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Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 92-95

A conservative approach towards the restoration of coronal fracture in anterior teeth

Department of Conservative Dentistry and Prosthetic, Collage of Health Science School of Dentistry Moi University, Eldoret, Kenya

Date of Web Publication11-Jul-2014

Correspondence Address:
Mohamed A Arnaout
P.O. Box 3818, Rift Valley, Eldoret
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4619.136647

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Coronal fractures of permanent dentition are the most frequent type of dental injury. Reattachment of the fractured anterior tooth, if the tooth fragment is available, is highly conservative and provides good esthetics as the (because the tooth's original anatomic form, color, and surface texture are maintained) esthetic treatment has gained popularity in the recent past. It also restores function, provides a positive psychological response, and is a relatively simple procedure. This article reports on two coronal tooth fracture cases that were successfully treated using tooth fragment reattachment.

Keywords: Conservative, coronal fracture, esthetics, reattachment

How to cite this article:
Arnaout MA. A conservative approach towards the restoration of coronal fracture in anterior teeth. J Res Dent 2014;2:92-5

How to cite this URL:
Arnaout MA. A conservative approach towards the restoration of coronal fracture in anterior teeth. J Res Dent [serial online] 2014 [cited 2020 Jun 4];2:92-5. Available from: http://www.jresdent.org/text.asp?2014/2/2/92/136647

  Introduction Top

Fracture of anterior teeth by trauma is the most frequent type of injury in the permanent dentition, especially among children and adolescent affecting up to 25% of this patient population. [1] Most dental injuries involve just one tooth, and the majority of the affected teeth are maxillary central incisors. [2],[3],[4] Dental injuries usually affect only a single tooth; however, certain trauma types such as automobile accidents and sports injuries involve multiple tooth injuries. [5] This may be attributable to their anterior position and protrusion caused by the eruptive pattern. [6]

Several factors influence the management of coronal tooth fractures, including extent of fracture (biological width violation, endodontic involvement, alveolar bone fracture), pattern of fracture and restorability of fractured tooth (associated root fracture), secondary trauma injuries (soft tissue status), presence/absence of fractured tooth fragment and its condition for use (fit between fragment and the remaining tooth structure), occlusion, esthetics, finances and prognosis. [7],[8],[9] Clinicians used a variety of procedures (e.g., pin-retained resin, orthodontic bands, modified three-quarter crowns, full-coverage gold with bonded porcelain, porcelain jacket crowns, porcelain-bonded crowns, porcelain inlays) for the restoration of the fractured crown. [10]

Despite the recent advances in adhesive materials and restorative technique, there is no restorative material that can reproduce the esthetic and functional needs as much as the natural dental structures. [11] One of the options for managing this clinical situation, especially when there is no or minimal violation of the biological width, is the reattachment of dental fragment. [12] Tooth fragment bonding offers the advantage of being a highly conservative technique that promotes preservation of natural tooth structure, good esthetics and acceptance by the patients, who receive a psychological benefit from amelioration of the mutilation. [13],[14]

Patient cooperation and understanding the limitations of the treatment is of utmost importance for good prognosis. When there is a substantial associated periodontal injury and/or invasion of the biological width, the restorative management of the coronal fracture should follow the proper management of those associated issues. Coronal fractures must be approached in a systematic way to achieve a successful restoration. [15]

Recent developments in restorative materials, placement techniques and adhesive protocols allow reattachment using resin-based composites. Tannery was the first to use acid etch techniques for the reattachment of fractured tooth fragment. [16] Subsequently, Starkey and Simonson have reported similar cases. [17],[18]

This article reports on two coronal tooth fracture cases that were successfully treated using tooth fragment reattachment.

  Case report Top

0Case 1

A 32-year-old male patient presented at the Dental clinic at Moi Teaching and Referral hospital with chief complaint of fractured upper anterior teeth due to road traffic accident [Figure 1]. The patient's medical history was noncontributory. Initial examination revealed a horizontal fracture on teeth no. 21 and 22, and associated pulp exposure. A diagnosis of Ellis class 3 fracture (complicated crown fracture) was made. On clinical examination the fracture lines were extended obliquely, from labial to palatal direction. The fragments were still attached by soft tissues at the palatal aspect. Radiographic examination showed the horizontal fracture line at cervical third of both the crowns, and no root fracture.
Figure 1: Clinical appearance of the patient

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The patient expressed the desire to maintain teeth and restore them. A detailed explanation about the treatment plan, advantages and disadvantages were given to the patient, including root canal treatment and reattachment of the crowns by using posts and dental resin composite filling. Due to financial issues, treatment plan was accepted by the patient.

After infiltration of local anesthesia, the coronal fragments were separated, cleaned from blood remnants and stored in sterile normal saline to prevent dehydration and discoloration. Root canal treatments were carried out on both the teeth on a single visit basis, and were obturated by Gutta-percha using lateral condensation technique. The post spaces were prepared with corresponding drills to receive threaded dental gold plated cross head post (Dental NORDIN, Switzerland). The posts were cemented using glass ionomer luting cement. The fractured segments were cleaned to remove pulpal remnants. Box-like preparations were made in the pulp chamber of fractured segments which corresponded to the retentive part of extruding post. A step was prepared on the labial, mesial and distal surfaces of the fractured segment of the central incisor with shoulder finish line and two small inner grooves on both mesial and distal surfaces [Figure 2] and [Figure 3]. All sharp angles and rough areas on remaining teeth structure and the fractured segments were eliminated and smoothed.
Figure 2: Shoulder finish line preparation on the labial, mesial and distal surfaces

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Figure 3: Inner grooves on the mesial and distal surfaces

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The fractured segments were checked for fitting and positioning. After the operating field was isolated, the remaining part of tooth structure and the fracture segments were etched with 37% phosphoric acid for 15 seconds, rinsed, and dried. Bonding agent was then applied with a microbrush in two coats and gently air-dried, followed by light curing for 15 seconds. Both fractured segments were reattached with Nano Hybrid Composite resin (META BIOMED). Light curing was applied for 40 seconds from various directions. During curing firm and stable finger pressure was applied to the coronal fragments to closely oppose it to each tooth. Finishing and polishing were carried on using SS White (complete composite Finishing and Polishing Kit). Follow-up examinations were carried out at 1 month, 3 months and 6 months intervals, during which the teeth remained normal in esthetics and function [Figure 4].
Figure 4: Follow up clinical view after segments reattachment

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Case 2

A 66-year-old male patient presented at the conservative and prosthetic Dental clinic of Moi University School of dentistry with chief complaint of fractured upper anterior tooth due to accidental chewing on hard object. The fractured segment was still attached [Figure 5]. Upon examination, the treatment plan of choice was to reattach the coronal fragment to the remaining tooth. Patient agreement was obtained, and the fractured fragment was cleaned and stored in sterile normal saline and endodontic therapy was carried out. The coronal tooth fragment was reattached to the remaining tooth using the same procedures like that followed in case 1. Follow-up examinations were carried out at 2 months, 4 months and 6 months intervals, during which the teeth remained normal in esthetics and function [Figure 6].
Figure 5: Clinical appearance of the patient showing the fractured segment

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Figure 6: Follow up clinical view after segments reattachment

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  Discussion Top

Reattachment of the crown fragment to a fractured tooth influences esthetic by retaining natural translucency and surface texture and is the first choice for crown fractures of anterior teeth. Once the original fragment is reattached, the natural appearance will be restored instantly. Also, this procedure is relatively simple, atraumatic, and inexpensive. [19] The treatment performed and presented in this clinical case report is one of the many possible options that could have been used to rehabilitate these patients. The other treatment options may have included the endodontic therapy followed by restoration of the tooth with composite resin or with a full-coverage crown. Selection of the treatment plan should be made, considering the advantages and disadvantages of each technique available and should be in conjunction with the desires and limitations of the patient. [20]

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. However, the professional has to keep in mind that a dry and clean working field and proper use of bonding protocol and materials is the key for achieving success in adhesive dentistry. Reports and clinical experiences indicate that the reattachment of fractured coronal fragments results in successful short- and medium-term outcomes. [21],[22]

Reattachment of the original tooth fragment also gives an emotionally and socially positive response due to the protection of the natural tooth structure. The patients are at least satisfied of the original fragment being used in the restoration of their fractured tooth. [23]

Various authors have recommended extra preparation of the fractured fragment and the remaining tooth structure to enhance the bonding of the fractured fragment to the remaining tooth. They pointed out that when reattaching without making any extra preparation for the broken incisal part and for the remaining tooth in the mouth, lower values than intact tooth fracture strength were obtained. Therefore, they stated the necessity of the application of an extra preparation on the tooth when reattaching the broken incisal part. [6],[24],[25]

With the materials available today, in conjunction with an appropriate technique, esthetic results can be achieved with predictable outcomes. Thus, the reattachment of a tooth fragment is a viable technique that restores function and esthetics with a very conservative approach, and it should be considered when treating patients with coronal fractures of the anterior teeth, especially younger patients. [15] In those cases, if the patient could benefit from the restoration for some years before receiving a more complex-and expensive-prosthetic solution, our objective will be achieved. [20]

  References Top

1.Murchison DF, Burke FJ, Worthington RB. Incisal edge reattachment: Indications for use and clinical technique. Br Dent J 1999;186:614-9.  Back to cited text no. 1
2.Shulman JD, Peterson J. The association between incisor trauma and occlusal characteristics in individuals 8-50 years of age. Dent Traumatol 2004;20:67-74.  Back to cited text no. 2
3.Caliskan MK, Turkun M. Clinical investigation of traumatic injuries of permanent incisors in Izmir, Turkey. Endod Dent Traumatol 1995;11:210-3.  Back to cited text no. 3
4.Shayegan A, De Maertelaer V, Abbeele AV. The prevalence of traumatic dental injuries: A 24-month survey. J Dent Child 2007;74:194-9.  Back to cited text no. 4
5.Andreasen JO, Andreasen FM. Text book and Color Atlas of Traumatic Injuries To the Teeth, 3 rd ed. Copenhagen, Denmark: Munksgaard  Danmark; 1993.  Back to cited text no. 5
6.Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured teeth: Review of literature regarding techniques and materials. Oper Dent 2004;29:226-33.  Back to cited text no. 6
7.Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15.  Back to cited text no. 7
8.Reis A, Francci C, Loguercio AD, Carrilho MR, Rodriques LE. Re-attachment of anterior fractured teeth: Fracture strength using different techniques. Oper Dent 2001;26:287-94.  Back to cited text no. 8
9.Andreasen FM, Norén JG, Andreasen JO, Engelhardtsen S, Lindh-Strömberg U. Long term survival of fragment bonding in the treatment of fractured crowns. Quintessence Int 1995;26:669-81.  Back to cited text no. 9
10.Badami AA, Dunne SM, Scheer B. An in vitro investigation into the shear bond strengths of two dentine-bonding agents used in the reattachment of incisal edge fragments. Dent Traumatol 1995;11:129-35.  Back to cited text no. 10
11.Álvares I, Sensi LG, Araujo EM, Araujo E. Silicone index: An alternative approach for tooth fragment reattachment. J Esthet Restor Dent 2007;19:240-5.  Back to cited text no. 11
12.Shivakumar A, Bardvalli SG. An alternative approach for reattachment of the fractured fragment-a case report. J Contemp Dent Pract 2011;2:48-51.  Back to cited text no. 12
13.Capp CI, Roda MI, Tamaki R, Castanho GM, Camargo MA, de Cara AA. Reattachment of rehydrated dental fragment using two techniques. Dent Traumatol 2009;25:95-9.  Back to cited text no. 13
14.Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth fragments. Quintessence Int 2000;31:385-91.  Back to cited text no. 14
15.Georgia VM, Patricia ID, Carlos AF, André V. Reattachment of anterior teeth fragments: A conservative approach. J Esthet Restor Dent 2008;20:5-20.  Back to cited text no. 15
16.Tennery NT. The fractured tooth reunited using acid etch bonding technique. Tex Dent J 1988;96:16-7.  Back to cited text no. 16
17.Starkey PE. Reattachment of the fractured fragment to a tooth. J Ind Dent Assoc 1979;58:37-8.  Back to cited text no. 17
18.Simonsen RJ, Osborne JW, Lasmen RL. Restoration of fractured central incisor using original teeth. J Am Dent Assoc 1982;105:46-8.  Back to cited text no. 18
19.Giachetti L, Bertini F, Rotundo R. Crown-root reattachment of a severe subgingival tooth fracture: A 15-month periodontal evaluation. Int J Periodont Restor Dent 2010;30:393-9.  Back to cited text no. 19
20.Oliveira GM, Oliveira GB, Ritter AV. Crown fragment reattachment: Report of an extensive case with intra-canal anchorage. Dent Traumatol 2010;26:174-81.  Back to cited text no. 20
21.Rappelli G, Massaccesi C, Putignano A. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol 2002;18:281-4.  Back to cited text no. 21
22.Oz IA, Haytac MC, Toroglu MS. Multidisciplinary approach to the rehabilitation of a crown-root fracture with original fragment for immediate esthetics: A case report with 4-year follow-up. Dent Traumatol 2006;22:48-52.  Back to cited text no. 22
23.Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of success in the reattachment of coronal fractures. Dent Traumatol 2008;24:151-8.  Back to cited text no. 23
24.Goenka P, Marwah N, Dutta S. Biological approach for management of anterior tooth trauma: Triple case report. J Ind Soc Pedodon Prev Dent 2010;3:223-9.  Back to cited text no. 24
25.Demarco FF, Fay RM, Pinzon LM, Powers JM. Fracture resistance of re-attached coronal fragments-influence of different adhesive materials and bevel preparation. Dent Traumatol 2004;20:157-63.  Back to cited text no. 25


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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