Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2014  |  Volume : 32  |  Issue : 1  |  Page : 79--82

Biologic restoration of a traumatized maxillary central incisor in a toddler: A case report

Sheen Ann John, S Anandaraj, Sageena George 
 Department of Pedodontics and Preventive Dentistry, PMS College of Dental Science and Research, Thiruvanthapuram, Kerala, India

Correspondence Address:
Sheen Ann John
Department of Pedodontics and Preventive Dentistry, PMS College of Dental Science and Research, Thiruvanthapuram - 695 028, Kerala


Trauma to the anterior teeth is relatively common in young children and teenagers. Traumatized anterior teeth require quick functional and aesthetic repair, and poses a challenge to the dental practitioner owing to the lack of co-operation ceded and the longer time invested. Reattachment of tooth fragment should be the first choice to restoring teeth when a usable fragment is available, since it gives a psychological and aesthetic advantage over the conventional technique. With the vast improvement in adhesive technology, reattachment is definitely a predictable treatment option for very young children. This paper describes the treatment of a 2½ year old female child who sustained crown-root fracture, extending subgingivally, in primary upper central incisor.

How to cite this article:
John SA, Anandaraj S, George S. Biologic restoration of a traumatized maxillary central incisor in a toddler: A case report.J Indian Soc Pedod Prev Dent 2014;32:79-82

How to cite this URL:
John SA, Anandaraj S, George S. Biologic restoration of a traumatized maxillary central incisor in a toddler: A case report. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2020 Jul 7 ];32:79-82
Available from:

Full Text


Injury to a young child's teeth and face is a traumatic experience for the child and parents. It is not only traumatic in the physical sense but also in an emotional and psychological sense. [1] Maxillary incisors are most frequently injured in the primary and permanent dentition. Traumatized anterior tooth requires quick functional and aesthetic repair. Therefore, if a broken fragment is available, the restoration of a tooth with its own fragment has been suggested as an alternative treatment. Such a "biologic restoration. [2] provides excellent results regarding surface smoothness and aesthetics. This clinical report describes reattachment of tooth fragment of deciduous maxillary central incisor in a 2½ year old with extensive fracture involving pulp following trauma.

 Case Report

A 2½ year old female child reported to the department of Pedodontics and Preventive dentistry, P.M.S College of dental Science and Research, Kerala with the complaint of fractured maxillary deciduous central incisor in the left quadrant. History revealed trauma about 1week back and there was no relevant medical history.

Intra-oral clinical examination revealed a fractured, mobile tooth segment in relation to the left deciduous maxillary central incisor [Figure 1]. Closer examination revealed extensive fracture involving the enamel, dentin and pulp. Tooth was fractured in a vertical plane that extended subgingivally. The tooth exhibited no mobility. There was little injury associated with the soft tissue, but none with the alveolar bone.{Figure 1}

Radiographic examination revealed that there was no associated root fracture, no resorption of the root and no damage to the permanent tooth bud [Figure 2]. After obtaining parental consent for the treatment procedure, physical restraints were used as the child was emotionally immature and lacking co-operative behavior.{Figure 2}

Under local anesthesia, the fractured tooth segment was carefully removed taking care not to damage either the fragment or the remaining tooth [Figure 3]. The fractured fragment was stored in saline [Figure 4]. [3] {Figure 3}{Figure 4}

Endodontic therapy was done for the fractured tooth and obturated with metapex. The entrance of the root canal was plugged with a glass ionomer plug. The pulp chamber, dentin and enamel and the fractured tooth segment was etched with 37% phosphoric acid gel, rinsed and coated with bonding agent, simultaneously, and light cured. The fragment was then aligned and flowable composite used to reattach the segment to the tooth surface. After excess resin removal, the area was cured for 40 seconds. Finishing and polishing were done [Figure 5] and [Figure 6]. The patient was given instructions to avoid any heavy function on this tooth and to follow regular home care instructions.{Figure 5}{Figure 6}

On subsequent follow-up visits at 1, 2 and 6 months [Figure 7], the tooth was found to be asymptomatic.{Figure 7}


Trauma to anterior teeth is relatively common among young children and teenagers. Many of the accidents that affect the primary teeth occur during the first three years as the child is moving from a state of total dependence, with respect to movement, to one of independence and stability. [1] In the primary dentition, luxation injuries are more common than fractures due to the spongy nature of the bone and also the lower root/crown ratio in comparison to that of permanent dentition. [4] But in this case it was a complicated subgingival fracture involving the pulp also.

The psychological impact of such a trauma should be taken into consideration and must be restored to normal as soon as possible to relieve the consciousness of being different from other children. Moreover, the major consequence of early loss of maxillary primary incisors is most likely the delayed eruption of permanent successors as reparative bone and dense connective tissue covers the site. This would lead to adverse consequences like unattractive appearance, development of deleterious habits such as tongue thrust, forward resting posture of the tongue and also the improper pronunciation of frictative sounds, such as "s" and "f". [5]

To compensate, there are various treatment options to restore a fractured segment ranging from direct resin restoration to extraction of the tooth followed by an artificial appliance. But given the demands for co-operation in wear and frequent appliance loss or damage, such removable appliances can be problematic in pre-schoolchildren. [5] Hence, the primary teeth should be restored provided it is not damaging the permanent successor.

It has also been found that there is a positive emotional and social response from the patient to the preservation of natural tooth structure. [6] Hence, considering advantages like:

Regaining color and size of the original toothThe proportion of wear similar to adjacent tooth without traumaGiving an emotionally and socially positive response due to the protection of natural tooth structureRapid and conservative nature of the treatmentEconomical aspect of a one-visit treatment, [7] the decision to reattach the fractured segment was considered.

Reattachment techniques such as direct reattachment of the fragment, internal enamel groove, internal dentinal groove and external enamel groove in the shape of a V have been used. [ 8],[9],[10] Reis et al., and Demarco et al., pointed out that reattachment without any extra preparation or retention results in fracture strength lower than that of an intact tooth. On the other hand, some research [11] has shown that introduction of such bevels does not enhance fracture strength. Another factor influencing fracture strength is the hydration of tooth fragment. Prolonged dehydration causes change in color of the fragment [12] and also the collapse of the collagen fiber net, preventing adequate penetration of the resin monomer and resulting in a poor resin-dentin bonding. [13] But in our case, the patient presented to the clinic with the tooth fragment is still in the oral cavity. Hence, with all the above advantages and moreover considering the amount of tooth structure in a primary tooth the direct reattachment procedure was performed.

An endodontic treatment is recommended in cases of complicated fractures to eliminate bacterial contamination and pulp remnants within the root canal. [6]

Patient education about treatment limitations may enhance clinical success as reattachment failures may occur with new trauma or para functional habits. [14]


Thus with the remarkable advancement of adhesive systems and resin composites, reattachment of tooth fragments has become a procedure that is no longer a provisional restoration, but rather a restorative technique offering a favorable prognosis, especially in very young patients.


1Muthu MS. Pediatric dentistry. In: Traumatic injuries of teeth and supporting structures. 1 st ed. Amsterdam: Elsevier; 2009. p. 259.
2Correa-Faria P, Alcantara CE, Caldaz-Diniz MV, Botelho AM, Tavano KT. "Biological restoration": Root canal and coronal reconstruction. J Esthet Restor Dent 2010;22:168-77.
3Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth fragments. Quintessence Int 2000;31:385-91.
4Pinkham JR. Pediatric dentistry: Infancy through adolescence. In: Introduction to Dental Trauma: Managing Traumatic Injuries in the Primary Dentition. 4 th ed. Amsterdam: Elsevier; 2005. p. 236-37.
5Mcdonald DR, Avery JA. Dentistry for the child and adolescent. In: Managing the Developing Occlusion. 9 th ed. Missouri: Mosby; 2011. p. 558.
6Dhingra R, Avasthi K. Reattachment of fractured fragment of deciduous maxillary central incisor - A case report. J.Int Oral Health 2011;3:33-36
7Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of success in the reattachment of coronal fractures: Dental Traumatol 2008;24:151-8.
8Simonsen RJ. Restoration of a fractured central incisor original tooth fragment. J Am Dent Assoc 1982;105:646-8.
9Diangelis AJ, Jungbluth M. Reattaching fractured segments: An esthetic alternative. J Am Dent Assoc 1992;123:58-63.
10Rappelli G, Massaccesi C, Putignano A. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol 2002;18:281-4.
11Dean JA, Avery DR, Swartz ML. Attachment of anterior tooth fragments. Pediatr Dent 1986;8:139-43.
12Nakabayashi N, Pashly D. Hybridization of dental hard tissues. Tokyo: Quintessence; 2000.
13Perdigao J, Lopes M. Dentin bonding - state of the art 1999. Compend Contin Educ Dent 1999;20:1151-8, 1160-2.
14Andreasen FM, Nóren JG, Andreasen JO, Engelhardtsen S, Lindh-Stromberg U. Long-term survival of fragment bonding in the treatment of fractured crowns: A multicenter clinical study. Quintessence Int 1995;26:669-81.