Int J Dent Case Reports 2012; 2(3):35-41 IJDCR All rights reserved

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1 Int J Dent Case Reports 2012; 2(3):35-41 IJDCR All rights reserved CAS E IMAGES A MULTIDIS CIPLINARY APPROACH TO THE MANAGEMENT OF TRAUMATIC TOOTH CROWN FRACTURE: A CAS E REPORT Dr. Vaishali Parekh 1, Dr. Paras Kothari 2, Dr. Vandana Rathwa 3 1 Professor & Head, Department of Conservative Dentistry, K.M.Shah Dental College & Hospital, Sumandeep Vidyapeeth,Vadodara, Gujarat, India. 2 Post Graduate student, Department of Conservative Dentistry, K.M.Shah Dental College & Hospital, Sumandeep Vidyapeeth,Vadodara, Gujarat, India. 3 Senior Lecturer, Department of Periodontology, K.M. Shah Dental College & Hospital, Sumandeep Vidyapeeth,Vadodara, Gujarat, India. Address for Correspondence Dr.Paras Kothari 307, Sarla Sadan, Gember s Estate, S.V.Road, Malad (West). Mumbai Maharashtra, India drparaskothari@gmail.com Telephone: ABSTRACT Introduction: Anterior tooth fracture due to traumatic injuries frequently occurs in dentistry causing functional, esthetic, and psychosocial problems in addition to reducing the patient s quality of life. Over the past decades, dentistry has achieved great scientific and technological advances regarding restorative and adhesive materials. Nevertheless, to date, no restorative material has been more effective than the properties of the natural dental structures themselves. Case report: This case report refers to extensively damaged maxillary central incisor where fracture line is subgingival on palatal aspect. As fractured fragment was available, we planned multidisciplinary approach. Using esthetic post and dual cure resin cement we have reattached fractured fragments after rendering palatal subgingival margin supragingival through crown lengthening procedure. Discussion: Reattachment of fractured tooth fragments can provide good and long-lasting esthetics (because the tooth s original anatomic form, color, and surface texture are maintained). It also restores function, provides a positive psychological response, and is a relatively simple procedure. Patient cooperation and understanding of the limitations of the treatment is of utmost importance for good prognosis Conclusion: This is an immediate restorative technique resolving the acute problem of traumatic tooth fracture with pulpal and periodontal involvement, in which the fragments are re-alignble. Keywords: anterior tooth fracture; Glass fiber post; intact fragment; multidisciplinary approach; reattachment

2 INTRODUCTION Trauma to the permanent teeth is rather common event among school children. Crown fracture present almost 92% of all traumatic injuries of the permanent teeth. The anterior incisors are most often affected (80% central incisors and 16 % lateral incisors) because the anterior position of the maxilla and tooth protrusion (1). The main etiological factors of dental trauma are falls, cyclist accidents, sport exercises and domestic violence (2). As esthetics is of utmost importance to the patient and dentists, the importance of adequately restoring the esthetic elements of the tooth cannot be neglected. Case reports A 26 years old male patient reported to the Department of Conservative Dentistry with the history of road accident two days back resulting in broken teeth in upper front region. Figure 2 Pre operative radiograph Figure 1 Pre-operative intraoral photograph Factors influencing the treatment modalities of coronal fractures are: Site of fracture, Size of fractured remnant, Periodontal status, Pulpal involvement, Maturity of root formation, Biological width invasion and Occlusion (3). The immediate reattachment of a dental fragment is a technique that should be considered while treating patients with crown fractures of anterior teeth. The use of this technique requires the entire fractured segment that, if at all possible, is correctly p reserved or stored (1). This article presents a case report of interdisplinary approach towards restorating fractured maxillary central incisor using fragment reattachment technique Initial examination revealed a complicated crown root fracture of right maxillary central incisor. Fracture line was running obliquely from middle third of labial surface to cervical region on palatal side extended subgingivally in the palatal aspect (figure 1). On clinical examination 11 was tender on percussion with a mobile coronal fragment. There was no mobility with the retained root portion of & 22 had Ellis Class II fracture. Electric pulp vitality test was positive for 21 & 22. in a 26 year old male patient. 36

3 Radiographic observation revealed a fracture line at the middle third of the upper right central incisor. The periapical radiograph revealed that there was no associated root fracture and the apices were fully formed (figure 2). Figure 3 A non traumatic extraction of mobile fragment with tweezers On periodontal examination the coronal tooth fragment was still attached palatally by fragile soft tissue. The fractured fragment of 11 was loosely attached to the respective tooth. Palatally localised marginal gingivitis was present with respect to fractured site. Periodontal probing indicated clinically normal gingival sulcular depth of 2-3 mm all around adjacent teeth (4). No other injury was associated with the soft tissues or the alveolar bone. Laceration of upper lip was evident. Extrinsic stains of pan masala were present. Medical history was non contributory. In considering maintaining the retained tooth portion, the periodontal condition was deemed healthy enough to allow for reasonable longevity. The retained root portion was also of adequate length and sound in structure to allow for restoration otherwise extraction would have been considered. The patient was keen to retain the root. In view of favorable conditions, it was decided to reattach fractured fragments using fiber post in conjunction with dual cure resin cement. Figure 5 Isolation with rubber dam Figure 4 Cleaned fractured fragment 37

4 Figure 6 Master cone radiograph Lignocaine (1:80,000 adrenaline) buccal and palatal infiltrations were administered. A twizzer was used with minimal force to separate the coronal segment from its soft tissue attachment (figure 3). No caries or resorption defects were detected on fragments. Coronal tooth fragment was cleaned and stored in normal saline (figure 4). Single sitting root canal treatment was carried out. Sectional obturation was performed with gutta percha and AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland ). The post space was prepared (figure 5, 6, 7,). A corresponding Glass fibre post ( Glassix, H.Nordin sa, Chailly Montreaux, Switzerland ) was cut to size- allowing 3 4 mm for coronal fixation. A retentive box was cut into the coronal tooth fragment including the pulp chamber, ensuring all pulpal tissue remnants had been removed. The surface to be bonded in crown surface was pitted with dimples using a ½ round bur (5) (figure 8). The entire assembly was then approximated to check the fit. Figure 7 Sectional obturation and Post space prepared with peeso no 1,2,3 Figure 8 Retentive box and dimples Palatal inverse bevel incision was given using #15 scalpel blade. Full thickness palatal flap was raised showing the extent of subgingival tooth fracture. (Figure 9). Bone recontouring was carried out using coarse diamond points with copious amounts of normal saline. To reduce the risk of damaging the root surface, the authors consider that this final thin layer of bone should be removed by using a bone chisel or files. The bone was thinned to allow 38

5 adequate flap adaptation. Enough bone is removed to create a 3 mm space between the crest of the bone and the new crown margin. After bone recontouring, palatal flap is recontoured to follow the new position of bone. Haemostasis was achieved by the application of haemostatic agent - collagen sponge and digital pressure. cement flash (figure 12). Interrupted sling suture was given as only palatal flap was raised. The occlusion was checked and adjusted. Figure 11 Proper sitting of fragment was evaluated Figure 9 Full thickness flap was raised. Figure 10 Spunning of crown (a) & canal (b) with dual cure resin cement. The surfaces were etched and bonded with a Prime & Bond NT. Calibra (Dentsply DeTrey GmbH, Figure 12 Immediate radiograph to check Flakes of cement Konstanz, Germany) was spun into the root canal Healing after 1 week was uneventful. Composite and the fibre post seated ( figure 10). Simultaneously, build up was done with respect to 22 (figure 13). A 6- the coronal tooth fragment loaded with Calibra was monthly review showed the tooth fragment to be also placed. Fragments were held into position until firmly attached, no periodontal or endodontic the cement was light cured set (figure 11). problems were noted (figure 14). Subsequent follow A check radiograph was then taken to confirm up involved fabrication of an occlusal splint for night apposition of the tooth portions and highlight areas of 39

6 time wear, and occlusal adjustment to minimise excursive movement forces. DISCUSS ION The reattachment technique was first described in 1964 by Chosak and Eidelaman who considered it, at that time, a provisional restoration due to the low bond strength values achieved by the adhesive systems (6). However, the remarkable advancement of the adhesive systems and resin composites has made the reattachment of tooth fragments a procedure that is no longer a provisional restoration, but rather a treatment offering favourable prognosis. The advantages of using the original tooth fragment over all other materials may be listed to include (7) Colour, Morphology, Translucency, Physiochemical characteristics (including wear, thermal and hygroscopic expansion), Patient acceptance, structurally conservative and Economical. Retention of the apical tooth portion and conventional conservation e.g. periodontal correction if required, cast restoration Orthodontic extrusion, followed by restoration Surgical extrusion involving extraction then reimplantation and restoration. However, many of the above techniques have associated limitations. These may include multi-visit appointments, cost, stabilisation (splinting), and be less conservative in nature when compared with this case report (5) Figure 14 6 months follow up Figure 13 After a week Other treatment options available in the treatment of a fractured tooth include: Root extraction and prosthetic replacement e.g. fixed, implant, removable Root burial prosthetic replacement The successful reattachment depends on fragment s extent of dehydration. The longer the fragment remains dehydrated, poorer the tooth s strength will be. Performance of the technique becomes complicated when there is more than one fragment that must be connected to each other and then reattached to the tooth (8). In the present case crown lengthening procedure was done, To render subgingival margin supragingival for proper isolation and seating of fragment. To maintain the biological width for long term periodontal stability, the distance from the restoration margin to the alveolar crest should be at least 3 mm.(9,10) 40

7 By using fiber post with composite core and with recent advances in adhesive techniques and materials one can create a Monobloc, a multilayered structure with no inherent weak inter-layer interfaces. The unique advantage of this system is that it reinforces the teeth structure through this concept. Therefore, the integrity of the final endodontic-restorative continuum monobloc approaches that of the original healthy tooth itself (11). Limitations of tooth tissue reattachment include those associated with dental adhesion, in particular control of operating field from contamination and force application, particularly indirect or shear forces working in directions where bonding forces are weakest. The single visit, multidisciplinary approach to a crown fracture tooth requires consideration of periodontal, endodontic, restorative and occlusal factors. This presents a great challenge to the dental surgeon, with regard to both clinical skills and time management. Follow up must involve assessment of occlusion, periodontium and subsequent traumatic force reduction. This may take the form of a night guard, sports shield, or even subsequent more conventional tooth strengthening, such as the placement of a full coverage restoration or porcelain veneer (12). CONCLUS ION Reattachment of the intact fractured segment can be considered as an ultraconservative method for aesthetic rehabilitation. The need of the day is to educate the population to preserve the fractured segment and seek immediate dental treatment. REFERENCES 1. Belcheva. Reattachment of fractured permanent Incisors in schoolchildren (review) Journal Of Imab - Annual Proceeding (Scientific Papers) 2008, Book Tovo Mf, Dos Santos Pr, Kramer Pf, Feldens Ca, Sari Gt. Prevalence of crown fractures in 8-10 years old Schoolchildren in Canoas, Brazil. Dent traumatol 2004; 20(5): Georgia.V.Macedo, Patrica Diaz,Carlos Augusto. Reattachment of anterior tooth fragments: A conservative approach. Journal of Esthetic and Restorative dentistry 2008; 20: Philippe P. Hujoel, Joana Cunha-Cruz, Herbert Selipsky, Barry G. Saver. Abnormal pocket depth and gingival recession as distinct phenotypes. Periodontology 2000, Vol. 39, 2005, C. P.K. Wadhwani; A Single Visit, Multidisciplinary Approach To The Management Of Traumatic Tooth Crown Fracture ; British Dental Journal Volume 188 No. 11 June : Chosack a, Eildeman E. Rehabilitation of fractured incisor using the Patient s natural crown. Case report. J dent Child 1964; 31: Baratieri L N, Monteiro S jr, de Albuquerque F M. Reattachment of a tooth fragment with a new adhesive system, a case report, Quintessence Int 1994; 25: Hall Da. Restoration Of Shattered Tooth. J Am Dent Assoc 1998; 129: ) 9. Gargiulo A, Krajewski J, Gargiulo M. Defining biologic width in crown lengthening. CDS Rev 1995: 88: Gargiulo A, Wentz F, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol 1961:32: Tay FR, Pashley DH. Monoblocks in root canals: A hypothetical or tangible goal. J Endod 2007; 33: Andreasen F, Daugaard-Jensen, Munksgaard E. Reinforcement of bonded crown fractured incisor with porcelain veneers. Endod Dent Traumatol 1991; 7: ) 41