Class IV reattachment and restoration with one shade

Shadeguides - Direct anteriors
27 Apr 2017

It often happens that our younger patients experience trauma from falling, thus causing the fracture of their front teeth or – even worse – their avulsion. If the fractures are not complicated by pulp exposure, and if the parents have succeeded in recovering the fractured fragments, they may be immediatly bonded, sometimes enriched with a partial restoration of the missing parts. In the following clinical case a technique proposed that involves the use of a single body mass of composite material, exploiting modern medium-translucent and highly mimetic new composite materials.

Fig. 1

Img. 1 – A falling trauma occurred to this young female patient, 8 years old

Fig. 2

Img. 2 – Details of the fracture of 2.1

Fig. 3

Img. 3 – Details of the fracture of 2.1

Fig. 4

Img. 4 – Details from a palatal view. TIP: we often suggest you take a picture of the incisal edges with a mirror. This is helpful to have palatal details. Luckily, no pulp exposure occured, so I proceeded to the restorative session, without performing any pulp capping

Fig. 5

Img. 5 – TIP: isolation with the rubber dam is mandatory. Sometimes it's difficult to get proper isolation with children, so you can use a liquid dam to increase it, as done on tooth 2.2.

Fig. 6

Img. 6 – TIP: with a flame shaped, fine-grain bur, or with a round one (Direct Style kit by Style Italiano) remove the unsupported enamel and create a small bevel. With the modern body mass materials (medium transucency) there's no need to create a deep chamfer

Fig. 7

Img. 7 – Details of the two fragments of 2.1. The fragments are not the whole missing part so there'll be the need to replace 30-35% of the lost tissue with composite material.

Fig. 8

Img. 8 – After the bonding procedures, that we've been performing for 3 years now with a Universal Adhesive system (8th generation), with a self-etching protocol, we reattach the fragments with an A2 body mass, using the same material to fill the missing part among the fragments and on the vestibular and lingual surface, with two different layers to counteract the shrinkage of the composite material. You can use a matrix to protect the neighboring tooth

Fig. 9

Img. 9 – In a few minutes, the two pieces are bonded and the missing part is ended too, with the body mass. TIP: finish and polish it using the Style Italiano Finishing bur kit and the Diamond Twist high charged polishing diamond paste. You can use a disc to re-contour the mesial and distal edges if they looked too straight (as they seemed to be in this case) and a large-grain diamond bur to better mark the line between the incisal lobes

Fig. 10

Img. 10 – One week control: the happy young patient shows a beautiful smile and her joy is ours as well. There's no need to re-polish or to perform corrections, as the two fragments disappear among the restoration that shows a very nice integration

Fig. 11

Img. 11 – One month control

Fig. 12

Img. 12 – One month control, details of the two central incisors

Fig. 13

Img. 13 – Details of the Class IV restoration done with composite and the two reattached fragments

Fig. 14

Img. 14 – Details from a lateral view; you can appreciate the primary, secondary and tertiary anatomies that have been reproduced with the finishing procedures

Fig. 15

Img. 15 – The occlusal view shows a good shaping, also of the platal wall

Fig. 16

Img. 16 – Details of the two incisors from an incisal view that shows a good morphological and chromatic integration of the restored 2.1 and a perfect symmetry with his neighbouring, contralateral tooth.

 

Conclusions

The simplification of the operative procedures is one of the aims of the Philosophy of Style Italiano, so we suggest the use of a single mass also for anterior restorations and reattachment of fragments, in case of trauma and broken teeth. This is not something that can decrease the single individual skills or reduce the final quality of your work, but, on the contrary, it makes operating procedures more feasible, manageable and fluid also for the experienced operators, as you can see from the result just shown above.

Bibliography

Andreasen JO, Andreasen FM. Classification, etiology and epidemiology of traumatic dental injuries. In: Andreasen JO, Andreasen FM, editors. Fractured tooth fragment reattachment a or. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd edition. Copenhagen: Munksgaard Publishers; 1993. pp. 151–77.
Olsburgh S, Jacoby T, Krejci I. Crown Fractures in the permanent dentition: Pulpal and restorative consideration. Dent Traumatol. 2002;18:103–15.
Rappelli G, Massaccesi C, Putignano A. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol. 2002;18:281–4.
Baratieri LN, Monteiro S, Jr, Caldeira de Andrada MA. Tooth fracture reattachment: Case reports. Quintessence Int. 1990;21:261–70.
Andreasen FM, Noren JG, Andreasen JO, Engelhardtsen S, Lindh-Stromberg U. Long-term survival of fragment bonding in the treatment of fractured crowns: A multicenter clinical study. Quintessence Int. 1995;26:669–81.
Osbome JW, Lamsen RL. Reattachment of fractured incisal tooth segment. Gen Dent. 1985;3:516–7
Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth fragments.Quintessence Int. 2000;31:385–91.
Simonsen RJ. Restoration of a fractured central incisor using original teeth. J Am Dent Assoc. 1982;105:646–64.
Starkey PE. Reattachment of a fractured fragment to a tooth. J Indiana Dent Assoc. 1979;58:37–8.