|Year : 2015 | Volume
| Issue : 1 | Page : 31-34
Clinical management of a traumatized maxillary central incisor restored with the original fragment using fiber-reinforced post system
Erhan Tahan1, Mustafa Sadik Akdag2, Oguz Kose3, Mehmet Tanriver4
1 Department of Endodontics, Faculty of Dentistry, Recep Tayyip Erdogan University, Rize, Turkey
2 Department of Restorative Dentistry, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey
3 Department of Periodontology, Faculty of Dentistry, Recep Tayyip Erdogan University, Rize, Turkey
4 Department of Pediatric Dentistry, Faculty of Dentistry, Sifa University, Izmir, Turkey
|Date of Web Publication||27-Jan-2015|
Department of Endodontics, Faculty of Dentistry, Recep Tayyip Erdogan University, 53100 Rize
Source of Support: None, Conflict of Interest: None
This case report describes the management of a supragingivally complicated crown fracture of a maxillary central incisor. A 19-year-old male patient was referred to the Department of Endodontics for the management of his traumatized maxillary incisors. He had no medical disorders and there was no evidence of a periapical pathology in the initial radiograph. The maxillary left central and right lateral incisors had an enamel fracture but were asymptomatic to palpation and percussion tests so it was decided to be treated with a direct composite restoration. Whereas, the right central one was symptomatic and had a supragingivally complicated crown fracture. Therefore, it was medicated with calcium hydroxide dressing for one week. After the root canal treatment was completed, the tooth was restored using a light-transmitting fiber-reinforced post system with the original fragment. There was an excellent satisfaction with using original fractured fragment even after 12 months.
Keywords: Crown fracture, dental trauma, fiber-reinforced post, reattachmentt
|How to cite this article:|
Tahan E, Akdag MS, Kose O, Tanriver M. Clinical management of a traumatized maxillary central incisor restored with the original fragment using fiber-reinforced post system. J Res Dent 2015;3:31-4
|How to cite this URL:|
Tahan E, Akdag MS, Kose O, Tanriver M. Clinical management of a traumatized maxillary central incisor restored with the original fragment using fiber-reinforced post system. J Res Dent [serial online] 2015 [cited 2020 Apr 4];3:31-4. Available from: http://www.jresdent.org/text.asp?2015/3/1/31/150029
| Introduction|| |
Crown and/or root fractures with pulpal involvement in permanent dentition are relatively uncommon injuries that range between 5% and 8% of all traumatic injuries.  In literature, it is revealed that 85% of traumatized incisors are fractured in an oblique fashion from labial to palatal aspect and the fracture line proceeds in apical direction. 
It is an important problem for dentists to restore the complicated crown and/or root fractures. This is because of the fact that such teeth necessitate comprehensive endodontic, periodontal, prosthodontic and restorative knowledge.  The treatment process may vary depending on the fracture line and remaining root structure. When the fracture line is at the maximum level and the remaining structure of the root is enough, the fractured fragment of the teeth is extracted and then root canal treatment is performed. If the fracture line progresses subgingivally, gingival flap surgery is required. Then surgical, orthodontic and periodontological procedures may be required to transform the subgingival case to a supragingival one. Thus, it can be restored with different prosthodontic procedures, such as metal or porcelain crown with post-core systems. ,
Restoration of the tooth with the original fragment allows better esthetics with function and contour. Moreover, it is easier, faster and cost-effective when compared with prosthetic protocols. To restore the traumatized tooth with its original fragment via reattachment procedures, if it is possible, is the most proper application. This case report describes the clinical management of a supragingivally fractured maxillary central incisor using the reattachment approach.
| Case report|| |
A 19-year-old male patient was referred to the Department of Endodontics for the management of his traumatized permanent maxillary incisors. Patient and his parent reported a bicycle accident that occurred on the day before yesterday. He had no systemic diseases in his medical history. Clinical examination revealed that there was a swelling and surgical sutures with the upper lip performed in an emergency department of a hospital immediately after the trauma [Figure 1]. There was an open bite in the anterior region and the maxillary incisors were at protrusion. There was no evidence of alveolar bone fracture or periradicular pathology in the radiograph [Figure 2]. Roots of the affected incisors were completely formed. All of the affected teeth were diagnosed as vital using thermal and electrical pulp vitality tests. Before commencement of any treatment, an informed consent has obtained from both the patient and his parents.
|Figure 1: Presence of swelling (a) and surgical sutures (b) with the upper lip|
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|Figure 2: Initial radiograph shows a complicated crown fracture line of right maxillary central incisor|
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Maxillary left central and right lateral incisors had enamel-dentin fractures but were asymptomatic to palpation and percussion tests so they were decided to be treated with only a direct composite restoration. Whereas, the right central incisor was symptomatic and had a supragingivally complicated crown fracture from labial to palatal aspect. The margin on palatal surface was located about 2 mm apically from the free gingival margin that could be probed easily. Several treatment options were explained to the patient and his parent. They preferred to retain the original fragment. Therefore, a profound anesthesia was obtained and the rubber-dam was placed after the mobile fragment was meticulously removed and stored in distilled water to be used for a later reattachment procedure [Figure 3]. Remaining root was medicated with calcium hydroxide dressing for one week after the root canal preparation by using ProTaper rotary files (Dentsply, Tulsa, Oklahoma, USA). Access cavity was sealed with glass-ionomer cement temporarily.
|Figure 3: Labial (a) and palatal (b) appearances of the fractured fragment are photographed after being removed|
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At the second visit, affected tooth was asymptomatic. Therefore, root canal was filled with gutta-percha and a sealer, after adjusting the gingival margins periodontically in the palatal region. Excessive gutta-percha was removed with Gates-Glidden drills and the post space was prepared. On the other hand, the decayed surface of the fractured fragment was restored with a composite resin (Z-100, 3M Espe, St. Paul, MN, USA) and a groove was made on it for matching to the post. A prefabricated fiber post (DT Light Post Illusion X-RO, Bisco, Schaumburg, USA) was tried in the post space and the excessive material was removed with a diamond bur. The root canal was etched with 37% phosphoric acid and the fiber-reinforced post was cemented with dual-cure resin cement followed by light curing for 40 s. Then the exposed root surface and fragment were acid etched and the bonding agent (Single Bond, 3M Espe) was applied to the etched surfaces. The groove in the fragment was filled with dual-cure resin cement. Then the fragment was repositioned and cured for 40 s from both the labial and palatal aspects. Finishing and polishing procedures were performed. Finally, it was impossible to see any radiographic pathology [Figure 4].
|Figure 4: Final restoration of the traumatized tooth with reattached fractured fragment using fiber-reinforced post|
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When the patient was recalled 12 months after the completion of the treatment, it was showed that there was a satisfactory esthetic appearance with a stable reattachment of the fragments, without any periodontal problem such as bleeding on probing or developing periodontal pocket [Figure 5]. In addition, there was no problem in function due to the anterior open bite.
|Figure 5: Clinical view of the right central tooth reattached with the fractured fragment and the other incisors restored with direct composite resin in the follow-up session 12 months later|
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| Discussion|| |
There are many surgical or prosthetic options available to treat crown/root fractures in clinical practice. To obtain a fracture line above the gingival margin, the root has to be shortened to extrude the tooth orthodontically or surgically. ,,, Post-core systems and fixed dentures as crown/bridge applications are the prosthetic treatment choices. On the other hand, it is advised to use the adhesive techniques with fiber-reinforced posts, recently. The fragment reattachment procedure is a good alternative treatment and has been widely accepted with the development of dentin adhesive techniques. ,, For restoring the crown/root fractures with a resin composite especially using the original fragment via reattachment procedure provides more favorable outcomes. , This approach is preferable, because of better adaptation and maintaining the original tooth contour. In addition, more desirable results are obtained especially in anterior region, because patients with a fractured tooth have a quick restoration in a single appointment using their original tooth fragments. Moreover, this technique may be the most conservative alternative among other treatment options. 
One important advantage of the technique applied was making it possible to employ the patient's own original tooth fragment. It can be seen that oral disorders cause psychological and emotional problems.  When it is concluded according to this vision, it can be understood that the reattachment of fractured fragment has desirable psychological results. But fractured fragment of the tooth must be appropriately restored. An appropriate reattachment procedure with a good joint and repositioning between composite resin and enamel might let an esthetic and natural appearance. On the other hand, function of the restoration is another important matter in clinical application.
As we have applied in this case study, the lack of tooth structure necessitated to be supported with an anchorage system. A fiber-reinforced post system is an appropriate option because it can be bonded to the root canal walls and tooth fragment. This system presents required physical and mechanical properties that allow a better distribution of occlusal stresses thanks to its modulus similar to dentin.  The post and core material should be esthetically compatible with the crown and gingival tissues.  We have used composite resin in conjunction with a fiber-post in this case. Because resin luting agents show good adhesion with fiber posts.  On the other hand, composite resins reveal enough esthetical and mechanical properties. In addition, it was showed that favorable gingival reactions may occur with resin composites.  A sensitive bonding procedure is also essential if the target is to maximize the longevity of the restoration. According to this opinion, we have removed any undesirable materials from the fragment before reattaching it. Dentin removal from the fragment before bonding has been revealed to increase the bond strength and prevent the darkening of the devitalized dentin fragment. 
It is highly difficult to detect the proper restoration technique for achieving successful results in such a case with crown/root fracture. Because the pattern and location of the fracture are different from case to case, it is not simple to perform well-controlled studies. Conversely, many case reports are becoming available recently. ,,, If clinicians are engaged enough to report follow-ups, a more detailed analysis could be performed in the future to extract reliable conclusions based on clinical reports.  Ultimately, if the young patient could benefit from the restoration for some years before receiving a more complex and expensive solution as surgical or prosthetic, the treatment goals will have been achieved.
Reattachment procedure in fractured teeth necessitates very sensitive technique that is intended to maintain tooth structure integrity. Therefore, it must be remembered that there is enough esthetical and retentional form of the teeth. In that case, fragment reattachment using intra-canal fiber-reinforced post system of supragingivally complicated crown fracture of a vital tooth was found to be successful clinically 12 months after the treatment.
| References|| |
Wood EB, Freer TJ. A survey of dental and oral trauma in south-east Queensland during 1998. Aust Dent J 2002;47:142-6.
Murchison DF, Burke FJ, Worthington RB. Incisal edge reattachment: Indications for use and clinical technique. Br Dent J 1999;186:614-9.
Caliskan MK, Ceyhanli KT. Reattachment of endodontically treated lateral incisor with supragingivally complicated crown fracture using fiber-reinforced post. Dent Traumatol 2011;27:305-8.
Caliskan MK. Surgical extrusion of a cervically root-fractured tooth after apexification treatment. J Endod 1999;25:509-13.
Caliskan MK, Turkun M, Gomel M. Surgical extrusion of crown-root-fractured teeth: A clinical review. Int Endod J 1999;32:146-51.
Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15.
Kocadereli I, Tasman F, Guner SB. Combined endodontic-orthodontic and prosthodontic treatment of fractured teeth. Case report. Aust Dent J. 1998;43:28-31.
van Dijken JW, Sjostrom S, Wing K. The effect of different types of composite resin fillings on marginal gingiva. J Clin Periodontol 1987;14:185-9.
Eden E, Yanar SC, Sonmez S. Reattachment of subgingivally fractured central incisor with an open apex. Dent Traumatol 2007;23:184-9.
Baratieri LN, Monteiro S, Jr, Caldeira de Andrada MA. Tooth fracture reattachment: Case reports. Quintessence Int 1990;21:261-70.
Baratieri LN, Monteiro Junior S, Caldeira de Andrada MA. The "sandwich" technique as a base for reattachment of dental fragments. Quintessence Int 1991;22:81-5.
Dragoo MR. Resin-ionomer and hybrid-ionomer cements: Part II, human clinical and histologic wound healing responses in specific periodontal lesions. Int J Periodontics Restorative Dent 1997;17:75-87.
Martens LC, Beyls HM, de Craene LG, D′Hauwers RF. Reattachment of the original fragment after vertical crown fracture of a permanent central incisor. J Pedod 1988;13:53-62.
Oliveira GM, Oliveira GB, Ritter AV. Crown fragment reattachment: Report of an extensive case with intra-canal anchorage. Dent Traumatol 2010;26:174-81.
Nakamura T, Ohyama T, Waki T, Kinuta S, Wakabayashi K, Mutobe Y, et al
. Stress analysis of endodontically treated anterior teeth restored with different types of post material. Dent Mater J 2006;25:145-50.
Tamse A. Iatrogenic vertical root fractures in endodontically treated teeth. Endod Dent Traumatol 1988;4:190-6.
Mannocci F, Ferrari M, Watson TF. Intermittent loading of teeth restored using quartz fiber, carbon-quartz fiber, and zirconium dioxide ceramic root canal posts. J Adhes Dent 1999;1:153-8.
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.
Nair KR, Das AN, Kuriakose MC, Krishnankutty N. Management of crown root fracture by interdisciplinary approach. Case Rep Dent 2013;2013:138659.
Stojanac I, Ramic B, Premovic M, Drobac M, Petrovic L. Crown reattachment with complicated chisel-type fracture using fiber-reinforced post. Dent Traumatol 2013;29:479-82.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]