Fig.1
Initial situation, patient presented to us referred from hospital asking to reconstruct the tooth.

Fig.2
While doing an anamnesis the patient asked if it was useful or of clinical value for us to share her “selfies” with us. After agreeing we could take some valuable information about these images.

Fig.3
Patient after 48 hours, she was told that the level of swelling would reach the maxim level at this time. Following instructions from the medical team she waited and followed the meds therapy.

Fig.4
After 72 hours swelling was still worse, she was instructed that it could be normal.

Fig.5
After 4 days and with the swelling not solving, the patient felt something scratching inside the lip. Immediately she went to the emergency room and they removed the tooth fragment that was being expelled by the body.

Fig.6
We asked immediately if she had the tooth fragment. She gave it to us and the fragment was kept in an sterilization bag, dry, for more than one month.

Fig.7
It was clear that the fragment had sever dehydration, and as it was told at the beginning of the article, many authors consider these kind of fragments not viable. We decided to proceed.

Fig.8
Pulp vitality test was positive and surprisingly normal after more than one month of the exposed dentin to the oral environment. The patient was anesthetized.

Fig.9
Try-in of the remanent fragment. Where we can see that the fitting is very good except for a small fragment near the mesial transition angle.

Fig.10
Superposition of the two pictures to appreciate the shape of the fragment. Patient was told that the fragment was going to be reattached and in case of not looking good a correction or a full replacement would be done afterwards.

Fig.11
After validating that the tooth fragment is good for cementation we left the tooth for 30 minutes in saline solution to start the dentin rehydration.

Fig.12
testo sotto immagineComplete isolation. Strong wedging is of outmost importance in this cases where we need to provide space for the perfect passive fit of the fragment without interferences or pressure from the proximal areas.

Fig.13
Intraoral wet sandblasting with 29 micron aluminium oxide with Acquacare (Velopex) at 1 bar pressure, making the sandblasting very delicate and controllable in order to clean perfectly the surface. Matrixes were used for neighbor teeth protection.

Fig.14
After sandblasting both natural tooth and tooth fragment were disinfected with 2% chlorhexidine for at least 1 minute, with the aim of dropping the bacterial charge and reducing MPP enzymes action. Selective etching of the enamel was performed for 15 seconds and washed thoroughly. Given the fact that selective etching takes a little more time to do, the etching time is 15 seconds to compensate the other 15 seconds of application and to not surpass the 30 seconds frame and over-etch.

Fig.15
Selective etching of the fragment, requires delicacy and preferably magnification.

Fig.16
Tooth fragment ready for bonding agent application.
A matter of discussion is always, should we cure the bonding before cementing or not. The answer we give is always “depends on the density of your bonding agent” and for better standardization, and not to make any irreversible mistake, with such a good fitting fragments, better not to cure before.

Fig.17
Fragment being cemented with a body A2 shade, the resin was selected from a carpule, being these masses way softer than the ones of syringes. These kind of cementation is indicated especially when we need to fill up areas as the defect displaying in the margin.

Fig.18
After a very careful cementation and excess removal, we cure thoroughly the restored area through all its directions. Is very important to say that the procedure is not finished until the surface is finished an polished.

Fig.19
Aspect after finishing and polishing. This procedure removes invisible excess from the surface avoiding short term staining and leaving the surface enamel as permeable as possible to achieve rehydration.

Fig.20
Immediate postoperative view. Fragment is still looking extremely white. We cannot evaluate anything until the fragment has the chance to rehydrate at least for one month.

Fig.21
Happily for both patient and staff, the fragment recovered its full color and opacity, other aspect with is very important. Frequently the fragments dehydrate so badly that the dentin denaturalizes and becomes opaque and with an unpleasant aspect. Fortunately in this case it was not the exception.
Scientific community still has no agreement in which are the precise factors that drive fragments to opacify badly.

Fig.22
An almost real rehydration comparison made with images.

Fig.23
Final aspect.

Fig.24
Detail of the margin. Which being not perfect, at a near distance is not visible. Regardless of the decision of not taking further action, it can be corrected aesthetically at any moment.

Fig.25
Misalignment of the teeth will be corrected by orthodontic treatment..

Fig.26
Aspect of the case the day of orthodontic appliances cementation. Note how the fragment, even if it blended perfectly, is now more prone to quick dehydration than its neighbor teeth.

Conclusions

No fragment should be considered not viable, unless it is proven that it really lacks of any kind of fit or has suffered irreversible damage.

Bibliography

1.  Sargod, Sharan S.; Bhat, Sham S. A 9 year follow-up of a fractured tooth fragment reattachment. Contemporary Clinical Dentistry. Oct-Dec2010, Vol. 1 Issue 4, p243-245.
2. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, Diangelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, Von Arx T. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Endodontic Topics 2006, 14, 102–118