reattachment of anterior teeth fragments: a conservative … · 2008-07-14 · dure.11 in addition,...

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*Graduate student, Department of Operative Dentistry, University of North Carolina at Chapel Hill, NC, USA†Graduate student, Department of Periodontology, University of North Carolina at Chapel Hill, NC, USA

‡Associate professor, Department of Operative Dentistry, Federal University of Ceara, Fortaleza, Brazil§Associate professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill, NC, USA

Reattachment of Anterior Teeth Fragments: A Conservative Approach

GEORGIA V. MACEDO, DDS*

PATRICIA I . DIAZ, DDS, PHD†

CARLOS AUGUSTO DE O. FERNANDES, DDS, MS, PHD‡

ANDRÉ V. RITTER, DDS, MS§

ABSTRACTCoronal fractures of the anterior teeth are a common form of dental trauma that mainly affectschildren and adolescents. One of the options for managing coronal tooth fractures when thetooth fragment is available and there is no or minimal violation of the biological width is thereattachment of the dental fragment. Reattachment of fractured tooth fragments can providegood and long-lasting esthetics (because the tooth’s original anatomic form, color, and surfacetexture are maintained). It also restores function, provides a positive psychological response, andis a relatively simple procedure. Patient cooperation and understanding of the limitations of thetreatment is of utmost importance for good prognosis. This article reports on two coronal toothfracture cases that were successfully treated using tooth fragment reattachment.

CLINICAL SIGNIFICANCEReattachment of fractured tooth fragments offers a viable restorative option for the clinicianbecause it restores tooth function and esthetics with the use of a very conservative and cost-effec-tive approach.

(J Esthet Restor Dent 20:5–20, 2008)

I N T R O D U C T I O N

Coronal fractures of the anteriorteeth are a common form of

dental trauma that mainly affectschildren and adolescents.1,2 Themajority of dental injuries involvesthe anterior teeth, especially themaxillary incisors (because of itsposition in the arch), whereas themandibular central incisors and themaxillary lateral incisors are less

frequently involved. Dental injuriesusually affect only a single tooth;however, certain trauma types such as automobile accidents andsports injuries involve multipletooth injuries.3

Several factors influence the man-agement of coronal tooth fractures,including extent of fracture (biolog-ical width violation, endodontic

involvement, alveolar bone fracture), pattern of fracture andrestorability of fractured tooth(associated root fracture), secondary trauma injuries (soft tissue status), presence/absence offractured tooth fragment and itscondition for use (fit between fragment and the remaining toothstructure), occlusion, esthetics,finances, and prognosis.4–6 Patient

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cooperation and understanding of thelimitations of the treatment is ofutmost importance for good progno-sis. When there is a substantial associ-ated periodontal injury and/orinvasion of the biological width, therestorative management of the coro-nal fracture should follow the propermanagement of those associatedissues. Coronal fractures must beapproached in a systematic way toachieve a successful restoration.

One of the options for managingcoronal tooth fractures, especiallywhen there is no or minimal viola-tion of the biological width, is thereattachment of the dental frag-ment when it is available.7 Toothfragment reattachment offers a con-servative, esthetic, and cost-effective restorative option that hasbeen shown to be an acceptablealternative to the restoration of thefractured tooth with resin-basedcomposite or full-coveragecrown.6,8–10 Reattachment of afragment to the fractured tooth canprovide good and long-lastingesthetics (because the tooth’s origi-nal anatomic form, color, and surface texture are maintained),9

can restore function, can result in apositive psychological response,and is a reasonably simple proce-dure.11 In addition, tooth fragmentreattachment allows restoration ofthe tooth with minimal sacrifice ofthe remaining tooth structure. Fur-thermore, this technique is lesstime-consuming and provides a

more predictable long-term wearthan when direct composite isused.12 Clinical trials and long-termfollow-up have reported that reat-tachment using modern dentin-bonding agents or adhesive lutingsystems may achieve functional and esthetic success.6,13

Several aspects may govern thechoice of a reattachment technique.Studies have reported that the pri-mary cause of fragment loss is newdental trauma or the nonphysiolog-ical use of the restored tooth.6

Therefore, most concerns aboutreattachment techniques have beendirected toward the fracturestrength of the restored tooth.5,14

Clinicians have employed an assort-ment of bevel designs, chamfers,dentinal and enamel grooves, andchoices of resin composite materialsand techniques for the reattachmentof tooth fragments. Reis and col-leagues5 have shown that a simplereattachment with no further prepa-ration of the fragment or tooth wasable to restore only 37.1% of theintact tooth’s fracture resistance,whereas a buccal chamfer recovered60.6% of that fracture resistance;bonding with an overcontour andplacement of an internal groovenearly restored the intact tooth frac-ture strength, recovering 97.2 and90.5% of it, respectively.

In cases of complicated fractures,when endodontic therapy is

required, the space provided by thepulp chamber can be used as aninner reinforcement, thus avoidingfurther preparation of the fractured tooth.15,16 However, insuch cases, esthetics may become animportant issue as pulpless teethlose part of their translucency and brightness.

This article reports on two coronaltooth fracture cases that were successfully treated using toothfragment reattachment.

C A S E R E P O R T S

Case 1A 17-year-old patient presented atthe emergency clinic at the Univer-sity of North Carolina School ofDentistry after sustaining a compli-cated crown fracture to her maxil-lary left central incisor duringsports activities (Figures 1 and 2).The fractured tooth fragment wasrecovered by the patient at the siteof the injury and maintained in astorage media (Save-a-tooth,Phoenix-Lazerus Inc., Pottstown,PA, USA) (Figure 3).

Clinical and radiographic examina-tion revealed a complicated obliquecrown fracture that extended sub-gingivally on the mesiopalatal area(Figures 4 and 5).

After endodontic therapy, thepatient was referred to the Graduate Operative DentistryClinic (Figure 6).

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Figure 1. Preoperative—smile view. Figure 2. Preoperative—frontal view.

Figure 3. Storage media (Save-a-tooth, Phoenix-LazerusInc., Pottstown, PA, USA).

Figure 5. Preoperative—occlusal view. Figure 4. Radiographic image of the fractured tooth.

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Upon examination, the treatmentoptions were presented to thepatient and to her legal guardian,including (1) no treatment, (2) post-and-core and crown, (3) crownbuildup restoration with a resin-based composite, and (4) reattach-ment of the tooth fragment. Aftersome deliberation about the advan-tages, disadvantages, prognosis,and cost of every treatment option,the patient and the patient’s motheropted to have the tooth fragment

reattached. It is important to notethat the reattachment option waspresented only after confirming thatthe fragment was in good conditionand that it fit reasonably well onthe fractured tooth.

One important complication of thiscase was the subgingival extensionof the fractured margin on themesiopalatal area as mentioned ear-lier. The gingival aspect of the frac-tured site revealed a shallow,

knife-edge subgingival fracturemargin. Upon probing this areaduring the clinical examination, itwas determined that the biologicalwidth was only minimally invadedand that bone recontouring viacrown lengthening would not beindicated or required as long as the restorative margin were placedat or above the level of the cemen-toenamel junction. As depicted inFigure 7, the tooth fragment com-prised two pieces, one of which

Figure 6. Radiographic image of the root canaltreatment.

Figure 7. Fragments.

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consisted of the majority of thecoronal aspect, and the other was asmall and thin fragment corresponding to the gingival aspect of the fracture site. Afterconsultation with a periodontist,the strategy followed consisted of discarding the small gingivalfragment, recontouring the shallow, knife-edge fractured area in the root of the tooth, and reattaching the coronal fragment.

To gain access to the subgingivalfracture line and verify that thefracture did not extend apically, alingual flap was raised. A 1-mm tis-sue collar was removed from themesiopalatal aspect of the tooth.The root surface was then recon-toured with a finishing bur toobtain a smooth surface and facili-tate tissue healing (Figure 8).

The operating field was isolatedwith a rubber dam (Figure 9) to

ensure moisture control. Theendodontic temporary restorativematerial was removed from thepulp chamber, and the entrance ofthe root canal was sealed with aglass ionomer plug (Vitrebond, 3MESPE, St. Paul, MN, USA) (Figure10). The pulp chamber, dentin, andenamel were etched with a 37%phosphoric acid gel, rinsed, andcoated with an ethanol-based adhe-sive system (Adper Single BondPlus, 3M ESPE) (Figures 11 and

Figure 10. Rubber dam isolation—occlusal view.

Figure 8. Lingual surface was smoothed with a finishing bur.

Figure 9. Rubber dam isolation—frontal view.

Figure 11. Phosphoric acid-etching of the tooth.

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12). The adhesive was not light-cured at this point.

The coronal tooth fragment wassecured by a “pick-and-stick”device in order to facilitate han-dling (Figure 13), and the fracturedsurface of the fragment was treatedwith 37% phosphoric acid gel for30 seconds (Figure 14), followed bydelicate rinsing. The adhesive sys-tem was then applied to the etchedsurface (Figure 15).

Composite resin (Venus, HeraeusKulzer, Dormagen, Germany) wasapplied to both fragment and toothsurfaces. The fractured segmentwas then accurately placed on thetooth, paying special attention tothe fit between the segments (Figure16). When the original position hadbeen reestablished, excess resin wasremoved and the area was light-cured for 40 seconds on each surface, making sure that no displacement of the fragment

occurred before adhesive/resin polymerization was complete (Figures 17 and 18).

The margins were properly finishedwith diamond burs and polishedwith a series of Sof-Lex disks (3M ESPE) and diamond polishing paste.

The rubber dam was removed, andthe gingival tissues were reposi-tioned and sutured (Figure 19).

Figure 12. Application of bonding agent on the tooth surface.

Figure 13. Fragment attached to a “pick-and-stick” device.

Figure 14. Phosphoric acid-etching of the fragment. Figure 15. Application of bonding agent on the fragment.

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Figure 18. Composite resin was light-cured for 40 secondson each surface.

Figure 16. The fractured segment was accu-rately placed on the tooth, paying special atten-tion to the fit between the segments. Fingerpressure was used for better adaptation.

Figure 17. Profile view to ensure that the origi-nal position had been reestablished.

Figure 19. Immediate postoperative. Rubber dam wasremoved, and the gingival tissues were repositioned andsutured.

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The occlusion was carefullychecked and adjusted, and thepatient was dismissed after receiv-ing instructions to avoid exertingheavy function on this tooth and tofollow regular home care proce-dures relative to oral hygiene. Thepatient and the patient’s motherwere informed that the reattach-ment line might be visible, and, ifnecessary, this could be managed in future visits. Most importantly,an athletic mouth guard was fabricated for the patient to usewhile involved in sports activities(Figure 20).

The patient returned for 1-, 6-, and14-month follow-ups (Figures21–25), and it was observed thatboth endodontic and restorativetreatments remained clinicallyacceptable for the entire time.Although the reattachment line canbe noted in a close-up view, thepatient was very satisfied with the results and opted not to havethe line masked with a partial composite veneer.

Case 2A 12-year-old patient was injuredand suffered an uncomplicated

crown fracture to his maxillary cen-tral incisors and left lateral incisor(Figures 26 and 27). The fracturedtooth fragments were recovered atthe site of the injury and stored inwater until his time of appointmentin the Operative Dentistry Clinic,Federal University of Ceará, Brazil.

Upon examination, the treatmentplan of choice was to reattach thedental fragments of the teeth. Thefragments were analyzed (Figure28) and tried in intraorally to checkfor proper positioning and fit withthe fractured coronal structure.

Figure 20. Athletic mouth guard was fabricated. Figure 21. One-month follow-up—smile view.

Figure 22. One-month follow-up—close-up view. Figure 23. One-month follow-up—occlusal view. Note theadequate healing of soft tissues.

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Figure 24. Six-months follow-up—frontal view. Figure 25. Fourteen-months follow-up—frontal view.

Figure 26. Preoperative—smile view. Figure 27. Preoperative—frontal view.

Figure 28. Fractured segments.

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They were then stabilized in placeby small composite increments onthe facial surfaces of each tooth(Figure 29), and a positioning stentwas fabricated with green com-pound (Figures 30 and 31).

The operating field was isolatedwith a rubber dam (Figure 32) inorder to prevent saliva or gingivalfluids that negatively affect thebonding procedures.

At chairside, the fractured surfacesof the fragments were cleaned withflour of pumice (Figure 33), treatedwith 37% phosphoric acid gel for30 seconds, followed by rinsing(Figure 34). The adhesive system(Adper Single Bond Plus, 3M ESPE)was then applied to the etched sur-faces (Figure 35). The fragmentswere kept away from light until thefragment was to be reattached tothe tooth.

Dentin and enamel were cleanedwith flour of pumice, etched with a37% phosphoric acid gel (Figures36–38), rinsed, and coated with anethanol-based adhesive system(Adper Single Bond Plus, 3M ESPE).

Composite resin (Z-100, 3M ESPE)was applied to both fragment andtooth surfaces. The fractured seg-ments in the stent were checked for

Figure 29. Fragments were stabilized in place by smallcomposite increments on the facial surfaces of each tooth.

Figure 30. Positioning stent was fabricated with green compound.

Figure 31. Fragments were stabilized with the stent. Figure 32. Rubber dam isolation—frontal view.

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Figure 38. Adhesive was applied to the fractured surfaces.

Figure 34. Fragments were etched for 30 seconds.Figure 33. Fragments were cleaned with flour of pumice.

Figure 35. Adhesive was applied to the fragments. Figure 36. Fractured surfaces were cleaned with flour ofpumice.

Figure 37. Fractured surfaces were etched for 30 seconds.

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correct positioning. When the origi-nal position had been reestablishedfor all three fragments, excess resinwas removed and the area waslight-cured for 40 seconds (Figure39), making sure that no displace-ment of the fragment occurredbefore adhesive/resin polymeriza-tion was complete. Additional com-posite was placed after the first curein order to restore any undercoun-toured areas (Figures 40 and 41).

Margins were properly finishedwith diamond burs and polishedwith a series of Sof-Lex disks (3MESPE) and diamond polishing paste(Figure 42).

The immediate postoperative view(Figures 43 and 44) shows adequateesthetic results with restored functionality by the use of a very conservative and cost-effective approach.

D I S C U S S I O N

The techniques described in thesecase reports are reasonably simple,while restoring function and esthet-ics with a very conservativeapproach. However, the profes-sional has to keep in mind that adry and clean working field and the proper use of bonding protocol and materials is the keyfor achieving success in adhesivedentistry. Reports and clinical

Figure 39. The fractured segments in the stent werechecked for correct positioning.

Figure 40. Additional composite was placed after the firstcure in order to restore any undercountoured areas.

Figure 41. Postoperative—lingual view. Figure 42. Margins were properly finished and polished.

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experience indicate that the reattachment of fractured coronal fragments results in successful short- and medium-term outcomes.10,12,13

Fabrication of a mouth guard andpatient education about treatmentlimitations may enhance clinicalsuccess as reattachment failuresmay occur with new trauma orparafunctional habits.6

With the materials available today,in conjunction with an appropriatetechnique, esthetic results can beachieved with predictable out-comes. Thus, the reattachment of a tooth fragment is a viable technique that restores function and esthetics with a very conserva-tive approach, and it should be considered when treating patientswith coronal fractures of the anterior teeth, especially younger patients.

D I S C L O S U R E

The authors do not have any finan-cial interest in the companies whoseproducts are included in this article.

R E F E R E N C E S

1. Dietschi D, Jacoby T, Dietschi JM,Schatz JP. Treatment of traumaticinjuries in the front teeth: restorativeaspects in crown fractures. Pract Peri-odontics Aesthet Dent 2000;12(8):751–8,quiz 760.

2. Hamilton FA, Hill FJ, Holloway PJ. Aninvestigation of dento-alveolar traumaand its treatment in an adolescent popu-lation. Part 1: the prevalence and inci-dence of injuries and the extent andadequacy of treatment received. Br DentJ 1997;182:91–5.

3. Andreasen JO, Andreasen F, AnderssonL. Textbook and color atlas of traumaticinjuries to the teeth. 3rd ed. St Louis(MO): Mosby; 1994.

4. Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent denti-tion: pulpal and restorative considera-tions. Dent Traumatol2002;18(3):103–15.

5. Reis A, Francci C, Loguercio AD, et al.Re-attachment of anterior fracturedteeth: fracture strength using differenttechniques. Oper Dent2001;26(3):287–94.

6. Andreasen FM, Noren JG, Andreasen JO,et al. Long term survival of fragmentbonding in the treatment of fracturedcrowns. Quintessence Int1995;26:669–81.

7. Baratieri LN, Ritter AV, Junior SM,Filho JCM. Tooth fragment reattach-ment: an alternative for restoration of fractured anterior teeth. Pract Periodont Aesthet Dent 1998;10:115–27.

8. El-Askary FS, Ghalab OH, EldemerdashFH et al. Reattachment of a severelytraumatized maxillary central incisor,one-year clinical evaluation: a casereport. J Adhes Dent 2006;8(5):343–9.

9. Reis A, Loguercio AD, Kraul A, MatsonE. Reattachment of fractured teeth: areview of literature regarding techniquesand materials. Oper Dent2004;29(2):226–33.

10. Rappelli G, Massaccesi C, Putignano A.Clinical procedures for the immediatereattachment of a tooth fragment. DentTraumatol 2002;18(5):281–4.

11. Maia EA, Baratieri LN, de Andrada MA,et al. Tooth fragment reattachment: fun-damentals of the technique and two casereports. Quintessence Int2003;34(2):99–107.

12. Baratieri LN, Monteiro S Jr., AndradaMAC. Tooth fracture reattachment: casereports. Quintessence Int1990;21(4):261–70.

Figure 43. Immediate postoperative—frontal view. Figure 44. Immediate postoperative—smile view.

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13. Oz IA, Haytac MC, Toroglu MS. Multidisciplinary approach to the rehabilitation of a crown-root fracturewith original fragment for immediateesthetics: a case report with 4-year follow-up. Dent Traumatol2006;22(1):48–52.

14. Farik B, Munksgaard EC, Andreasen JO.Impact strength of teeth restored by

fragment-bonding. Endod Dent Traumatol 2000;16(4):151–3.

15. Diangelis AJ, Jungbluth M. Reattachingfractured tooth segments: an estheticalternative. J Am Dent Assoc1992;123(8):58–63.

16. Ehrmann EH. Restoration of a fracturedincisor with exposed pulp using original

tooth fragment: report of case. J AmDent Assoc 1989;118(2):183–5.

Reprint requests: Dr. Georgia Macedo, UNCSchool of Dentistry, Department of Opera-tive Dentistry, 429 Brauer Hall, Chapel Hill,NC 27599-7450. Tel.: 919-843-9743; Fax: 919-966-5660; e-mail:[email protected]

reattachment of anterior teeth fragments: a conservative … · 2008-07-14 · dure.11 in addition,...

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