Biological Rehabilitation of Complex Oblique Crown-root Fracture Segment Reattachment.

Dental trauma can predominantly affect the maxillary anteriors. Trauma can occur to any age group due to accidents, assaults, or leisure activities. The goal of the treatment for traumatically injured teeth is to return the teeth to acceptable function and form. In this case presentation, the endodontic and esthetic treatment approach of crown fracture is presented.

INTRODUCTION

Trauma is a reasonable, severe, nonphysiological lesion to any part of the body. A dental injury should always be considered as an emergency and should be treated immediately to relieve pain, facilitate reduction of displaced teeth, and improve prognosis.[1] Dental injuries can occur at any age; however, they are most common between ages of 8 and 12 years. Most dental injuries occur during the first two decades of life.[2] The outcome of traumatic injuries involving teeth depends on the extent of injury, quality and timeliness of initial care and follow-up evaluation. Fracture mechanism in a crown-root fracture is that the horizontal impact produces compression zones at the point of impact cervically on the palatal aspect and apically on the labial aspect of the root. The shearing stress zones, which extend between the compression zones, determine the course of the fracture [Figure 1].[1] Maxillary arch was the most commonly affected arch, and maxillary central incisor was the most commonly fractured tooth. This can be due to its position and protrusion of the tooth.[3] Crown-root fracture usually presents a fracture line that originates in crown portion and extends apically in an oblique direction. They are often accompanied with pulp exposure.

Figure 1

Stress impact, which determine the fracture zone

Many techniques were advised to rehabilitate the fractured teeth. Acid etch technique and advancement of dental adhesives lead to the development of minimal invasive procedures such as tooth fragment reattachment.[4] This could be done only if intact fracture tooth segment is available for reattachment. Tooth fragment reattachment has several advantages over conventional restorations: it can serve as temporary or permanent crown, cost-effective, single visit technique, color stability, and proper tooth contour maintenance. In this case report, tooth segment reattachment of a maxillary permanent central incisor is discussed with 1-year follow-up.

CASE REPORT

A 35-year-old male had reported to the department of conservative and endodontics, with chief complaint of continuous pain in upper front tooth region that aggravated when kept in occlusion for past 3 days. On examination, he sustained complicated crown-root fracture in right central incisor [Figure 2]. On further inquiry, he accepted that he had sustained injury due to fight before 3 days. The fracture line was oblique extending apically from the labial surface to palatal surface. Fracture line was 1 mm subgingival to the free gingival margin. The fracture fragment was attached to the root at a point. The fragment was removed after infiltrating lignocaine [Figure 3] and stored in distilled water for further use [Figure 4]. Diode laser (Biolase ezlase 940 nm) treatment was done for gingivectomy with 3.5 W in continuous mode [Figure 5]. Gelatin sponge was inserted to control bleeding in the labial side. The pulp was extirpated and single visit root canal therapy was done in right central incisor and postspace of 1.5 mm was prepared for receiving fiber post of size # 3(HiRem Post 203). The fiber post was tried in the canal for removing obscurities and excess was cut using diamond points. Fracture segment was tried at the end of the post after placing retention grooves using rotary diamond points. Pulp remnants were removed from the fragment and flushed with saline followed by chlorhexidine.

Figure 2

Complicated oblique fracture in 11

Figure 3

Fracture segment removed

Figure 4

Segment stored in distill water

Figure 5

Diode laser used for fracture line exposure

Once the fragment was repositioned, proper fit was attained. Gelatin sponge was removed from the labial surface. The tooth fragment was etched using 37% phosphoric acid (3M Scotchbond™) followed by universal adhesive bond (3M ESPE Single bond universal adhesive) application for 20 s and light cured (Blue Phase G2 light cure unit) for 20 s. Dual cure (G CEM Link Ace GC) resin cement was used as per the manufacturer's instructions for luting the post to tooth fragment [Figure 6]. Excess cement oozing out was removed using applicator tip. Postspace was etched and adhesive was applied in the same manner. Dual cure resin cement was used to reposition the fracture fragment. Groove was made at the exposed fracture lines labially and palatally and restored with conventional composite (3MESPE Filtek Z350 XT). Finishing and polishing of the surfaces were done using polishing discs (Sof-Flex 3MESPE) [Figure 7]. Radiographic examination was carried out for accuracy.

Figure 6

Fiber post positioned in fracture segment

Figure 7

Repositioned fracture segment

After 1-year follow-up, the treated tooth had satisfactory healing, periodontal status was also satisfactory. There was no discoloration of the teeth on clinical examination.

DISCUSSION

Management of complex crown-root fractures requires a multidisciplinary management in which various specialists should work together to achieve the optimum treatment. Dental fractures can be managed with different treatment modalities such as composite or other prosthetic management after evaluating factors such as depth of fracture line subgingivally, lesion morphology, and root length morphology. However, if fracture segment is retained and time of restoration is less, fracture reattachment is the best method of choice, since fracture reattachment can restore 50%–60% of original strength.[2] Pediatric dentists at Hebrew University, Hadassah School of dentistry, reported first reattachment of incisal edge in 1964. Single visit endodontic therapy was undertaken to reduce the extraoral time.[5] Epoxy resin-based sealers were used for preparing the postspace in the same visit. Fiber post was used because of its modulus of elasticity same as that of dentin.

Various techniques of fragment reattachment were there such as using circumferential bevel before attaching, using V-shaped notch, placing chamfer at fracture line after reattaching, superficial over contour, and simple reattachment.[6] Here, internal groove is placed due to its ease of preparation and extensive retention. Isolation is essential in luting using resin cements. Rubber dam was not used in this technique instead moisture control was achieved by using cotton rolls, gelatin foam, and cheek retractors. Dual cure resin cements were used to lute the post since it completely cures and has high bond strength. Gingivectomy was done to expose the fracture line, instead of orthodontic extrusion for time consumption and seal the visible defect. No splinting was done in this case since tooth mobility was not elicited.

Clinical and radiographic follow-up of 1 year was only presented in this report; follow-up should be done yearly till 5 years for esthetics, tooth mobility, and periodontal status. Failures of fracture reattachment can occur due to new trauma, parafunction, and horizontal traction.[2] Athletic soft splints and patient education enhance the clinical success.

CONCLUSION

Use of self-etch dual cure composite with fiber post can provide better results in fracture segment reattachment in a single visit, thereby increasing the positive emotion in patients who might have reported with stressed emotions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.