Total reattachment

Among all facial injuries, dental traumas are the most common and mainly affect young people.
In case of coronal fracture of an anterior tooth, we need an appropriate treatment plan if we want to have a good prognosis.
If the complete fragment is available, total reattachment with composite is the best option for long lasting outcome. It will help us to save time by using a simple, predictable and reliable procedure. It will help the patient as well to save money because he won’t need any direct or indirect restoration that can be expensive.
Let’s see how to proceed with a clinical case.

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Fig.1
A young patient comes in emergency after an accident on his 11. The fracture involves enamel and dentin. The pulp is not exposed and the tooth is painful. We do not make a sensibility test of the pulp at this moment but a pulpal monitoring will be done during several month until a definitive pulpal diagnosis can be made. According to the treatment guidelines described in the litterature, this patient has an uncomplicated crown fracture.

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Fig.2
Occlusal view of the fractured tooth.

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Fig.3
The patient could keep the entire fragment and when he called us on the phone, we told him to keep it in his mouth. With uncomplicated crown fracture, the best option is to reattach this fragment, by using bonding agent and composite resin and without any preparation of the tooth or the fragment.

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Fig.4
View of the internal portion of the fragment.

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Fig.5
First step, we check the adaptation of the fragment on the tooth. We can note that despite being in the patient mouth, the fractured piece is dehydrated and appears more “white” than the teeth

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Fig.6
The occlusal view shows the perfect adaptation and the different color due to dehydration. If it is difficult to try the fragment on the tooth because of strong contact points, a tip can be to use wedges to separate the teeth and ease the adaptation.

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Fig.7
After the anesthesia, an individual operative field is used. Using the rubber dam on one tooth is an easy way to work in order to avoid to bond an indirect restoration on the adjacent teeth and this makes easy to remove the excess.

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Fig.8
We can start the bonding procedure both on the tooth and the fragment, without any preparation. We choose an etch and rinse procedure. The first step is to sandblast the surface and after we use an 37% orthophosphoric acid on enamel and dentin.

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Fig.9
Then we rinse, dry and rehydrate with 0,2% chlorhexidine.

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Fig.10
The fragment is put on a stick to handle it easily. Before starting the bonding procedure, the fragment was put in physiological serum to be rehydrated and then it is cleaned with 0,2% chlorhexidine.

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Fig.11
The fragment is etched, rinsed, dried and rehydrated with 0,2% chlorhexidine.

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Fig.12
Many layers of primer agent are used on the the tooth and the fragment and after are carefully dried. The surface is then brushed with the bonding agent and light cured for 1 minute.

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Fig.13
Reattachment is done by using a preheated composite. The fragment is pushed firmly on the tooth. Like in the try-in procedure, in case of strong contact points, wedges can be used to separate the teeth and ease the positioning.
Excesses are removed with sharp instrument (LM Arte Fissura), brushes and dental floss is used to remove composite around the contact points. We can now light cure in a soft mode for 20 seconds and then for 1 minute for buccal and palatal sides with glycerin gel to avoid the inhibited layer.

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Fig.14
Result after rubber dam removal. We have to wait for the rehydration of the fragment. We also reassure the patient about the injury on the gum caused by the clamp. Last excesses are removed with LM Arte Eccesso. Polishing step is done with goat brush and diamond paste.

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Fig.15
One week later, the fragment is rehydrated and integrated. The patient has no pain and the pulp response to cold test is positive. We can notice that the gum has perfectly healed.

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Fig.16
The occlusal view confirms the perfect integration of the fragment.

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Fig.17
6 months later, the outcome is still good. Pulp is vital. The patient tells us that the teeth is asymptomatic. According to the literature, for uncomplicated crown fracture, the follow-up procedure must be around 6-8 weeks so we can tell our patient that the definitive prognosis for his tooth is good and will last a long time.

Conclusions

In such cases, the best treatment is to seal immediately the “tooth injury” and we have to do our best to complete the treatment in one session in a conservative way.
When we can have the complete fragment, we have the best material to do it.
By using an appropriate method, we will have predictable outcome and we will give back esthetic and function to the tooth.

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
3. Gauthier Weisrock, Jean-Louis Brouillet. Le champ opératoire évidemment. L’information dentaire n° 42 – 3 décembre 2008

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