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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 70-74

Conservative treatment of traumatic crown fracture extending into cementum by glass post aided adhesive bonding of autogenous tooth fragment: A report of two cases

Department of Conservative Dentistry and Endodontics, Dr. ZA Dental College, AMU, Aligarh, Uttar Pradesh, India

Date of Submission11-Jan-2020
Date of Decision18-Feb-2020
Date of Acceptance01-Apr-2020
Date of Web Publication20-Jun-2020

Correspondence Address:
Sharique Alam
Department of Conservative Dentistry and Endodontics, Dr. ZA Dental College, AMU, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_3_20

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Advancement in the adhesive system has made fragment reattachment a viable treatment option for treating tooth fractures. It offers a simple and conservative technique to restore esthetics and function. Reattachment of a completely disjointed crown may need additional fiber post retention due to the greater functional load borne by the fragment. This article reports two cases of complicated crown root fracture managed by utilizing fiber post to reattach the disjointed crown fragment. The reattached fragment has shown reliable retentivity and periodontal health at 1-year follow-up.

Keywords: Crown reattachment, crown root fracture, dental trauma, fiber post

How to cite this article:
Saha B, Alam S, Mishra SK, Mahore D. Conservative treatment of traumatic crown fracture extending into cementum by glass post aided adhesive bonding of autogenous tooth fragment: A report of two cases. J Dent Res Rev 2020;7:70-4

How to cite this URL:
Saha B, Alam S, Mishra SK, Mahore D. Conservative treatment of traumatic crown fracture extending into cementum by glass post aided adhesive bonding of autogenous tooth fragment: A report of two cases. J Dent Res Rev [serial online] 2020 [cited 2022 Jun 28];7:70-4. Available from: https://www.jdrr.org/text.asp?2020/7/2/70/287336

  Introduction Top

Treatment of crown root fractures has conventionally focussed on a multidisciplinary approach. Definitive prosthetic rehabilitation is carried out after surgical crown lengthening procedures or orthodontic extrusion or follows extraction with implant-supported crown or fixed partial dentures.[1] The esthetic importance of the anterior maxillary region, especially in a young patient, would greatly benefit from quick esthetic and functional repair. Tooth fragment reattachment could form an acceptable alternative treatment option, especially with the evolution and advancement of adhesive dentistry. Reattachment can provide an inexpensive, quick rehabilitation of the fractured tooth, and in addition provide patients the psychological comfort of retaining the natural tooth and its esthetics.

This treatment alternative was first reported by Chosack and Eildeman in 1964. They utilized cast post intracanal retention to reattach the tooth fragment.[2] With the evolution of adhesive dentistry, bonded fiber post with a more favorable stress distribution and esthetics has become the preferred system to increase retentivity of reattached autogenous tooth fragment. The use of acid etches bonded restorative technique for fragment reattachment was introduced by Tennery.[3]

Reattachment of a large coronal fragment, as in the case of crown root fracture, might need added retention by fiber post reinforcement. The fiber post interlocks the fractured coronal fragment to the retained tooth and minimizes unfavorable stress concentration by redistributing the functional stresses.[4] Tooth-colored fiber post offers several advantages such as esthetics, adhesive bonding, and having a modulus of elasticity similar to that of dentin.[5] This case report discusses two cases to illustrate the successful management of a traumatically fractured crown involving the pulp and extending on the cementum by translucent glass post aided fragment reattachment.

  Case Reports Top

Case Report 1

A 20-year-old female patient reported to the dental college seeking treatment for pain due to traumatic dental injury on her upper front teeth after accidentally tripping and falling on her face. The patient presented 1 day after suffering the traumatic injury. The patient was apparently healthy and did not suffer from any systemic disease. On clinical examination, no associated swelling or injury of extraoral hard and soft tissue was found. Intraoral examination revealed a horizontal fracture running through the cervical third of the buccal surface of tooth 22. The crown was freely movable and could be completely split along the fracture line. The fracture line ran circumferentially along the cervical third of crown in the buccal surface and extended subgingival along the palatal surface [Figure 1]. The crown was sensitive even to gentle palpation as the fracture line involved the pulp. Electric and cold pulp testing elicited positive responses in all maxillary anterior teeth. A periapical radiograph revealed that the involved fracture on tooth 22 was associated with mature fully formed root apices, which did not show any evidence of periapical pathology. The patient was explained about all the available treatment options and their associated treatment and prognostic considerations [Chart 1]. The patient desired to retain the natural tooth, and a decision to re-adhere the tooth fragment with the aid of fiber post retention was taken.
Figure 1: (a) Illustrates the fracture line at the cervical third of the crown (b) The fracture line extending deep on the root in the palatal aspect can be appreciated (c, d) Both the crown and post were etched before the application of the bonding agent and luting cement (e) Postoperative appearance after 1 year follow up reveals a retained functional fragment with acceptable aesthetics and gingival health (f) Preoperative IOPA radiograph (g) IOPA radiograph after post space preparation (h) IOPA radiograph after luting of fiber post and fragment reattachment

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Local anesthesia was administered, and the segment was gently removed and placed in normal saline. The tooth was isolated by rubber dam using a split dam technique and light-cured resin barrier (Opaldam, Ultradent, USA). Access to root canal was prepared through the exposed pulp, and working length was determined with an electronic apex locator (Tri Auto ZX 2, J. Morita, Japan) and confirmed radiographically. This was followed by biomechanical preparation using a modified step-back technique with endodontic K-file and H-file (Dentsply Maillefer, Ballaigues, Switzerland). The canals were copiously flushed with 2.5% sodium hypochlorite (Vishal Dentocare, India) during biomechanical preparation and a final rinse of normal saline (Lifusion, India) was used to remove traces of the hypochlorite solution from the canal which may interfere with the adhesive bonding. The canals were obturated in the same appointment by AH Plus sealer (Dentsply Maillefer, North America) and gutta-percha points (Metabiomed, Korea) using cold lateral condensation technique.

Post space was prepared using Peeso reamers, leaving adequate Gutta-percha to maintain apical sealing. A glass fiber post of corresponding diameter (Reforpost Glass Fiber, Angelus, Brazil) was selected. The fiber post was adjusted such that the post extended 3–4 mm beyond the supragingivally located buccal fracture line. A corresponding groove was placed in the fractured crown fragment to accommodate the fiber post. An internal enamel bevel with a V-shaped notch, as advocated by Simonsen, was placed in the buccal surface of both the detached fragment and the tooth to provide additional retention. The prepared post space and the fragment were then acid-etched, and the bonding agent was applied. The fiber post was bonded in the canal with dual-cure resin cement (Multilink, Ivoclar, Vivadent). The light-cured resin barrier paste (Opaldam) placed around the split dam was then removed. Expasyl gingival retraction paste (Acteon) was syringed in the gingival sulcus to achieve adequate hemostasis as well as mechanically open the free gingiva to increase visualization of the fit of the fractured fragment. After carefully verifying the close adaptation of the fragment along the line of fracture, the fractured tooth fragment was reattached using resin cement. A groove with a beveled chamfer was created over the fracture line on the labial surface and filled with over contoured composite restoration to mask the fracture line as well as reinforce the strength of the reattached fragment. Follow-up examination scheduled at 1, 3, 6, and 12 months revealed a stable coronal reattached fragment with no pathologic signs evident clinically or radiographically.

Case Report 2

A 25-year-old male reported with a chief complaint of fractured upper front teeth after a road traffic accident when his motorbike skidded on an uneven road. He had initially reported to the emergency unit of the medical hospital where he was evaluated and treated for bruise injuries on his arms and knees and referred to the dental hospital for treatment of his dental injury. The patient reported 1 week after the incident of his injury, and during this period, he had been taking antibiotics and analgesics prescribed in the hospital emergency. The patient presented with no associated extraoral hard or soft-tissue injury when he reported to the dental hospital. Intraoral examination revealed that both maxillary central incisors (11 and 21) had a fracture line running through the cervical third of the crown. The fracture line of teeth 11 and 21 were supra-gingival on the labial aspect and below the gingival margin on the palatal aspect [Figure 2]. Both the crowns were completely mobile and disengaged and were kept in place intraorally by subgingival adherence of the fractured fragment to the periodontal ligament. Fractured fragments were intact and retained complete morphology. Intraoral periapical radiographs corroborated the clinical assessment that the subgingival extent of fracture violated the biologic width. There was no evidence of periapical destruction of tissue or infection. The patient was explained the available treatment options [Chart 1], and he expressed desire to retain his natural teeth by fiber post assisted fragment reattachment. Feedback was taken to assess that the patient understood the prognostic complexity of the associated treatment [Chart 1] following which written consent was obtained.
Figure 2: (a-d) Illustrates the initial presentation of the patient with fracture of crown at the cervical third on the labial aspect and extending deep on the root on the palatal aspect. (e) After placement and luting of fiber post following post space preparation. (f) Postoperative palatal view after reattachment of fragment. (g) Postoperative view after fragment reattachment (h) Initial preoperative radiograph. (i,j,k) IOPA radiographs after completion of single visit root canal treatment, post space preparation and after fragment reattachment with fiber post

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Local anesthesia was administered. The coronal fragments were gently removed using forceps and immersed in a container filled with saline to prevent discoloration and dehydration. Root canal treatment was completed in the same clinical appointment using the hybrid technique. The coronal and middle third of the root canal was prepared by crown down technique utilizing rotary Protaper Universal SX, S1, and S2 shapers (Dentsply Maillefer, Ballaigues, Switzerland). The apical preparation was then completed with hand K files with the master apical size of 50 K file. Root canals were obturated using cold lateral condensation technique. Post space preparation was then accomplished, and a glass fiber post of the corresponding diameter was selected, verified for fit, and bonded using dual-cure resin cement (Variolink, Ivoclar Vivadent). The inner portion of the coronal fragment was prepared with a groove to accommodate the fiber post. A palatal flap was raised, and alveolar bone osteotomy was done to expose the fracture line for accurate approximation of the fractured fragment as well as achieve favorable biologic width for periodontal health. Meticulous attention was placed to achieving good hemorrhage control by packing absorbable gelatin sponge (gelfoam) in the raised palatal flap. The fragment was then etched, bonded, and reattached to the fractured tooth using resin cement (Variolink, Ivoclar Vivadent). The excess flash of resin cement was removed before light curing it, and the attachment interface was finished with a diamond finishing bur to achieve a flushed and smooth surface. The interface was further polished with Soflex polishing discs (3M ESPE). A groove with beveled chamfer was created on the labial surface and restored with composite restoration to reinforce the strength of the reattachment zone. The approximation of the reattachment was verified radiographically before suturing the flap. Follow-up examinations conducted at 3, 6, 9, and 12 months revealed a stable reattachment of the crown fragment with healthy overlying gums and periodontium.

  Discussion Top

Evolution and advancement of adhesive dentistry have allowed conservative treatment of crown root fracture by fiber post retained reattachment of the fractured tooth segment when the fractured crown segment is available. Scientific evidence suggests that contemporary adhesive bonding systems can predictably achieve short- and medium-term outcomes.[4] In both cases, fragment reattachment achieved acceptable functional and esthetic result with healthy gingival and periodontal tissue over a 1-year follow-up.

The clinical decision of reattachment of autogenous crown fragment should consider certain factors during treatment planning. These factors include the level of fracture line (extent of biologic width violation), the existence of associated luxation injury, approximation, and fit of the fractured fragment along the fracture line and presence of single or multiple fractured fragments.[6]

In both the reported case, the crowns were disjointed as a single fractured fragment and had good adaptability at its junction of severance. The fracture line extended supragingival buccally while it extended obliquely and subgingival palatally. In the first case, the reattachment was achieved without the reflection of the flap, while in the second case, reattachment was achieved following flap surgery and ostectomy. The decision of whether flap reflection and ostectomy is undertaken was made based on the principle suggested by Ramjford.[7] He propositioned that ostectomy, if undertaken, should be minimal and necessitated only by the need to gain accessibility and smooth approximated finish along the fracture line.[7] In the first case, adequate visibility and access to the fracture line could be gained by displacing the free gingival margin by Expasyl gingival retraction paste. Expasyl also facilitated hemostasis and dry operatory zone during the adhesive bonding of the fragment. In the second case, access to the fracture line was impeded by coverage of bone, and ostectomy was undertaken to expose the fracture line for precise adaptation and to facilitate the finishing of the bonding interface. The reattachment zone was finished and polished by diamond points and Soflex discs to ensure a smooth nonirritating surface. The operative consideration facilitating adequate plaque control as well as reinforcement of patient towards maintaining good oral hygiene could be attributed to adequate gingival and periodontal health of the patient during follow-up.

Isolation and a dry operating field for adhesive bonding were achieved by packing absorbable gelatin sponge (gelfoam) in the reflected flap. In addition, cotton rolls, cheek retractor, and high volume suction evacuator was utilized to achieve adequate isolation as rubber dam could not be utilized during reattachment due to the deep subgingival extension of the fracture.

The fractured fragment in the two cases described in this article were quite extensive and nearly involved the complete clinical crown. Glass fiber post was, therefore, utilized to retain the disjointed coronal fragment. Studies have established that while posts may not strengthen the endodontically treated teeth, it does have a significant role in providing retention to the core or the fractured coronal fragment in extensive crown fracture.[8]

Glass-fiber post offers good esthetic, bonding, and reinforcement of reattached segment, modulus of elasticity similar to dentin, clinical simplicity, and reduced chair time.[5] The bonding of the fiber post to the canal, as well as the reattached fragment, creates a monobloc and reinforces and retains the reattached fragment against the dislodging occlusal forces.[9],[10]

Additional secondary retention to reinforce the bond strength of reattachment was utilized by placing a V-shaped notch bevel in the enamel of the labial surface of the detached fragment as well as the tooth in the first case. This technique was advocated by Simonsen for added retention.[11],[12] Over contoured composite restoration after creating a grooved preparation was also utilized to reinforce the strength of the reattachment zone. Reis has demonstrated that over contoured composite restoration may allow recovery of 97% of the fracture resistance of teeth.[13]

The fiber post, as well as the fragments, were bonded using dual-cure resin cement as it helps impart considerable adhesive strength between the bonded interfaces. Dual cure resin cement also helps overcome the limitation of light cure resin cement, which may not be completely polymerized in deeper inaccessible areas.[14]

During the period, the fractured fragments were extracted and had not been bonded back to the tooth; they were stored in physiologic saline. The rationale for storage in physiologic saline was to keep the coronal fracture fragment hydrated. Dehydration can significantly decrease the fracture strength of the teeth as well as cause discoloration and compromise the aesthetics.[15]

One-year follow -p of in both cases has demonstrated acceptable esthetics and function. The re-adhered fragment was securely attached, retained its natural esthetics, and the periodontium was healthy during the follow-up assessment. The clinical success despite extensive crown root fracture fragment reattachment could be attributed to careful treatment planning incorporating restorative and periodontal considerations.

  Conclusion Top

Reattachment of disjointed crown fragment utilizing fiber-reinforced post in a crown root fracture may offer the simplicity of clinical technique and chairside time while achieving pleasing esthetics and functional results. Treatment assessment in reattaching disjointed crown with the cemental extension should involve restorative and periodontal considerations to achieve clinical longevity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gopal R, Raveendran L, Pathrose SP, Paulaian B. Management of tooth fractures using fiber post and fragment reattachment: Report of two cases. J Pharm Bioallied Sci 2017;9:S295-S298.  Back to cited text no. 1
Raut AW, Mantri V, Shambharkar VI, Mishra M. Management of complicated crown fracture by reattachment using fiber post: Minimal intervention approach. J Nat Sci Biol Med 2018;9:93-6.  Back to cited text no. 2
Tennery TN. The fractured tooth reunited using the acid-etch bonding technique. Tex Dent J 1978;96:16-7.  Back to cited text no. 3
Hegde SG, Tawani GS, Warhadpande MM. Use of quartz fiber post for reattachment of complex crown root fractures: A 4-year follow-up. J Conserv Dent 2014;17:389-92.  Back to cited text no. 4
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Plotino G, Grande NM, Bedini R, Pameijer CH, Somma F. Flexural properties of endodontic posts and human root dentin. Dent Mater 2007;23:1129-35.  Back to cited text no. 5
Macedo GV, Ritter AV. Essentials of rebonding tooth fragments for the best functional and esthetic outcomes. Pediatr Dent 2009;31:110-6.  Back to cited text no. 6
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Altun C, Guven G. Combined technique with glass-fibre-reinforced composite post and original fragment in restoration of traumatized anterior teeth – A case report. Dent Traumatol 2008;24:e76-80.  Back to cited text no. 9
Oh S, Jang JH, Kim HJ, Seo NS, Byun SH, Kim SW, et al. Long-term follow-up of complicated crown fracture with fragment reattachment: Two case reports. Oper Dent 2019;44:574-80.  Back to cited text no. 10
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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.  Back to cited text no. 13
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