Introduction

Esthetic smile with intact well aligned anterior teeth is important for one’s psychological perception of beauty, self-esteem and confidence. A fractured anterior tooth can be a serious nightmare and shatter one's self confidence. Amongst dental professionals, significant efforts were made in the past to classify "tooth trauma" as seen in tables 1 and 2.¹ The intent of this case report is to focus on clinical education, hence, no further detailed discussion of classifications is aimed through this report. Both permanent and deciduous maxillary incisors are most commonly involved teeth for uncomplicated crown fractures. ^2-7 It is estimated that in children 28%-44% of fractures are uncomplicated crown fractures involving enamel and dentin. ^8-10 With advent of composite resin material and micromechanical bonding in 1960’s there has been a significant drift in the specialty of restorative dentistry. The term micromechanical bond is self-explanatory and is derived from the microscopic resin tags anchoring the etched dentinal tubules providing a successful retention to the composite resin restoration. As early as 1978, it was documented that when the fractured piece of tooth is available, reattachment of the fractured piece has been considered an ideal option to restore esthetics, function, patient’s emotional and psychological status. This was only possible due to a micromechanical bond, i.e. the acid etch bonding technique.^11-17 This technique has significant patient satisfaction ¹⁸ and clinician satisfaction in terms of esthetics, contour, alignment, translucency, surface texture and positioning of the tooth.^19-21 Also, it was noted that the wear rate of the incisal edges was similar to natural teeth, in comparison to any other restorations, leading to more predictable long-term success and final outcome of the procedure ¹⁹. Due to lack of many clinical studies, case reports continue to add to the pool of available relevant literature.¹⁹ Though many researchers have performed studies involving complex retentive features, grooves and chamfers, ^8,22,23 a simple reattachment could be considered an ideal option as per a systematic review by Garcia et al published in 2017.²⁴ However, the complex tooth preparations with grooves, bevels and chamfering technique have shown significant fracture resistance compared to simple bonding.^25,26,27 These complex preparation techniques are discussed in detail in a literature review “Reattachment of fractured teeth: a review of literature regarding techniques and materials” by A Reis et al ²⁸ and is beyond scope of discussion in this case report. As this technique of bonding became popular, there were multiple publications emphasizing the long-term success of such restorations.²⁹ Further research proved that such reattachment techniques would result in long term success if porcelain veneers were a treatment of choice in future, preventing fracture of such reattachment procedures.³⁰  A study by Andreasen FM,Noren JG et al demonstrated long term success of 334 cases of reattachment of fractured teeth followed up over 2 years.³¹  To achieve ideal esthetic outcomes and to rehydrate desiccated dentin, a study suggested leaving fractured piece in filtered water for one week before performing the reattachment procedure (Federal University of Amazonas, Manaus, Brazil (registration CAAE 12200019.0.0000.5020).³² However, outcome of another study stated that rehydration of fragmented piece would happen 2 weeks post restoration providing a good esthetic outcome.¹⁷ As waiting for a week before reattachment is not an ideal option in all scenarios, the procedure was performed immediately taking in to consideration the later study.

Table 1:¹ Andreasens-Andreasen’s classification.

Table 2 ¹: Ellis Daveys classification.

Materials and Methods

A 24-year old male patient came to our clinic for an emergency visit in severe anxiety about his broken front tooth. Our dental assistant triaged the patient and gathered information that the patient is temporarily in town for a wedding and fell forward on his face while walking, which broke his front tooth a day ago. Patient gave no pertinent medical or surgical history. He denied any concussions or fractures that were confirmed through clinical exam. There was a superficial partially healing lip laceration on left side of his lower lip. Patient expressed severe anxiety about his broken tooth with no positive history of pain or discomfort. His concern was about esthetic restoration of the tooth since he has to attend a wedding the next day. He brought in the piece of tooth that fractured from his central incisor in a clear zip lock bag (Figure 3).

After the clinical consult and examination, it was noted that #9 had fractured at the junction of incisal and middle 1/3^rd extending in to dentin without any pulpal involvement (Figure 1). A radiographic prescription was made for an intraoral periapical radiograph of # 9 (Figure 2) and a panoramic radiograph to rule out any fractures of root and alveolar process and the surrounding bony structures. The radiographs ruled out any root or bone fractures. Although 24 hours post trauma is clinically too early to arrive at a definitive pulpal diagnosis; in order to address the patient’s emergent need for restoring the tooth for esthetics, a cold pulp test with endo-ice was performed. With # 9 as the test tooth and multiple other teeth #8, 24, 4, 12 as control teeth, # 9 responded normally to the cold stimulus similar to control teeth, with no signs of reversible or irreversible pulpitis. The broken piece of # 9 was rinsed with normal saline water and left aside to rehydrate.

After thorough investigation and clinical consult, the patient was given treatment options of either a full ceramic veneer OR a full ceramic crown for long term success. However, patient was wanting an immediate temporary solution to attend the occasion he is visiting the town for and declined both treatment options. Patient also insisted that he would like the broken piece of tooth glued back and was not ready to dispose it off. This led to the clinical challenge of a paradox between clinician satisfaction & patient’s request. Once the clinical situation was analyzed, fractured piece of # 9 was positioned against the fractured tooth structure to check for approximation. Surprisingly, there was no missing tooth structure and there was perfect alignment between #9 and the fractured tooth. Hence, the clinical findings were reviewed with the patient and option of a modified technique with direct composite restoration was discussed in order to achieve a potentially ideal esthetic and functional outcome. Informed consent was discussed and patient signed consent forms for having the procedure performed and photographed.

Figure 1: Clinical photograph of fractured #9. Click here to view Figure

Figure 2: Fractured # 9 on periapical radiograph. Click here to view Figure

Figure 3: Fractured segment brought by the patient. Click here to view Figure

Procedure

As an initial step, muco-gingival junction of # 9 was dried with gauze and 20% Benzocaine Advance topical anesthetic gel was applied for a complete minute. Patient was anesthetized with one carpule 2% Lidocaine with 1:100000 epinephrine as local infiltration. Positioning of the fractured piece of # 9 on to the fractured surfaces of #9 was reanalyzed and verified. Once the anesthetic was effective, all maxillary anterior teeth were isolated and retracted with cotton rolls. All surfaces of # 9 were dried using three-way/air water syringe. Fractured surface areas on both the tooth and fractured piece were etched with 37 % phosphoric acid for 20 seconds (Figures 4, 5) Selective etch technique was used, etching only the cavosurface margins to prevent post op sensitivity. Universal Bonding Agent Prime & Elect universal adhesive was applied on both surfaces and the fractured piece was approximated to the fractured # 9 to perfect alignment. # 9 was light cured for 20 seconds each on facial and lingual surfaces using DENTSPLY Smart Lite Focus curing light. Note that no bevels were placed during initial bonding as that could challenge proper alignment of the fractured surfaces. The fractured piece was secured to #9 at this point (Figure 6). Shade of composite was selected to the closest as A3. Four retention grooves 1mm deep and 3 mm inciso-cervically, similar to depth orientation grooves were placed on the facial and lingual surfaces of # 9 across the fracture line using a chamfer diamond bur. Then, enamel bevels were placed using a flame shaped diamond bur on both facial and lingual surfaces to achieve flushed margins of the final restoration. Mylar strips were placed on both mesial and distal surfaces and were secured with wedges to prevent bonding agent from flowing on to adjacent teeth. All prepared surfaces were etched with 37 % phosphoric acid for 20 seconds. Once the etch was thoroughly rinsed, it was verified that all etched enamel surfaces had chalky white appearance. Universal Dentin bonding agent was applied and thinned out by spraying air gently. Dentin bonding agent was light cured with DENTSPLY Smart Lite Focus curing light for 20 seconds and incremental buildup of composite restoration was completed using DENTSPLY TPH Low Viscosity Shade A3 composite resin. The Mylar strips and wedges were removed. All excess flash was removed with a flame shaped diamond bur. The Restoration was finished with diamond burs of various grits and a flame shaped white Arkansas stone. Final polishing was done using diamond polishing paste. Occlusion was checked both in centric and excursive motions. Relevant adjustments were made to the composite restoration to conform to normal occlusion. The final restoration was left out of occlusion due to high risk of fracture. All isolating materials were removed. Patient was given a hand-held face mirror to verify the appearance of the outcome. Patient was immensely happy and grateful with the outcome (Figures 7, 8).

Follow up – Patient was followed up 36 months post procedure. As mentioned in the history of presenting illness, patient was in town visiting for a wedding when the clinical situation was addressed. Patient was contacted through a phone call and a telephonic interview was conducted. Patient stated he was very satisfied with the outcome of the procedure and reported no adverse outcomes or follow ups with any other dentists post procedure. No clinical photographs could be documented as patient lives in a different geographic location and patient has no plans to travel for a follow up appointment.

Drawbacks in this case report – It would be ideal to have photographic documentation during follow up visits. Due to the unique personal situation, timing and geographic location, such documentation could not be completed.

Figure 4: Selective etch technique of #9. Click here to view Figure

Figure 5: Etching of fractured segment Click here to view Figure

Figure 6: #9 with secured fragment in place. Click here to view Figure

Figure 7: Final restoration before polishing. Click here to view Figure

Figure 8: Final restoration after polishing Click here to view Figure

Conclusion

In a clinical situation with conflict between a Dentist’s treatment plan and patient’s expectations, an innovative resolution can be made by thinking out of the box and empathizing with the patient’s concerns, while staying within the ethical boundaries of care. A literature review would always be helpful to make a final decision. So far, the available literature has showed that both the simple reattachment techniques and the procedure with complex preparations have comparable success. Here, we have utilized a hybrid modified technique of initial simple reattachment followed by additional groove placement to buttress the fracture line and provide care with predictable long-term success. This additional preparation is instrumental in restoring the fracture strength of the tooth. Every clinical situation is unique and several factors decide what material or technique could be used for treatment. Hence, the combination of thorough research and clear communication regarding relevant applicable treatment options with the patient, followed by the clinician’s expertise can achieve a successful outcome of the planned treatment.

Acknowledgement

This would not have been possible without support of our wonderful dental assistants Ms. Mary Grace Hilario and Ms. Tonja Messer. No funding was received for presenting this case report.

Conflict of Interest

The authors declare no competing interest.

References

1. S,c, Ahila. (2011). 10 manikant
2. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J. 2000;45:2–9
   CrossRef
3. Sharmin DD, Thomas E. Evaluation of the effect of storage medium of fragment reattachment. Dent Traumatol. 2013;29: 99–102
   CrossRef
4. Glendor U. Epidemiology of traumatic dental injuries – a 12 year review of the literature. Dent Traumatol. 2008;24:603–11
   CrossRef
5. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg. 1972;1:235–9
   CrossRef
6. Lam R. Epidemiology and outcomes of traumatic dental injuries: a review of the literature. Aust Dent J. 2016;61:4–20
   CrossRef
7. Lamilton FA, Hill FJ, Holloway PJ. An investigation of dento- alveolar trauma and its treatment in an adolescent population. Part 1: the prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J. 1997;182:91–5???????
   CrossRef
8. Garcia FCP, Poubel DLN, Almeida JCF, et al. Tooth fragment reattachment techniques: a systematic review. Dent Traumatol. 2018;34(3):135-143???????
   CrossRef
9. Kirzioglu Z, Ozay Erturk MS, Karayilmaz H. Traumatic injuries of the permanent incisors in children in southern Turkey: a retrospective study. Dent Traumatol. 2005;21:20–5
   CrossRef
10. Kargul B, Caglar E, Tanboga I. Dental trauma in Turkish children, Istanbul. Dent Traumatol. 2003;19:72–5
    CrossRef
11. Marder C. Restoration of a fractured anterior tooth. JADA 96 (1):113-115, 1978
    CrossRef
12. Tennery TN. The fractured tooth reunified using the acidetch bonding technique. Texas Dent J 96 (8):16-17, 1978
13. Mendes L, Laxe L, Passos L. Ten-year follow-up of a fragment reattachment to an anterior tooth: a conservative approach. Case Rep Dent. 2017;2017:2106245. doi:10.1155/2017/2106245
    CrossRef
14. Nagaveni NB, Bajaj M, Lobo N, Poornima P. Treatment regime for crown fractures: autogenous tooth fragment reattachment—case reports. Int J Dent Oral Health. 2015;1(6):1-3. doi:10.16966/2378-7090.136
    CrossRef
15. Lo Giudice G, Alibrandi A, Lipari F, et al. The coronal tooth fractures: preliminary evaluation of a three-year follow-up of the anterior teeth direct fragment reattachment technique without additional preparation. Open Dent J. 2017;11(1):266-275. doi:10.2174/1874210601711010266
    CrossRef
16. Pathan ML, Gaddalay S. Reattachment of anterior teeth fragments: a case report. Int J Appl Dent Sci. 2017;3(2):101-103
17. Bozkurt FO, Demir B, Erkan E. Reattachment of dehydrated teeth fragments: two case reports. Niger J Clin Pract. 2015;18(1):140-143
    CrossRef
18. Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of success in the reattachment of coronal fractures. Dent Traumatol. 2008;24: 151–8
    CrossRef
19. Andreasen FM, Norén JG, Andreasen JO, Engelhardtsen S, Lindh-Strömberg U. Long-term survival of fragment bonding in the treatment of fractured crowns: a multicenter clinical study. Quintessence Int. 1995;26(10):669-681
20. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28:02–12
    CrossRef
21. Bruschi-Alonso RC, Alonso RCB, Correr GM, Alves MC, Lewgoy HR, Sinhoreti MAC et al. Reattachment of anterior fractured
22.  de Sousa APBR, França K, de Lucas Rezende LVM, et al. In vitro tooth reattachment techniques: A systematic review. Dent Traumatol. 2018;34(5):297-310
    CrossRef
23. Panchal D. A case report of uncomplicated crown fracture: tooth fragment reattachment.  Br Dent J. 2019;227(4):259-263
    CrossRef
24. Garcia, F. C. P., Poubel, D. L. N., Almeida, J. C. F., Toledo, I. P., Poi, W. R., Guerra, E. N. S., & Rezende, L. V. M. L. (2018). Tooth fragment reattachment techniques-A systematic review. Dental Traumatology, 34(3), 135–143. https://doi.org/10.1111/edt.12392
    CrossRef
25. Brambilla GPM, Cavallé E. Fractured incisors: a judicious restorative approach – part 1. Inter Dent J. 2007;57:13–8
    CrossRef
26. Reis A, Francci C, Loguercio AD, Carrilho MR, Rodriques Filho LE. Re- attachment of anterior fractured teeth: fracture strength using different techniques. Oper Dent. 2001;26:287–94
27. 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;27:15–8
    CrossRef
28. Alessandra Reis, Alessandro Dourado Loguercio, A. Kraul, & E. Matson. (2004). Reattachment of fractured teeth: a review of literature regarding techniques and materials. Operative Dentistry, 29(2), 226–233.
    https://pubmed.ncbi.nlm.nih.gov/15088736/
29. 1994. 21. Andreasen FM, Daugaard-Jensen J et al. Reinforcement of bonded crown fragments with porcelain veneers. Endod Dent Traumatol 7(2):78-83, 1991
    CrossRef
30. DiAngelis, A. J. (1998). Bonding of Fractured Tooth Segments: A Review of the Past Twenty Years . CDA Journal , 26, 753–756. https://doi.org/October 1998
    CrossRef
31. Andreasen FM,Noren JG et al. Long-term survival of fragment bonding in the treatment of fractured crowns: a multicenter clinical study. Quintessence Int 26 (10):669-681, 1995
32. Santos Silva, J. dos, Cohen - Carneiro, F., Medina, P. O., de Queiroz, A. C., de Queiroz Herkrath, A. P. C., & Pontes, D. G. (2021). Clinical and Subjective Success of Tooth Fragment Reattachment: a Case Series, (Nov/Dec 2021), 18–23. https://doi.org/NOV/DEC 2021