A Holistic Approach To The Management Of A Fractured Tooth Fragment- A Case ReportCorrespondence Address :
*(MDS), Professor, Dept. of conservative Dentistry and endodontics
surendera dental college&research institute
Anterior crown fractures are a common form of traumatic dental injuries that mainly affect the maxillary central incisors in children and teenagers.(1) Traumatic injuries of the teeth involve varying degrees of damage to the supporting soft tissues, or the teeth itself. In the pre-adhesive era, fractured teeth needed to be restored either with pin retained inlays or cast restorations that sacrificed the healthy tooth structure and were a challenge for clinicians to match with the adjacent teeth.(3) With the advent of adhesive dentistry, the process of fragment reattachment has become simplified and more reliable. This study reports a case of fragment reattachment of the maxillary right central incisor.
Often, dental trauma has a severe impact on the social and psychological well being of a patient. Coronal fractures of the permanent incisors represent 18-22% of all trauma to the dental hard tissues.(5) The superior central incisiors are the teeth with the greatest visibility during common functions and are the most susceptible to fractures by direct trauma, especially in children and teenagers.(1) Traumatized anterior teeth require quick functional and aesthetic repair. The conventional approaches for the restoration of the fractured anterior teeth include composite restorations and post and core supported prosthetic restorations. They have the primary disadvantage of colour mismatch and variable wear. Therefore, if a broken fragment is available, the restoration of the tooth by using its own fragment has been suggested as an alternative.(1) This technique can be applied to fractured crowns resulting in simple enamel-dentine fragments and to more complex situations in which the pulp and the periodontium are involved. The advantage of the reattachment of the fractured fragments include immediate aesthetics, a more reliable outline form, the possibility of maintaining the occlusal function, absence of differential wear, lowered economic burden and excellent time resource management.(5)
This clinical case of tooth reattachment was performed in a fractured upper right central incisor, which was treated with conservative therapy and restored with its own fragment.
A 48 year old man was referred to the conservative dentistry department of Surendra Dental College and Research Institute; Sri Ganganagar, with a history of fall, resulting in a fractured tooth in the upper front region. [Table/Fig 1]. The patient presented with a coronal fracture of the maxillary right central incisior. The fragment was brought by the patient, wrapped in a dry handkerchief, with an elapsed time of 15 mintues. The fragment was then stored in Hankâ€™s balanced salt solution [HBBS] to prevent dehydration. [Table/Fig 2]. Preoperative assessment and diagnosis was done to evaluate the vitality of tooth number 11, which gave a positive result. A diagnosis of Ellis class ll fracture of tooth 11 was made. The tooth was isolated with rubber dam and placement of the fragment into position was done to evaluate the result. The fragment was prepared for reattachment by giving an external chamfer bevel on both the fragment and the tooth. Acid etching was done on both the fragment and the tooth by using 37% orthophosphoric acid for 15 seconds and this was thoroughly rinsed off. Both the fragment and the tooth dentin were kept moist and excess water was removed by using blotting paper. A bonding agent [3M ESPE Adper Single Bond] was applied on both the substrates and this was light cured for 20 seconds. A dual cure composite [Variolink II Base and Catalyst] was used for filling the interfragmentary space and the fit was reverified. The excess was removed and the composite layer was polymerized from both the buccal and the palatal surfaces. Finishing and polishing were done by using soflex discs. [Table/Fig 3].
The patient was kept under follow-up for a period of two years. After two years, a good functional and aesthetic resolution was observed. The patient was satisfied with the final result. [Table/Fig 1].
With the advancement in dental bonding technology, it is now possible to achieve excellent results with the reattachment of dislocated tooth fragments, provided that the biological factors, materials and techniques are logically assessed and managed. The use of natural tooth substances clearly eliminates the problems of the differential wear of the restorative material, unmatched shades and the difficulty of contour and texture reproduction which are associated with other techniques. The treatment plan can be made after the evaluation of the periodontal, endodontic, coronal and occlusal status.(4),(5)
The reattachment technique which has been described, provides several advantages which are as follows.(1)
â€¢ The exact initial crown shape and surface morphology can be obtained.
â€¢ The crown restorations are realized in a material that wears at the same rate as the adjacent teeth. (6),(7)
â€¢ The colour characteristics remain unchanged.
â€¢ The method is faster and more conservative than the conventional restorative approaches.
â€¢ The treatment costs are lower.
The resistance of the fractured segment can be directly proportional to the surface area of adhesion. Most of the 5th generation bonding agents increased the fracture resistance of the reattached coronal fragments when used in conjunction with unfilled resin.(5) The fracture resistance was obtained by chemically cured composite, followed by light cured and resin cement and it was achieved least by only the bonding agent.
In other studies (8),(9), it was stated the fracture strength obtained by the direct reattachment of the fragments was lower than an intact tooth fracture strength and additional preparations were recommended(3).
1) The combination of the dual cure composite and additional chamfer bevel preparation technique which was used to reattach the toothâ€™s fractured coronal part was successful.
2) The use of the original fragments of the fractured teeth was reported as aesthetic, economical and very satisfactory in terms of patient satisfaction.
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