A N T H O N Y J. DI AN G ELIS, D .M .D ., D .D .S ., M .S.

ABSTRACT

R e a tta c h in g fra ctu red to o th seg m en ts offers an e sth e tic tr a n sitio n a l r e sto r a tiv e a lte r n a tiv e to b o n d ed c o m p o site and fu ll crow n s. T he au th ors r e v ie w th is te c h n iq u e and d em o n stra te its a p p lic a tio n .

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M O N IC A J U N G B L U T H ,

the acid-etch adhesive technique, we can restore function and esthetics to fractured anterior teeth. M any reports document tooth preparation m ethods as well as selection and m anipulation of restorative m aterials w ith this technique.1'5While acid-etch resinbonded restorations rem ain the stan d ard treatm ent, recent reports suggest th at, when available, reattaching of fractured tooth segm ents create a good alternative. In 1964, Chosack and Eidelm an used a cast post to reattach the crown segm ent of a 12-year-old boy’s am putated anterior crown.6 The acid-etch technique was not used. R ather, conventional dental cem ents were used to cem ent sim ultaneously the post and fractured crown to th e rem aining tooth. Spasser described reattaching an anterior tooth fragm ent w ith interlocking m inipins, composite and a light-cured resin.7 His report was followed by a series of case reports describing m ethods to bond fractured incisal fragm ents to the rem aining tooth using the acid-etch m ethod exclusively.811 Beginning in 1978, clinicians were a t last willing to rely on the micromechanical retentive properties of the acid-etch technique and not depend on the more traditional forms of mechanical retention, such as posts and pins for reattachm ent of tooth segm ents. In 1982, Simonsen described the use of an internal V-shaped notch bevel w ithin the enamel of the fractured segm ent as well as in the enam el of the rem aining tooth.12 This was designed to elim inate the band of composite resulting when external bevels are placed during the reattachm ent process, a m ethod earlier advocated by Sim onsen.10Additionally, he thought th a t by exposing th e ends of the enamel rods, a higher quality etch could be achieved. Shortly thereafter, McDonald and others advocated reattaching of tooth segm ents w ith m inim al or no enam el preparation except acid-etching.1314 In 1986, Dean and others investigated tooth preparation and resin types in th e rep air of fractured incisors by reattaching tooth segm ents.15T heir results showed no significant differences in retention between tee th prepared w ith a 45-degree

Figure 1. Class III Ellis fracture of maxillary right central incisor (case 1).

external circum ferential bevel and those w ith no enam el preparation. The authors did not evaluate retention provided by the in tern al bevel. They also found chemically and lightcured resin system s equally retentive w hen reattaching tooth segments. Since 1986, studies on reattach m en t strongly advocate the alternative of reattachm ent w ith anterior tooth fractures. M any reports suggest refine­ m ents of earlier efforts based on th e availability of improved enam el and dentin bonding agents, the incorporation of glass ionomer cem ents and o ther m eans to enhance the retentive bond between the tooth segm ents.1619 Several reports describe reattach m en t in more severe injuries, and others present the m anagem ent of pulpal and periodontal injuries often associated w ith such fractures.2024 Although there is growing evidence th a t rea tta c h ­ ing of tooth segm ents has m any im m ediate advantages, the restoration longevity requires fu rth e r study. W ith the high

tion of th e enam el a t the labial fracture site, and the segm ents fit together w ith no discernible disruptions or defects. This facilitates accurate apposition of segm ents and m inim izes an enamel composite interface. M inor cavosurface discrep­ ancies are easily m anaged, and even significant defects m ay be m anaged w ith adjunctive restorative m easures. If the tooth fragm ent dehydrates, there m ay be a color difference betw een the tooth and incisal segm ent after reattachm ent. G enerally this color discrepancy disappears as rehydration proceeds. B ut if the fractured segm ent cannot be reattached im m ediately, it should be stored in sterile saline solution or sterile w ater. R EPO R T OF OASES

Figure 2. Recovered incisal frag­ ment of maxillary right central incisor (case 1).

frequency of injuries in children and adolescents and the disadvantages of im m ediate definitive restorations such as cast crowns, reattaching tooth segm ents m ay provide a tran sitio n al restoration th a t satisfies both functional and esthetic demands. The obvious indication for reattach in g a segm ent is its availability. Esthetically, the m ost favorable situation exists w hen th ere ’s m inim al disrup­

Case 1. An 8-year-old boy received an Class III Ellis fracture of the m axillary right central incisor, after colliding w ith another child (Figure 1). An hour later, th e p atien t brought the fractured tooth segm ent in a moist towel, to the office (Figure 2). There was little dehydration. O ur clinical and radiographic exam ination indicated no additional injuries to either the h ard or soft tissues. We anesthetized the p atien t and used cotton roll isolation. The fractured segm ent fit the tooth w ith no discernible disruption of the cavosurface m argin a t the fracture site. We covered a pinpoint pulpal exposure w ith calcium hydroxide (Dycal, L.D. Caulk) and allowed it to set. We covered th e rem ainder of the exposed dentin and the calcium hydroxide w ith a th in layer of glass ionomer cem ent (VitraJADA, Vol. 123, August 1992

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bond, 3M D ental Products). W ith the edge of a num ber 35 inverted cone bur, a circum fer­ ential V-shaped notch was placed internally in the enam el of th e tooth fragm ent and the tooth (Figure 3).12 While the advantages of th e in tern al bevel are speculative and not thoroughly evaluated, we have used this m ethod in more th an 30 clinical cases. We removed sufficient dentin from the tooth fragm ent to accommodate the placem ent of calcium hydroxide and a glass ionomer liner/base and allow intim ate reapposition of the segm ent. A 37 percent phosphoric acid etchant gel was applied to th e in tern al surface of the tooth segm ent and to the enam el m argins of the fragm ent and tooth extending about 2 m illim eters beyond the fracture line. The etch an t rem ained in place 20 seconds. The tooth and fragm ent were rinsed w ith a w ater spray for 20 seconds and dried until the enam el appeared frosty and opaque. A th in layer of bond resin (Scotch Bond 2, 3M D ental Products) was placed on the etched enam el walls and the in tern al surfaces of th e tooth and tooth fragm ent. The resin was gently air blown to remove excess and ensure a th in film thickness and th en light cured for 20 seconds. An auto-polymerizing, microfilled composite (Silar, 3M D ental Products) was mixed w ith a small am ount of resin m aterial to produce a cream y consistency and was gently syringed onto the tooth and tooth fragm ent. The segm ent w as replaced on the tooth, excess composite removed from the m argins and held firm ly in place during polymerization. 60

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Figure 3. Illustration of internal enamel bevel preparation for reattachment procedures (photo, courtesy of Dr. Richard J. Simonsen).

Figure 4. Reattached incisal fragment on maxillary right central incisor (case 1).

We polished the segment with finishing disks. The final restor­ ation (Figure 4) is virtually indistinguishable from the un­ affected m axillary left central incisor. Auto-polymerizing, visible light-polymerized or dual (auto- and light-polymerized) cured composite resins m aterials m ay be used for luting. Case 2. The technique can be applied to more severely fractured teeth. A 27-year-old woman came to our office 48 hours after a m otor vehicle accident. She complained of

sensitivity in her m axillary anterior teeth. D uring clinical and radiographic exam ination, we discovered a severe coronal fracture of the m axillary right central incisor. This extended obliquely from the cervical third of the labial surface to below the gingival crest on the palatal surface, essentially resulting in crown am putation w ith pulp exposure (Figure 5). After we anesthetized the patient, a rubber dam was applied, the pulp extirpated and the canal enlarged, shaped and

time. R ather th a n proceed im m ediately to a cast post and crown, we placed a direct composite veneer. Both the veneer and coronal re a tta c h ­ m ent rem ain satisfactory a t the four-year recall (Figure 8). PULPAL M A N A G E M E N T

Figure 5. Coronal amputation of maxillary right central incisor (case 2).

Figure 6. Amputated coronal segment of maxillary right central incisor before and after internal bevel and pulp chamber undercut preparation (case 2).

obturated w ith gutta-percha and sealer. We used electro­ surgery on the p alatal aspect to gain adequate access to the apical m argin of the tooth and to achieve hem ostasis. P re p ar­ ing the am putated crown and tooth was sim ilar to th a t described in case 1. In addition, a circum ferential undercut was placed in th e pulp cham ber of the tooth and the pulpal space in the detached crown for additional m echanical

retention (Figure 6). We etched, bonded and finished the tooth as in case 1. As the facial fracture m argins were not splintered or defective, and the fractured crown had n ’t dehydrated, the esthetic result was m ost acceptable (Figure 7). Incom plete fractures were evident on the m axillary left incisor. Three m onths after treatm ent, the p atien t indicated th a t she was to be m arried and w anted to look h er best a t th a t

A nterior tooth crown fractures require pulp protection. In complicated fractures involving the enam el, dentin and pulp, we m ust tre a t the exposed pulp. W here there is superficial exposure of the dentin, we recommend applying a layer of light-cured glass ionomer liner/base. Glass ionomer’s advantages are well-documented and include: *■ release of fluoride ions into the surrounding dentin; ■" m inim izing microleakage; ■■ resisting dissolution; ■“ chemically bonding to the m ineralized tissues and “ reduction of postoperative sensitivity.25'27 An alternative is placing a new generation dentin-enam el bonding agent directly on the dentin and enam el. The m erits of these two approaches are discussed by Jo rd an and Suzuki in relation to pulpal protection during the placem ent of posterior composites.28 Regardless of which m ethod is selected, obtaining wellsealed m argins betw een the tooth fragm ent, composite and tooth interface m inimizes further irritatio n to the pulp. If the fracture is deep, b u t th ere is no exposure, protect th e pulp by a layer of calcium hydroxide over the exposed dentin, followed by a glass ionomer liner/base. If th e pulp is exposed, tre a tm e n t m ay involve pulp capping, partial or comJADA, Vol. 123, August 1992

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Figure 7. Appearance of maxillary right central incisor immediately after reattachment (case 2).

plete pulpotomy or pulpectomy. In teeth w ith open apexes, m ain tain pulp vitality for continued root developm ent and apical closure. Cvek reported good success using a p artial pulpotomy technique coupled w ith calcium hydroxide use.29,30 E hrm ann described a restored incisor and reviewed the literatu re th a t com pares the pulpotomy and p a rtial pulpotom y techniques.31 W hat em erges from all these discussions is th a t preservation of a vital pulp, particularly in th e im m ature tooth, is desir­ able, and th a t calcium hydrox­ ide continues to be preferred for pulpal protection. W hen severe crown fractures occur, as described in case 2 in which the pulp is exposed and th e root is fully formed, pulpectomy and obturation w ith g utta-percha are suggested. This is based more on resto ra­ tive ra th e r th a n purely pulpal considerations. R eattachm ent is currently suggested as a tem p­ orary or tran sitional restor­ ation. Losing such considerable coronal tooth structure eventu­ 62

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ally w arrants placing of a post and core and crown, and hence access to the pulp cham ber and canal. Continued im provem ents in bonding technology plus advances in vital pulpal therapy m ay well lim it pulpectomy in traum atic injuries to extrem e situations. D IS C U S S IO N

M any authors have described good short-term success in

reattaching fractured tooth segm ents with acid-etch resin techniques. While the strength of such bonds results prim arily from the micromechanical retention through enamel etching, increased interest in dentin bonding has produced technique refinem ents w ith new generation dentinal bonding agents for increased bond strength of resin to dentin. An alternative incorporates glass ionomer cem ent as a luting agent because of its high chemical bond to both dentin and enam el.21,23 Because the set glass ionomer cement can be etched, it provides an added micromechanical retention for composite resin. Recently, Santos and Bianchi used glass ionomer cement, a dentin enamel adhesive, a composite resin and coronal portions of extracted teeth to restore teeth severely damaged by trau m a or caries.32 In addition to maximizing the benefits of glass ionomer cements, resin adhesives and composites, they facilitated coronal reconstruction by

Figure 8. Appearance of veneered maxillary right central incisor four years after reattachment (case 2).

bonding portions of extracted teeth when original tooth segments were missing. Dr. DiAngelis is In case 2, we p ro f e s s o r , D e p a rt­ described m e n t of P reven tive placing a direct S c ie n c e s , University of M in n eso ta School composite of D e n tistry, a n d veneer to m ask C hief of Dentistry« H en nep in County the fracture M edical C e n te r, 7 1 0 line, thereby P a rk Ave. S o u th , M inneapolis, 5 5 4 1 5 . enhancing the A d d re s s re p rin t esthetic r e q u e s t s to Dr. appearance. DiAngelis. This m ay have increased the strength of the restoration as well. In 1988, Croll reattached a severely fractured canine w ith a glass ionom er cem ent and then veneered both the labial and lingual surfaces to improve appearance and add stren g th to th e repaired crown.21 A ndreasen and colleagues, trying to prolong the longevity of fractured incisors restored by bonded reattach m en t of tooth segm ents, studied the effect of adding porcelain lam inate veneers.33 They restored fractured sheep incisors by enam el etching, sealer (Gluma, Bayer AG) p retrea tm e n t of the dentin and bonding of the fractured segm ent w ith the sealer. They then bonded porcelain lam inate veneers to th e restored incisors, and subjected them to controlled force u n til the teeth fractured. The fracture strength of teeth restored in this m anner was in the sam e range as th a t of intact incisors. According to this study, the longevity of reattach m en t restorations can be extended by enhancing both stre n g th and esthetics w ith a porcelain lam inate veneer.

C O N C L U S IO N S

R eattaching fractured tooth segm ents offer several advantages: *■* The tre a tm e n t is rapid, conservative and relatively atraum atic. **■ The restoration of original tooth contours and color is excellent. ■■ Incisal edge w ear proceeds a t the sam e rate as adjacent teeth, w hereas a composite restoration is likely to w ear more rapidly.12 ■* E sthetic appearance is excellent, particularly when there is no disruption of labial enam el cavosurface m argins. *■* F u tu re restorative alternatives are not precluded. Despite the im m ediate ad­ vantages of m anaging tra u ­ m atic fractures by rea tta c h ­ m ent, such restorations m ust be considered transitional or tem ­ porary. In tim e, and with continued im provem ent of ad­ hesive technology and innova­ tions such as the use of bonded veneers, th eir longevity m ay be significantly prolonged. ■ Inform ation about th e m anufacturers of the products m entioned in th is article m ay be available from th e authors. N either the authors nor the A m erican D ental Association h as any commercial interests in th e products mentioned. 1. Buonocore MG, Davila J . Restoration of fractured an terio r teeth w ith ultraviolet-lightpolymerized bonding m aterials: a new technique. JADA 1973;86:1349-54. 2. Jo rd an RE, e t al. Restoration of fractured and hypoplastic incisors Dr. J u n g b lu th is by th e acid etch resin a s s i s t a n t p ro fe ss o r, technique: a th re e year D e p a rtm e n t of report. JADA 1977;95:795-803. Pre v e n tiv e S c ie n c e s , 3. Sheykholeslam Z, University of Oppenheim J , H oupt MI. M in n eso ta S chool of Clinical com parison of D e n tistry, a n d h e a d , sealan t and bonding P e d ia tric D entistry, system s in the restoration of fractured H en nep in County anterior teeth. JADA M edical C e n te r, 1977;95:1140-4. M inneapolis. 4. Black JB , R etief DH, Lemons JE . Effect of cavity design on reten tio n of Class IV composite resin restorations. JADA 1981;103:42-6. 5. Bagheri J , Denehy G. Effect of enam el bevel and restoration lengths on Class IV acid-etch retained

composite resin restoration. JADA 1983;107:951-2. 6. Chosack A, Eidelm an E. R ehabilitation of a fractured incisor using th e p atien t’s n a tu ra l crown— case report. J D ent Child 1964;31:19-21. 7. S passer HF. R epair and restoration of a fractured, pulpally involved an terio r tooth: rep o rt of a case. JADA 1977;94:519-20. 8. M arder C. R estoration of a fractured an terio r tooth. JADA 1978;96:113-5. 9. Tennery TN. The fractured tooth reunified using the acid-etch bonding technique. Texas D ent J 1978;96:16-7. 10. Simonsen RJ. T raum atic fracture restoration: an altern ativ e use of th e acid-etch technique. Q uintessence In t 1979;101:15-22. 11. S tarkey PE. R eattachm ent of a fractured fragm ent to a tooth. J Indiana D ent Assoc 1979;58:37-9. 12. Sim onsen RJ. R estoration of a fractured central incisor usin g original tooth fragm ent. JADA 1982;105:646-8. 13. McDonald RE, Avery DR. D entistry for the child and adolescent. 4 th ed. St. Louis: Mosby;1983: 436-8. 14. O sborne JW , L am bert RL. R eattach m en t of fractured incisal tooth segment. Gen D ent 1985;33:516-7. 15. D ean JA, Avery DR, Sw artz ML. A ttachm ent of anterio r tooth fragm ents. P ed ia tr D ent 1986;8:13942. 16. A ndreasen FM, Rindom JL , M unksgaard EC, Andreasen JO . Bonding of enam el-dentin fractures with G lum a and resin. Endod D ent Traum atol 1986;2:1-4. 17. M unksgaard EC, H ojtred L, Jorgensen EHW, A ndreasen FM, A ndreasen JO . Enam el-dentin crown fractures bonded w ith various bonding agents. Endod D ent T raum atol 1991;7:73-7. 18. M artens LC, Beyls HM, DeCraene LG, D’H auw ers RF. R eattachm ent of th e original fragm ent after vertical crown fracture of a p erm anent central incisor. J Pedod 1988;13:53-62. 19. Dorignac G, N ancy J , G riffiths D. Bonding of natu ral fragm ents to an terio r teeth. J Pedod 1990;14:132-5. 20. DiAngelis AJ, Ju n g b lu th MA. R estoration of an am putated crown by th e acid-etch technique. Q uintessence In t 1986;18:829-33. 21. Croll TP. R epair of a severe crown fracture with glass-ionom er and composite resin bonding. Q uintessence In t 1988;19:649-54. 22. Am ir E, Bar-Gil B, S a rn a t H. R estoration of fractured im m ature m axillary central incisors using the crown fragm ents. P ed ia tr D ent 1986;8:285-8. 23. B aratieri LN, M ontiero S, C aldeira de A ndrada MA. The “sandw ich” technique as a base for reattach m en t of d en tal fragm ents. Q uintessence In t 1991;22:81-5. 24. B aratieri LN, M ontiero S, C aldeira de A ndrada MA. Tooth fractu re reattachm ent: case reports. Q uintessence In t 1990;21:261-9. 25. Kidd EA. C avity sealing ability of composite and glass-ionom er cem ent restorations: an assessm ent in vitro. B r D ent J 1978;144:139-42. 26. H icks J , et al. Secondary caries form ation in vitro aro u n d glass-ionom er restorations. Q uintessence In t 1986;17:527-32. 27. Wilson AD, McLean JW . Glass-ionomer cement. Chicago: Q uintessence 1988. 28. Jo rd an RE, Suzuki M. Posterior composite restorations: w here and how they w ork best. JADA 1991;122(12):31-7. 29. Cvek M. A clinical rep o rt on p artial pulpotomy and capping with calcium hydroxide in p erm anent incisors w ith com plicated crown fracture. J Endod 1978;4:232-7. 30. Cvek M. Endodontic tre a tm e n t of trau m atized teeth. In: A ndreasen JO , ed. T raum atic injuries of the teeth. 2nd ed. Copenhagen: M unksgaard; 1981. 31. E h rm an n EH. R estoration of a fractured incisor w ith exposed pulp using original tooth fragm ent: report of case. JADA 1989;118:183-5. 32. S antos JF , Bianchi J. R estoration of severely dam aged te eth w ith resin bonding system s: case reports. Q uintessence In t 1991;22:611-5. 33. A ndreasen FM, D augaard-Jensen J, M unksgaard EC. R einforcem ent of bonded crown fragm ents w ith porcelain veneers. Endod D ent T raum atol 1991;7:78-83.

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Reattaching fractured tooth segments: an esthetic alternative.

Reattaching fractured tooth segments offers an esthetic transitional restorative alternative to bonded composite and full crowns. The authors review t...
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