Use of quartz fiber post for reattachment of complex crown root fractures: A 4-year follow-up.

Dental hard tissue trauma is among the most common cases encountered in dental practice. Simple tooth fractures, which occur due to sharp blows, are widely seen in all age groups, especially in young adults. If in case of complex fractures the fractured tooth fragments are available to the dentist in a clean and hydrated state, reattachment of the tooth fragment is the most conservative and biological treatment option possible. Cases of enamel and dentin fractures not involving pulp are treated by reattaching the fragment with adhesives and composite resin. However, fractures involving the pulp require reinforcement by quartz fiber posts and resin luting cement. In cases of fractures extending subgingivally, an envelope flap helps to achieve the desired isolation and visibility. This article presents 2 case reports of reattachment of fractured tooth fragments. The first case showing a 4-year success was treated without raising a flap. The second case with a subgingival fracture was treated by raising a flap. Reattachment is the most economical, biologically acceptable and esthetic restorative option for dental trauma.

INTRODUCTION

Dental fractures account for 26-76% of dental injuries in the permanent dentition.[1] Coronal fractures of permanent incisors represent 18-22% of all trauma to dental hard tissues, 28-44% being simple (enamel and dentin) and 11-15% complex (enamel, dentin, and pulp).[2] Traumatized anterior teeth require quick functional and esthetic repair. This is particularly true in case of young patients as it not only causes physiologic impairment, but also esthetic disfigurement leading to a psychological impact.[3]

The most common etiological factors of crown and crown root fractures in the permanent dentition are injuries caused by fall (about 40%), contact sports (about 20%), automobile accidents, and foreign body striking the teeth.[4]

Early techniques to restore the fractured crown include jacket crown, orthodontic bands, pin retained resin, porcelain bonded crown and composite resin.[5] Tooth fragment reattachment has been shown to be an acceptable alternative to the restoration of the fractured tooth. Tennery was the first to report the reattachment of a fractured fragment using the acid-etch technique.[6] Subsequently, Starkey and Simonsen have reported similar cases.[78]

Reattachment of fragment offers following advantages:

Better aesthetics and achievement of life-like translucency,

Incisal edge wear at a rate similar to that of the adjacent teeth,

Replacement of fractured portion involving less time,

A positive emotional and social response from the patient,

Relatively inexpensive procedure.[8]

Reattachment of tooth fractured at the cervical level can be reinforced with the use of post as it interlocks the two fragments and minimizes the stresses on the reattached tooth fragment.[9] With the recent improvements in resin based restorative materials, tooth colored fiber posts along with resin luting cement are of choice because of several advantages such as esthetics, bonding to tooth structure and low modulus of elasticity similar to that of dentin.[10] In some cases where the fracture extends subgingivally, but is supra alveolar, a full-thickness envelope flap provides the required isolation and visibility. This article reports two cases of reattachment, one performed without a flap and one after raising an envelope flap.

CASE REPORTS

Case 1

A 16-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with fractured maxillary anterior tooth. The tooth had fractured 12 h ago on account of a minor two wheeler accident. Patient complained of severe sensitivity with 22. Examination revealed Ellis Class III fracture with 22. The oblique fracture line was supragingival both labially and palatally [Figure 1a]. As the fragment was stored in water by the patient, it had not got dehydrated. The patient was undergoing orthodontic treatment hence metal bracket was present on the labial surface of the fractured fragment [Figure 1b]. Radiographic examination showed no other fractures in the root and healthy periapical tissues. The treatment plan decided for the patient was reattachment of the fragment.

Figure 1

Case 1. (a) Preoperative photograph and radiograph, (b) Fractured fragment, (c) Post obturation radiograph, (d) Post cementation radiograph, (e) Postoperative photograph, (f) 6 months follow-up, (g) 4 years follow-up

As the patient was due for debonding, the brackets were removed from the maxillary arch. The fragment was placed in normal saline. Single visit root canal treatment of 22 was carried out. The obturation radiograph was used to determine the size of the prefabricated fiber post [Figure 1c]. The post selected was HiRem post size 2 (Overfibers, Italy). Post space preparation was done, retaining 6 mm of apical Gutta-percha. After the seating of the post was checked, it was trimmed, leaving about 2 mm of post beyond the tooth. An arbitrary preparation was done on the pulpal aspect of the tooth fragment using round bur and straight fissure bur and hence that it would fit over the 2 mm of the post. The post and the fragment were adjusted until the fragment approximated in its original position. This adjustment was done to obtain a lock and key type of fit between the post and fragment in order to provide additional retention for the fractured fragment. The post and the fragment were luted using resin based luting cement, Calibra (Dentsply, U.K.) [Figure 1d].

The fracture line was camouflaged with composite resin [Figure 1e]. The patient was given oral hygiene instructions and was recalled for follow-up after 6 months [Figure 1f]. The 4 years follow-up photograph shows satisfactory results [Figure 1g].

Case 2

A 20-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of mobile maxillary anterior tooth. He gave a history of sport injury the evening before. Clinical examination revealed Ellis Class III fracture with 11 with the fracture line extending subgingivally palatally [Figure 2a]. As the fragment was in the oral cavity, it had not got dehydrated. Radiographic examination showed no other fractures in the root and healthy periapical tissues. The treatment plan decided for the patient was reattachment of the fragment.

Figure 2

Clinical photograph and radiograph of case 2. (a) Pre operative photograph, (b) Post obturation radiograph, (c) Palatal envelope flap raised, (d) Post and fractured fragment luted, (e) Sutures given, (f) Post cementation radiograph, (g) At 6 months follow-up

The fractured fragment was removed and bleeding controlled. Single visit root canal treatment was carried out with 11 [Figure 2b]. Then, based on the post obturation radiograph, no 2 HiRem quartz fiber post (Overfibers, Italy) was selected. Post space was prepared using Gates Glidden drills and peeso reamers. As the fracture line was subgingival palatally, isolation of the fracture line during reattachment was not possible. Hence, a mucoperiosteal envelope flap was raised palatally to completely expose the fracture line [Figure 2c]. The fractured fragment was prepared on the pulpal aspect to accurately fit over the post as described in the case report 1. The post and tooth fragment were luted with resin luting cement (Calibra) and the flash was cleaned. The palatal aspect was finished and polished so as not to act as a nidus for plaque accumulation [Figure 2d]. The flap was sutured with 000 silk sutures [Figure 2e]. A radiograph was taken to evaluate the post cementation [Figure 2f]. When the patient was recalled after 1 week for suture removal, the soft tissues showed favorable healing. The fracture line labially was camouflaged with composite resin. The 6 months photograph showed symptomless tooth with satisfactory esthetics [Figure 2g].

DISCUSSION

Fracture of a tooth may be a most traumatic incident for a young patient. However, it has been found that if the natural tooth structure is preserved it has a positive emotional and social response from the patient.[11]

Factors determining the treatment plan and prognosis for coronal teeth fractures include the extent of fracture, endodontic involvement, periodontal status, maturity of root, biological width invasion, pattern of alveolar bone fracture, restorability of fractured tooth, secondary traumatic injuries, presence/absence of fractured tooth fragment and the fit between the fragment and remaining tooth, occlusion, esthetics, and finances.[12]

Depending on these factors various treatment options are composite restorations, orthodontic extrusion, surgical extrusion or crown lengthening followed by post and core supported restorations and reattachment of fractured fragment.[13]

Composite restorations can be considered only for less extensive fractures in enamel and dentin. Post and core supported crowns are recommended in cases of major tooth loss where the fractured fragment is not available. With the fracture line extending below the alveolar crestal bone orthodontic extrusion or surgical extrusion is recommended before the restoration. But with the fracture lying above the alveolar bone crest reattachment of the fractured fragment is a more viable option.[9] There is sufficient evidence to show that the reattachment of the fractured coronal fragments using modern adhesive systems results in predictably successful short- and medium-term outcomes.[14] However, this technique can be used only when the intact tooth fragment is available.[15] As the fractured fragments were intact in the cases described above, use of natural tooth substance clearly eliminated problems of differential wear of restorative material, unmatched shades and difficulty of contour and texture reproduction associated with other restorative techniques.

Hayashi et al.[16] have highlighted that the selection of restorative technique in cases of extensive loss of structure where reinforcement of pulpless teeth is required is highly critical. When a tooth has more than 50% of its coronal structure missing, the use of a post and core foundation is recommended prior to restoration.[17] In recent literature reviews, it has become clear that posts do not strengthen endodontically treated teeth. However, their use is justified for retention of the reattached coronal fragment.[18]

The common complications in the post and core system are debonding and root fracture.[9] These are more common with cast metal posts used earlier which can cause wedging forces coronally that may result in irreversible failure because of fracture of an already weakened root.[14] The newer variety of nonmetallic posts is made of either ceramic or fiber reinforced materials like carbon, quartz or glass in an epoxy matrix. Fiber reinforced composite resin post offers many advantages for reattachment procedure such as conservation of tooth structure, bonding to the tooth structure, low modulus of elasticity equal to that of dentin, esthetics, simplicity of procedure requiring less chair time and cost-effectiveness.[19] By using glass fiber post with composite core and with recent advances in adhesive techniques and materials one can create a Monobloc, a multi-layered structure with no inherent weak interlayer interfaces. Early retrospective studies indicate that the clinical performance of fiber post is promising and the failure rate recorded is 3.2% over a period of up to 4 years.[16]

Trope et al.[20] in 1985 showed that endodontically treated teeth can be reinforced with the use of resin composite restoration. The flowable composite reinforces the tooth, helps in achieving higher bond strengths and minimizes the inclusion of air voids.

In the second case presented here, the fracture line extended subgingivally palatally. However, as the fracture was supraalveolar, sufficient access, visibility and isolation was achieved by raising a palatal envelope flap.[19]

Tooth fracture reattachment allows restoration of the tooth with minimal sacrifice of the remaining tooth structure. The use of natural tooth substance clearly eliminated problems of differential wear of restorative material, unmatched shades and difficulty of contour and texture reproduction associated with other restorative techniques.[21]

CONCLUSION

The remarkable advancement of adhesive systems and resin composites has made reattachment of tooth fragments a procedure that is no longer a provisional restoration, but rather a restorative treatment offering a favorable prognosis. If an intact tooth fragment is present after trauma, the reattachment procedure presents a conservative, simple, esthetic, and economical treatment option.