Authors: Dr. Shikha Jaiswal, Dr.Sachin Gupta, Dr. Abhishek Gupta.
Swami Vivekananda Subharti University, Delhi – Haridwar bypass road, Meerut , UP.
ABSTRACT:
Crown fractures comprise of 26 – 76 % of dental injuries especially in young patients and adolescents. Initiation of root canal treatment, when needed, can further predispose them to fracture . One of the options to manage coronal tooth fracture is reattachment when the tooth fragment is available.This case report discusses a surgical approach for the reattachment of a palatally fractured maxillary lateral incisor which was undergoing root canal treatment. Surgical exposure of the fracture site was done as the fracture extended subgingivally and an adhesive resin was used to reattach the fractured segment.Additionally ,fibre post was used as an intraradicular splint to reinforce the fractured segment.
Reattachment is a viable alternative for the biological and functional rehabilitation of a tooth . However , in cases of gross violation of biological width, reflection of flap and surgical exposure of the fracture site is necessary to perform reattachment.
INTRODUCTION:
Tooth fractures comprise of 26-76% of total dental injuries in the permanent dentition, of these the teeth that are mostly affected are the maxillary incisors which may be because of their anterior and protruded position in the oral cavity1. As these teeth are a major component in the oro-facial aesthetics, their fracture is of an immense psychological trauma for a young patient and requires immediate attention. Many conventional treatment modalities exist including post and core restorations, orthodontic extrusions, osteotomy / osteoplasty, gingivectomy, etc.2
However , several factors influence the management of coronal tooth fractures , including extent of fracture (biologic width violation , endodontic involvement , alveolar bone fracture and restorability of fractured tooth ), secondary trauma injuries (soft tissue status) , presence /absence of fractured tooth fragment and its condition for use (fit between fragment and the remaining tooth tructure ) , occlusion , aesthetics , finances and prognosis .3,4
Reattachment of the fractured segment in such cases can be a viable alternative to the conventional approach. This treatment modality is popular because of its simplicity, conservation of tooth structure and attainment of immediate natural esthetics. Clinical trials and long term follow up have reported that reattachment using moderrn dentin bonding agents or adhesive luting systems may achieve functional and esthetic success5 However, when there is substantial associated periodontal injury and /or invasion of biologic width ,the restorative management of coronal tooth fracture should follow the proper management of associated tissues also.6
This case report describes reattachment of the original tooth fragment in a root canal treated lateral incisor with fracture line extending subgingivally.
CASE REPORT:
A 26 years old male patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of pain in upper right lateral incisor (12) since four days which aggravated on consuming food. History revealed trauma as the patient hit himself with hand pump handle.
Past dental history revealed trauma 4 years ago to the same region. Because of not having much pain at that time the trauma went unnoticed . Soft tissue examination revealed marginal inflammation of the gingiva with respect to maxillary right lateral incisor .Intraoral periapical radiograph revealed periapical radiolucency with respect to maxillary right lateral incisor hence endodontic therapy was planned for the tooth. Clinically , no fracture line could be appreciated at this stage.
Access cavity was prepared , working length was determined by electronic apex locator (Root ZX ,J.Morita corp,Kyoto ,Japan) and confirmed by radiography. Root canal was enlarged to ISO Size #60 at working length .After completion of biomechanical preparation, temporary restoration was placed (Cavit G . 3M , ESPE , Germany )and the patient was recalled after three days for obturation. .However, after two days patient reported back to the department with the fractured palatal segment of the tooth and a history of having bit something hard with the same tooth . Clinical examination revealed a complicated oblique crown – root fracture that extended subgingivally and above the alveolar crest on the palatal aspect(Fig 1) . After confirming that the fragment was in good condition (Fig 2) and that it fit reasonably well on the fractured segment reattachment option was considered after the completion of endodontic therapy. For gaining further reinforcement from the canal, placement of an esthetic fiber post was planned which would act as a splint between root and fractured segement.
PROCEDURE FOR REATTACHMENT OF TOOTH FRAGMENT:
Fractured fragment with respect to maxillary right lateral incisor was immediately kept in saline.
Sectional obturation was done using 2% GP cones (Dentsply, Mallifer) and AH – Plus Sealer . Post space preparation was done with a No .2 Pesso drill and the fit of no. 2 fibre post( Reforpost , angelus ) was confirmed clinically and radiographically. .
Coronal portion of fibre – post was cut to fit into the coronal fractured fragment . Under local anaesthesia a sulcular incison was made on the palatal gingival tissue of tooth 12 with a no . 12 scalpel blade and a full thickness palatal mucoperiosteal envelope flap was raised for exposure of fracture line (Fig 3) . After achieving isolation ,the fractured portion of the tooth and the tooth fragment was etched with a 37 % phosphoric acid gel for 15 sec followed by delicate rinsing . The adhesive system (Adper Single Bond , 3M ESPE , USA ) was then applied on the etched surface . A flowable composite (Filtek Flow , 3M –ESPE ,USA )was applied in a thin layer on both the fragment and tooth surface .The fractured segment was then accurately placed on the tooth , paying special attention to the fit between the segments. Excess resin was removed and the area was light – cured for 40 seconds. The gingival tissues were repositioned and sutured (Fig 4)
The root canal space , pulp chamber , dentin and enamel were etched and bonded with a 2 – step etch and rinse system(Adper Single Bond , 3M ESPE , USA ). Self cure resin cement (RelyX, 3M ESPE) was mixed and applied to the canal and post. Fibre reinforced post was cemented into the canal (Fig 5) and the coronal restoration was completed with composite resin (Z – 100,3 M ESPE ) . On recall after one week the sutures were removed and one week later a PFM(Porcelain fused to metal crown )was given for the affected tooth .(Fig 6)
DISCUSSION:
Fracture of an anterior tooth may be a psychological trauma especially to a young patient and preserving the natural tooth structure may lead to a positive emotional and social response from the patient5.Tooth structure loss during root canal treatment weakens a tooth and a preexisting fracture line further predisposes it to fracture .A subgingival fracture line may not always be visible clinically and radiographically and the diagnosis is made only when the repeated trauma episodes lead to complete detachment of the tooth fragment .
Coronal fractures must be approached in a systematic way to achieve a successful restoration. A no . of factors influence the treatment modalities of coronal fractures which include site of fracture , size of fractured fragment , pulpal involvement , biological width invasion etc.6
The various treatment options may include reattachment , orthodontic extrusion , surgical extrusion and composite restoration. With the fracture line extending subgingivally below the alveolar crestal bone ,orthodontic extrusion or surgical extrusion is recommended before the restoration 6.However, with the fractured segment available and the fracture lying above the bone crest reattachment of the fractured segment is a more viable treatment option .
Reattachment of fractured segment is possible due to the advancements in bonding technology and is an excellent way to preserve what is natural. However, the professional has to remember that a dry and clean working field and the proper use of bonding protocol and materials is the key for achieving success in adhesive dentistry6 .Thus, when fracture line is extending subgingivally and when there is violation of biologic width reflection of flap is necessary for proper accessibility to the fracture site, proper positioning and for successful outcome.
In this case , a glass fibre post has been used along with self cure resin cement to to reattach the coronal fragment which gives a monobloc effect7. Reis and Colleagues have shown that a simple reattachment with no further preparation of the tooth or fragment was able to restore only 37.1 % of the intact tooth’s fracture resistance 4.Early retrospective studies indicate that the clinical performance of fibre post is promising and the failure rate is 3.2% over a period for upto 4 years8
The fibre post acted as a splint between the fractured tooth segment and intact tooth, further reinforcing the fractured segment. Use of fibre post in cases of reattachment have a no. of advantages .They help not only in conservation of tooth stucture , good esthetics , better adhesion but also the stress distribution is better as the modulus of elasticity is similar to that of dentin.9
CONCLUSION:
Reattachment of the intact fractured segment can be considered as an alternative method for biological and functional rehabilitation while preserving maximum tooth structure .
REFERENCES:
SALVAGING A SUBGINGIVALLY FRACTURED MAXILLARY LATERAL INCISOR : A MULTIDISCIPLINARY APPROACH
Swami Vivekananda Subharti University, Delhi – Haridwar bypass road, Meerut , UP.
ABSTRACT:
Crown fractures comprise of 26 – 76 % of dental injuries especially in young patients and adolescents. Initiation of root canal treatment, when needed, can further predispose them to fracture . One of the options to manage coronal tooth fracture is reattachment when the tooth fragment is available.This case report discusses a surgical approach for the reattachment of a palatally fractured maxillary lateral incisor which was undergoing root canal treatment. Surgical exposure of the fracture site was done as the fracture extended subgingivally and an adhesive resin was used to reattach the fractured segment.Additionally ,fibre post was used as an intraradicular splint to reinforce the fractured segment.
Reattachment is a viable alternative for the biological and functional rehabilitation of a tooth . However , in cases of gross violation of biological width, reflection of flap and surgical exposure of the fracture site is necessary to perform reattachment.
INTRODUCTION:
Tooth fractures comprise of 26-76% of total dental injuries in the permanent dentition, of these the teeth that are mostly affected are the maxillary incisors which may be because of their anterior and protruded position in the oral cavity1. As these teeth are a major component in the oro-facial aesthetics, their fracture is of an immense psychological trauma for a young patient and requires immediate attention. Many conventional treatment modalities exist including post and core restorations, orthodontic extrusions, osteotomy / osteoplasty, gingivectomy, etc.2
However , several factors influence the management of coronal tooth fractures , including extent of fracture (biologic width violation , endodontic involvement , alveolar bone fracture and restorability of fractured tooth ), secondary trauma injuries (soft tissue status) , presence /absence of fractured tooth fragment and its condition for use (fit between fragment and the remaining tooth tructure ) , occlusion , aesthetics , finances and prognosis .3,4
Reattachment of the fractured segment in such cases can be a viable alternative to the conventional approach. This treatment modality is popular because of its simplicity, conservation of tooth structure and attainment of immediate natural esthetics. Clinical trials and long term follow up have reported that reattachment using moderrn dentin bonding agents or adhesive luting systems may achieve functional and esthetic success5 However, when there is substantial associated periodontal injury and /or invasion of biologic width ,the restorative management of coronal tooth fracture should follow the proper management of associated tissues also.6
This case report describes reattachment of the original tooth fragment in a root canal treated lateral incisor with fracture line extending subgingivally.
CASE REPORT:
A 26 years old male patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of pain in upper right lateral incisor (12) since four days which aggravated on consuming food. History revealed trauma as the patient hit himself with hand pump handle.
Past dental history revealed trauma 4 years ago to the same region. Because of not having much pain at that time the trauma went unnoticed . Soft tissue examination revealed marginal inflammation of the gingiva with respect to maxillary right lateral incisor .Intraoral periapical radiograph revealed periapical radiolucency with respect to maxillary right lateral incisor hence endodontic therapy was planned for the tooth. Clinically , no fracture line could be appreciated at this stage.
Access cavity was prepared , working length was determined by electronic apex locator (Root ZX ,J.Morita corp,Kyoto ,Japan) and confirmed by radiography. Root canal was enlarged to ISO Size #60 at working length .After completion of biomechanical preparation, temporary restoration was placed (Cavit G . 3M , ESPE , Germany )and the patient was recalled after three days for obturation. .However, after two days patient reported back to the department with the fractured palatal segment of the tooth and a history of having bit something hard with the same tooth . Clinical examination revealed a complicated oblique crown – root fracture that extended subgingivally and above the alveolar crest on the palatal aspect(Fig 1) . After confirming that the fragment was in good condition (Fig 2) and that it fit reasonably well on the fractured segment reattachment option was considered after the completion of endodontic therapy. For gaining further reinforcement from the canal, placement of an esthetic fiber post was planned which would act as a splint between root and fractured segement.
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Figure 1. Palatal view of fractured maxillary lateral incisor |
Figure 2. Fractured palatal segment |
Figure 3. Flap reflected to expose the fracture line |
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Figure 4. Fractured segment reattached and suturing completed |
Figure 5. Fibre post luted in the canal |
Figure 6. Post – operative palatal view after crown fabrication |
PROCEDURE FOR REATTACHMENT OF TOOTH FRAGMENT:
Fractured fragment with respect to maxillary right lateral incisor was immediately kept in saline.
Sectional obturation was done using 2% GP cones (Dentsply, Mallifer) and AH – Plus Sealer . Post space preparation was done with a No .2 Pesso drill and the fit of no. 2 fibre post( Reforpost , angelus ) was confirmed clinically and radiographically. .
Coronal portion of fibre – post was cut to fit into the coronal fractured fragment . Under local anaesthesia a sulcular incison was made on the palatal gingival tissue of tooth 12 with a no . 12 scalpel blade and a full thickness palatal mucoperiosteal envelope flap was raised for exposure of fracture line (Fig 3) . After achieving isolation ,the fractured portion of the tooth and the tooth fragment was etched with a 37 % phosphoric acid gel for 15 sec followed by delicate rinsing . The adhesive system (Adper Single Bond , 3M ESPE , USA ) was then applied on the etched surface . A flowable composite (Filtek Flow , 3M –ESPE ,USA )was applied in a thin layer on both the fragment and tooth surface .The fractured segment was then accurately placed on the tooth , paying special attention to the fit between the segments. Excess resin was removed and the area was light – cured for 40 seconds. The gingival tissues were repositioned and sutured (Fig 4)
The root canal space , pulp chamber , dentin and enamel were etched and bonded with a 2 – step etch and rinse system(Adper Single Bond , 3M ESPE , USA ). Self cure resin cement (RelyX, 3M ESPE) was mixed and applied to the canal and post. Fibre reinforced post was cemented into the canal (Fig 5) and the coronal restoration was completed with composite resin (Z – 100,3 M ESPE ) . On recall after one week the sutures were removed and one week later a PFM(Porcelain fused to metal crown )was given for the affected tooth .(Fig 6)
DISCUSSION:
Fracture of an anterior tooth may be a psychological trauma especially to a young patient and preserving the natural tooth structure may lead to a positive emotional and social response from the patient5.Tooth structure loss during root canal treatment weakens a tooth and a preexisting fracture line further predisposes it to fracture .A subgingival fracture line may not always be visible clinically and radiographically and the diagnosis is made only when the repeated trauma episodes lead to complete detachment of the tooth fragment .
Coronal fractures must be approached in a systematic way to achieve a successful restoration. A no . of factors influence the treatment modalities of coronal fractures which include site of fracture , size of fractured fragment , pulpal involvement , biological width invasion etc.6
The various treatment options may include reattachment , orthodontic extrusion , surgical extrusion and composite restoration. With the fracture line extending subgingivally below the alveolar crestal bone ,orthodontic extrusion or surgical extrusion is recommended before the restoration 6.However, with the fractured segment available and the fracture lying above the bone crest reattachment of the fractured segment is a more viable treatment option .
Reattachment of fractured segment is possible due to the advancements in bonding technology and is an excellent way to preserve what is natural. However, the professional has to remember that a dry and clean working field and the proper use of bonding protocol and materials is the key for achieving success in adhesive dentistry6 .Thus, when fracture line is extending subgingivally and when there is violation of biologic width reflection of flap is necessary for proper accessibility to the fracture site, proper positioning and for successful outcome.
In this case , a glass fibre post has been used along with self cure resin cement to to reattach the coronal fragment which gives a monobloc effect7. Reis and Colleagues have shown that a simple reattachment with no further preparation of the tooth or fragment was able to restore only 37.1 % of the intact tooth’s fracture resistance 4.Early retrospective studies indicate that the clinical performance of fibre post is promising and the failure rate is 3.2% over a period for upto 4 years8
The fibre post acted as a splint between the fractured tooth segment and intact tooth, further reinforcing the fractured segment. Use of fibre post in cases of reattachment have a no. of advantages .They help not only in conservation of tooth stucture , good esthetics , better adhesion but also the stress distribution is better as the modulus of elasticity is similar to that of dentin.9
CONCLUSION:
Reattachment of the intact fractured segment can be considered as an alternative method for biological and functional rehabilitation while preserving maximum tooth structure .
REFERENCES:
- Kumar A: Reattachment of Fractured Tooth Using Self Etching Adhesive and Esthetic Fiber Post. Journal of Dental Sciences & Research. Vol 1; 2:Sep2010.
- Andreasen JO, Andreasen FM. Essentials of traumatic injuries to the teeth. 1. Copenhagen: Munksgaard; 1991. pp. 47–62.
- Olsburgh T , Jacoby T , Krejki I . Crown fractures in the permanent dentition : Pulpal and restorative considerations . Dental Traumatol 2002 ;18(3) :103 – 15.
- Reis A , Francci C , Loguercio AD , etal . Reattachment of anterior fractured teeth :fracture strength using different techniques . Oper Dent 2001 ; 26 (3):287 – 94.
- Andreason FM , Noren JG , Andreason JO , etal . Long term survival of fragment bonding in the treatment of fractured crowns . Quintessence Int 1995 ; 26:669 – 81.
- Georgia V. Macedo, Patricia I. Diaz. Reattachment of Anterior Teeth Fragments: A Conservative Approach. J Esthet Restor Dent 20:5–20, 2008.
- Anil Kumar . S , Jyothi K. N .Reattachment of fractured tooth using self – etching adhesive and esthetic fibre post . Journal of Dental sciences and research Vol 1 Issue 2 Sept 2010.
- Ferrarin,Vinci . A , Mannochi F , Mason PN . Retrospective study of the clinical performance of fibre posts . American Journal of dentistry ; 2000 ; 13 (Spec No) : 9B – 13 B
- Necdet Adanier , Everen OK , Yesinerder . Reattachment of subgingivally oblique fractured central incisor using fibre post . European Journal of Dentistry 2008 ;2:137 – 41.
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