenario three different types of post systems such as custom fitted posts, pre formed alloy posts and fiber posts can be used for this purpose.

Management strategies of crown, crown root fracture should consider several factors which in turn dictate the prognosis of the same. Some of such factors include magnitude of fracture like biological width violation, endodontic involvement, alveolar bone fracture, restorability of fractured tooth and fragment, injury to adjacent soft tissue, availability of fractured fragment and its condition, match between fractured fragment and the remaining tooth structure, occlusion, aesthetics & finances. [10] Chosak and Eidleman were the first to report a case of fragment reattachment in 1964. [9],[20] Since then the technique has been subjected to various modifications and enriched with the advent of refined restorative techniques and materials. Reattachment of tooth fragment is an aesthetically promising, minimally invasive and most natural form of restoration compared to other treatment modalities. It also upholds original function of the tooth and offers positive psychological response. [1],[10] Thus, the present article intends to explicate the clinical dilemmas and challenges in managing complicated crown fractures.


   Case Report Top


Case 1

A 12 yr female patient reported to us complaining of pain and sensitivity in her lower front teeth after sustaining a blow to chin while playing with siblings. She was otherwise healthy with no remarkable medical history. There was no soft tissue injury intra or extra orally. The hard tissue examination revealed complicated crown fractures. The left mandibular central incisor (FDI # 31) had Ellis class 8 fracture whereas left mandibular lateral incisor (FDI # 32) had Ellis class 3 fracture with fractured portion loosely attached [Figure 1]. Periapical radiographs showed absence of root or alveolar bone fractures, complete roots with closed apices and absence of periapical pathology with 31, 32 [Figure 2]. The fracture line on 32 was localized just below the gingival margin on the buccal and lingual surfaces, with no visible damage to the coronal fragment. Various treatment options including reattachment of broken fragment were presented to the patient along with merits and demerits of each. Reattachment was considered as treatment option after confirming that the fractured fragment was never dehydrated and was in good condition. Fit also was reasonably good on the fractured tooth. As a definitive treatment, the fractured fragment of was carefully separated from tooth 32. It was stored in normal saline to prevent dehydration. Root canal therapy was initiated on the first visit itself with pulp extirpation of 31, 32. Tooth 32 was carefully evaluated for biological width violation and no such violation was observed. In second visit, the teeth were obturated after thorough biomechanical preparation to predetermined working length. The tooth # 32 had type II canal system [Figure 2]. On subsequent visit, pre-formed metal posts of appropriate size were selected. The gutta percha was removed to make space for metal posts in both 31, 32. The post spaces of 31, 32 were etched; bonding agent was applied and cured. Posts were then cemented using flowable composite [Figure 3]. Post placement on 32 was performed carefully due to bifurcated canals.
Figure 1: Complicated crown fractures involving 31, 32 with broken fragment of 32


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Figure 2: IOPA showing Type II canal with 32


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Figure 3: Metal posts placed over 31, 32


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Crown fragment preparation

The crown fragment of 32 was then modified to receive a part of metal post within it and to act as core. The pulp space of crown fragment was drilled using a small round bur so as to accommodate the post. Etching, bonding was done on the space created for post. fragment portion receiving the metal post was then filled with flow able composite, accurately placed over post and light cured.

The core build up of 31 was done using restorative composite. Later crown preparation carried out and finally tooth was restored with a full coronal restoration [Figure 4]. One year follow-up showed successfully retained fragment
Figure 4: Reattached fragment on 32 and crown with 31


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Case 2

A 13 yr female patient was referred to our department following trauma to her front teeth while playing at home. Her medical history was insignificant. The detailed extra oral examination ruled out any injury to soft tissue and hard tissue. On intra oral examination right maxillary central incisor (# 11) had complicated crown fracture with fracture line at the level of marginal gingival [Figure 5]. The broken fragment was loosely attached to the tooth. This tooth was discoloured and root canal treated one year back. Peri apical radiographs were made to rule out any root fracture or periapical pathology. Based on clinical and radiographic findings the tooth was planned for reattachment procedure. The fractured crown fragment was then separated from the tooth and stored in saline. The gutta percha was removed to optimum level using peso reamers and post space was created. Pre formed metal post of suitable size was selected and threaded into the canal [Figure 6].
Figure 5: Ellis class 8 # with 11 and separated crown fragment


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Figure 6: Metal post threaded over 11


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Crown fragment preparation

The Crown Portion was freed from all previous restorations and fragment was trial fitted to check proper fit on tooth along the fracture line. The inner surface of fragment was flooded with flowable composite and cured after etching and bonding procedure [Figure 7]. The final aesthetic modification of tooth will be under taken after completion of fixed orthodontic treatment.
Figure 7: Aesthetic rehabilitation of 11 with autologous fragment


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   Discussion Top


An ideal treatment for a complicated crown fracture should suffice two important criteria such as, aesthetics and function of the diseased tooth. Various factors dictate an ideal treatment option. The following factors must be considered while choosing an appropriate treatment protocol in complicated crown fracture. Time lag between injury and initiation of treatment, level of tooth fracture line, Stage of Root development, Extent of Pulp involvement, Condition and availability of tooth fragments, associated alveolar bone injury. [4] Based on these factors one can decide and deduce the feasibility of reattachment. The reattachment carried out in the two cases presented here is one of many possible treatment options available for this clinical problem. Other treatment options may have included extraction of the tooth and placement of a single-tooth implant, removable Partial dentures etc. The prognosis of reattachment depends on the condition of fractured fragment. Dehydrated fragments for more than an hour render poor prognosis and poor fracture resistance. [1],[6] In both the cases the fragments were mobile but intact with tooth and never dehydrated. Hence reattachment was our first priority treatment option.

In complicated crown, crown-root fractures it is advisable to maintain pulp vitality, particularly in children. [21] But this may not be feasible always because many complicated crown fractures report with extensive loss of tooth structure and require post placement. In such cases the vitality of the tooth needs to be compromised for better prognosis. After considering the merits and demerits, in case 1 though the pulp was vital when patient reported the clinical decision on complete root canal therapy with post placement on both 31,32 was carried out. Reattachment of fragment in the two cases presented here necessitated the use of post systems due to lack of integrity between the coronal fragments and remaining tooth structure and to enhance the resistance and retention of the teeth. Depending on clinical scenario 3 different types of post systems such as custom fitted posts, pre formed alloy posts and fibre posts can be used for this purpose.

Out of three post systems available, we used pre fabricated metal posts in the two cases. Fibre post system is a logical option as it reunites the root portion to the coronal fragment along with acceptable aesthetic. But the mechanical properties are comparatively inferior to metal posts. The fracture load of metal posts and other post types of were assessed in vitro by Newman et al., 2003, McLaren et al., 2009. Studies deduced that metal posts were better in terms of mechanical properties and fracture resistance. [22] some concern exists that post and core separation is more likely to occur when composite is used as a core material. Though fibre post has been shown to be a reliable and successful, studies indicate that they lack sufficient mechanical strength. Naumann et al., 2005 found that risk was greater when used in anterior teeth, teeth with a missing proximal contact (Naumann et al., 2005), excessive coronal tooth destruction and teeth supporting removable dental prosthesis (Naumann et al., 2005). Under these circumstances other post restorations might be useful. [22] Thus pre formed metal posts were used in case 1 and 2. In case 1, the tooth 32 had bifurcated canal. Type II canal system. Type two canals are usually found in 23% of cases. Placement of post in type II canal makes it clinically more challenging taking into consideration the level of bifurcation, root anatomy, thin dentinal walls. The lower anterior teeth have lip coverage and less visible making it to consider the strength as paramount while placing posts in lower anterior teeth. Thus in case 1 metal posts were placed carefully in type II canal giving priority importance for strength. In case 2 the tooth was root canal treated and were discolored. The patient had to undergo fixed orthodontic therapy. Hence an orthodontic opinion was taken. Orthodontists opined for reattachment and also suggested to use metal posts for better strength during orthodontic tooth movements. Thus use of fibre posts was discouraged and metal posts were used in case 2 also. Definitive treatment for esthtic rehabilitation of discolored tooth will be planned after completion of orthodontic treatment.

The decision on treatment must consider merits and demerits of different treatment modalities and should never discourage patient's preferences. It is difficult to ascertain the success of reattachment with few years of follow-up. Crown fractures particularly complicated fractures present with wide range of variations in terms of fracture line, extent of fracture, vitality of tooth, condition of surrounding soft tissue etc. Hence treatment plan has to be tailor made based on individual cases. 'Prevention always better than cure'. In any case Patient and parent education regarding predisposing factors for dental trauma and methods to prevent traumatic dental injuries is pivotal.

Thus in any possible clinical scenario, reattachment of the fractured tooth segment should be attempted in priority, as it is aesthetically more predictable for translucency, opalescence, fluorescence, characterizations and texture of the surface. [9] In young children it provides psychological benefit compared to other treatment modalities. Studies have also concluded that strength and fracture resistance attained with fragment reattachment is superior to composite restorations though it may not match intact tooth.

 
   References Top

1.
Iºeri U, Ozkurt Z, Kazazoglu E. Clinical management of a fractured anterior tooth with reattachment technique: A case report with an 8-year follow up. Dent Traumatol 2011;27:399-403.  Back to cited text no. 1
    
2.
Tovo MF, dos Santos PR, Kramer PF, Feldens CA, Sari GT. Prevalence of crown fractures in 8-10 years old schoolchildren in Canoas, Brazil. Dent Traumatol 2004;20:251-4.  Back to cited text no. 2
    
3.
Zuhal K, Semra OE, Hüseyin K. Traumatic injuries of the permanent incisors in children in southern Turkey: A retrospective study. Dent Traumatol 2005;21:20-5.  Back to cited text no. 3
    
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Oliveira GM, Oliveira GB, Ritter AV. Crown fragment reattachment: Report of an extensive case with intra-canal anchorage. Dent Traumatol 2010;26:174-81.  Back to cited text no. 4
    
5.
Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235-9.  Back to cited text no. 5
    
6.
Ojeda-Gutierrez F, Martinez-Marquez B, Rosales-Ibanez R, Pozos-Guillen AJ. Reattachment of anterior teeth fragments using a modified Simonsen's technique after dental trauma: Report of a case. Dent Traumatol 2011;27:81-5.  Back to cited text no. 6
    
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American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on management of acute dental trauma. Pediatr Dent 2008-2009;30:175-83.  Back to cited text no. 7
    
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Andreasen JO. Tooth and bone loss related to dental trauma. In: Koch G, Bergendal T, Kvint S, Johansson UB, editors. Consensus conference on oral implants in young patients. Stockholm: Fo¨rlagshuset Gothia AB; 1996. p. 40-5.  Back to cited text no. 14
    
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18.
Macedo GV, Ritter AV. Essentials of rebonding tooth fragments for the best functional and esthetic outcomes. Pediatr Dent 2009;31:110-6.  Back to cited text no. 18
    
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Ertugrul F, Eden E, Ilgenli T. Multidiciplinary treatment of complicated subgingivally fractured permanent central incisors: Two case reports. Dent Traumatol 2008;24:e61-6.  Back to cited text no. 19
    
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Chosack A, Eidelman E. Rehabilitation of a fractured incisor using the patient's natural crown. Case report. J Dent Child 1964;31:19-21.  Back to cited text no. 20
    
21.
Tosun G, Yildiz E, Elbay M, Sener Y. Reattachment of fractured maxillary incisors using fiber-reinforced post: Two case reports. Eur J Dent 2012;6:227-33.  Back to cited text no. 21
    
22.
Schmitter M, Lippenberger S, Rues S, Gilde H, Rammelsberg P. Fracture resistance of incisor teeth restored using fibre-reinforced posts and threaded metal posts: Effect of post length, location, pretreatment and cementation of the final restoration. Int Endod J 2010;43:436-42.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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