One of the most common place emergency patients who walk into a dental clinic are patients with fractured anterior teeth. If the accident is not severe enough to cause a bony fracture but leads to only tooth damage, the role of the dentist becomes very important. Dr. Mona Kakar brings to you a very detailed management of this situation.

RESTORATION OF FRACTURED ANTERIOR TEETH

Trauma to the anterior teeth is a common enough occurrence. The resultant manfestations are not a pleasant sight to behold: discoloured teeth due to pulp damage, intrusion, extrusion and even total luxation of the teeth and broken or fractured teeth. As neither of these is a desirable manifestation, management of different situations becomes a must so as to restore the patient to normal function and looks as soon as possible. The mental trauma alleivated in such situations is beyond compare, even though the physical discomfort is relieved as well. A particular challenge is the restoration of fractured segments to match form and color so as to be indistinguishable from the real thing.

If a fractured tooth or teeth presents at a practice (especially the typical incisal half or third of the tooth), the first thing to enquire about, even before the preliminary history, would be about the fractured fragment or piece of the broken tooth, since it often is a valuable item and can often be re-attached to the tooth as if it had never broken. If the piece has not been brought in, a scouting of the site of trauma for the missing piece/s is in order.

One such patient presented herself one morning and was extremely distraught: a pretty looking teenaged girl who had tripped and fallen face down at her college. Examination revealed the upper two central incisors fractured in an angular fashion, involving the incisal half of one and the incisal third of the other. The right central incisor had an obvious pulp exposure. The left one was fractured just short of the pulp. Tissue trauma was also noted, however, it was nothing that required active intervention other than a thourough debridement and antiseptic swabbing; this was promptly carried out while eliciting the details of the trauma and calming the distressed patient. The parents were also dispatched to the site of the fall to hunt for the missing pieces of tooth.

One large, and several other tiny tooth pieces were retrieved from the site, brought back to the clinic, cleansed and disinfected. The large piece was the only one that fitted perfectly over the fractured left central incisor. The other pieces were too fragmented to be of any help, and were discarded. The reattachable piece was stored in saline solution and the patient was prescribed anti-inflammatory tablets and recalled after a couple of days so that the soft tissue inflammation would have subsided.

Treatment Plan: It was established that the right central incisor would definitely require endodontic treatment. The salvaged fragment of tooth was to be reattached on the day the Endodontic treatment was scheduled for the right central. Subsequent to that, an appointment was scheduled for build up of the right central to match the left. The build up appointment was scheduled four days after the Reattachment appointment so that the reattached tooth would have had sufficient time to get rehydrated in the oral environment and proper matching of form and color would be possible. Also, enough time would have elapsed to determine whether or not the left incisor required Endodontic intervention.

Endodontic treatment was performed for the right central incisor under infiltration local anaesthesia, after two days of the initial visit. Having been reassured that her teeth would be as good as before in a few days time, the patient was in a much better state of mind than on the day of trauma. The left tooth had begun to feel a bit tender and the patient was warned that Endodontic intervention might be necessary for this tooth as well. This visit was the scheduled one for reattachment of the fractured segement of the left incisor as well.

The fractured segment was prepared: A small groove was made on the face of the fragment which was to adhere back to the base tooth, from mesial to distal, to increase surface area for bonding. The to-be-adhered surface was also subjected to microetching with aluminium oxide particles. Etchant was then applied to the surface for fifteen seconds, washed, dried and Bond1 single step bonding agent (acetone based) was applied. After a waiting period of 30 seconds for the bonding agent to soak, the surface was gently dried and light cured for 20 seconds.

Next, the fractured surface of the tooth was prepared. Under rubber dam isolation and infiltration anaesthesia, the surface was similarly microetched, then etched with phosphoric acid gel, washed, dried, Bond 1 bonding agent applied and light cured. The closest matching base paste of a resin-based dual cureable cement was selected and carefully flowed into the groove of the fragment and spread on the remaining surface liberally. A small portion of the same paste was smeared on the prepared surface of the base tooth as well. The fragment was aligned and gently seated back on to the base tooth. The excess material was wiped off and since it was not auto or dual-cured, plenty of time was available to mke minor adjustements on the alignment. These adjustments were made by sliding the fragment on the base tooth without detaching at any point of time. This care is to ensure no entrapment of air between the two parts. The fragment was held firmly in place and the joint subjected to light curing for at least 90 seconds: 30 seconds each from the labial, palatal and incisal aspects in that order.

The exposed surfaces of cement were then trimmed and polished with polishing burs and silicone tips. The fragment was obviously distinguishable from the base tooth due to the difference in hydration levels. The patient was reassured that the piece would blend in within a couple of days. It was observed that the base paste was also distinguishable and would require adequate masking later.

The patient was then recalled after four days, the visit being scheduled for the build up of the right central incisor. The tenderness of the left incisor was very pronounced: Endodontic intervention was mandatory, and undertaken immediately. The attached fragment did not hinder the Endodontic therapy in any way; the access was made in the routine fashion and the treatment completed in the same visit. The rehydration of the reattached fragment was noticeable and aside from the luting agent, the fragment was well blended with the remainder of the tooth structure. Next, the right central incisor was built up with directly placed light cured composite.

A very broad bevel was made from the fracture line towards the cervical third of the tooth, on the labial surface. The purpose of the bevel is two-fold: providing a larger enamel surface area for bonding, and most important, aid in the blending of the composite material with the base tooth colour. The Endodontic access cavity was emptied and the remaining fractured surface roughened with a coarse diamond bur. This prepared area was etched with phosphoric acid for 15 seconds, washed and then dried (not dessicated). Bond1 single step bonding agent was applied to the etched surface. After 30 seconds of soak time, the bond layer was gently dried and light cured for 20 seconds on the labial and 20 seconds from the incisal. A mylar matrix strip was inserted between the two central incisors to prevent bonding them together.

The composite buildup was done, by adding material of appropriate shades in increments. A backing of opaque white material (such as the Pearl Snow shade from Ultradent Products Inc.), was made first, to provide a neutral backdrop against which the proper tooth shades could be applied. The palatal side of the build up was done with this material. The access cavity was filled with the body shade composite material (such as the A3 shade of Clearfil APX from Kuraray Co.). This same shade was then applied in layers in such a way as to simulate the dentin layers of the tooth. The material was made to overlap the border between the broken face and the bevel and extend most of the way into the bevel. The incisal quarter was then blended with the A2 body shade, into which was incorporated the tiny indents to create the mammelon pattern mirrored from the adjacent tooth fragement. The final quarter millimetre of material thickness was completed with a transparent material to recreate the enamel translucency, especially at the incisal edge (such as the TransIce shade from Ultradent Products Inc.). The build up was viewed from all angles and detailed attention was paid to developing the same surface irregularities, shape and outline form as seen on the adjacent central incisor.

One more visit was scheduled, during which the access cavity of the left central incisor was sealed with light cured composite and the distinguishable luting agent was masked. Here, a shallow, wide, V shaped groove was made on the labial surface with the centre on the distinguishable luting agent line. The groove in totality was at least 4 mm wide incisocervically and 1.5 mm deep labiopalatally. Here again, the opaque white material wa laid at the very bottom of the groove and the remaining groove layered with A3, A2 and transparent shades as done in the built up incisor. The trimming, finishing and polishing for both teeth were undertaken with diamond polishing burs and silicone wheels and tips. Interdental polishing was achieved with polishing strips.

The patient was extremely satisfied with the result and the radiant smile that followed spoke volumes about the restoration of confidence. Build ups of fractured teeth is indeed an area of finesse. The restoration of the tooth with attention to the minutest of detail is imperative if a satisfactory visual result is to be achieved along with restoration of function. In today's day and age of Bondodontics, rare is the situation where the fractured tooth has to be sacrificed still further for the fabrication of a Jacket Crown as in the days gone by. A slight roughening of the surface to enhance bonding, a bevel here and there is all the tooth reduction that is needed. The results are achieved much faster without the need for laboratory work.

A few other fractured incisor build ups with directly place composite are presented:

1. Raju Bajaj: A fourteen year old boy who had a fall from a bicycle chipped the angle of his upper central incisors. No Endodontic intervention was necessary. The teeth were built up in one visit.
2. S. Prasanna: A sixteen year old boy had had a fall during childhood and was now desirous of gettng his fractured upper central incisor repaired. The tooth was vital and asymptommatic. One sitting was required to build up the missing portion with composite resin, matching the adjacent central incisor shade, translucency and form.>
3.Mohan: A 25 year old male reported fracture of his upper central incisor during childhood; no endodontic damage noted. The tooth was matched to the adjacent central incisor in one visit.