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| CASE REPORT |
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| Year : 2021 | Volume
: 11
| Issue : 3 | Page : 129-134 |
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Tooth fragment reattachment: A case series
Vishwakarma Sucharita1, Khera Archie2
1 Consultant Endodontist, Swagat Dental Clinic, Nadiad, Gujarat, India
2 Consultant Endodontist, Apollo Hospitals, Mumbai, Maharashtra, India
| Date of Submission | 06-Jul-2020 |
| Date of Decision | 04-Aug-2020 |
| Date of Acceptance | 02-Feb-2021 |
| Date of Web Publication | 22-Dec-2021 |
Correspondence Address:
Dr. Vishwakarma Sucharita
B-235, Shaligram Greens, Near Ram Bhai Kaka Marg, Bakrol, Ahmedabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_60_20
 Abstract | | |
Appropriate management of anterior tooth fracture not only restores the function and esthetics but also provides a positive psychological impact for the patient. One of the most conservative approaches for such a restoration is reattachment, if fracture fragment is available. This case report provides three cases with varied approaches for the management of complicated and uncomplicated crown fracture using reattachment procedure. First case describes management of a complicated fracture of the upper central incisor which invades the biological width using flap elevation and fiber post cementation. Second case report describes reattachment of complicated fracture of the central incisor managed using fiber post cementation and reattachment after nonsurgical endodontic treatment. Third case report describes management of Ellis Class II fracture. Reattachment of fractured fragment is indeed a cost-effective conservative treatment. Keywords: Biologic width, conservative treatment, endodontically treated teeth, fracture, reattachment
How to cite this article:
Sucharita V, Archie K. Tooth fragment reattachment: A case series. J Interdiscip Dentistry 2021;11:129-34 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
Utilising various aspects of dentistry, such as Oral surgery, Endodontics and Conservative dentistry, tooth fragment reattachment provides dentists with conservative approach for an aesthetically satisfactory tooth reconstruction.
| Introduction | | |
Management of a fractured anterior tooth requires immediate attention and if left untreated can lead to pulpal and periapical changes, which can further have a psychological impact on the patient due to delayed treatment and improper esthetics.[1] Multiple variables such as extent and location of fracture line, restorability of fractured tooth, injury to the adjaent structures, presence or absence of fractured fragment, occlusion, esthetics, economical factors and age of the patient are to be considered during treatment planning. Depending upon whether fracture involves the pulp organ or not, an anterior tooth fracture may be classified as complicated or uncomplicated fracture.[1] Most traumatic tooth injuries are uncomplicated and merely involve damage to the enamel and/or dentin without pulp exposure.[2] In such cases, the commonly preferred treatment option is to replace the missing tooth structure using esthetic composite restoration. However, composite resin has the disadvantage of poor abrasion resistance in comparison with enamel, difficulty in color matching, and postoperative sensitivity.[3] Treatment options to restore traumatized teeth with complicated fractures may include root canal therapy followed by direct and indirect restorative procedures, such as composite restorations, ceramic restorations, and crowns with or without an intraradicular post. Such procedures are expensive, require long clinical sessions, and may reduce sound tooth structure. Direct or indirect restorative materials used in such cases may not be able to reproduce color, opacity, and translucency of sound tooth structure.[4],[5],[6]
When the tooth fragment is present, the best option to restore the morphological, functional, and esthetic aspects of dentition will be fragment reattachment. It will not only maintain the shape, contour, texture, color, and alignment of natural teeth but also will be a fast, cost-effective solution, creating a positive psychological response in the patient.[2],[7],[8],[9]
This paper describes three different cases of anterior teeth fracture. All of them were successfully treated using natural tooth fragment reattachment.
| Case Reports | | |
Case report 1
A 26-year-old male patient presented to the dental clinic with a coronal fracture of the maxillary right central incisor caused by a domestic fall 2 days before. Clinical examination revealed an oblique crown fracture on 11 originating in the middle third of crown labially [Figure 1]a and extending transversely till the junction of anatomic crown and anatomic root, slightly below the cementoenamel junction subgingivally on the palatal aspect [Figure 1]b and [Figure 1]c. The probing depth was normal and the teeth had no associated soft tissue injuries. A diagnosis of complicated crown fracture with respect to maxillary left central incisor was made. Medical history was noncontributory. All the treatment options were explained to the patient. The patient agreed to opt for the evaluation of fractured fragment followed by reattachment procedure. Consent was obtained. Local anesthetic using 2% lidocaine and 1:80,000 adrenaline (XICAINE) was given. The fracture line was subgingival on the palatal aspect [Figure 1]d. During the removal of fractured fragment, it was observed that the fragment was retained by the palatal gingival tissue. Fracture line was involving pulp chamber. A palatal intrasulcular incision followed by a gingival flap was performed to remove the fragment. The tooth fragment was thoroughly rinsed with 2% sodium hypochlorite to remove any pulpal tissue and then stored in normal saline. The fracture line in the retained tooth was located 1 mm intraosseously, invading the biological space. In the palatal region, 2 mm of bone was removed using osteotomy and osteoplasty. Rubber dam isolation was performed using a #212 retraction clamp, which was modified by bending the palatal jaw so that the palatal beak of the clamp could be placed subgingivally. Single-visit endodontic therapy was planned. Access opening was performed. Working length was determined using Root ZX II apex locator and confirmed using radiograph. Cleaning and shaping was performed using ProTaper Universal rotary file system (Dentsply) up to an apical size of ISO size 50. 5.25% sodium hypochlorite was used as an irrigant during the preparation. Seventeen percent ethylenediaminetetraacetic acid (EDTA) was used as final rinse. The root canal was dried with paper points and obturated using cold lateral condensation with gutta-percha and AH Plus sealer (Dentsply). | Figure 1: Case report 1 – (a) Fracture line at the level of middle third of clinical crown on labial aspect. (b) Removed fractured fragment. (c) Preoperative radiograph showing horizontal fracture line. (d) Palatal flap reflection indicating pulpal involvement and infra-alveolar fracture line. (e) Single tooth rubber dam isolation and cemented fiber post. (f) Radiograph indicating 5 mm of remaining obturating material and fiber post adaptation. (g) Reattached and cemented fractured fragment on the palatal aspect. (h) Immediate postoperative radiograph
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Post space was prepared using peeso reamers #1 and #2 leaving 5 mm of gutta-percha for apical seal. The fiber post #2 (Reforpost, Angelus) was tried in the canal and adjusted to the desired length. A groove was prepared on the palatal side of the fractured fragment to allow venting of excess flowable composite resin. The alignment of the coronal fragment was verified with the post in place. Post space was rinsed thoroughly with 17% EDTA followed by normal saline. Paper points were used to dry the post space. Fiber post was coated and cemented using 3M ESPE RelyX U200 self-adhesive resin cement and light cured into the post space [Figure 1]e and [Figure 1]f. Following this, the tooth with fiber post and the fractured fragment were etched with 37% Phosphoric Scotchbond™ Etchant applied to enamel and dentin for 15 s and rinsed for 10 s. Excess water was blotted using a cotton pellet. This was followed by application of 2–3 consecutive coats of 3M ESPE Adper Single Bond Plus bonding agent to etched enamel and dentin for 15 s with gentle agitation using a fully saturated applicator, gently air thinned for 5 s to evaporate solvents followed by light curing for 10 s The fragment was reattached to the tooth using flowable composite resin 3M ESPE Filtek Z350 XT flowable composite resin and light cured [Figure 1]g. At the end, flap was repositioned and sutured [Figure 2]a, occlusion was checked, and postoperative instructions were given to the patient [Figure 2]b and [Figure 2]c. Immediate post-operative radiograph was taken [Figure 1]h. Teeth 12, 22, and 21 were restored using esthetic composite restorations during the follow-up visits. Clinical and radiographic examinations were carried out after six months [Figure 2]d. | Figure 2: Case report 1 – (a) Immediate postoperative view on labial aspect with suture. (b) 1-week follow-up, labial view. (c) 1-week follow-up, palatal view. (d) Six months of follow-up with composite restorations on adjacent teeth
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Case report 2
The second case of reattachment presented with Ellis Class III fracture in the permanent maxillary right central incisor [Figure 3]a and [Figure 3]b. The fracture line was supragingival with intact fractured fragment [Figure 3]c. Fracture line was located at the middle third of clinical crown. The patient had reported with the fractured fragment on the day of trauma itself. No signs and symptoms of periapical infection were observed [Figure 3]d. After obtaining consent from patient, root canal treatment (RCT) was completed using single-visit endodontics under rubber dam isolation [Figure 3]e. Cleaning and shaping was performed using ProTaper Universal rotary file system (Dentsply) up to an apical size of ISO size 50 under rubber dam isolation. Apical size was determined using apical gauging. 5.25% sodium hypochlorite was used as an irrigant during the preparation. 17% EDTA was used as final rinse. The root canal was dried with paper points and obturated using cold lateral condensation with gutta-percha and AH Plus sealer (Dentsply) [Figure 3]f. Post space preparation was done till #2 peeso reamer as mentioned in the previous case [Figure 3]g. Fragment was debrided of any remaining pulp tissue, thoroughly rinsed with sodium hypochlorite, and preserved in saline. The fiber post #2 (Reforpost, Angelus) was tried in the canal and adjusted to the desired length and cemented using 3M ESPE Rely X U200 self-adhesive resin cement and light cured [Figure 3]h. A groove was created on the palatal side of the fractured fragment to allow venting of excess flowable composite resin. Bonding and reattachment protocol was followed similar to the case discussed above [Figure 4]a,[Figure 4]b,[Figure 4]c,[Figure 4]d,[Figure 4]f. After the procedure, occlusion was checked, the patient was given the postoperative instructions [Figure 4]g and [Figure 4]h, and postoperative X-ray was taken [Figure 4]e. Clinical examinations were carried out at 3 months of follow-up along with esthetic composite restorations in teeth 12 and 21 [Figure 4]i. | Figure 3: Case report 2 – (a) Preoperative labial view, fracture line at the middle third level of clinical crown at supragingival level. (b) Preoperative palatal view, supragingival fracture line indicating pulpal involvement. (c) Fractured fragment. (d) Preoperative Radiograph. (e) Single tooth rubber dam isolation. (f) Master cone radiograph. (g) Radiograph with 5 mm of remaining obturating material after post space preparation. (h) Post cementation
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 | Figure 4: Case report 2 – (a and b) Acid etching of tooth and fractured fragment with 37% phosphoric acid. (c and d) Bonding agent application on tooth and fractured fragment. (e) Immediate postoperative radiograph with attached fractured fragment. (f) Reattachment of fractured fragment using flowable composite. (g) Immediate postoperative labial view. (h) Immediate postoperative palatal view. (i) Follow-up after 3 months
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Case report 3
The third case was presented with uncomplicated Ellis Class II fracture in the permanent maxillary left lateral incisor. Clinical crown was fractured obliquely without any involvement of the pulp chamber [Figure 5]a. Fracture line was located supragingivally. The patient presented after 3 days of trauma and had preserved his tooth fragment in water [Figure 5]b. No signs and symptoms of pulpal and periapical infection were present. Pulp sensibility tests can be nonreliable, and hence, they were recorded only for baseline parameter. To preserve the vitality of pulp, root canal procedure was not performed. To conserve the tooth structure and achieve optimal adaptation of the tooth fragment, tooth was left unprepared. First premolar to first premolar anterior isolation was performed using rubber dam [Figure 5]c. Similar bonding and reattachment protocol was followed as mentioned in previous cases [Figure 5]d,[Figure 5]e,[Figure 5]f. After the procedure, occlusion was checked and the patient was given the postoperative instructions [Figure 5]g. Clinical examinations along with pulp sensibility test were performed at 3 months of follow-up [Figure 5]h. Tooth showed similar response to adjacent and contralateral teeth. | Figure 5: Case report 3 – (a) Preoperative labial view with oblique fracture line. (b) Fractured fragment. (c) Premolar to premolar rubber dam isolation. (d) Acid etching of tooth. (e) Bonding agent application. (f) Fragment reattachment using flowable composite resin. (g) Immediate postoperative view. (h) Follow-up after 3 months, labial view
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| Discussion | | |
When compared to other procedures, tooth fragment reattachment is a more conservative, affordable, and less time-consuming treatment option with favorable advantages, such as original color match, preservation of contour, contacts, and incisal translucency.[2] The type of treatment depends on pulp vitality and the stage of root development or resorption. In complicated fractures, RCT followed by reattachment of the fractured segment with fiber post reinforcement is a feasible option. In fractures involving two-thirds or more of the crown, post systems are usually recommended.[10] Out of wide variety of post systems available, tooth-colored fiber post was considered to be the best option with a number of important advantages such as esthetics, good bonding between post and cement, lower chair side time, and minimal tissue removal.[10],[11] Wide variety of treatment protocols are available for reattachment procedures. Some techniques of fragment reattachment include a bonding procedure without any type of preparation of the remaining tooth or tooth fragment surfaces. This technique is called simple reattachment. However, some authors prefer tooth preparation in the form of external chamfering, over contouring or internal dentinal groove before bonding to aid in retention.[4]
In this case report, no tooth preparation was performed to conserve the tooth structure, prevent the difference in color perception between tooth and composite resin, and allow adequate adaptation of the fragments. According to a recent systematic review, simple tooth fragment reattachment is the preferred reattachment technique. An increase in the bond strength between tooth fragment and dentin was observed when an intermediate material was used and both the fragments had complete adaptation.[4]
The first case discussed in this case report was crown root fracture involving biologic width. The two available treatment option for the same was flap technique, i.e., gingival flap displacement with osteotomy and osteoplasty and extrusion, i.e., orthodontic extrusion of the apical portion until the fracture margin is exposed. Flap technique with osteotomy is considered to be a safe and effective treatment. However, there may be compromised bone support and increase in clinical crown height reducing the cervical diameter of the tooth. Although orthodontic extrusion brings no change in gingival level and alignment, it is a slow technique which requires stabilization time. It also can lead to blank space appearance and edge wear due to incisal length adjustment.[2] Keeping in mind all these aspects, surgical crown lengthening was opted in the first case.
To maintain periodontal health, a space of 2–3 mm between the bone crest and the apical limit of the restoration is necessary. However, it is hard to justify the surgical removal of the bone at the alveolar crest just to create a 2–3-mm biologic width apical to the margin of the restoration. It appears to be more sensible to remove bone to the minimal extent needed to ensure access for placement and finishing of proper restorations in the areas of subgingival fracture.[12]
In Case 1 and 2, single-visit root canal therapy was performed. In dental literature, there is insufficient evidence to rule out whether there are important differences in outcomes between single-visit or multiple-visit RCT.[13] In both the cases, there were no signs and symptoms of periapical infection and pulp sensibility test was nonreliable as trauma was recent. In Case 1, the fracture line was involving the pulp chamber along with subgingival extension. Single-visit endodontic therapy was performed as delayed postendodontic restoration would complicate precise reattachment of fractured fragments and contribute to infection due to substandardized provisional restoration, owing to the extension of fracture line. It would further lead to dehydration of fractured fragment. 5.25% sodium hypochlorite was used as an irrigant during the preparation. Earlier studies have reported conflicting results of the comparative effectiveness of hypochlorite at different concentrations; however, recent studies have confirmed the superiority of high concentration hypochlorite over 1% and 2% solutions.[14],[15],[16] Variety of preparation techniques are advocated to improve bond between the fractured fragment and the tooth. However, to reduce the technical sensitivity of the procedure and the length of the clinical phase, several studies and case reports have attempted to simplify the procedure by eliminating any additional preparation in the traumatized tooth. There is no consensus in the literature about the ideal technique for reattachment. However, according to a systematic review by Poubel et al., simple reattachment can be considered as the currently preferred technique when there is complete fragment adaptation, compared with other reattachment techniques using over-contouring and dentinal groove preparation.[4] Although the tooth was restored with post in Case 1 and 2, a vent was created palatally to remove excess flowable composite resin and precisely align the fragment with the remaining tooth structure.
Metal posts often cause catastrophic root fracture owing to higher elastic modulus than dentin. This leads to nonhomogenous and dangerous stresses in root dentin. Fiber post, on the other hand, best preserves the integrity of root. Lower modulus of elasticity, similar to dentin, creates root strain similar to that on intact tooth. Apart from this, glass fiber posts (GFPs) are biocompatible and esthetic and do not discolor at gingival margin.[17] Hence, in Case 1 and 2, where teeth were endodontically treated, fiber post was used to retain and support the fractured tooth structure. Unlike cast posts, post length, post diameter, or taper do not meaningfully affect the adhesion and long-term behavior of GFPs.[18] Hence, in these cases, post space preparation was kept minimal to conserve the natural tooth structure and not deteriorate the fracture resistance of restored tooth.[18]
Compared to acid-etch or self-etch resin cements, self-adhesive resin cements are less technique-sensitive and their performance for luting GFPs is not influenced by operator's experience. In vitro studies have reported higher bond strength of self-adhesive cements with root dentin as the acidic monomers simultaneously demineralize and infiltrate the tooth substrate, creating moisture resistant micromechanical as well as chemical bond. This bond strength has lower polymerization stress which is required to resist the 100-fold higher configuration factor in root dentin. Multiple factors such as control of dentin moisture, proper infiltration of adhesive solution and evaporation, excess adhesive removal, and adequate photo polymerization in apical areas must be taken into consideration while using acid rinse and self-etch resin cements. And hence, self-adhesive resin cement was used in all the three case reports.[19],[20]
| Conclusion | | |
The overall knowledge of dental emergencies and their management seems to be unsatisfactory both among lay people and caregivers. Despite crown fractures' higher frequency, knowledge regarding tooth fracture management seems to be relatively lower than tooth avulsion. Even among clinicians, there is wide range of dispute for management crown fractures, especially for reattachment procedures. Having a unified protocol for the management of the traumatized tooth would help keep the protocols as simple as possible, which could eventually lead to an easier and more rapid spread of information.[17]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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