INTRODUCTION:

Traumatic dental injuries (TDIs) occur frequently in children and young adults, comprising 5% of all injuries. Twenty‐five percent of all school children experience dental trauma and 33% of adults have experienced trauma to the permanent dentition, with the majority of the injuries occurring before age 19.¹ Anterior teeth are most frequently affected by trauma, especially the maxillary incisors due to the position in the dental arch, whereas the mandibular central incisors and the maxillary lateral incisors are less frequently involved.² The uncomplicated fracture of a crown is absolutely the most common form of trauma, affecting 25% of the population under the age of 18.³ A majority of these fractures involved the maxillary central incisors, with boys outnumbering girls almost two to one. The choice of restorative treatment for fractured permanent anterior teeth is the major concern for the dentist nowadays. Various treatment options are available like light cure composite resin restoration, fragment reattachment, and ceramic crowns, laminate veneers.

When the fractured segment is found at the site of trauma and if it is in good condition, the ideal option for the treatment of an uncomplicated crown fracture is fragment reattachment.⁴ There are variable factors which influence the success rate of coronal tooth fractures such as extent of fracture, biological width, pulp involvement, associated bone fracture, pattern of fracture and crown- root fracture, recurrent trauma, injuries to soft tissue, availability of fractured tooth fragment and its condition, occlusion, esthetics, socioeconomic status, parent cooperation and prognosis.⁵ This clinical case report focuses on the management of coronal fracture that was successfully treated using fragment reattachment and flowable composite resin.

Case Report:

A 11-year-old female patient reported to the OP with the chief complaint of fractured upper front teeth with presence of sensitivity while having food for the past one day (Figure 1) after a trauma which occurred 3 days before. The patient also presented the fragment of the detached tooth that had broken due to trauma. Clinical examination revealed the presence of Ellis class II fracture in 11, 12. Intraoral examination also revealed that there was no apparent trauma to the soft tissue or any bone fracture. The intact tooth fragment was recovered at the accident site brought to the clinic by her father in folded paper, which was transferred to the saline bowl. (Figure 2) Pulp vitality test was done and it showed positive result. (Figure 3) Radiographic examination indicated complete root formation and a closed apex with no periapical radiolucency and did not show any other fracture or injury on the adjacent teeth.

Following assessment of the tooth fragment, minimal loss of tooth structure was evident. After explaining the possible treatments for the patient, the patient opted for tooth fragment reattachment with a composite resin technique. The fractured segment was accurately placed on the tooth. The accurate fit between the tooth and the fragment was checked. Finger pressure was used for better adaptation to ensure that the original position had been re-established. Isolation was done using cotton pellets. A shade was selected by positioning the patient at a 45-degree angle using natural daylight using classical A1-D4 shade guide and an appropriate shade match was selected. The tooth was bevelled and the tooth fragment was acid etched using 37% orthophosphoric acid. Bonding agent application was done and cured. This was followed by stabilization using sticky wax and reattachment light cure flowable composite resin restoration. (Figure 4) Curing of the composite resin was completed using a LED unit with a light intensity of 1200 mW/cm² and was finished and polished (Figure 5) Patient was advised to avoid chewing on hard items to reduce the risk of fragment debonding. The final restoration was polished using a white stone-finishing burs and abrasive discs to achieve a glossy and smooth surface. (Figure 8) Occlusion was also checked for any interference.

Figure 1: Preoperative photograph of the fractured teeth 11, 21

Figure 2: Tooth fragment recovered at the accident site

Figure 3: Pulp vitality testing using gutta percha sticks

Figure 4: Fragment Reattachment using Sticky wax

Figure 5: Post-operative photograph

DISCUSSION:

Coronal fractures are the most common dental injury occuring in the permanent dentition, approximately 26 -76% of fractures. Divakar and Nayak et al., 2007 reported that crown fractures accounts for up to 92% of all traumatic injuriesto the permanent dentition. Coronal fractures of permanent incisors is approximately 18–22% of all dental trauma, 28–44% being uncomplicated (enamel and dentin) and 11–15% complicated crown fractures (enamel, dentin and pulp).⁶ Tennery was the first to report the re-attachment of a fractured fragment using acid-etch technique. Subsequently, Starkey and Simonsen have reported similar cases. The use of the patient’s own tooth fragment is aesthetically more pleasing. Despite these clinical advantages, it will be impossible to do a fragment attachment if the fracture is below the alveolar bone height. When the fracture is below the alveolar bone height then other techniques like orthodontic extrusion, surgical crown lengthening or tooth repositioning should be considered.⁷ Many techniques are available for treatment varying from tooth fragment reattachment to full-coverage crown restorations. The treatment and prognosis differs according to the patient’s age, amount of remaining enamel, presence of the tooth fragment for adhesion.⁸ Studies have shown that original tooth fragment reattachment can be considered the best option for fragment reattachment in children younger than 18–20 years.⁹ This technique is reasonably simple and restores function and aesthetics in a conservative approach. A dry and clean working field and proper bonding and materials is the key for achieving success.¹⁰ The technique used in this case is a very simple, non-complicated technique, whenever the fractured fragment is available intact.¹¹ Coronal fractures should be assessed carefully by the dentist and have to do appropriate treatment to achieve the successful outcome.

CONCLUSION:

Fragment reattachment is more aesthetically pleasing and a conservative approach as it uses patient’s own tooth fragment and also restores the function. So, it can be considered as a viable alternative to other techniques in management of uncomplicated crown fractures.

CONFLICT OF INTEREST:

The author declares no conflict of interest.

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Received on 19.02.2020 Modified on 11.05.2021

Research J. Pharm. and Tech. 2022; 15(6):2439-2441.

DOI: 10.52711/0974-360X.2022.00406