Download TITLE PAGE A conservative approach for rehabilitation of fractured

TITLE PAGE
A conservative approach for rehabilitation of fractured maxillary incisor through
reattachment: a case report
Dr Varun Nagpal *
MDS, Oral and Maxillofacial Surgery
Senior Lecturer, Department of Oral and Maxillofacial Surgery
Jan Nayak Chaudhary Devi Lal Dental College and Hospital, Sirsa
Dr Priyanka Setia†
MDS , Conservative Dentistry and Endodontics
Senior Lecturer, Department of Conservative Dentistry and Endodontics
Jan Nayak Chaudhary Devi Lal Dental College and Hospital, Sirsa
Dr Varun Aroraⱡ
MDS, Dept of Prosthodontics
Reader , Department of Prosthodontics
Jan Nayak Chaudhary Devi Lal Dental College and Hospital, Sirsa
Dr Namita Jain€
MDS, Conservative Dentistry and Endodontics
Senior Lecturer, Department of Conservative Dentistry and Endodontics
Jan Nayak Chaudhary Devi Lal Dental College and Hospital, Sirsa
Corresponding author: Dr Varun Nagpal *
MDS, Oral and Maxillofacial Surgery
Senior Lecturer, Department of Oral and Maxillofacial Surgery
Jan Nayak Chaudhary Devi Lal Dental College and Hospital, Sirsaⱡ
Email: [email protected]
Running Title : Esthetic Rehabilitation through Reattachment
One line Summary: Reattachment procedures offer a reliable treatment modality for
restoration of fractured tooth
ABSTRACT OR INTRODUCTION
Background: Fracture of anterior teeth is a very common form of dental
injuries that require an immediate attention owing to its social and
emotional impact on the patient. Various treatment modalities exist
including orthodontic or surgical extrusion followed by crown placement.
But reattachment of the broken fragment provides an esthetically
satisfactory and economical alternative
Method: This article discusses a case of 28 year old male patient with
fractured left lateral incisor. Reattachment of fractured fragment was done
after single sitting endodontic treatment using fibre post and dual cure
resin cement
Result: Post treatment evaluation yields good reattachment, intact post,
good esthetics and good periodontal health.
Conclusion: Reattachment of the fractured segment presents an
inexpensive, esthetically pleasing and reliable mode of treatment for
complicated crown root fractures. However long term prognosis needs to
be evaluated
Key words: reattachment, oblique fracture, fibre post, dual cure resin
One line Summary: Reattachment procedures offer a reliable treatment
modality for restoration of fractured tooth
Introduction
The maxillary incisors are most prone to traumatic injuries encountered during
fall, sports injuries or fights because of their position in the arch (1). The trauma
to the anterior teeth is associated with a social and emotional blow to the
patients and thus require an immediate attention and rehabilitation. . Various
treatment modalities exist including orthodontic or surgical extrusion followed
by crown placement. But reattachment of the broken fragment provides an
esthetically satisfactory and economical alternative . Reattachment of fractured
tooth provides the best esthetic results as natural tooth shape, contour, surface
texture, occlusal alignment and color are maintained(2,3). Moreover, the
treatment is usually carried out in single appointment thus sparing the patient
from psychological distress of multiple sittings .
Tennery (1988) (4) was the first to report the reattachment of a fractured
fragment using acid-etch technique. The advent of superior bonding techniques
have further , made restoration possible for the fractured incisor, with minimal
preparation. The sudden blow to the anterior tooth usually leads to complicated
fractures, involving enamel, dentin, cementum and pulp, that takes an oblique
trajectory such that the fracture occurs subgingivally along one or more walls. .
This article presents a case report of complicated fracture extending
subgingivally on the palatal aspect managed successfully through reattachment
procedure.
CASE DESCRIPTION AND REULTS
A 28 years-old male came to the department of conservative dentistry and
endodontics with a fractured maxillary left lateral incisor with a lapse of three
hours. The extra-oral examination revealed no significant findings. The clinical
and radiographic maxillofacial examination indicated that the maxilla, mandible
and other facial bones were intact. Intraorally, the maxillary left lateral incisor
had a fracture horizontal on the buccal, 3mm above the gingival margin and
oblique in the buccal-palatal direction, extending 2mm below the gingival
margin on the palatal side.
The pulp was totally exposed. The crown fragment was detached and patient
was carrying it in hand (Figure 1 and 2). The apical fragment had no pathologic
mobility. In the periapical radiograph, an oblique fracture line was clearly
observed (Figure 3).. Other adjacent teeth had no sign of trauma and were vital.
Though the left central incisor was non vital due to a previous injury that
occurred few years back. The left maxillary canine also reported tenderness at
the time of presentation and was intact. The patient was informed of all the
treatment alternatives. Considering the cost effectiveness and
esthetic
superiority patient opted for reattachment of the fractured fragment.
The fractured fragment was immediately soaked in saline solution to prevent
dehydration (figure 4). Local anesthesia was administered. A decision was made
to carry out a single sitting endodontic treatment , raise an envelope flap to
expose the palatal margin and place a fiber-reinforced post into the root canal
for retention of the reattached fragment. Following extirpation of the pulp
tissues, the root canal was prepared using protaper files upto F3 filled with a
sealer (Hybrid Root SEAL , Sun Medical, Japan) and gutta-percha using the
sectional obturation technique to create a seal of 4 mm in the apical third and
post space was prepared(figure 5 and 6). The fracture extending subgingivally
on the palatal surface was apparent. Palatally a crevicular incision was given
and an envelope flap was raised to reestablish the gingival margin and expose
the subgingival fracture in order to evaluate the possibility for a crown
attachment procedure . A small hole was created in the middle of the crown
fragment (Figure 7) in which to lay the fibre post. Before reattachment, the
fractured margins were checked to ensure an accurate fit. Additionally bevel
was given and grooves were made on the internal surface of fractured crown
and retained crown portion to increase surface area and enhance bonding.
Isolation with respect to crevicular fluid seepage was achieved with cotton rolls
and gauzes. Gauze pieces soaked with adrenaline were used to achieve blood
free surgical site to ensure optimal bonding. The root canal was thentreated with
self etch non rinse primer/ adhesive. The preselected fibre post ( Parapost- Fibre
white, Coltene), was luted inside the root canal using a dual cure resin cement
(Ivoclar Vivadent). Subsequently the coronal fragment was acid etched , treated
with bonding agent and luted to the post segment. (figure 8 and 9)
The restoration was finished and polished and the occlusion checked (figure 10
and 11). Oral hygiene instructions were given to the patient and a diet of soft
food was advised. The patient was scheduled for follow up.
Patient reported with no post treatment discomfort .
Discussion
The maxillary incisors are commonly traumatized teeth in orofacial injuries
associated with automobile accidents ,sports injuries, violence or fall. Among
traumatic injuries, uncomplicated crown fracture accounts to more than 50%
cases whereas complicated crown fractures accounts to 2 to 13% of all
dental injuries (1). The fractures pertaining to maxillary incisors pose a huge
social and emotional distress to the patient. Such traumatic injuries demand
urgent services to prevent the onset of periapical infection and rapid
rehabilitation of the esthetics.
Reattachment of fractured fragment presents as an alternative to conventional
restoration techniques that require multiple sittings, and are less economical.
Moreover preservation of natural tooth form provokes a positive emotional
and social response from the patient. The choice of treatment for complicated
crown and/or root fractures with reattachment protocol depends upon the stage
of root formation, time elapsed between injury and presentation to the clinic and
medium in which fragment is carried if detached from the tooth. In our case the
root closure was complete and barely three hours lapsed between the occurrence
of injury and initiation of the treatment. Thus the single sitting endodontic
treatment was planned and fragment was stored in saline to enhance the
treatment outcome.
Sectional obturation was preferred over lateral condenation to accomplish the
procedure in a single sitting. A fibre post was selected to enhance the retention .
Fiber reinforced posts are reported to possess adequate rigidity and are not
prone to produce tooth fracture and have been shown to be clinically successful
(5). A bevel was made on the factured segment and the retained crown
structure along with grooves to enhance retention(6). The post and the coronal
fragment were cemented using, dual cure resin cement as per manufacturer’s
instructions . The dual cure resin cements were used because they increase
retention tend to leak less than other cements(7) . Case presented with an
effective seal and satisfactory adaptation of the fractured crown root segment
with the rest of the tooth and yielded pleasant esthetics.
Conclusion
Reattachment of the fractured segment presents an inexpensive, esthetically
pleasing and reliable mode of treatment for complicated crown root fractures.
However long term prognosis needs to be evaluated .
References
1. Andreasen JO, Andreasen F, Andersson L. In: Textbook and Color Atlas
of Traumatic Injuries to the Teeth. 4th ed. Oxford, Blackwell; 2007.
Classification Epidemiology Etiology; 227–44
2. N Joshi, N shetty M Kuundabala. Immediate reattachment of fractured
tooth segment using dual cure resin. Kathmandu university medical
journal. Vol 6, no 23, 386-388.
3. Nitin Kararia, Ajay Chaudhary, Vandana Kararia. Tooth Fragment
Reattachment:An Esthetic, biological restoration. World Journal of
Dentistry 2012;3(1):91-94
4. Tennery NT. The fractured tooth reunited using the acid etch bonding
technique. Texas Dent J 1988;96:16
5. 5. Sidoli GE,King PA,Stechell DJ.An in vitro evaluation ofa carbon fiberbased post and core system.J Prosthet Dent 1997;78-85
6. Vishwanathan B , Faizudin U, Jayadev M , Shrawani S . regaining back
to normal . Case reports in Dentistry vol 2013, 28618
7. Ferrari M, Vichi A, Grandini S, Goracci C. Efficacy of a self-curing
adhesive-resin cement system on luting glass-fiber posts into root canals:
an SEM investigation. Int J Prosthodont 2001;14:543–9.
FIGURE LEGENDS
Figure 1: Fractured left lateral
incisor
Figure 2: Palatal view
Figure 3 : IOPA showing fractured lateral incisor
Figure 4: Fractured segment stored in
saline
Figure 5:
Crevicular incision given
palatally
Figure 6: IOPA showing Post space preparation
Figure 7: Tooth segment modified to accomodate post
Figure 8: Fractured segment etched and
bonded alongwith post and root canal
Figure 9: Fragment positioned alongwith post
Figure
view
10:
Post-operative
Figure 11: IOPA showing reattached fragment