Biological approach for management of anterior tooth trauma: triple case report

Anterior crown fractures are a common form of injury that mainly affect children and adolescents. The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. In the pre-adhesive era, fractured teeth needed to be restored either with pin-retained inlays or cast restorations that sacrificed healthy tooth structure and were a challenge for clinicians to match with adjacent teeth. The development of adhesive dentistry has allowed dentists to use the patient's own fragment to restore the fractured tooth. Three cases are presented here with complicated crown fracture of maxillary central incisors; the reattachment of the fractured tooth segment in this case has been performed using different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.     

Biological approach for management of anterior tooth trauma: triple case report

Anterior crown fractures are a common form of injury that mainly affect children and adolescents. The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. In the pre-adhesive era, fractured teeth needed to be restored either with pin-retained inlays or cast restorations that sacrificed healthy tooth structure, and were a challenge for clinicians to match with adjacent teeth. The development of adhesive dentistry has allowed dentists to use the patient's own fragment to restore the fractured tooth. Three cases are presented here with complicated crown fracture of maxillary central incisors; the reattachment of the fractured tooth segment in these cases has been performed using different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.     

In vitro tooth reattachment techniques: A systematic review

Background/Aims

Fragment reattachment is a procedure that offers advantages, such as preservation of tooth structure and maintenance of color, shape, and translucency of the original tooth. The aim of this study was to analyze the reattachment techniques used to restore anterior teeth fractured by trauma.

Materials and Methods

The PubMed, LILACS, Web of Science, Cochrane, and Scopus databases were searched in October 2016, and the search was updated in February 2017. A search of the gray literature was performed in Google Scholar and OpenGrey. Reference lists of eligible studies were evaluated to identify additional studies. Two authors assessed studies for inclusion and extracted the data. In vitro studies that evaluated permanent human teeth fractured by trauma were included.

Results

Twenty‐one studies remained after screening. The bond strength between the fragment and the crown was evaluated in 119 experimental groups. Ten different techniques were evaluated as follows: no preparation, chamfer, bevel, anchors, overcontour, internal groove, no preparation associated with chamfer after reattachment, fragment dentin removal associated with chamfer after reattachment, bevel associated with overcontour, and groove associated with shoulder. Five different materials were used to reattach the fragment: bonding system, luting composite resin, flowable composite, microhybrid composite, and nanocomposite.

Conclusion

Fragment reattachment using a technique with no preparation and an adhesive system associated with an intermediate composite with good mechanical properties can restore part of the resistance of the fractured tooth.     

Case report: removal of fractured endodontic posts with a sonic instrument

Fracture of endodontic posts within the root canal system is one of the causes of failure to restore endodontically treated teeth. Various techniques, with varying degrees of success, have been proposed in the literature for the removal of fractured posts prior to re-restoring the tooth. This case report describes the use of a sonic device to dislodge and remove two fractured prefabricated metal endodontic posts from teeth UR1 and UL2. The reader is also introduced to a variety of post removal techniques available.     

Fracture strength of intact and fragment-bonded teeth at various velocities of the applied force

Bonding of a tooth fragment to the remaining tooth substance can restore crown fracture of an anterior tooth. In this study, sheep central incisors were used. The crowns were fractured transversely and the crown fragment was bonded to the remaining tooth structure. This technique involves acid etching, use of an experimental adhesive (Gluma+) and a BisGMA/TEGDMA resin. The mean fracture strength of the restored teeth was not significantly different from that of intact teeth when tested at a rather low crosshead speed (0.5 mm/min) but different and about 30% lower when tested at a higher crosshead speed (500 mm/min). In studies aiming to test resistance to forces which might cause trauma, it might be appropriate to use a high crosshead speed.     

Impact strength of teeth restored by fragment-bonding

The objective of this in vitro study was to investigate the impact strength of anterior teeth that have been fractured and restored by bonding with a dentin-bonding agent and a composite resin. Twenty sheep central incisors were divided into two groups, 10 in each. One group (intact teeth) served as the control and the teeth in the other group were fractured and then bonded with a bonding agent and a low-viscous composite resin. The specimens were tested in a modified impact-testing machine (pendulum type). The mean impact strength of the intact teeth was 30.6 +/- 2.16 KJ/m2 and of the bonded teeth was 30.2 +/- 1.86 KJ/m2. Statistics revealed that the two means were not significantly different. The results related well with the fracture strength obtained by loading intact and bonded teeth at constant but low speed until fracture. It was concluded that bonding fragments to the remaining tooth structure may restore the tooth to its original strength, measured at modest velocities of the applied force. In other words, reattaching the original coronal fragment of traumatised fractured anterior teeth restored with One-Step dentin bonding system and AEliteflo composite resin would withstand a second trauma to the same extent as intact teeth.     

Restoration of anterior teeth with indirect composite partial coverage crowns: a clinical report

When an esthetic restoration with minimal tooth reduction is desired, for example in patients with uncomplicated tooth fractures, composite partial coverage crowns may be a therapeutic option. The indirect composite restoration allows restoration of the original tooth anatomy, function, and esthetics to be reproduced while preserving tooth structure. The use of composite partial coverage crowns to restore fractured anterior teeth is described.     

Impact strength of teeth restored by fragment-bonding

Abstract – The objective of this in vitro study was to investigate the impact strength of anterior teeth that have been fractured and restored by bonding with a dentin-bonding agent and a composite resin. Twenty sheep central incisors were divided into two groups, 10 in each. One group (intact teeth) served as the control and the teeth in the other group were fractured and then bonded with a bonding agent and a low-viscous composite resin. The specimens were tested in a modified impact-testing machine (pendulum type). The mean impact strength of the intact teeth was 30.6±2.16 KJ/m² and of the bonded teeth was 30.2±1.86 KJ/m². Statistics revealed that the two means were not significantly different. The results related well with the fracture strength obtained by loading intact and bonded teeth at constant but low speed until fracture. It was concluded that bonding fragments to the remaining tooth structure may restore the tooth to its original strength, measured at modest velocities of the applied force. In other words, reattaching the original coronal fragment of traumatised fractured anterior teeth restored with One-Step dentin bonding system and Æliteflo composite resin would withstand a second trauma to the same extent as intact teeth.     

Compomers, reattachment method expand restoration capabilities.

The purpose of this article is to review one new material and one new technique being used in restorative dentistry today. Compomers, new fluoride-releasing resin restorative materials, are compared to conventional glass ionomers in terms of classification, physical properties, and clinical usage. Compomers are not true glass ionomer materials since the acid/base setting reaction, charactheristic of conventional glass ionomers, does not occur. As a consequence, their physical properties of translucency, coefficient of thermal expansion, and strength more closely resemble composite resins than conventional glass ionomers. These differences in physical properties have clinical implications in their usage. In terms of new techniques, clinical and laboratory data now exist to support the method of reattachment of fractured tooth fragments using only dentin bonding agents, in cases where the tooth fragment is available. This method can restore up to 50 percent of the original strength of intact teeth. The technique advocates the use of acid etching and enamel and dentin bonding, without any tooth preparation. In vitro studies have achieved total (100 percent) restoration of intact teeth by bonding a porcelain veneer to the tooth after the reattachment.     

Dental fracture fragment attachment: fracture model and luting agent comparisons

PURPOSE: The purpose of this study was twofold: 1. To compare two different research models for simulating a traumatic anterior tooth fracture: the blunt trauma method (standard method) and an AL2O3 sectioning method (experimental method). 2. To compare the bond strength of tooth fragments bonded with resin modified glass ionomer vs. a light cured composite resin. METHODS: Two hundred bovine incisors were used in the study and kept in plain tap water throughout. The study consisted of five basic steps: 1. Fracture of the teeth by either blunt trauma (chisel and hammer) or AL2O3 sectioning disc. 2. Luting of the fractured fragments back to the teeth using either a composite resin or resin modified glass ionomer. 3. Thermocycling of the repaired teeth. 4. Dislodging the teeth to determine the strength of repair. 5. Determination of fracture type. RESULTS: One-way ANOVA revealed a statistically significant difference in the forces required to fracture the resin modified glass ionomer and composite resin regardless of whether the teeth were originally fractured with the blunt force method (p=0.030) or the disc sectioning method (p=.001). One-way ANOVA also revealed a statistically significant difference between the forces required for fracture by blunt trauma and the disc fracture techniques with the resin modified glass ionomer group (p=0.000345). However, there was no significant difference when the two techniques were compared for the composite resin (p= 0.2941). CONCLUSIONS: 1. The resin modified glass ionomer was significantly stronger than the composite resin when both the blunt trauma and the disc fracture techniques were employed. 2. The study's results do not support substituting the ease of the AL2O3 disc for the more time-consuming blunt trauma method.     

Reattachment using a fragment from an extracted tooth to treat complicated coronal fracture

Abstract –  Reattachment of fragment is the preferred alternative to restore the fractured teeth, offering several advantages. Partial pulpotomy has demonstrated satisfactory results as a conservative treatment for pulp exposures because of trauma. This study reports a case in which the treatment of a complicated coronal fracture was accomplished by partial pulpotomy and reattachment of a dental fragment obtained from an extracted tooth using composite resin. The results show the feasibility of the conservative pulp therapy and the restorative approach.     

Endodontic and restorative management of incompletely fractured molar teeth

The treatment of fractured teeth poses significant problems for the practitioner. However, once the treatment planning decision has been made to attempt to retain the tooth, various practical regimens are available to effect this goal. This paper addresses the specific use of glass ionomer in the restorative management of incompletely, vertically fractured molar teeth integrated with specific root canal treatment techniques.     

Dental trauma: restorative procedures using composite resin and mouthguards for prevention

AIM: The aim of this article is to describe a step-by-step protocol for emergency care of a patient with a dentoalveolar injury in the anterior region of the mouth as well as the fabrication of a mouthguard to prevent future trauma. BACKGROUND: Dental trauma is one of the most serious oral health problems in active children and adolescents. Care of traumatized patients requires immediate initial emergency treatment followed by integrated procedures to restore damaged oral structures along with a subsequent trauma prevention strategy. Dentoalveolar injuries in the anterior region of the mouth are often characterized by tooth avulsion and coronal fracture. They are managed using procedures such as dental splinting, endodontic therapy with its unique characteristics, and restorative techniques to re-establish function and esthetics as well as protective mouthguards. REPORT: A 16-year-old male presented with avulsion of his maxillary central incisors as a result of a direct, unintentional impact with an opponent during a basketball game. The teeth had been stored in physiological serum immediately following the injury and the patient received immediate care. On clinical examination, the right central incisor was fractured at the incisal third of the crown but no bone fractures were found. The teeth were reimplanted and splinted. The fractured right central incisor was restored following endodontic treatment and a mouthguard was fabricated for the patient. SUMMARY: The dentist must be knowledgeable about the most efficient and suitable treatment for each traumatic scenario in order to provide appropriate care for dental injuries. Coordinated multi-disciplinary action is fundamental in the successful treatment of these injuries. The dental mouthguard is an effective device for protecting the teeth and supportive structures during physical activities and must be part of the protective equipment used by athletes. It is the responsibility of the dental professional to make parents, trainers, and athletic associations aware of the risks associated with physical activities without orofacial protection; this should encourage the proper use of all protective devices to prevent dentoalveolar injuries that compromise oral functions, esthetics, and increase the cost of healthcare.     

Buonocore memorial lecture. Adhesive dentistry applied to the treatment of traumatic dental injuries

Dental adhesive techniques have led to a significant simplification of the immediate and definitive treatment of traumatic dental injuries. Composite restoration of fractured teeth, bonding of tooth fragments, the use of laminate veneers or porcelain onlays and resin retained bridges are some of the ways adhesive techniques are used to treat fractured teeth. Furthermore, splinting of luxated teeth almost entirely relies on the combination of adhesion and a flexible resin which simulates the mobility of a normal periodontal ligament during the healing period. The internal strengthening of immature root-filled teeth with composite using an adhesive technique may possibly prevent late root fractures caused by weakening of the tooth structure resulting from endodontic procedures. Finally, the adhesive principle using a retro-seal with composite after apicoectomy significantly increases the healing rate and healing mode.     

Performance of techniques used for re-attachment of endodontically treated crown fractured teeth

OBJECTIVES: The aim of this study was to compare the fracture strength of three techniques used to re-attach tooth fragments in sound and endodontically treated fractured teeth with or without fiber post placement. MATERIAL AND METHODS: Ninety human lower incisors were randomly divided into three groups of 30 teeth each. In group A teeth were not subjected to endodontic treatment; while teeth from groups B and C were endodontically treated and the pulp chamber restored with a composite resin. All teeth were fractured by an axial load applied to the buccal area in order to obtain tooth fragments. Teeth from each group were then divided into three subgroups, according to the re-attachment technique: bonded-only, buccal-chamfer and circumferential chamfer. Before the re-attachment procedures, fiber posts were placed in teeth from group C using dual cure resin luting cement (Duo-Link). All teeth (groups A-C) had the fragments re-attached using a same dual cure resin luting cement. In the bonded-only group, no additional preparation was made. After re-attachment of the fragment, teeth from groups buccal and circumferential chamfer groups had a 1.0 mm depth chamfer placed in the fracture line either on buccal surface or along the buccal and lingual surfaces, respectively. Increments of microhybid composite resin (Tetric Ceram) were used in subgroups buccal chamfer and circumferential chamfer to restore the chamfer. The specimens were loaded until fracture in the same pre-determined area. The force required to detach each fragment was recorded and the data was subjected to a three-way analysis of variance where factors Group and Re-attachment technique are independent measures and Time of fracture is a repeated measure factor (first and second) and Tukey's test (alpha=0.05). RESULTS: The main factors Re-attachment technique (p=0.04) and Time of fracture (p=0.02) were statistically significant. The buccal and circumferential chamfer techniques were statistically similar (p>0.05) and superior to the bonded-only group (p<0.05). The first time of fracture was statistically superior to second time of fracture (p<0.001). CONCLUSIONS: The use of fiber post is not necessary for the reinforcement of the tooth structure in re-attachment of endodontically treated teeth. When bonding a fractured fragment, the buccal or circumferential re-attachment techniques should be preferable in comparison with the simple re-attachment without any additional preparation. None of the techniques used for re-attachment restored the fracture strength of the intact teeth.     

Class IV preparations for fractured anterior teeth restored with composite resin restorations

Pediatric dentists play a major role in treating most of the anterior teeth fractures due to the fact that most patients who suffer such traumatic injuries are between the ages of seven and fourteen. Several techniques has been developed to restore the fractured incisors to the original shape and color, these include full-coverage of the traumatized tooth, or restoring the incisors with a resin. The purpose of this study is to find the ideal combination of tooth preparation and restorative material, namely, to determine if stair step chamfer preparations provide more retention in class IV restorations than the plain chamfer preparation technique when restored with a combination of a hybrid composite resin and a microfilled composite resin. This was done by comparing the shear strength values between the buccal stair-step chamfer preparation, and a modification on it (buccal and lingual stair-step chamfer preparation) and the plain chamfer preparation techniques in class IV restorations on anterior incisors using different composite resin materials. The Instron machine was used to test shear strength. One hundred and two bovine incisor teeth were freshly harvested from the slaughterhouse. The teeth were prepared and restored according to the following six groups; Plain Chamfer preparation with Tetric Ceram Composite, Plain Chamfer preparation with Renamel Composite, buccal stair-step chamfer preparation with Tetric Ceram composite, buccal stair-step chamfer preparation with Renamel composite, Buccal and lingual stair-step preparation with Tetric Ceram Composite, Buccal and lingual stair-step chamfer preparation with renamel composite. All samples were fractured using the Instron testing machine then the surface area were measured using Image-J software. Shear strength for every sample was calculated using the load numeric result from the Instron machine and the measured surface area. The Two-Factorial (AB) Analysis of Variance For Independent Samples showed that the buccal stair-step chamfer preparation showed significantly higher shear strength and fracture resistance than plain chamfer or the buccal and lingual stair-step chamfer preparation. The combination of Renamel Hybrid and Renamel Microfill composite materials showed better results than the Tetric Ceram composite when used with all three preparation techniques, but did not show a statistical significance. It was concluded that buccal stair-step preparation technique provided the ideal preparation technique with bonded composite resins in fractured anterior teeth. Only 7% of the entire sample size had an adhesion failure versus 93% that had cohesion failure. There was no significant difference in shear strength, between the restorative materials used, in conjunction with all the preparation techniques.     

Fractured incisors: a judicious restorative approach--part 3

AIM: To consider different conservative options in the literature to restore fractured anterior teeth. MATERIALS AND METHODS: Only anterior tooth fractures not involving the pulp were considered, without limitation on age. Treatment options were chosen depending on the clinical situation of patients at first visit. The authors considered 15 cases each of: reattachment; porcelain veneers; direct composites. RESULTS AND CONCLUSIONS: The techniques analysed were revealed to be valid during the period of observation. No failures were recorded with vital teeth keeping their vitality and no radiographic signs of apical or root pathology. With reattachment, two cases have shown the visibility of fracture line after 2 years, depending on the angle of light incidence on the tooth surface. For direct restorations, three adult cases have shown partial discolouration at 24, 28 and 40 months. No fractures or debonding have occurred among porcelain veneers. The authors suggest, whenever possible, to utilise the reattachment technique. Direct restorations are suitable for young patients: they have a higher chance of sustaining further trauma than adults, and composites have a favourable failure mode compared to ceramics. In adults, where long-lasting restorations are needed, restoration of with porcelain veneers is the treatment of choice.     

Re-attachment of anterior tooth fragment using a self-etching adhesive: a case report

AIM: The purpose of this case report is to describe the re-attachment of an anterior tooth fragment using a self-etching adhesive. BACKGROUND: Fracture of anterior teeth by trauma is a common problem in children and teenagers due to their active lifestyle. Restoration of these teeth often presents a challenge because of the large pulp in young teeth and open apical foramen depending on the age of the child. New dental adhesive materials offer an alternative solution for the treatment of some anterior tooth fractures. REPORT: A 17-year-old female patient presented for treatment of a fractured maxillary left central incisor. The clinical examination revealed the exposure of dentin, but there was no exposure of the pulp. The patient saved the tooth fragment making it available for re-attachment to the remaining tooth structure. Under local anesthesia and rubber dam isolation the tooth fragment was re-attached using a self-etching adhesive and a microhybrid composite. SUMMARY: The re-attached tooth fragment was assessed clinically, radiographically, and using photographs at one, six, 12, 24, and 36 month intervals. The tooth remained vital, and there was no change in the color of the tooth at the three-year recall.     

Fractured incisors: a judicious restorative approach--part 1

AIM: To consider different conservative options in the literature to restore fractured anterior teeth. MATERIALS AND METHODS: Only anterior tooth fractures not involving the pulp were considered, without limitation on age. Treatment options were chosen depending on the clinical situation of patients at first visit. The authors considered 15 cases each of: reattachment; porcelain veneers; direct composites. RESULTS AND CONCLUSIONS: The techniques analysed were revealed to be valid during the period of observation. No failures were recorded with vital teeth keeping their vitality and no radiographic signs of apical or root pathology. With reattachment, two cases have shown the visibility of fracture line after 2 years, depending on the angle of light incidence on the tooth surface. For direct restorations, three adult cases have shown partial discolouration at 24, 28 and 40 months. No fractures or debonding have occurred among porcelain veneers. The authors suggest, whenever possible, to utilise the reattachment technique. Direct restorations are suitable for young patients: they have a higher chance of sustaining further trauma than adults, and composites have a favourable failure mode compared to ceramics. In adults, where long-lasting restorations are needed, restoration with porcelain veneers is the treatment of choice.     

应用改良冠延长术桩核冠修复上颌磨牙冠根折的临床观察

目的：评价上颌磨牙冠根折采用改良牙冠延长手术后,行桩核冠修复的短期临床效果。方法选取腭尖劈裂至牙龈下3~6mm的上颌磨牙23颗,分为4mm组、5mm组和6mm组,采用改良牙冠延长术即牙根改形结合少量去骨的方法重建牙生物学宽度,术后4周进行金属桩核冠修复。修复后即刻和1年检查牙齿松动度、菌斑指数、出血指数和探诊深度,并测量手术牙和对侧同名牙的力值和患者满意度。结果6mm组术牙中有1例术中出现基牙Ⅰ°松动,术后1周、修复后即刻、修复后1年复查松动度未出现明显变化;5mm组术牙中有1例在修复后9个月根折,其余术牙术后牙龈健康、未出现牙齿松动。修复后即刻和1年时,术牙力值与对侧同名牙差异没有统计学意义(P >0．05);冠缘位置未发生明显变化,患者对冠修复体功能满意。结论牙根改形结合少量去骨的方法作为一种改良的牙冠延长术,扩大了牙冠延长术的适应证,可以应用于临床上颌磨牙劈裂牙的保留。