Aesthetic correction after fragment reattachment

Fragment reattachment can be a valid alternative to a direct restoration whenever coronal fractures occur in anterior teeth. If the fragment is available, and if it fits well enough, it should be reattached to the remaining tooth structure. After the reattachment procedure the margin should be opened with a round bur to create a double bevel on the tooth and on the fragment. This procedure (described in our previous article) is also known as post-reattachment bevel, and it will ensure esthetic results together with an increased resistance to dislocation of the fragment.
Tommaso, 8 years old, had a traumatic accident 2 years ago causing the fracture of tooth #21, which was restored in another dental office. Last August he had an additional trauma resulting in the fracture (the fragment was available) of tooth #11. The fragment reattachment and the margin hiding procedure had already been performed, and it was time to improve the aesthetic quality of the restoration of tooth #21.

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Fig.1
The initial situation 30 days after fragment reattachment. A good integration of the fragment/remaining tooth structure/composite at the margin can be observed. The level of dental hygiene of this patient was not perfect. However, it was decided to perform a class IV restoration on tooth #21, hoping that the new aesthetic appearance of his smile would motivate him to change his brushing approach.

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Fig.2
After placing the rubber dam, cleaning procedures were carried out on both teeth. A classical bevel preparation was made on tooth #21. According to the concepts of minimally invasive restorations, the bevel is as small as practical and it is only placed on the buccal surface.

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Fig.3
Alginate impressions had been taken after the reattachment procedure, and our dental technician prepared a silicon key to help us layer the palatal enamel.

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Fig.4
The palatal enamel is layered using a mass of enamel resin composite.

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Fig.5
A sectional matrix for premolars is generally very useful to create the mesial enamel.

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Fig.6
A dentin layer is placed underneath a last layer of enamel, following the principles of anatomic stratification. In this case one dentin and one enamel mass were used.

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Fig.7
Contouring procedures are directed to recreate a perfect anatomical appearance of the restoration, as shape is of primary importance. Polishing and finishing ensure a stable aesthetic result.

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Fig.8
The situation immediately after removal of the rubber dam.

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Fig.9
A 7 days control shows a very good marginal integration regarding the class IV restoration on #21. On the other hand, the reattached fragment shows signs of dehydration, which is not so common.

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Fig.10
A case with a 31 years control by Prof. Romano Grandini.

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Fig.11
Another very old case showing no sign of dehydration.

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Fig.12
Partial fragment reattachment. A good level of integration can be seen between fragment, tooth and resin composite.

Conclusions

In our experience, the reattached fragment becomes quite completely invisible after the procedure. Images 10, 11 and 12 show other examples of reattached fragments showing a good marginal integration.

Bibliography

1. Andreasen JO, Andreasen FM, Andersson L. Textbook andcolor atlas of traumatic injuries to the teeth, 4th edn. Oxford,UK: Wiley-Blackwell; 2007.
2. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012; 28: 66-71.
3. Chazine M, Sedda M, Ounsi HF, Paragliola R, Ferrari M, Grandini S. Evaluation of the fracture resistance of reattached incisal fragments using different materials and techniques. Dent Traumatol. 2011 Feb;27(1):15-8.
4. Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur J Esthet Dent. 2010 Spring;5(1):102-24.
5. Betrisey E, Krejci I, Di Bella E, Ardu S. The influence of stratification on color and appearance of resin composites. Odontology. 2015 Feb 5.

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