Biologic restoration: A successful treatment option for immediate esthetics – A case report

INTRODUCTION

Crown fractures mainly in the anterior region are the most common outcome of traumatic injuries. The etiology can be ascribed to falls, motor vehicle accidents, and contact sports.^[1] Out of all the dental trauma injuries, dentoalveolar trauma contributes to about 25%, which may vary from simple crown fracture of enamel and/or dentin to complicated crown root fractures.^[2] Retaining the original tooth segment and its usage for restoring the tooth form and shape can provide better and immediate esthetics, improved function. It also precludes the patient from psychological stress of tooth loss without having to undergo major procedures.

This paper reports successful treatment of an uncomplicated tooth fracture using adhesive reattachment technique.^[3]

CASE REPORT

An undergraduate dental student reported with a fractured crown due to a fall an hour earlier.

She gave no history of previous restoration to the same tooth. The tooth segment was brought stored in distilled water.

Fracture line was extending obliquely up to the middle third of the crown involving enamel and dentin. No intraand extra-oral soft-tissue injuries were noted. Periodontal apparatus was in good physical condition without any mobility.

Pulp sensibility tests were performed for the baseline value assessment of the pulp status using an ice stick. Similarly, it was assessed for adjacent teeth also periapical radiographs were assessed to rule out any root fracture. Subsequently, follow-up was done for 4 weeks to note for any degenerative changes in the pulp.

The clinical and radiographic assessment steered the diagnosis toward an uncomplicated crown fracture. Tooth segment adaptation was evaluated, and decision was made to attempt for reattachment procedure

The prognosis of the reattachment was appraised based on the following parameters: Patient’s esthetic concern, age of the patient, sound adaptation of fractured tooth segment, and the health of the periodontium. The patient was explained about the procedure and written consent was obtained.

Before start of reattachment procedure, oral prophylaxis was done. Tooth segment was disinfected using 2% CHX (STEDMAN Pharmaceutical Pvt. Ltd.). Before the commencement of reattachment procedure, short bevel was placed along the margins of the tooth segment and the tooth portion with a thin tapered diamond point (Dia-burs Mani, Japan).

The tooth was isolated using rubber dam, as improper isolation affects bonding. The tooth remnant and the fragment were etched with 37% phosphoric acid (Scotchbond Multi-purpose etchant, 3M ESPE, USA) for 20 s followed by washing with air/water spray and subsequent drying. Then, a conventional 5^th generation adhesive system (Scotchbond Multi-Purpose Plus, 3M ESPE, USA) was applied over the fragments and cured.

Flowable microfilled composite was placed on the tooth surface and tooth fragment was placed back, firm pressure was applied to improve the adaptation and was light cured for 40 s each on labial and palatal aspects. Excess flowable composite was removed before polymerization [Figure 1].

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Figure 1:

Intraoperative procedure.

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The patient was advised to avoid any excess occlusal loading.

Clinical and radiographic assessment of the traumatized tooth was done at 1 and 3 months interval [Figure 2], but no degenerative changes of pulp or periodontium were observed. Attached segment was assessed for color stability and esthetics.

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Figure 2:

Pre-operative, follow-up 1 month, 3 months, respectively.

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During the follow-up period, slight color change of tooth fragment was noted, but without causing any esthetic concern. Clinical and radiographic assessment revealed healthy pulp and periodontium at subsequent follow-up visit at 1 and 3 months.

DISCUSSION

The newer advancement in adhesive dentistry and flowable resin composites has made reattachment of tooth segment a procedure with predictable restorative outcome, offering a favorable prognosis. However, this technique is limited to use of only intact tooth fragment and when occlusal forces are within physiological limits.^[3] Advantages of tooth fragment reattachment are an immediate esthetically pleasing result, with a perfect shade and translucency match. This technique prevents the patient from the psychological stress of losing tooth, and good clinical satisfaction is achieved due to rerestoration of natural tooth contour and contacts. Tooth segment attachment is an economical option along with immediate esthetic. In the past, different procedures for retaining the tooth segment on the tooth have been advocated, namely, usage of posts, pins, circumferential external bevel of the enamel, undercut preparations within the pulpal chamber, and creating the notch within the enamel. Reports suggest no uniformities in any particular procedure having a better prognosis than the other.^[4]

In the present case, an ultraconservative approach was adopted and the fractured fragments were reattached.

Soon after the trauma, it is advisable to keep the tooth segment hydrated outside the mouth for maintaining natural esthetics and to ensure sufficient bond strength. In the present case, the fractured fragment was preserved in distilled water until reattachment, it improved the esthetics with proper color matching to the natural tooth structure. Biological restoration is minimally invasive procedure for restoring the tooth function and esthetics with minimal sacrifice of the remaining tooth structure.^[5]

Few limitations of tooth fragment reattachment are compromised esthetics in dehydrated tooth segment and discoloration of fracture tooth segment overtime. Such cases require monitoring for a longer period due to failure in the bonded junction since its progressive breakdown leads to separation of tooth segment.

There is no unanimity in the published data concerning the type of marginal preparation and the long-term efficiency in the reinforcement of the tooth after fractured segment reattachment. It has been observed that, beveling enamel surface enhance strength of the tooth, when equated to direct adhesion devoid of any type of preparation.^[6] However, any of these procedure can only reinforce the tooth to certain extend without reaching the initial tooth strength of normal tooth present. Thus, incisal loading is not preferred due to lack of strength.^[5]

There is a constant increase in the esthetic demand among the general population and loss of anterior tooth causes huge impact on person’s well-being, self-esteem, and confidence. Any delay in the restoration of anterior impacts daily routine and has negative psychological effects. Thus, in the present case report, the patient being a dental student had high esthetic demand and concern of peer pressure was factored, hence, option of getting it restored with minimal intervention was considered.^[7,8]

Survival rate varies due to many factors [Tables 1 and 2].^[12-21] According to different studies, Andreasen et al.^[9] in their clinical follow-up of 334 reattached fractured incisors reported 50% and 25% retention after 5 and 7 years, respectively. Another study by Vijayakumaran^[10] that investigated 50 reattached incisor fragments over 5 years showed 80% survival rate. The survival rate in patients treated with biological method of tooth reattachment was reported by Sarapultseva and Sarapultseva^[11] to be 88.9%

In this case report, the fragment was well adapted, so we opted for the use of flowable microfilled composite along with a short bevel to achieve thorough hybridization of the dental tissue.

CONCLUSION

Tooth segment attachment is a minimally invasive procedure with immediate esthetic and it’s not time consuming. This procedure has a predictable long-term prognosis with minimal complication due to advances in adhesive technique. Various factors should be taken into consideration for maximizing the benefits. Thus, this simple procedure is an alternative to the other complex restorative procedure for restoring tooth function, form, and esthetics.

Recent advances in flowable composites can be used for a much more predictable result pertaining to strength and esthetics.