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CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 36-40

Tooth reattachment: An immediate esthetic restorative procedure for crown root fracture


Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Kheri More, Village Bhopani, Faridabad, Haryana, India

Date of Web Publication10-Dec-2012

Correspondence Address:
Meenu G Singla
Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Kheri More, Village Bhopani, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.104420

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  Abstract 

Crown root fractures in the maxillary anterior region represent an intriguing challenge for clinicians. An interdisciplinary approach based on exposing fractured margins and the definitive prosthetic rehabilitation represent the standard modality of treatment for these conditions to restore the appropriate biologic dimension and esthetics. However, if the margins of the fragment and the tooth show perfect juxtaposition with no interfragmentary space and immediate esthetic replacement is needed, reattachment of the fractured segment using adhesives may be indicated. The aim of this case report is to describe the treatment of a crown root fracture at CEJ of an endodontically treated tooth having porcelain fused to metal crown by means of metal post placement and reattactment of the fragment using Glass ionomer cement with follow up of one year. Conclusion: Reattachment of a tooth fragment is a viable technique that restores function and aesthetics with a very conservative approach in a single visit and can be considered when treating patients with crown/root fractures of the anterior teeth.

Keywords: Crown root fracture, metal post, tooth reattachment


How to cite this article:
Singla MG, Mittal R, Singla A. Tooth reattachment: An immediate esthetic restorative procedure for crown root fracture. Saudi Endod J 2012;2:36-40

How to cite this URL:
Singla MG, Mittal R, Singla A. Tooth reattachment: An immediate esthetic restorative procedure for crown root fracture. Saudi Endod J [serial online] 2012 [cited 2019 Dec 8];2:36-40. Available from: http://www.saudiendodj.com/text.asp?2012/2/1/36/104420


  Introduction Top


Fracture of the anterior teeth by trauma is the most frequent type of injury in the permanent dentition. [1] The most affected teeth are maxillary incisors due to their anterior position. [2] Endodontic treatment of such teeth makes them even more fracture prone because of loss of structural integrity, moisture, and dentin toughness during root canal treatment. [3] Although crowns strengthen the root canal-treated teeth, but if a trauma occurs in such anterior teeth, then the probability of fracture to occur at CEJ (crown-root fracture), which is a weakest portion, is high. [4]

The management of such cases involves simple to complex restorative intervention depending upon the severity and extent of the fracture. A few approaches have already been established for such types of fractures like orthodontic extrusion; forced surgical extrusion; and periodontal crown lengthening procedures to expose the fracture site, followed by restoring the lost tooth structure by prefabricated or custom cast post and core build up with composite resin or prosthodontic restoration. [5] But each is not without inherent drawbacks. All these approaches turn out to be time consuming, elaborate, and not so very cost effective. [5],[6]

Chosack and Eidelman, in 1964, have proposed the restoration of fractured crowns by reattachment using the dental fragment. [7] This technique offers several advantages over other techniques. It is a conservative and an immediate restoration procedure. It provides total aesthetical recovery because the tooth contour, color, translucency, and surface texture are of the natural tooth. [8] It also provides color stability over time and the rate of wear similar to other natural teeth. [9] Moreover, trauma to oral structures like teeth poses a great psychological impact on the minds of patients and reattaching patients' own fragment may reduce this impact. [10] The clinical procedure is safe and simple; therefore, less time in the chair is required, which might reduce the cost of the treatment. [8] Thus, reattachment can also be one of the lines of treatment for crown root fracture cases.

The following case report presents management of crown root fracture of endodontically treated tooth covered with full crown by reattachment procedure using glass ionomer cement (GIC).


  Case Report Top


A 30-year-old man had reported with a fractured maxillary left central incisor that had been endodontically treated followed by porcelain fused to metal crown placement about two years back. The fracture had reportedly happened 4 hours before from the time of reporting. On examination, the upper left central incisor showed a complicated crown-root fracture which was completely subgingival. The fracture segment was grade III mobile. The involved tooth was tender on vertical percussion. Medical history was not contributory. Radiographical examination revealed well-obturated root canal with healthy periapical tissues and a mesiodistal oblique fracture line near CEJ but supraosseous [Figure 1]. The patient was advised with a treatment plan of removal of fracture segment and orthodontic extrusion of remaining tooth root followed by placement of post and core with a crown. But, the patient was very keen on an immediate restoration of his esthetics as he was very satisfied with his esthetics of previously placed crown. Thus, the treatment plan was changed to removal of fracture segment and placement of pre-fabricated post followed by reattachment of the fractured crown segment. As the fracture line was subgingivally placed, surgical exposure of the fractured segment was planned. The operation site was scrubbed with 2% povidone-iodine solution; then, anesthesia was achieved by administering 2% Lignocaine with Adrenaline (1:200000). Then, fractured segment was removed [Figure 2] which showed labiolingual oblique fracture line, extending from the crown margin lingually to 2-3 mm apical to the CEJ labially. Fractured fragment was placed in saline. After that, a faciolingual flap was elevated without relaxing incision, exposing the fractured margins of the remaining tooth. The bleeding was controlled by using a hemostatic agent (adrenaline solution, 1:1000). The juxtaposition of the fragment with the tooth showed that the margins of each fit well against one another and no inter-fragmentary space was present. Now, the post space was prepared using the no. 4 drill available in ParaPost one office visit kit (Coltene, Whaledent AG Altsatten/Switzerland), leaving 4-5 mm of gutta-percha at the apical third. A prefabricated post corresponding to the drill size was cemented with GIC (Fuji II, GC International, Tokyo, Japan) [Figure 3]. The gutta-percha from the inner aspect of coronal fragment was removed. Then, selective grinding of the inner aspect of coronal fragment was done with the help of articulating paper so that coronal portion of the post could fit fractured segment. The fit of coronal segment with radicular segment was confirmed. The coronal segment was then cemented with GIC. The flap was sutured back with 3-0 black silk [Figure 4]. After 1 week, the sutures were removed. The patient was then recalled for follow up. At 1-year follow-up, clinical evaluation reveals no gingival inflammation or mobility and there was no pocket formation, but the slight gingival recession was observed on the buccal aspect of the tooth. Radiographic evaluation reveals healthy periodontal and periapical status [Figure 5].
Figure 1: Preoperative periapical radiograph showing the fractured area at the cementoenamel junction distally

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Figure 2: The clinical picture of the fractured maxillary left central incisor (a) showing buccal (b) and lingual (c) view of a fractured coronal segment.

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Figure 3: Periapical radiograph after segment removal (a). Gingival flap reflection and cementation of the prefabricated post (b)

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Figure 4: Radiograph after post placement (a). Coronal tooth fragment showing preparation on the inner aspect to receive coronal part of the post (b). Reattachment of coronal fragment and suturing of flap (c)

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Figure 5: Clinic (a) and radiographic view (b) of one-year postoperative

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  Discussion Top


A crown-root fracture is defined as a fracture involving enamel, dentin, and cementum and comprises 5% of the traumatic injuries affecting the permanent dentition. [11]

Several factors influence the management of crown root fractures, including

  • Extent of fracture (biological width violation, endodontic involvement, alveolar bone fracture),
  • Pattern of fracture and restorability of fractured tooth,
  • Presence/absence of the fractured tooth fragment,
  • Its condition for use (fit between fragment and the remaining tooth structure),
  • Esthetics, finances, and prognosis. [12],[13],[14]
A number of treatment options have been proposed for crown-root fractures, each with their own advantages and disadvantages. Orthodontic extrusion of a root, to facilitate restoration, can be one of the treatment options to expose the fractured tooth margins. But, to avoid relapse, a period of retention is necessary. Although this is an effective solution, it is rather time-consuming and requires commitment and motivation from the patient. [5] Surgical extrusion is another way of exposing the fracture line before restoration. This is a simpler and less time-consuming procedure, requiring minimal commitment from the patient. The main disadvantage of this procedure is the possible risk of root resorption because of damage of the periodontal ligament. Another reason of criticism for the use of extrusion in anterior teeth is the reduction in cervical diameter of the extruded tooth to considerably less than that of adjacent teeth that markedly compromises esthetics. [15],[16] Surgical exposure of the fracture margin by raising flap is another approach to reach the fracture line. This is relatively easy to perform and the tooth can be restored soon after injury. After exposing site, the traditional approach is restoring a crown-root fracture by using cast post or prefabricated post and a core buildup with composite resin followed by prosthodontic restoration (crowns), but it is time consuming and not so cost effective. [7]

Another approach for treating these types of cases is the reattachment of fractured segment. The fragment reattachment provides the immediate reestablishment of function and aesthetics. It is less time consuming and is very economical. The tooth color, contour, and texture are same, so it is superior to any restoration. [7],[8],[9]

The success of the reattachment technique is directly related to the evolution of the adhesive materials, which currently provide a high-quality bond strength between the fragment and the remaining tooth structure. [17],[18] However, the restorative materials should not be selected based exclusively on their mechanical properties, but other properties like biocompatibility and microleakage of the material should be considered for long-term success. [19]

The materials which have been used in literature for reattachment are GIC, [20] resin-modified GIC, [21] total etch adhesive systems, [22] self-etch adhesive systems, [18] light-, dual-, or self-cured luting cements, as well as conventional or flowable composite. [12]

Furthermore, composites are the most frequently used material for reattachment of fractured fragments as they provide high bond strength between the reattached fragment and the traumatized tooth, [17] while GICs are one of the groups of adhesive materials that present biological compatibility with the dental tissues. They have fluoride-release capacity and ability to adhere chemically to the dental structures (forms a chelation bond to the actual enamel and dentin surfaces) in a simple and rapid manner. [18],[23],[24] GIC has negligible dimensional changes during the hardening reaction and coefficient of thermal expansion is similar to that of tooth structure. Thus, potential for eventual microleakage is greatly decreased with glass ionomer bonding. [24] Burrow et al. have shown that conventional GIC provide significantly lower bond strength as compared to resin-based adhesives and failure mode showed cohesive failure of GIC and mostly adhesive failure for resin-based adhesives. [25]

In the present case, considering time, cost, and patient's immediate demand of restoration of aesthetics, reattachment of crowned fragment was planned using prefabricated post. Non-rigid and rigid post systems offer different advantages because of their different physical and optical properties. Post properties that enhance resistance to root fracture must be balanced with opposing post properties that enhance the maintenance of the marginal seal integrity.

Rigid posts are an appropriate choice for teeth with less than 3 to 4 mm of vertical height or when less than 25% of the tooth structure remains. However, teeth with minimal tooth structure above the tissue for a ferrule need additional cervical stiffness for a more rigid post to resist distortion from the force. In the absence of the cervical tooth structure, excessive flexibility can result in micromovement of the core and coronal leakage. Non-rigid post such as flexible post is beneficial for teeth with 25% to 50% of remaining tooth structure. [3] In this particular case of crown root fracture, no ferrule could be achieved, because of very less coronal tooth structure. Further, we had planned to reattach the two fragments where crown was already present on coronal fragment which could not encircle any crown portion to increase cervical stiffness, making a rigid post the material of choice.

The fractured segment had porcelain fused to metal crown on it. Thus, light cure materials could not be used as it was not possible to achieve the proper depth of cure. Considering these factors, GIC was used for bonding fractured segment. Although GIC has lower bond strength (with the cohesive mode of failure) than composite, post placement which connected the root fragment and coronal fragment might have reinforced the attachment of fractured segments. Some previous case reports also support it. [24],[26],[27]

In the current case, a successful treatment was done as showing promising results at follow-up of 6 months and 1 year. Thus, reattachment of a tooth fragment is a viable technique that restores function and aesthetics with a very conservative approach in a single visit and can be considered when treating patients with crown/root fractures of the anterior teeth.

 
  References Top

1.Zuhal K, Semra OE, Huseyin K. Traumatic injuries of the permanent incisors in children in southern Turkey: A retrospective study. Dent Traumatol 2005;21:20-5.  Back to cited text no. 1
    
2.Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured teeth: A review of literature regarding techniques and materials. Oper Dent 2004;29:226-33.  Back to cited text no. 2
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3.Trope M, Chivian N, Sigurdsson A, Vann W Jr. Traumatic injuries. In: Cohen S, Hargreaves K, editors. Pathways of the pulp. 8 th ed. St Louis, MO: Mosby; 2006. p. 642-50.  Back to cited text no. 3
    
4.Lee WC, Eakle WS. Possible role of tensile stress in the etiology of cervical erosive lesions of teeth. J Prosthet Dent 1984;52:374-80.  Back to cited text no. 4
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5.Brown GJ, Welbury RR. Root extrusion, a practical solution in complicated crown-root incisor fractures. Br Dent J 2000;189:477-8.  Back to cited text no. 5
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6.Grossman Y, Arauz-Dutari J, Chogle SM, Blatz MB, Sadan A. A conservative approach for the management of a crown-root fracture. Quintessence Int 2006;37:753-9.  Back to cited text no. 6
    
7.Chosack A, Eidelman E. Rehabilitation of a fractured incisor using the patient's natural crown. Case report. J Dent Child 1964;31:19-21.  Back to cited text no. 7
    
8.Maia EA, Baratieri LN, de Andrada MA, Monteiro S Jr, de Araújo EM Jr. Tooth fragment reattachment: Fundamentals of the technique and two case reports. Quintessence Int 2003;34:99-107.  Back to cited text no. 8
    
9.Kanca J. Replacement of a fractured incisor fragment over pulpal exposure: A long-term case report. Quintessence Int 1996;27:829-32.  Back to cited text no. 9
    
10.Chaugule V, Bhat C, Patil V, Mithiborwala SH. Reattachment of a vertical complicated subgingival crown root fracture in a 10-year old child: A case report. Int J Clin Pediatr Dent 2009;2:53-9.  Back to cited text no. 10
    
11.Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3 rd ed. Copenhagen: Munksgaard, 1994. p. 257-77.  Back to cited text no. 11
    
12.Reis A, Kraul A, Francci C, de Assis TG, Crivelli DD, Oda M, et al. Reattachment of anterior fractured teeth: Fracture strength using different materials. Oper Dent 2002;27:621-7.  Back to cited text no. 12
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13.Andreasen FM, Norén JG, Andreasen JO, Engelhardtsen S, Lindh-Strömberg U. Long-term survival of fragment bonding in the treatment of fractured crowns: A multicenter clinical study. Quintessence Int 1995;26:669-81.  Back to cited text no. 13
    
14.Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15.  Back to cited text no. 14
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15.Potashnick SR, Rosenberg ES. Forced eruption: Principles in periodontics and restorative dentistry. J Prosthet Dent 1982;48:141-8.  Back to cited text no. 15
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16.Andreasen JO. Traumatic injuries of the teeth. 2 nd ed. Copenhagen: Munksgaard; 1984.  Back to cited text no. 16
    
17.Demarco FF, Fay RM, Pizon LM, Powers JM. Fracture resistance of re-attached coronal fragments-influence of different adhesive materials and bevel restoration. Dent Traumatol 2004;20:157-63.  Back to cited text no. 17
    
18.Sengun A, Ozer F, Unlu N, Ozturk B. Shear bond strengths of tooth fragments reattached or restored. J Oral Rehabil 2003;30:82-6.  Back to cited text no. 18
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19.Costa CA, Giro EM, Nascimento AB, Teixeira HM, Hebling J. Short term evaluation of the pulp-dentin complex response to a resin-modified glass-ionomer cement and a bonding agent applied in deep cavities. Dent Mater 2003;19:739-46.  Back to cited text no. 19
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20.Lehl G, Luthra R. Reattachment of fractured fragments of maxillary central incisors-report of a case. J Indian Soc Pedod Prev Dent 2004;22:54-5.  Back to cited text no. 20
    
21.Jardim Pdos S, Negri MR, Masotti AS. Rehabilitation to crown-root fracture by fragment reattachment with resin-modified glass ionomer cement and composite resin restoration. Dent Traumatol 2010; 26:186-90.  Back to cited text no. 21
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22.Pagliarini A, Rubini R, Rea M, Campese M. Crown fractures: Effectiveness of current enamel-dentin adhesives in reattachment of fractured fragments. Quintessence Int 2000;31:133-6.  Back to cited text no. 22
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23.Yiu CK, Tay FR, King NM, Pashey DH, Sidhu SK, Neo JC, et al. Interaction of glass-ionomer cements to moist dentin. J Dent Res 2004;4:283-9.  Back to cited text no. 23
    
24.Croll TP. Repair of severe crown fracture with glass ionomer and composite resin bonding. Quintessence Int 1988;19:649-54.  Back to cited text no. 24
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25.Burrow MF, Nopnakeepong U, Phrukkhanon S. A comparison of microtensile bond strength of several dentin bonding systems to primary and permanent dentin. Dent Mater 2002;18:239-45.  Back to cited text no. 25
    
26.Baratieri LN, Monteiro S Jr, Caldeira de Andrada MA. Tooth fracture reattachment: Case reports. Quintessence Int 1990;21:261-70.  Back to cited text no. 26
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27.Baratieri LN, Monteiro Júnior S, Cardoso AC, de Melo Filho JC. Coronal fractures with invasion of the biologic width: A case report. Quintessence Int 1993;24:85-91.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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