Tooth Fragment Reattachment
An Alternative for Restoration of Fractured Anterior Teeth
Luiz N. Baratieri, CD, MS, PhD
Fractures of the maxillary anterior dentition occur with increasing frequency, particularly in the teenage population. The extent and complexity of such fractures depend on the nature and intensity of the trauma and the characteristics of the involved tooth, such as periodontal support, degree of facial protrusion, quality and quantity of sound tooth structure, and endodontic health. Fractures may be simple and contained in the enamel, although the percentages vary among regions (64.8%1; 58%2; 73.9%3); or they may be complex, involving dentin and pulp and extending into the critical area of the “biological width” (6.4%1; 9.7%2; 7.2%3).
Fractures of the anterior teeth can be transverse, oblique, or longitudinal. The tooth fragment may be completely separated from its original site, or it may be retained in position by the junctional epithelium and connective tissue or even by the tooth remnant itself, as is the case in incomplete fractures.
Treatment options for fractured anterior teeth depend on factors such as fracture extension, pulpal involvement, periodontal involvement, aesthetic compromise, and functional compromise. The treatment may involve simple maintenance without restoration4 or may require extraction of the tooth remnant and placement of an osseointegrated implant or fixed prosthesis. The biocompatibility of current advanced adhesive technology (eg, the total acid etch technique—enamel/dentin/pulp—and the current resin adhesives) allows the application of solutions in direct contact with the pulpal tissue4-18 and the periodontal ligament,4 as required in the reattachment of fractured tooth fragments. The treatment options provided by these advanced adhesive systems include:
- Fragment reattachment.
- Direct adhesive restoration.
- Indirect adhesive restoration.
- Root coverage and fabrication of a fixed prosthesis.
- Extraction and placement of an osseointegrated implant or a fixed prosthesis.
- Indefinite retention of the unrestored fractured tooth with the fractured edges contoured, smoothed, and polished.
Factors to Consider in Selecting a Treatment
Availability of the Tooth Fragment
Reattachment can be considered a treatment alternative only when the fragment has been preserved following the fracture. In some cases, the fragment does not separate completely from the fracture site and is retained in position by the existing connective tissue.
Usability of the Tooth Fragment
The availability of the fragment does not necessarily indicate that the reattachment to the tooth remnant is indicated. To perform the reattachment with a predictable prognosis, several requisites must be achieved:
- The fragment must be adaptable to the remaining tooth, ie, the loss of tooth structure must not be so extensive that it would prevent adaptation of the fragment.
- The fragment must exhibit sufficient sound tooth structure.
- The fragment and the remaining tooth must demonstrate color compatibility and dental composition to prevent aesthetic compromise. When a darkened or widely restored tooth suffers fracture, it is advisable to select a full-coverage restoration that is capable of solving the color disharmony and treating the fracture simultaneously.
- The fragment must exhibit sufficient size and dentin involvement. Minute fragments (eg, enamel fractures without dentin involvement) are not indicated for reattachment.
- Multiple fragments may render reattachment unpredictable or impossible. A “reassembling” of the components is required prior to reattachment.
- The fragment must be sufficiently hydrated. When a fragment remains out of either the intraoral environment or an adequate wet medium (water, saliva, milk, etc.), dehydration may alter the biostructural characteristics of the fragment.
The extent of the overbite involving the incisive function determines the extent of the reattachment challenge and the restoration of the fractured tooth. The occlusal force on the fragment/adhesive restoration/remnant ensemble is extensive and may introduce failure at the reattachment line. Such cases require full-coverage restorations, with or without the use of intracanal posts for retention of the coronal restoration.
In the evaluation of the degree of exposure of the reattachment, the lip line has to be examined and its influence on dentofacial aesthetics considered. A lower lip line can conceal the fragment reattachment line, and, when the advantage of reattachment (a conservative restoration) is presented, even patients with a high lip line generally accept the conservative treatment.
Type and Extension of Fracture
A fracture extended to the apical aspect presents a greater challenge when restoring the tooth, either by reattachment of the fragment or by the direct/indirect restorative procedures required. Vertical coronoradicular fractures generally require tooth extraction. Slanted fractures, in which the apical extremity reaches the bone crest level or extends slightly below it, can be considered for reattachment.
Eruptive Stage of a Fractured Tooth
If a dental fracture occurs in a child, the eruption chronology of the patient’s permanent teeth must be observed. In cases where the eruption of an anterior tooth has not been completed, coronary fractures can extend on a subgingival level, or even to bone crest level, creating a “false” invasion of the biological width. It is “false” since the dentogingival complex is not yet defined, permitting the supragingival positioning of a subgingival fracture line upon the completion of spontaneous dental eruption. Therefore, even in cases where the tooth fragment is recovered and a successful reattachment can be anticipated, it is advisable to wait for the definitive eruption prior to the initiation of the definitive treatment. A provisional restoration can be fabricated to protect the dentin/pulp complex, maintain the mesiodistal and interocclusal space, and impart a natural appearance. In such cases, the fragment can be optimally preserved by freezing it in water.
Age of the Patient
It is more important to institute noninvasive procedures for younger patients. Fractures, including those with enamel and dentin involvement, can remain unrestored, as long as no pulpal or periodontal compromise has occurred. The sooner the young patient is introduced to the restorative cycle, the sooner this restoration will require replacement. With a recovered and reattachable fragment, reattachment is the optimal treatment alternative. The procedure is simple, time-effective, and does not require the use of rotary instruments.
Since aesthetics is a subjective factor, the degree of aesthetic requirement varies among patients. It is important to form a clear perception of a patient’s demands and expectations of the definitive aesthetics of a restoration. This information directs whether a reattachment, a direct adhesive restoration, or an indirect ceramic or composite resin restoration should be selected.
Patient’s Time and Resources
There are instances when the clinician is forced to select a treatment to suit the patient’s financial resources and the availability of time. It is not sufficient to select an aesthetically, biologically, and functionally appropriate treatment option; the option must also be suitable for realistic implementation.
Advantages and Disadvantages of Reattachment Treatment Techniques
Utilization of reattachment techniques provides the patient and the clinician with the following benefits:
- Optimal aesthetics may be attained, since reattachment of a tooth fragment is the optimal method to reinstate the original shape, contour, surface texture, alignment, and color of the tooth.
- Aesthetic results are more lasting than those accomplished with composite resin materials. Only a small amount of composite resin is exposed on the facial surface, and the enamel of the fragment exhibits the same smoothness and brightness as the enamel on the coronary remnant.
- Function is more readily reinstated and maintained with a reattachment than a composite resin restoration, since anterior guidance is maintained. The wear of the reattached tooth is similar to that of intact adjacent dentition.
- In the majority of cases, reattachment is a simpler and more efficacious procedure than resin or porcelain restorations.
- The positive emotional and social factor, particularly in children, is also provided by the reattachment procedure.
When electing to perform reattachment techniques, the clinician must consider the following complications of the treatment:
- The fragment can be reattached in an improper position.
- The potential of debonding exists, particularly in children and patients with marked overbite, severe incisive function, extensive fracture, or parafunctional habits.
- The fragment may fail to recover the original color, creating an aesthetic compromise, and the attachment line may exhibit a color shift following reattachment therapy.
Fractured Anterior Teeth Involving the Biological Width
The biological width is an area in the dentogingival complex that institutes and maintains the physiological balance of the epithelial junction and the connective tissue. It encompasses the tooth structures present in the cementoenamel junction, the area coronal to the bone ridge, and reaches the base of the gingival sulcus (Figure 1). This space measures 2 mm to 2.5 mm and remains
constant throughout an individual’s life, as long as no structural alterations occur.19
The clinical importance of an intact biological width is in the maintenance of periodontal health. When this space is violated (due to carious lesions, cavity preparations, or dental fractures), the balance is disturbed, resulting in periodontal inflammation and irregular and progressive resorption of the bone crest. There is no natural compensation for such invasion. Once the biological width is compromised, a surgical correction must be performed to restitute the area.
Once the biological width has been compromised by a fracture in an anterior tooth, the condition must be accurately diagnosed and the treatment correctly directed. Enamel/dentin fractures, with or without pulp exposure and with invasion of biological width, are exceptionally challenging. They represent 4.3%20 to 10%2 of the cases presented to dental practices, are the most difficult to treat, and require an interdisciplinary approach for the achievement of a successful restoration. Invasion of biological space can occur on a coronal or apical level, or even at the same level as the bone crest. The more apical the compromise, the more difficult it is to restore the tooth.
Invasion of the biological width may occur without pulp exposure, and the exposed vital dentin can be
protected if a base material or an adhesive composite resin system is used; however, the pulp is generally involved. The clinician has to determine whether to maintain the exposed vital pulp, employing a conservative treatment, or to sacrifice the pulp and perform the endodontic treatment. Treatment options for fractures involving biological width include4:
- Flap surgery to restitute biological width with either reattachment of fragment, direct adhesive restoration using composite resin materials, or indirect adhesive restoration using porcelain or a composite resin at a subsequent appointment.
- Flap surgery, osteoplasty, and subsequent adhesive restoration (fragment reattachment or utilization of composite resin at the same appointment).
- Flap surgery (without osteoplasty) to gain access to the fracture margin (a fracture coronal to the bone crest) with subsequent reattachment of the fragment (even where biological widths have been compromised at the same appointment.
- Fragment reattachment without flap surgery.
- Root extraction and subsequent use of an adhesive fixed prosthesis or dental implant.
- Root coverage and adaptation of an adhesive or a conventional prosthesis.
- Partial extrusion of the root to restitute biological width, with subsequent restoration of the tooth.
- Fragment reattachment or composite resin restoration to protect vital dentin and exposed pulp, pending tooth eruption and subsequent restoration.
- Extrusive luxation of tooth remnant to gain access to fracture margin, reattachment of the fractured fragment, and repositioning of restored tooth in the socket.
The selection of the most appropriate treatment option depends on the degree to which the biological width has been compromised, and the fracture direction (transverse, oblique, or longitudinal). Only fractures with an invasion coronal to the bone ridge, on the same level or slightly below the bone ridge, have a favorable prognosis.
In fractures causing a longitudinal or oblique line, with the apical extremity at the mean third of the root, the restoration of the tooth is nearly impossible. Transversal fractures on the mean third of the root or on its apical third should be retained for a period of observation, since the coronal segment may be maintained free from intervention as long as it has not been dislodged.
The aspect of the biological width invasion (facial, proximal, or palatal) and fragment adaptability, once the fragment is dislodged or held in the fracture site by the periodontium, are important factors. If the compromise can be classified by the prescribed requisites, a smaller circumferential extension of invasion will have a more favorable chance of recovery without significantly compromising tooth aesthetics and structural stability. Facial invasions are easier to access than those on the lingual and palatal aspects.
Presence of pulp exposure is another decisive factor. In trauma, the pulp is exposed to the intraoral environment for a period of time, and the tissue contacts potentially pathogenic bacteria. Upon exposure, the pulp becomes covered with a layer of fibrin. An area of acute inflammation can be observed immediately below the exposure site. Two days subsequently, proliferative alterations occur, resulting in the protrusion of pulp through the exposure site. The inflamed area extends 1 mm to 2 mm beyond the pulp surface following 1 week of exposure.21 Therefore, care is required from the clinician when opting for conservative treatment of pulps exposed to the oral medium. The repair potential of pulp tissue has not yet been fully determined. Although direct pulp capping with adhesive systems is a controversial technique, reports exist of successful clinical cases with direct adhesive restorations on vital teeth where the pulp had been exposed for several days.4 Such potential for repair appears to be greater in young patients and in cases when trauma does not induce perialveolar lesions. Pulp repair potential is considerably greater in teeth with an incompletely formed apex. In these circumstances, the traditional endodontic treatment becomes quite complex, due to the difficulty in determining an apical stop.
A 15-year-old male patient presented with a fracture of tooth #9; the same tooth had been fractured 1 year previously (Figures 2 and 3). Clinical examination revealed a fracture with subgingival extension into the facial region (Figure 4), where a portion of the gingival tissue was inflamed and hyperplastic, and the pulp chamber and canal openings had been partially sealed with debris and a base material (Figure 5). In attempting to adapt the coronal fragment (Figure 6), gingival ischemia was found at the facial aspect, indicative of tissue hyperplasia (Figure 7). The initial periapical radiograph revealed no pathological complication and a strong indication of decalcified barriers at the canal opening.
Upon inquiry of the procedures performed following the initial fracture, it was learned that a pulpectomy had been completed, followed by pulp capping with
calcium hydroxide paste and reattachment using a restorative composite resin system. Once the patient’s history was recorded, diagnostic evaluation was performed. The tooth responded positively to vitality tests, and the adaptation between fragment and tooth remnant was excellent. Considering the age of the patient, it was determined to attempt reattachment.
A flap surgery was planned to permit access to the gingival margin of the fracture. The preoperative treatment plan also required adaptation of the fragment for reattachment, and avoidance of excess material at the cervical region. Using a #15 scalpel blade, an intrasulcular incision was made from tooth #10 to #8 (Figure 8). The incision was modified at tooth #9 to include the removal of a small band of hyperplastic gingival tissue that impinged on the coronal region (Figures 9 and 10). A facial flap was dissected, and the bone ridge was exposed at the facial aspect of tooth #9 (Figure 11). Invasion of the bone ridge was confirmed. The fracture line was located 1 mm from the ridge (Figure 12). Using a Wedelstead chisel, a discreet osteotomy/osteoplasty was performed at the region of tooth #9 only (Figure 13). A rubber dam was applied and retained in position by a clamp (Figure 14). The coronal fragment was placed into position, and its adaptation on a cervical level observed (Figures 15 and 16).
Once the treatment site was isolated by the rubber dam, a 37.5% phosphoric acid gel was applied for 15 seconds to the enamel and the dentin. The “calcified barrier” was also etched. A plastic strip was utilized to protect the adjacent teeth from the etchant (Figure 17). The etchant was removed with a 30-second air-water spray, and the surface was maintained in a slightly moist state to prevent dehydration. Multipurpose primer was subsequently applied over the dentin surface (Figure 18). Compressed air was utilized to remove the excess of water and primer. Following the removal of the excess primer, a multipurpose adhesive was applied to the treatment site, although it was not polymerized at this stage of the reattachment procedure (Figure 19). The fragment was prepared in a similar fashion (Figure 20).
Following the completion of the etching process, a small increment of composite resin was applied to the pulp chamber region (Figure 21). The tooth fragment was filled with a minute layer of composite resin and positioned on the reattachment site (Figure 22). The excess composite resin material was removed with an explorer (Figure 23).
The light-curing unit was positioned on the lingual aspect and the tooth was irradiated for 60 seconds. The margin area was finished utilizing a flexible disc system. The gingival flap tissue was subsequently repositioned and stabilized with sutures, and the incisal aspect was corrected with a round diamond point to remove ancillary composite resin material from the tooth remnant and the fragment (Figures 24 and 25).
The incisal function of the patient was verified to ensure balanced contact between the central incisors and the anterior mandibular dentition (Figures 26 and 27). Seven days following the reattachment of the tooth fragment, the fragment was rehydrated (Figure 28). The patient was periodically recalled for clinical and radiographic evaluation of the site (Figures 29-30-31). The soft tissue healing and the integration of the tooth fragment were determined to be adequate, and the patient was pleased with the aesthetic and functional result of the reattachment procedure.
Due to the adhesive potential of advanced composite resin materials and dental adhesive systems, tooth reattachment has become a more comfortable and safer procedure in recent years.22-28 Since these adhesive materials can be applied directly to vital dentin and the exposed pulp surface, the procedure has been simplified. The use of base materials between the remnant and fragment requires a provision of a space, requiring abrasion of either the tooth fragment, the remnant, or both.
The biological width acts as a circumferential histophysiological barrier located in the dentogingival region. Any interference in the relationship between the junctional epithelium and connective tissue elicits a chronic inflammatory response. Histologically, a resorption of the bone ridge can be observed, with apical migration of connective tissue and junctional epithelium.29 Whenever the biological width is compromised due to restorative procedures, caries, or a fracture, the consequences include persistent gingival inflammation, gingival sensitivity to mechanical stimuli, gingival resection, and formation of periodontal pockets. There are two basic methods utilized to correct usurpation of biological width — orthodontic tooth tractioning and periodontal resectional surgery (enlargement of the clinical crown). The objective of these treatments is to reinstate the normal physiological relationship between the preparation/restoration margin and the alveolar bone ridge at the dentogingival union area.
The case presented exemplifies an invasion of biological width due to a fracture of an anterior tooth of a young patient. In such cases, the compromise is generally limited to only one surface of the tooth, often restricted to no more than a small extension on that surface. Correction of biological width involves only the invaded area, applying a localized osteotomy that does not extend to the adjacent teeth, the proximal areas, or the palatal aspect of the tooth involved. However, this procedure is possible only in patients with adequate plaque control, who demonstrate low risk of periodontal disease. In addition, tooth fractures in such patients must cause only a localized invasion of the biological width, and must not reach the infraosseous level.4
In cases where the biological width has been invaded without infraosseous compromise, apicoplasty is another treatment alternative. It seeks to reposition the fracture margin (to be involved at restoration) on a level that is more coronal and compatible with the biological width. A new periodontal protection is formed at the apical region that has undergone surgery, reinstating the histophysiological balance between structures. Advantages of these conservative approaches include aesthetics and a minimal surgical trauma. Utilized in combination with recent advancement in adhesive technology, this treatment represents a useful alternative for the restoration of fractured teeth in the anterior region.
*Professor, Operative Dentistry, CCS/STM, Federal University of Santa Catarina, Florianopolis, Brazil.
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