An Innovative Method for Fragment Reattachment after Complicated Crown Fracture An Innovative Method for Fragment Reattachment after Complicated Crown Fracture RICCARDO TONINI* ABSTRACT The case of a[.]
CLINICAL REPORT An Innovative Method for Fragment Reattachment after Complicated Crown Fracture RICCARDO TONINI* ABSTRACT The case of a nineteen-year-old female with atypical fractures to three maxillary incisors (#11FDI, #8 universal; #21 FDI, #9 universal and #22 FDI, #10 universal) with one showing a complicated crown fracture and pulp exposure is reported A partial pulpotomy had been carried out immediately after trauma and the patient complained of acute pain on percussion of the left centralincisor.Direct restoration with resin-based composite was carried out on the two teeth where fragments were not available (tooth #8 and #10) and root canal treatment with reattachment of fragments and f|ber post was carried out on the third (tooth #9) An innovative method was used to reattach the tooth fragments whereby the f|ber post was inserted without drilling a hole in the crown thus preserving the integrity of the crown.Follow-up visits conf|rmed the success of treatment based on clinical and radiographic evaluations.The patient was pain free with no tooth sensitivity and good function and esthetics after four years of follow-up CLINICAL SIGNIFICANCE Case report with a follow-up of years, provides conf|rmatory evidence of the long-term eff|cacy of an innovative method to reattach tooth fragments whereby f|ber post is inserted without drilling a hole in the crown thus preserving the integrity of the crown (J Esthet Restor Dent 00:00^00, 2016) BACKGROUND Management of traumatic dental injuries (TDI) involves a multidisciplinary approach to maximize healing while maintaining function and esthetics.1,2 The challenge is to identify the most suitable treatment for a given patient using a combination of evidence-based guidelines and clinical experience.3,4 Complicated crown fractures, account for up to 20% of all TDI with the majority being in young permanent teeth.5,6 The most common injuries are in the maxillary anterior region, which can have a physical as well a psychological impact on the patient.7 Reattachment of the fragment, previously a provisional restoration, is now the permanent treatment of choice—made possible by the introduction of resin composites that ensure a lasting solution The type of treatment depends on pulp vitality and the stage of root development or resorption In complicated fractures root canal treatment (RCT) followed by reattachment of the fractured segment with fiber post reinforcement is a feasible option In fractures involving two-thirds or more of the crown, post systems are usually recommended The case of a young woman with atypical fractures of the maxillary central incisors (permanent) is reported that were successfully treated using an innovative method of tooth fragment reattachment and preservation of coronal integrity after post placement *Dental school tutor for Endodontics teaching, University of Brescia, Brescia, BS, Italy This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproductioninanymedium, providedthe originalworkisproperlycitedandisnotusedforcommercialpurposes C 2016 The Authors Journal of Esthetic and Restorative V Dentistry Published by Wiley Periodicals, Inc DOI 10.1111/jerd.12281 Journal of Esthetic and Restorative Dentistry Vol 00 No 00 00^00 2016 FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini FIGURE A partial pulpotomy was conducted immediately after trauma Tooth #9—Root canal treatment—reattachment of fragments and fiber post Tooth #10—Direct restoration with resin-based composite (fragment not available) After explaining the treatment plan to the patient and her parents, written informed consent was obtained FIGURE Patient showing three fractured teeth (a), intraoral periapical radiographs show absence of root fractures (b) CASE PRESENTATION A nineteen-year-old young woman presented at our clinic with acute pain at the level of tooth #21 FDI, #9 universal Examination showed she had poor oral hygiene as pain prevented her from brushing properly The patient had fractured the coronal part of three teeth (#11 FDI, #8 universal; #21 FDI, #9 universal and 22 FDI, universal #10) Tooth #9 had a complicated fracture and pulp exposure with a palatal second fragment still present (Figure 1a) Intraoral periapical radiographs did not show signs of root fractures and #8 and #10 responded positively to pulp thermal testing on the labial surface (Figure 1b) A partial pulpotomy had previously been carried out immediately after trauma by another dentist and she complained of acute pain on percussion of the left central incisor (Figure 2) TREATMENT The proposed treatment protocol was as follows: Tooth #8—Direct restoration with resin-based composite (fragment not available) Vol 00 No 00 00^00 2016 Journal of Esthetic and Restorative Dentistry Treatment of tooth of #9 posed a particular problem and following discussions with the multidisciplinary team, we decided to adopt an innovative approach We first removed, cleaned, and stored the fragments in saline at 48C All three teeth were then isolated with a rubber dam positioning clamp on #9 under the fracture line exposing the sound enamel (Figure 3a,b) After preparation, RCT was initiated and apical filing was performed with at least mm of guttapercha seal (Shaping: Step back technique, Proglider and Protaper next X1, X2, X3, X4 [Dentsply Maileffer] Irrigation: Chlor Xtra 6%, EDTA 17%, Vista Dental, obturation: AH plus as sealer and warm Guttapercha condensation) The patient was then sent home to return 24 hours later when the reattachment process was started All fragments were treated with a conventional three-step adhesive technique and then joined together with a thin layer of flowable resin-based composite To ensure better adhesion of the crown a small amount of resin-based composite was positioned on the palatal side above fracture line, with a K-file holder inside The root canal was cleaned and prepared with a dental bur (Largo, number 3) and the length of the fiber post (Tech 2000TM, Isasan, Como, Italy) was tested and the C 2016 The Authors Journal of Esthetic and Restorative DOI 10.1111/jerd.12281 V Dentistry Published by Wiley Periodicals, Inc FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini FIGURE Fiber post fixed inside the fragment pulp chamber with resin-based composite without polymerization and without drilling a hole in the crown post head was cut to size until the crown fragment fitted perfectly with the post and the margins of the tooth The post was then treated with silane coupling agent and the head was fixed inside the fragment pulp chamber with resin-based composite without polymerization and importantly without drilling a hole in the crown (Figure 4) The root canal was prepared with a three-step adhesive technique, using adhesive mixed with activator (OptiBond FLTM, Kerr, Scafati, Italy) We applied a dual-cure resin-based composite (ClearfilTM DC Core Dual-Cure, Kuraray Noritake, New York, NY, USA) using a microcannula starting from the bottom to top to ensure even application The fragments with the post in-situ were then put in position and any resin-based composite excess was removed before polymerization (Figure 5) The K-file holder was removed and the procedure was completed by finishing and polishing the teeth (Figure 6a–c) Routine direct restoration with resin-based composite (Clearfil MajestyTM A2 and A2E, Kuraray Noritake, New York, NY, USA) of tooth #8 and tooth #10 was conducted during the same session, as fragments were not available FIGURE The three fractured teeth were isolated with a rubber dam positioning clamp on #9 (a), the fracture line exposing the sound enamel (b) C 2016 The Authors Journal of Esthetic and Restorative V Dentistry Published by Wiley Periodicals, Inc DOI 10.1111/jerd.12281 Follow-up visits confirmed the success of treatment based on clinical and radiographic evaluations—the patient reported to be pain free with no tooth sensitivity and no symptoms or radiographic defects were recorded at 2-year of follow-up (Figure 7a,b) The patient remained pain-free with good function and aesthetics after four years of follow-up Journal of Esthetic and Restorative Dentistry Vol 00 No 00 00^00 2016 FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini FIGURE Fragments with the fiber post in situ were positioned and excess resin-based composite removed before polymerization FIGURE a–c, Patient post-treatment showing three fractured teeth repaired with good aesthetic characteristics DISCUSSION Management of complicated crown fragments has undergone major changes in recent years Although the procedure of tooth fragment reattachment is not new—it was first reported in 1964—what was for years a theoretical technique has now been shown to be a viable and conservative treatment option for fractured incisors.8 The remarkable advances in adhesive systems and resin-based composites have made reattachment procedures all the more achievable FIGURE a, Patient at follow-up two years after fragment reattachment b, X ray at 2-year follow-up Vol 00 No 00 00^00 2016 Journal of Esthetic and Restorative Dentistry The case history reported here not only confirms the long-term effectiveness of the reattachment technique using fiber posts but also illustrates the effectiveness and innovativeness of attaching the fiber post without drilling a hole in the crown Our data adds to the growing number of case reports in the literature demonstrating that reattachment of a fractured tooth fragment is effective for the treatment of a coronal C 2016 The Authors Journal of Esthetic and Restorative DOI 10.1111/jerd.12281 V Dentistry Published by Wiley Periodicals, Inc FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini fracture of anterior teeth when the fracture segment is available,9–11 Sapna et al reported three cases of successful reattachment of fractured segment of maxillary anterior teeth with a 12-month follow-up period.9 They also concluded that tooth-colored fiber post may be the best option with a number of important advantages such as esthetics, good bonding between post and cement, lower chair time, and minimal tissue removal.9 It appears that the use of a fiber post with fractured teeth minimizes the stress on the reattached tooth fragment as it interlocks the two fragments Likewise, our innovative procedure of attaching the fiber post without drilling the crown helps to further reduce stress on the fragment Oliveira et al reported a very similar case using a conservative approach for the treatment of an extensive crown-root fracture of an endodontically treated maxillary central incisor, where the fragment reattachment was made possible with the use of an intracanal fiber post system.11 However, the authors conclude It is difficult, if not impossible, to determine how long the restoration presented in this case report will provide a reasonable degree of esthetics and function Our case report, with a follow-up of years provides confirmatory evidence of the long-term efficacy of this technique Zicari et al investigated the influence of the ferrule effect and fiber-post placement on the fracture resistance of endodontically treated teeth subjected to cyclic fatigue loading and concluded that avoiding extra-removal of sound tooth structure, rather than placing a fiber post, can protect endodontically treated teeth against catastrophic failure However, when any ferrule can be preserved, a fiber-post may improve the retention and fatigue resistance of the restoration.12 Similarly, Adanir and Belli determined that the physical characteristics of posts were important on stress distributions in post and core applications.13 In conclusion, our results and similar cases reported in the literature provide further confirmatory evidence of the long-term efficacy of the reattachment procedure using fiber posts and provide dental health professionals with an effective and viable alternative treatment method Our method has long-term C 2016 The Authors Journal of Esthetic and Restorative V Dentistry Published by Wiley Periodicals, Inc DOI 10.1111/jerd.12281 effectiveness, is conservative, relatively cost-effective, not time-intensive, and has superior esthetics DISCLOSURE The author does not have any financial interest in the companies whose materials are included in this article REFERENCES Diangelis AJ, Andreasen JO, Ebeleseder KA, et al International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: Fractures and luxations of permanent teeth Dent Traumatol 2012;28:2–12 Andreasen JO, Ahrensburg SS, Tsilingaridis G Root fractures: the influence of type of healing and location of fracture on tooth survival rates - an analysis of 492 cases Dent Traumatol 2012;28:404–9 Sharif MO, Tejani-Sharif A, Kenny K, Day PF A systematic review of outcome 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1-year follow-up Case Rep Dent 2014; 376267:5 10 Baratieri LN, Ritter AV, Monteiro J unior S, de Mello FJC Tooth fragment reattachment: an alternative for restoration of fractured anterior teeth Pract Periodontics Aesthet Dent 1998;10(1):115–25 Journal of Esthetic and Restorative Dentistry Vol 00 No 00 00^00 2016 FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini 11 Oliveira GMS, Oliveira GB, Ritter AV Crown fragment reattachment: report of an extensive case with intra-canal anchorage Dent Traumatol 2010;26:174–81 12 Zicari F, Van Meerbeek B, Scotti R, Naert IJD Effect of ferrule and post placement on fracture resistance of endodontically treated teeth after fatigue loading J Dent 2013;41(3):207–15 doi: 10.1016/j.jdent.2012.10.004 Epub 2012 Oct 13 Vol 00 No 00 00^00 2016 Journal of Esthetic and Restorative Dentistry 13 Adanir N, Belli S Stress analysis of a maxillary central incisor restored with different posts Eur J Dent 2007;1(2):67–71 Reprint requests:Dr RiccardoTonini,Dental Clinic,University of Brescia,Via Duca D’Aosta 28,Brescia,BS,Italy;Tel.: 00 39 347 7840355; email: qantas21@hotmail.com C 2016 The Authors Journal of Esthetic and Restorative DOI 10.1111/jerd.12281 V Dentistry Published by Wiley Periodicals, Inc ... 2016 FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini 11 Oliveira GMS, Oliveira GB, Ritter AV Crown fragment reattachment: report of an extensive case with intra-canal anchorage.. .FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini FIGURE A partial pulpotomy was conducted immediately after trauma Tooth #9—Root canal treatment? ?reattachment of fragments and... Inc FRAGMENT REATTACHMENT AFTER COMPLICATED CROWN FRACTURE Tonini fracture of anterior teeth when the fracture segment is available,9–11 Sapna et al reported three cases of successful reattachment