Management of Tooth Fractures Using Fiber Post and Fragment Reattachment: Report of Two Cases.

Reattachment of the tooth fragment is an ultraconservative technique for managing coronal tooth fractures when the tooth fragment is available, and there is minimal violation of the biological width. The advances in adhesive dentistry have allowed dentists to use the patient's own fragment to restore the fractured tooth which provides fast and esthetically pleasing results. This article reports fragment reattachment technique and presents two clinical cases of complicated crown fracture.

INTRODUCTION

Restoring endodontically treated teeth with complicated crown or crown-root fracture is a major challenge for dental practitioners because it requires a comprehensive and accurate diagnosis and treatment plan.[1] The traditional treatments of complicated crown fractures are the use of definitive crown after crown lengthening or orthodontic or surgical extrusion, extraction followed by implant or fixed partial denture, and post and core-supported restorations.[2] If the crown fragment is retrieved at the time of injury, its reattachment provides several advantages over the other forms of restorations such as exact restoration of the crown form, surface morphology, color, and minimal violation of biologic width.[34] However, successful reattachment was determined by factors such as the site of fracture, size of fractured remnants, periodontal status, pulpal involvement, maturity of the root formation, biological width invasion, occlusion, material used for reattachment, use of post, and prognosis.[5] Purpose of this article is to report 2 cases of successful crown reattachment with 2-year follow-up.

Case report 1

A 23-year-old male patient presented to the Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, after sustaining a complicated crown fracture to his maxillary left lateral incisor due to fall on the ground. The patient's medical history was unremarkable. No mobility of the injured tooth was recorded and there was no apparent trauma to the soft tissues in the extraoral and intraoral examination. On hard tissue examination, Ellis Class III fracture was seen in the coronal portion of tooth No. 22, which extended from cervical 3rd of crown on labial aspect to 2 mm subgingivally on the lingual aspect. The fractured fragment was loosely attached to the tooth [Figure 1a to h].

Figure 1

(a) Preoperative view, (b) preoperative radiograph, (c) fracture segment removed, (d) sectional obturation, (e) fractured segment, (f) reattachment of fractured segment, (g) suturing of soft tissue, (h) review after 2 year

A periapical radiograph showed that the root formation was complete, with no extrusion. The patient expressed the desire to maintain the tooth and restore it due to the lower cost compared to an indirect restoration. A detailed explanation about the treatment plan was given to the patient, which included root canal treatment and reattachment with fiber post. The treatment plan was accepted by the patient. Local anesthetic was administered and the segment was removed with minimal force and recovered and stored in normal saline to prevent discoloration and dehydration. Following a detailed examination, the adaptation of the fragment was checked. The working length was determined with an electronic apex locator (Root ZX, J. Morita Corp., Japan) and confirmed with radiography. The gates glidden drills (Mani Inc., Japan) were used for coronal enlargement of the root canal. The root canal was enlarged to ISO size 60 at working length. About 3% sodium hypochlorite was used as irrigant during the preparation. The root canal was dried with paper points (Spident, Hand Rolled, Korea) and obturated using endodontic sealer (Sealapex, Kerr, USA) and laterally condensed with Gutta-percha (Spident, Hand Rolled, Korea). The root canal orifice was sealed with a temporary restoration. The day after completion of the endodontic treatment, gingival flap was raised as the fracture line was below the gingival level on the lingual aspect.

The root canal was prepared for the postplacement by removing the gutta-percha from the coronal two third of the canal with peso reamers. The fiber post (FIBRAPOST PD, Switzerland) was tried in the canal and adjusted to the desired length. Space was also prepared in the pulp chamber of the fractured crown fragment for receiving the coronal portion of the post and also the core. The alignment of the coronal fragment was verified with the post in place. The root canal was then etched with 37% orthophosphoric acid, rinsed, blot dried with paper points, and bonding agent (PRIME and BOND NT, DENTSPLY)) was applied. The post was then luted in the canal using dual-cured resin luting cement (RelyX, 3M, USA). The inner portion of the coronal fragment was similarly etched and bonded to the tooth using flowable composite resin (Esthet-X Flow, DENTSPLY) after proper shade matching. At the end, flap was repositioned, sutured, and occlusion was checked, and postoperative instructions were given to the patient. Clinical and radiographic examinations were carried out after 1 month, 3 months, 6 months, 1 year, and 2 years, and the tooth responded favorably.

Case report 2

A 19-year-old male patient reported to the Department of Conservative Dentistry, Mar Baselios Dental College, following trauma to maxillary left central incisor due to a motorcycle accident. On intraoral examination, Ellis Class III fracture was seen on the crown portion of tooth No. 22, which extended from cervical 3rd of crown on the labial side to 2 mm subgingivally on the lingual aspect. The fractured segment of the tooth was removed atraumatically and stored in normal saline. Single visit root canal treatment was done. Gingival flap was raised as the fracture line was below subgingival level on the lingual aspect. As mentioned earlier, the fracture crown fragment was reattached with remaining tooth portion by suitable fiber post with the help of dual core composite. At the end, flap was repositioned and sutured and postoperative instructions were given to the patient. The patient was recalled for regular review up to 1 year [Figure 2a to g].

Figure 2

(a) Preoperative view, (b) preoperative radiograph, (c) fracture segment removed, (d) obturation, (e) fractured segment, (f) reattachment of fractured segment, (g) review after 2 years

DISCUSSION

Complicated coronal fractures of permanent incisors represent 11%–15% of all trauma to incisors, of these 96% involve maxillary central incisors.[6] Conventionally custom cast post and core followed by metal ceramic crown was the treatment of choice for these types of complicated crown fractures. When compared to this, tooth fragment reattachment is a more conservative, affordable, and less time-consuming treatment option with favorable advantages such as original color match, preservation of contour, contacts, and incisal translucency.[78] Moreover, there has been a clearly observable transition from the use of metal alloy posts toward the use of fiber-reinforced resin-based composite (FRC) posts, especially with teeth in the esthetic zone such as maxillary incisors. FRC posts have a dentin-like modulus that allows a more even distribution of occlusal stresses in the root dentin,[9] which have led to fewer and less severe in vitro root fracture failures. FRC post needs less dentin removal as it uses the undercuts and surface irregularities to increase the surface area for bonding, thus minimizes the possibility of tooth fracture.[10] In addition, using glass fiber post with composite core and adhesive materials can create a monoblock, a multilayered structure with no inherent weak interlayer interfaces, which reinforces the tooth structure.[11]

In the above-mentioned cases, a dual cure resin cement RelyX 3M which is a self-etching and self-adhesive system was used for the reattachment of the fragments. This dual cure resin cement has a good bond strength, ensures complete curing and reduces microleakage. The coronal fragment was bonded to the remaining tooth using flowable composite resin Esthet-X Flow that offers excellent color stability, minimizes the inclusion of air voids, and helps in achieving higher bond strengths of the fractured segments.

The fracture line was below the gingival level in the mentioned cases; the gingival flap was raised to obtain access to the fractured site for bonding fractured component. As the biological width was only minimally invaded and the restorative margin could be placed at or above the level of the cementoenamel junction, the bone recontouring through crown lengthening would not be indicated in the present cases. The literature suggested that whenever biologic width is invaded, surgery should be performed with minimum osteotomy and osteoplasty.[12]

CONCLUSION

These case reports demonstrated the importance of establishing a multidisciplinary approach for a successful management of complex crown fracture and its possible sequelae. After almost 2 years of follow-up, the attached coronal fragments are in position with good esthetics as well as clinical and radiographic signs of periodontal health and root integrity, thus indicating treatment success.

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.