|Year : 2013 | Volume
| Issue : 2 | Page : 129-132
Fractured tooth rebonding: A ultra-conservative approach
Amit Yadav, Neeta Shetty
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India
|Date of Web Publication||11-Feb-2014|
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Majority of the traumatic dental injuries involves the anterior teeth specially the maxillary incisors. Rebonding of the fractured fragment to the tooth retrieved in a fairly intact condition provides an ultra-conservative treatment option. Rebonding techniques provide good esthetics, restores immediate function and provides positive psychological support to the patient. With the introduction of resin based material and the mono block concept, rebonding is a feasible treatment procedure. These case reports discuss the techniques for rebonding fractured fragment to the tooth in a very conservative and cost-effective manner.
Clinical Relevance to Interdisciplinary Dentistry
- Management of traumatic injuries requires a multidisciplinary approach.
- Fractured fragment rebonding where the fracture line violates the biological width will require periodontal procedures such as osteotomy, crown lengthening and gingivectomy to be carried out.
- With the advancement in materials and techniques fractured fragment rebonding offers a viable restorative option for the clinician which restores immediate esthetics using an ultra-conservative approach.
Keywords: Fractured tooth, rebonding, reattachment
|How to cite this article:|
Yadav A, Shetty N. Fractured tooth rebonding: A ultra-conservative approach. J Interdiscip Dentistry 2013;3:129-32
| Introduction|| |
Traumatic fractures of the anterior teeth are a common form of dental trauma.  It most commonly involves the maxillary central incisors due to its position in the arch. Fracture of the anterior teeth due to trauma requires immediate attention not only to restore immediate function and esthetics but also because of the psychological impact it has on the patient.  The treatment options offered to the patient in such a situation can vary from a simple composite build up to complex restorative intervention depending on the severity of the fracture and its extent. ,
One of the options for restoration of fractured anterior tooth is rebonding of the fractured fragment. Rebonding of the fractured fragment should be considered only in cases where there is no or minimal violation of biological width and the fragment is retrieved in a relatively intact condition.  Tooth fragment rebonding offers a conservative, cost-effective, esthetic, functional and less time consuming alternative to the restoration of fractured tooth compared with resin based composite or full coverage crown. 
Fractured fragment reattachment offers the advantage of good and long lasting esthetics because the tooth's original anatomical form, color, and surface texture are maintained. It also restores the function and has a positive emotional and psychological response from the patient due to the preservation of natural tooth structure. 
The present case report describes the successful management of two tooth fracture cases (one with and one without pulpal involvement) by fractured fragment rebonding.
| Case Reports|| |
This was a first case of a 29-year-old male patient who presented to the Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, with a chief complaint of fractured left maxillary central tooth. Patient's history revealed that he had sustained the injury during sports activity. The fractured fragment was recovered by the patient at the site of injury and was brought to the clinic stored in water.
Intraoral examination revealed that the maxillary left central incisor was fractured in the labiopalatal direction without the involvement of the pulp (non-complicated crown fracture - Ellis Class II) [Figure 1]a and b. An intraoral periapical (IOPA) radiograph revealed no associated root fracture, also the associated alveolar bone and periapical area appeared normal. Upon examination of the fractured fragment, it was found that the fragment was in healthy condition and it fit reasonably well on the fractured tooth [Figure 1]c. The treatment options suggested to the patient were (1) pulp protection with direct composite resin restoration (2) full coverage crown and (3) reattachment of the tooth fragment. After discussing about the advantages, disadvantages, prognosis and cost of every treatment option the patient opted to have the tooth fragment reattached.
|Figure 1: (a) Pre-operative view, labial (b) pre-operative view, occlusal (c) fractured fragment (d) teeth isolated with a rubber dam (e) pulp protection with Dycal and GIC (f) recess created in fractured fragment using round bur (g) Mylar strip placed interproximally before rebonding (h) post-operative view, labial|
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After administration of local anesthesia, the teeth were isolated using rubber dam (Hygenic, Coltene Whaledent Inc., USA) [Figure 1]d. Since the fracture line was in close proximity to the pulp a pulp capping procedure was carried out using calcium hydroxide (Dycal, Dentsply, Maillefer, Ballaigues, Switzerland), the calcium hydroxide and lined with a layer of Glass ionomer cement (GC Fuji II, GC Corporation, Tokyo, Japan) such that it did not extend onto the peripheral dentine and enamel [Figure 1]e. A recess was created in the fractured fragment corresponding to the position of GIC using a round bur and it was ensured that the fragments approximated properly [Figure 1]f. The fractured tooth surface and the fractured fragments were subjected to selective acid etching of enamel with 37% orthophosphoric acid (3M ESPE) for 15 s, then rinsed thoroughly with water and air-dried. Self-adhesive resin cement (Rely X TM U200, 3M ESPE) was applied to the fractured fragment and the tooth surface. The fractured fragment was then repositioned onto the tooth. The adaptation of the fragment to the tooth surface was confirmed before light curing. Visible light curing was done for 2 s, excess cement was removed with an explorer and final light curing was done for 20 s each on the labial and palatal side. Along the fracture line, a double chamfer was created using a round bur. The chamfer was restored with microhybrid composite (Filtek Z250 TM 3M ESPE) after etching and bonding the surface. The composite was cured for a time of 20 s per increment. The restored surface was finished and polished (Sof-Lex TM disks 3M ESPE). The immediate post-operative view [Figure 1]h shows optimal esthetic and functional restoration using a very conservative and cost-effective approach. Patient was instructed to prevent heavy loading of the anterior teeth. post-operative period was uneventful.
A 27-year-old male patient presented to our department with a chief complaint of fractured left maxillary lateral incisor because of trauma during sports activity.
Clinical examination revealed that the fractured fragment was mobile, but still attached to the soft-tissue palatally, further intraoral examination revealed a complicated crown root fracture (Ellis Class III) [Figure 2]a. The fracture line extended from the buccal to the palatal aspect subgingivally in an oblique direction. An IOPA radiograph revealed no associated root fracture, also the associated alveolar bone and periapical area appeared normal. The treatment options suggested to the patient were root canal treatment followed by (1) post- core and crown (2) reattachment of the tooth fragment. After discussing about the advantages, disadvantages, prognosis and cost of every treatment option the patient opted to have the tooth fragment reattached.
After administration of local anesthesia, the fractured fragment was detached from the palatal soft-tissue with the help of a periosteal elevator. Careful evaluation revealed that the biological width was only minimally invaded [Figure 2]b-2h.
|Figure 2: (a) Pre-operative view, labial (b) occlusal view after removal of the fractured fragment (c) fractured fragment (d) fractured fragment cleaned and pulp space enlarged (e) fiber post cemented (f) palatal flap elevated (g) fractured fragment rebonded (h) post-operative view, labial (i) palatal flap repositioned and sutured|
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As the fracture line involved the pulp, it was decided that a single visit endodontic treatment and reattachment of the fractured fragment with the placement of a fiber post will be carried out in the same appointment. After isolating the area, access was gained labially through the fractured region. The pulp tissue was extirpated and the root canal was irrigated with 5.25% sodium hypochlorite (NaOCl) and saline. Root canal was negotiated with a no. 15 k-file, the working length was determined using an electronic apex locator (Propex II, Dentsply, Maillefer, Ballaigues, Switzerland). The root canal was cleaned with 5.25% NaOCl and 17% ethylenediaminetetraaceticacid and shaped with hand protaper files (up to size F3). Final irrigation was done with 2% chlorhexidine and the canal was dried with paper point. Obturation was done with protaper Gutta-percha (F3 size) and AH plus sealer. Post-obturation IOPA radiograph was taken to confirm a satisfactory root canal filling.
A tapered fiber post (Mirafit white, L3, Hager Werken GmbH and Co. KG, Duisburg, Germany) was cemented after post space preparation using self-adhesive resin cement (Rely X TM U200, 3M ESPE) [Figure 2]e. After cleaning the fractured fragment with NaOCl, a recess was created in the coronal fragment corresponding to the position of the post [Figure 2]c and 2d. A palatal flap (without releasing incisions) was elevated to gain access to the fracture margin palatally [Figure 2]f. An osteotomy was performed using a Wedelstaedt chisel. Osteotomy was restricted to the palatal area where the biological width was violated. The fit of the coronal fragment was checked. Resin cement (Rely X TM U200, 3M ESPE) was applied to the fractured fragment, the post and the fractured tooth and the fragment was carefully repositioned. After light curing for 2 s the excess cement was carefully removed from the margins and final curing was done for 20 s [Figure 2]g. After finishing the marginal area, the palatal flap was repositioned and sutured (interrupted suture) [Figure 2]i. The immediate post-operative view [Figure 2]h shows optimal esthetic and functional restoration. Patient was instructed to prevent heavy loading of the anterior teeth. Post-operative period was uneventful.
| Discussion|| |
Management of crown and crown-root fractures pose a challenge to the clinician as several factors may play a role in their management. These factors include: 
- The extent of the fracture (complicated or uncomplicated, violation of biological width, alveolar bone fracture, concomitant luxation injury)
- Restorability of the fractured tooth and fracture pattern (subgingival extension of the fracture line and/or associated root fracture)
- Availability of the fractured fragment and its condition for use (fit of the fragment to the remaining tooth structure)
- Secondary soft-tissue injuries
- Occlusion, esthetics and finance.
The treatment options for anterior tooth trauma can range from direct resin based composite restoration, tooth fragment rebonding, ceramic veneer, root canal treatment and tooth fragment rebonding, crown, root canal treatment and crown with or without post and core and extraction followed by replacement.
For rebonding of a fractured fragment, various strategies have been advocated which include enamel beveling, V-shaped internal enamel groove, internal dentine groove, external chamfer, over contouring and simple reattachment.  In Case 1, an external chamfer technique was used, as it provides better strength as compared to simple reattachment. Reis et al. in their study have reported 60% recovery of the fracture strength with chamfer technique.  Moreover, in this technique a chamfer is placed after the fragment is reattached and thus there is minimal loss of fit as compared to techniques in which the fragment is manipulated before bonding. 
In Case 2, a fiber post extended into the pulp space of the coronal fragment for auxiliary retention. Fiber post was preferred over a metallic post because they have better esthetics, their modulus of elasticity is similar to that of root dentine. This results in less stress concentration on the root and thus low incidence of root fracture. 
Close adaptation of the fractured fragment is a prerequisite for rebonding of fractured fragment. In Case 1 after pulp protection, the intervening cement prevented the adaptation of the fractured fragment to the remaining tooth structure. A recess was therefore created in the fractured fragment to accommodate the intervening cement and allow proper adaptation of the fragment. Similarly in Case 2, the pulp space was enlarged in the coronal fragment to accommodate the fiber post and allow adaptation of the fragments.
Maintenance of the biological width is of utmost importance for a long lasting and predictable restorative treatment.  In Case 2, there was minimal violation of the biological width and thus osteotomy was performed strictly at the place where the biological width was invaded. The aim was to preserve maximum bone support. Elevating a flap during the surgical procedure exposed the fracture line and improved access for removing the excess cement and finishing the area.
Although rebonding technique offers several advantages there are few disadvantages such as color change of the fragment, exposure and discoloration of the fracture line over a period of time, less strength compared to full coverage restoration and unknown long-term survival rates.
| Conclusion|| |
Based on the above cases it can be concluded that rebonding of the fractured tooth segment benefits the patient with immediate esthetics. It requires thorough planning with a sound knowledge of techniques and use of materials and it is a conservative, less time consuming treatment option.
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[Figure 1], [Figure 2]