Esthetic and Functional Rehabilitation Via Reattachment of Dental Fragments

Dental trauma is more frequent in anterior dentition in young, mainly male patients (7 to 15 years old).^4-7 Common etiological factors are falls, sports activity, and traffic accidents.^1,4 The most common type of dental injury is a fracture involving enamel and dentin, which may be a crown or root-crown fracture and that usually affects the maxillary incisors.¹ Restorative treatment options include the possibility of direct resin composite restorations, indirect restorations, or even reattachment of the fragment.⁸ In most cases, the selection of the treatment is determined by a diagnosis that assesses the extent of periodontal damage, the quality of the remaining tooth structure, and, when applicable, the conservation of the dental fragment.⁹ Tooth fragment reattachment is a simple and conservative technique that offers the advantage of maintaining the original characteristics of the teeth, such as color, shape, and occlusal contacts.⁹ When possible, reattachment should always be the first choice, since modern materials and adhesive techniques enable its execution with safety and predictability.^8,10,11

For the success and longevity of the treatment of dental trauma, it is important to evaluate each situation in particular, since a clinician cannot generalize the treatment indication. Still, the multidisciplinary approach—often with the involvement of endodontics, periodontics, and restorative dentistry—is valuable for correct diagnosis and best prognosis. This article describes a clinical report in which restorative dentistry, periodontology, and adhesive materials were effective in restoring function and esthetics in a case of a subgingival fracture of central incisors.

Case Presentation

An 18-year-old male patient presented with a visible fracture in the left upper central incisor (tooth No. 9) due to a skateboard accident (Figure 1). The patient did not complain of pain. After the clinical examination, the clinician diagnosed an oblique root-crown fracture of enamel and dentin, with the involvement of the periodontal biologic space but without pulp exposure and mobility (Figure 2). The injury resulted in two dental fragments that were presented by the patient. The fragments were in good condition; they had been properly cleaned and stored in a saline solution for approximately 10 hours, and, in the examination, they adapted to the remaining tooth (Figure 3). The examination, including sensitivity and percussion tests, and the radiographic exams showed normal periapical and periodontal tissues, which gave the appearance of vitality to the damaged tooth, eliminating the need for endodontic treatment (Figure 4 and Figure 5). Thus, since there was no pulp exposure it was proposed to perform only the indirect pulp capping of the pulp-dentin complex, as this was the least invasive approach. The patient was informed about the risks and advantages of the treatment and consented to it.

After the diagnosis, reattachment of the dental fragments was chosen as the proper therapy. Due to the subgingival extension of the fracture, periodontal surgery was performed to re-establish a biologic distance in the palatine of the teeth. The surgical procedure consisted of removing soft tissue and bone in order to restore the biological bone crest extending to the end of the fracture.¹² With this procedure, it was possible to certify the correct adaptation of the fragment to the remaining tooth (Figure 6). Accordingly, a composite resin and adhesive was chosen as the restorative material. After the exposition of the fracture’s limit, the operating field was completely isolated, using a rubber dam stabilized with clamps in the premolars and in the left central incisor. For this tooth, a Ferrier 212 clamp for gingival retraction was used to maintain the exposition of the entire fracture and to allow the reattachment of the dental fragments (Figure 7). Sequentially, a round diamond 1014 (KG Sorensen, www.kgsorensen.com.br) was used to regularize the fracture line and remove unsupported enamel rods (Figure 8). To protect the tooth-pulp complex, the clinician used a combination of calcium hydroxide cement (Hydro C^®, DENTSPLY, www.dentsply.com) and glass ionomer (Vitrebond™, 3M ESPE, www.3MESPE.com) (Figure 9).

Before the fragments were reattached, they were treated with 35% phosphoric acid (Ultra-Etch^®, Ultradent Products, Inc., www.ultradent.com) for 30 seconds and 15 seconds on the enamel and dentin, respectively (Figure 10). Next, they were washed and dried for 60 seconds with sterile cotton and then treated with adhesive (Single Bond, 3M ESPE) (Figure 11), with photoactivation, as recommended by the manufacturer. To condition the fragments properly, a thin layer of composite resin was inserted (Filtek™ Z350 XT, 3M ESPE), without activation. As the fragments were prepared (ie, acid and adhesive conditioning), the remaining tooth was also conditioned with acid (Figure 12) and adhesive (Figure 13). For the adhesive, a polymerization was carried out for 10 seconds. After these steps, with the thin layer of composite resin the fragments were repositioned on the remaining tooth, and photoactivation of the set was performed (Figure 14). At the end of this stage, the complete rubber dam was removed, and the periodontal flap was repositioned and stabilized with sutures (Figure 15).

After 15 days (Figure 16 and Figure 17), the patient was re-evaluated, and the stability of color between the fragment and the remainder was verified. In order to improve the esthetics of the case, the clinician decided to conduct a reduction and resin restoration on the fragment–tooth interface. The reduction on the fragment–tooth interface was performed using a round diamond 1012 (KG Sorensen) and the restoration was filled with composite resin (Filtek Z350) in the selected color, A2, including both dentin and enamel. Finishing and polishing were carried out with a combination of abrasive sanding discs (Sof-Lex Pop-On™, 3M ESPE), rubber abrasive (Astropol Ivoclar Vivadent, www.ivoclarvivadent.com), and felt disc (FGM Dental Products, www.fgm.ind.br) with diamond paste. The result can be seen in Figure 18, immediately after the restorative treatment, and in Figure 19 and Figure 20, at a clinical follow-up of 6 months.

Discussion

The reattachment of dental fragments has been described as a conservative and effective technique for restoring esthetics and function to a patient with dental trauma.⁸ The technique is described as advantageous for maintaining the original characteristics of the patient's tooth—such as color and shape—and for maintaining occlusal contacts, which often involves restoring critical points in cases of direct anterior restorations.^9,11 The longevity of the treatment has been reported in the literature through the description of clinical cases,^8,9,11 and it attests to the safety of the achievement and the indications for use of the technique. This technique should always be preferred. Although current restorative materials are effective in replacing lost tooth structure, some factors are crucial to their effectiveness.

For the indication and success of the technique, it is important to consider the conditions under which the fragment was kept while outside the buccal environment. The recommendation is to keep the fragment hydrated, preferably in a saline solution, and to reattach the fragment as soon as possible. Hydration maintains the vitality and esthetic appearance of the original fragment,⁹ and it favors the union between the fragment and the restorative materials.³ According to some studies, the reattachment of dental fragments offers greater resistance to fracture than direct composite resin restorations, and this is achieved even in cases where the fragment was dehydrated within 48 hours.³ In addition to adapting the fragment to the remaining tooth, it is necessary to conserve biological distance in order to reduce possible localized bone resorption, gingival recession, gingival hyperplasia, or a combination of these problems.¹² In this case, it was necessary to surgically re-establish biologic width, because the subgingival extension was located just over the palatal surface, without compromising esthetics.¹³ If subgingival extension was in the buccal surface, it would offer an ideal situation for orthodontic extrusion technique.¹⁴

The success of the technique is directly related to choosing adhesive materials that have adequate mechanical properties and biocompatibility with the dental and periodontal tissues.¹⁵ It is important, at the time of the procedure, to maintain the conditions necessary to support the adhesive technique, such as the presence of a clean and a dry operative field—especially when there is a need for periodontal surgery. The combining of composite resin with dentin bonding has been shown effective in promoting the union between the fragment and the tooth remainder, offering resistance to the assembly as a whole.^9,15

All restorative treatments in patients with trauma—even the repositioning of dental fragments—should be followed by monthly clinical monitoring and control, with detailed clinical and radiographic examinations in order to detect both the success of the technique and its possible complications. As with any approach in cases of dental trauma, the restoration of a fractured tooth with pulp capping and fragment reattachment could present complications over time. It is common for pulp necrosis and root resorption to develop in these cases due to the trauma and the extent of the dental injury.^16,17 However, depending on the patient`s age, taking an immediate approach is always the recommended choice as the least invasive treatment option.^3,9,17 In this case, a 6-month follow-up with clinical and radiographic examinations, showed that the reattachment of the fragments—accomplished via periodontal surgery and indirect pulp capping—was effective in restoring esthetics and function for the patient.

Conclusion

In cases of dental trauma in the anterior dentition, the patient should always be rehabilitated using a conservative, esthetic, and functional treatment. Thus, the reattachment of dental fragments, when possible, should be the treatment of choice, since it presents an effective and predictable technique.

About the Authors

Diogo de Azevedo Miranda, DDS, MS
PhD student
Department of Restorative Dentistry
Operative Dentistry Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Núbia Pavesi Pini, DDS
MS student
Department of Restorative Dentistry
Operative Dentistry Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Lucas Alves Moura, DDS, MS
PhD student
Department of Prosthodontics and Periodontics
Periodontics Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Hugo Felipe do Vale, DDS, MS
PhD student
Department of Prosthodontics and Periodontics
Periodontics Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Marcio Zaffalon Casati, DDS, MS, PhD
Adjunct Professor
Department of Prosthodontics and Periodontics
Periodontics Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Debora Alves Nunes Leite Lima, DDS, MS, PhD
Adjunct Professor
Department of Restorative Dentistry
Operative Dentistry Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Giselle Maria Marchi, DDS, MS, PhD
Adjunct Professor
Department of Restorative Dentistry
Operative Dentistry Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

José Roberto Lovadino, DDS, MS, PhD
Adjunct Professor
Department of Restorative Dentistry
Operative Dentistry Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil

Flávio Henrique Baggio Aguiar, DDS, MS, PhD
Full Professor
Department of Restorative Dentistry
Operative Dentistry Area
Piracicaba Dental School
University of Campinas
Piracicaba, SP, Brazil