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Rev Clin Periodoncia Implantol Rehabil Oral. 2016;xxx(xx):xxx---xxx

www.elsevier.es/piro

Revista Clínica de Periodoncia,Implantología y Rehabilitación Oral

CLINICAL REPORT

Tooth fragment re-attachment in fracture withbiological width violation: Case report

Raniel Fernandes Peixotoa, Krysna Torres de Almeidab, Julia Peixoto Camposb,Antônio Vinicius Holanda Barbosac, Patrícia dos Santos Calderond,Bruno César de Vasconcelos Gurgeld,∗

a University of São Paulo, Ribeirão Preto Dental School, Department of Dental Materials and Prosthodontics, Ribeirão Preto, SP,Brazilb University Center of Maceió, Maceió, AL, Brazilc Integrated College of Pernambuco, Dental School, Department of Endodontics, Recife, PE, Brazild Federal University of Rio Grande do Norte, Department of Dentistry, Natal, RN, Brazil

KEYWORDSCrown fracture;Tooth fragmentre-attachment;Biological widthviolation

Abstract Dento-alveolar traumas are one of the most frequent injuries to teeth, mainly affect-ing the upper incisors due to their exposed position in the dental arch. In such cases, esthetics,function and phonetics of anterior teeth may be compromised. Furthermore, when there isinvolvement of the biological width, there is often a poor prognosis. This case report describesthe multidisciplinary approach to tooth fragment re-attachment in a fracture with biologicalwidth violation. The patient presented with an oblique crown fracture in the maxillary rightlateral incisor, extending from the buccal to palatal side, as well as a biological width invasion.The re-establishment of the biological width was obtained by periodontal surgery to achieveclinical-crown lengthening and tooth fragment re-attachment with a glass fibre post to increaseretention. After 3 years of follow-up, the rehabilitated lateral incisor remains in good condition,with satisfactory esthetic and periodontal health.© 2016 Sociedad de Periodoncia de Chile, Sociedad de Implantología Oral de Chile y

Sociedad de Prótesis y Rehabilitación Oral de Chile. Published by Elsevier España, S.L.U.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Peixoto RF, et al. Tooth fragment re-attachment in fracture with biological widthviolation: Case report. Rev Clin Periodoncia Implantol Rehabil Oral. 2016. http://dx.doi.org/10.1016/j.piro.2016.03.002

∗ Corresponding author.E-mail address: bcgurgel@yahoo.com.br (B.C.V. Gurgel).

http://dx.doi.org/10.1016/j.piro.2016.03.0020718-5391/© 2016 Sociedad de Periodoncia de Chile, Sociedad de Implantología Oral de Chile y Sociedad de Prótesis y Reha-bilitación Oral de Chile. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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PALABRAS CLAVEFractura coronaria;Anclaje de fragmentodental;Invasión del espaciobiológico

Anclaje de fragmento dental en fractura con invasión del espacio biológico: reportede caso

Resumen Traumatismos dentoalveolares son unas de las lesiones más frecuentes en losdientes, afectando principalmente los incisivos superiores debido a su posición expuesta enla arcada dental. En tales casos, la estética, la función y la fonética de los dientes anteri-ores pueden verse comprometidas. Además, cuando hay compromiso del espacio biológico, elpronóstico se vuelve desfavorable. Este reporte de caso describe el abordaje multidisciplinariopara el anclaje de fragmento en una fractura dental con invasión del espacio biológico. Elpaciente presentaba una fractura oblicua coronaria en el incisivo lateral superior derecho,extendiéndose desde la cara vestibular hasta la palatina, e invasión del espacio biológico. Elrestablecimiento del espacio biológico se obtuvo por medio de cirugía periodontal para lograralargamiento de corona clínica y anclaje del fragmento dental con poste de fibra de vidrio paraaumentar la retención. Después de 3 anos de seguimiento, el incisivo lateral rehabilitado semantiene en buenas condiciones, con salud y estética periodontal satisfactoria.© 2016 Sociedad de Periodoncia de Chile, Sociedad de Implantología Oral de Chile ySociedad de Prótesis y Rehabilitación Oral de Chile. Publicado por Elsevier España, S.L.U.Este es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Ao(UFRN), with the complaint of a crown fracture in the max-illary right lateral incisor (tooth 12), due to trauma duringsoccer training (Fig. 1). The patient signed a consent formauthorizing the use of images and publication of the case ina manuscript.

ntroduction

entoalveolar traumas are commonly caused by injuriesuch as contact sports, street fights and traffic accidents.1---3

hese manifestations can vary from an enamel-dentin sim-le fracture to pulp and root-involving fractures.1,2 Due toheir exposed position in the dental arch, maxillary incisorsre the teeth that are most commonly involved in dentalrauma2,4 and these fractures subsequently lead to esthetic,unctional and phonetic problems.2

A study by Murchison, Burke and Worthington5 estimatedhat about one-fourth of the population under the age of8 years has traumatic injury in anterior teeth and, of thisotal, 80% are central incisors and 16% are lateral incisors.owever, fractures involving crown and root with pulpalxposure constitute only 5%---8% of all traumatic injuries.6 Aeview of published case reports indicate that 85% of trau-atized incisors fracture in an oblique fashion from the

abial to lingual aspect.5

After the appearance of the acid-etching technique byuonocore in 1955, the treatment of fractured teeth hasecome more conservative, preserving the healthy toothtructure. Currently, two methods are being used to rehabil-tate fractured teeth, including resin composite restorationsnd tooth fragment reattachment.2

Tooth fragment reattachment is a good alternative in thereatment of dental fractures, since the fragment is ade-uately preserved in physiological saline solution or salivao prevent dehydration and discoloration.7 This procedureffers good esthetic and functional results in the short-termnd medium-term and also restores the patient’s emotionalalance.2 Other advantages of tooth fragment reattach-ent are improved enamel smoothness and hardness, dentin

ranslucency, maintenance of original tooth contours, asell as preservation of occlusal contacts, color stability

Please cite this article in press as: Peixoto RF, et al. Tooth fviolation: Case report. Rev Clin Periodoncia Implantol Rehabil O

nd procedure cost.1,7 In cases where the fracture extendso the biologic width, periodontal surgery associated withsteotomy and osteoplasty procedures is required.2,3

Fi

In spite of the high success rates in tooth fragment reat-achment reported in the literature,1,8 some dentists makeecision for other less conservative procedures such as toothxtraction and rehabilitation with implant-supported pros-hesis. This may be due to either lack of knowledge ofuch procedures or fear of failure.1 Therefore, this articleescribes the rehabilitation of a crown fracture in the max-llary lateral incisor using the tooth fragment reattachmentechnique and using a glass fiber post to increase retention,ith a 3-year follow-up.

ase report

24-year-old male patient was referred to the Departmentf dentistry of the Federal University of Rio Grande do Norte

ragment re-attachment in fracture with biological widthral. 2016. http://dx.doi.org/10.1016/j.piro.2016.03.002

igure 1 Preoperative view of the maxillary right lateralncisor after trauma.

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Tooth fragment re-attachment in fracture with biological width violation 3

Figure 2 Right lateral incisor with oblique crown fractureextending from the buccal to palatal aspect and biological widthinvasion (2 mm) in the palatal aspect.

Figure 4 Occlusal view after reestablishment of the biologicwidth through periodontal surgery.

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Figure 3 Crown fragment removed.

The clinical examination revealed that there was no frac-ture of the maxilla or any other facial bones. Intraorally,the crown fracture in tooth 12 was oblique and extendedfrom the buccal to the palatal aspect, involving enamel anddentin (Fig. 2).

A few days after the completion of semi-rigid con-tainment around the maxillary anterior teeth, the patientreported pain in the injured tooth. Thermal tests forassessing pulp vitality were performed and the tooth wasdiagnosed with irreversible pulpit. Before the endodontictreatment, biological width invasion of 2 mm in the palataland mesial aspect was diagnosed with a periodontal probe.Thus, the semi-rigid containment and the fragment wereremoved and were stored in physiological saline solutionfor use at a later stage (Fig. 3). The reestablishment of thebiologic width was obtained through periodontal surgery inorder to increase the clinical crown, using the internal bevel

Please cite this article in press as: Peixoto RF, et al. Tooth fviolation: Case report. Rev Clin Periodoncia Implantol Rehabil O

incision, associated with osteotomy and osteoplasty (Fig. 4).Vestibular papilla aspect was preserved during palatal flapelevation. On that occasion, tooth fragment reattachmentwas performed with the aid of absolute isolation and a

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Figure 5 Crown fragment reattached to remaining tooth.

aliva ejector was placed in position. In another section,he endodontic access was obtained, pulpal curettage andlacement of intra-canal medication were performednd the completion of endodontic treatment was postponedor one week.

Subsequently, for fragment reattachment, a small attri-ion in the remaining tooth and fragment was performed tonable a better fragment adaptation and promote enoughpace for placement of the adhesive system and composite.hus, after acid etching of both the remaining tooth andragment for 20s with 37% phosphoric acid (Alpha Etch, DFL,io de Janeiro, Rio de Janeiro, Brazil), an adhesive systemAdper Single Bond 2, 3M ESPE, Sumaré, São Paulo, Brazil)as applied and polymerized using a halogen light source

LD Max, Gnatus, Ribeirão Preto, São Paulo, Brazil) for 40 s.he composite (FiltekTM Z350 XT Universal Restorative; 3MSPE, Sumaré, São Paulo, Brazil) was then applied, and theooth fragment was positioned and polymerized for 40s. Ashe fracture line was visible on the buccal surface, a grooveas made and then restored with composite (Fig. 5). Fin-

shing and polishing was done using the Sof-Lex polishingystem (Sof-Lex, 3M ESPE, Sumaré, São Paulo, Brazil). Afterestoration, the rubber dam was removed.

One week after the tooth fragment reattachment proce-ure, endodontic treatment was carried out under absolute

ragment re-attachment in fracture with biological widthral. 2016. http://dx.doi.org/10.1016/j.piro.2016.03.002

solation and the root canal was filled with gutta-perchasing the vertical and lateral condensation technique. Inrder to provide higher resistance and increase the den-al fragment retention, two-thirds of the root canal filling

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4 R.F. Peixoto et al.

Figure 6 Glass fiber post placed after root canalpreparation.

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Figure 8 Labial view after 3 years of follow-up.

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igure 7 Labial view immediately after cementing the glassber post and lingual face restoration.

aterial were removed and a glass fiber post (Whitepost DC,GM, Joinvile, Santa Catarina, Brazil) was adapted in theanal and cut to the desired length (Fig. 6). After adequateost adjustment, acid etching of the root canal was per-ormed with 37% phosphoric acid, and the adhesive systemas applied according to the manufacturer’s instructions.he glass fiber post was then cemented with the help ofual-cure resin cement (RelyX ARC, 3M ESPE, Sumaré, Sãoaulo, Brazil) and then polymerized using a halogen lightource for 40s (Fig. 7).

After 3 years of follow-up, the maxillary right lat-ral incisor (tooth 12) remains in good condition, withatisfactory esthetic and periodontal health. Clinical andadiographic features such as absence of periodontal pock-ts, bleeding on probing and tooth mobility; intact andadiopaque lamina dura around the tooth; no periapicaladiolucency and satisfactory treatment of root canal couldhow success of the procedure of tooth fragment reat-achment, even in situations involving the biologic widthFigs. 8 and 9).

iscussion

Please cite this article in press as: Peixoto RF, et al. Tooth fviolation: Case report. Rev Clin Periodoncia Implantol Rehabil O

variety of traumatic conditions can cause crown fractures,lthough the literature shows some predominant causes suchs falling while playing and running, during sports activ-ties, and blows received to the face.1,9 According Taiwo

laoa

Figure 9 Radiographic view after 3 years of follow-up.

nd Jalo,10 the maxillary central incisors are most vulner-ble to injury, sustaining approximately 67% of all dentalnjuries followed by the maxillary lateral and the mandibularncisors. As also described by Goenka et al.,4 the major-ty of dental injuries involving the anterior teeth occur dueo their exposed position in the dental arch. In agreementith this information, this case report describes the multi-isciplinary approach to tooth fragment reattachment in aracture with biologic width violation of a maxillary lateralncisor using a glass fiber post to increase retention as anlternative method for restoring the esthetics and functionf traumatized teeth.

Although the indication of tooth fragment reattachments restricted to simple cases where the fracture line is clini-ally visible, this case report demonstrated, through clinicaluccess at 3 years of follow-up, that this procedure can beerformed even in complex fracture cases involving the bio-ogic width and tooth root, corroborating Durkan et al.3

ragment re-attachment in fracture with biological widthral. 2016. http://dx.doi.org/10.1016/j.piro.2016.03.002

nd Rajput et al.1 This case emphasizes the importancef long-term follow-up visits, where esthetics, functionnd periodontal health should be confirmed clinically and

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Tooth fragment re-attachment in fracture with biological wi

radiographically during 5 years.1 The avoidance of prema-ture occlusal contacts and correction of relationships withadjacent teeth favors treatment success.

The dental reattachment technique has improved alongwith the development of acid-etching technique and dentinadhesives.8 Failure of the teeth restored with metal postsand cores occurs typically due to root fractures, which areoften related to the stiffness and different mechanical prop-erties of metal posts.11 Unlike the metal post, glass fiberposts are less stiff and result in a better stress distributionin the root, which may result in fewer severe fractures afterfailure.12 In addition to the similarity in the elasticity coeffi-cient to that of dentin, the ability to cement glass fibers withadhesive system is very important, along with good estheticresults.13 Based on these aspects, a glass fiber post was usedto increase retention of the reattached crown fragment andits choice took into account the amount of tooth remainingand the presence of enamel, which improve adhesion to theadhesive system.

The tooth fragment reattachment is considered the mostconservative treatment for crown fractures of the anteriorteeth,4,14 as it provides enhanced fragment adaptation tothe remaining tooth in addition to good stability and biocom-patibility of the natural tooth surface to the periodontium,15

as well as keeping original tooth contours, preservation ofocclusal contacts.1,7 It also provides immediate esthetic andfunctional rehabilitation of the fractured tooth.

Conclusion

Currently, with the available materials, in conjunction withan appropriate technique, esthetic results can be achievedwith predictable outcomes. Thus, the reattachment of atooth fragment is a viable technique that restores functionand esthetics with a very conservative approach.

Ethical disclosures

Protection of human and animal subjects. The authorsdeclare that no experiments were performed on humans oranimals for this investigation.

Confidentiality of data. The authors declare that they havefollowed the protocols of their work center on the publica-tion of patient data.

Please cite this article in press as: Peixoto RF, et al. Tooth fviolation: Case report. Rev Clin Periodoncia Implantol Rehabil O

Right to privacy and informed consent. The authors musthave obtained the informed consent of the patients and/orsubjects mentioned in the article. The author for correspon-dence must be in possession of this document.

1

PRESSviolation 5

onflict of interest statement

one declared.

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2. Oz IA, Haytac MC, Toroglu MS. Multidisciplinary approach to therehabilitation of a crown-root fracture with original fragmentfor immediate esthetics: a case report with 4-year follow-up.Dent Traumatol. 2006;22:48---52.

3. Durkan RK, Ozel MB, Celik D, Bagis B. The restoration of a max-illary central incisor fracture with the original crown fragmentusing a glass fiber-reinforced post: a clinical report. Dent Trau-matol. 2008;24:e71---5.

4. Goenka P, Sarawgi A, Dutta S. A conservative approach towardrestoration of fractured anterior tooth. Contemp Clin Dent.2012;3:S67---70.

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Eur J Dent. 2012;6:227---33.5. Eden E, Yanar SC, Sönmez S. Reattachment of subgingivally

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