TOOTH FRAGMENT REATTACHMENT: A SINGLE SITTING TREATMENT APPROACH

Introduction

Any trauma with accompanying fracture of anterior teeth is a tragic experience for the young patient, not only because of damage to the dentition but also because of psychological effect of the trauma to the child and his parents. Recent investigations into the incidence of dental trauma have made it clear that this particular injury is of a significant nature and affects up to one-third of patients in pediatric age group (1)
A number of techniques have been developed to restore the fractured crown. Early techniques include stainless steel crowns, basket crowns, orthodontic bands, pin retained resin, porcelain bonded crown and composite resin (2). Functional, aesthetic, and biologic restoration of the fractured incisor often presents a daunting clinical challenge. Conventional composite resin restoration may result in less than ideal contours, colour match, and incisal translucency. Prosthodontic restoration in cases involving younger patients is questionable as confounding variables such as a large pulpal sizes, progressive eruption, and gingival margin instability take this treatment modality into one of uncertain longevity. When an intact fragment is available, incisal edge reattachment may offer a most functional and aesthetic treatment option. (3,4)
As with conventional restoration, restorative success hinges on proper case selection and strict adherence to sound principles of periodontal and endodontic therapies, and the techniques and materials for modern adhesive dentistry(4).The first published case reattaching a fractured incisor fragment was reported in 1964 by paediatric dentists at Hebrew University, Hadassah School of Dentistry (5). In an era of dentistry prior to commonplace acid-etching and bonding, the authors termed this treatment a temporary restoration. Tennery was the first to report reattachment of fragment using acid etch technique (6) .Reattachment techniques have been described in demanding clinical situations, including one case reported by Simonsen (7) in which an incisor fragment was reattached and the tooth subsequently subjected to orthodontic treatment without difficulties.
Though unsupported by laboratory studies or clinical trials, many successful case reports were published by a variety of authors(2,8,9,10).. An assortment of beveled designs, endodontic adjunctive care, dentinal channels, and composite resin materials and technique choices were employed. These case reports are positive regarding clinical success.

Case report

A 10 year old male patient reported following trauma to maxillary central incisors. (figure1).Trauma had occurred the previous night due to fall while playing . The child’s parents brought broken crown fragments along with him(figure 2). Patient’s medical history was non contributory. Examination revealed that the teeth had horizontal fracture involving enamel and dentin with pulpal involvement (Ellis class 3) Fractured portion of the teeth were intact .No mobility of the injured teeth was recorded and surrounding tissues were healthy. A periapical radiograph showed that the root formation was complete with no extrusion. The teeth fragment, after checking for approximation with the crown part were immediately maintained in normal saline during whole period prior to restoration. Following a detailed examination, the adaptation of the fragments was checked.

A single sitting RCT was done and the access cavity was sealed with glass ionomer cement. Phosphoric acid gel 37.5% was applied to the enamel on the fragment and the teeth for 20 seconds, Air-water spray was used to remove the acid and the surface was air dried taking care to keep the dentin slightly wet. Prime and bond NT adhesive system (Densply) was applied to the conditioned areas. A small increment of resin composite was applied to the tooth fragment which was then reattached to its proper position. Light cure polymerization was done for 30 seconds while fragment was kept in position under pressure. The teeth were polished with polishing discs .Occlusion was checked and post operative instructions to the patient were given to deter from loading the anterior teeth. Clinical examination carried out after 1 month, 3 months, and 6 (figure 4) months showed good retentive and esthetic results

Discussion

The incisal fragment reattachment procedure may offer a conservative, cost-effective, and aesthetic restorative option when patients present with intact incisal edge segments. The use of a moist bonding procedure using fourth or fifth generation dentine bonding agents without additional retention features such as internal or external preparation has been shown to provide clinical restorative success (10,11). An advantage of the incisal edge reattachment procedure is that it does not preclude any future treatment and therefore, represents a viable first treatment option(8,11,12) .
J. O. Andreasen, (12) state that the reattachment procedure may importantly serve as a transitional treatment alternative for pre-teens or teenage patients to postpone definitive treatment until an age where gingival margin contours are relatively stable. Patients should be appraised of the advantages and disadvantages and should make an informed decision based on the dentist's recommended treatment regimen
Current adhesive agents provide sufficient bonding strengths to withstand the slow loading from masticatory stresses eventhough this bonded interface is undeniably susceptible to the effects of cyclic fatigue and hydrolytic degradation over time (10,12). However, it appears that improvements in the luting and/or bonding systems employed and a greater knowledge of the factors influencing restoration longevity should serve to enhance the potential for success of reattachment techniques in the future.

References

1) Attila IO, Cenk MHA, Serdar MT. Multidisciplinary approach to the rehabilitation of a crown –root fracture for immediate esthetics. Dent traumatol. 2006; 22(1):48-52.
2) Burke F.J.T.: Reattachment of a fractured central incisor tooth fragment. Br Dent J 1991; 170: 223 –5
3) Wadhwani CPK. A single visit, multidisciplinary approach to the management of traumatic tooth crown fracture.Br Dent J. 2000;188:593-8.
4) R Hegde: Tooth fragment reattachment - an esthetic alternative: Report of a case J Indian Soc Pedo Prev Dent September (2003) 21 (3) 117-9
5) Reis A, Loguercio AD, Kraul A, Matson E.Reattachment of fractured teeth: A review of literature regarding techniques and materials.Oper Dent. 2004; 29(2):226-33
6) Tannery NT. The fractured tooth reunited using acids etch bonding technique. Tex Dent J 1988:16-7
7) Simonsen RJ. Restoration of a fractured central incisor using orginal teeth. J Am Dent Assoc 1982: 105: 646-8
8) Giorgio R, Claudia M, Angelo P. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol.2002;18:281-4.
9) Baratieri L.N., Monteiro S.: Tooth fracture reattachment: Casereports. Quint Int 1990; 21: 261- 70.
10) Attila IO, Cenk MHA, Serdar MT.Multidisciplinary approach to the rehabilitation of a crown –root fracture for immediate esthetics. Dent traumatol. 2006;22(1):48-52.).
11) Giorgio R, Claudia M, Angelo P. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol.2002;18:281-4.
12) Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th Edition,Jens O. Andreasen , FrancesM. Andreasen Lars Andersson ,July 2007, Wiley-Blackwell

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Dr. Faizal CP, MDS Professor, Dept of Pedodontics Kannur Dental College Anjarakkandy, Kannur	Dr. Shiraz usman MDS Senior Lecturer Kannur dental college, Anjarakkady Kannur