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Dental trauma often has a severeimpact on the social and psy-chological well-being of apatient. A large U.S. study indi-

cated that 25 percent of the populationaged 6 to 50 years may have sustainedtraumatic injuries to the anteriorteeth.1 Maxillary central incisors, fol-lowed by maxillary lateral incisors andthen the mandibular incisors, were theteeth most frequently involved. Themost commonly observed dentaltrauma involved fracture of enamel, orenamel and dentin, but without pulpinvolvement. No single dental distur-bance has a greater psychologicalimpact on the patient than the loss orfracture of anterior teeth.

Complicated fractures of anteriorteeth can be treated by means of director indirect restorations. The treatmentoptions depend on the relationship ofthe fracture to the alveolar crest, thedegree of pulpal involvement, thetooth’s level of eruption, the degree ofapex formation and the patient’sesthetic requirements.2-5 The highercost of indirect restorations, thepatient’s desire to maintain remaining

Dr. Badami is a reader, Department of Conservative Dentistry and Endodontics, Academy of Medical Education’s Dental College and Hospital, IV/29,Kalamma St., Bellary District 583101, Raichur District, Karnataka State, India, e-mail “vijetha.mds@gmail.com”. Address reprint requests to Dr. Badami.Dr. Reddy is a postgraduate student, Department of Conservative Dentistry and Endodontics, Academy of Medical Education’s Dental College and Hospital,Raichur District, Karnataka State, India.

Treatment of complicated crown-root fracture in a single visit by means of rebondingVijetha Badami, MDS; S. Kranthikumar Reddy, MDS

AB ST RACTBackground. Crown-root fractures of anterior teeth arerelatively common but often time consuming and difficult totreat. In some cases, the clinician can complete the treat-ment in a single visit by reattaching the fractured fragment.Case Description. In this case report, the authorsdescribe the treatment of a complicated crown-root fractureof the maxillary right central and lateral incisors. Amongthe treatment options for such cases, the treating clinicianconsidered a single-visit rebonding procedure to be the bestchoice. The treatment consisted of a multidisciplinaryapproach involving coronal fragment removal, gingivectomyto expose the margins and single-visit endodontic therapy,followed by a rebonding of the fractured fragment by meansof prefabricated posts. Results. Evaluation at 12 months indicated stable re-attachment of the fragments, good esthetics and good perio-dontal health.Clinical Implications. The reattachment of a tooth fragment is a viable, conservative technique that restoresfunction and esthetics, and clinicians should consider itwhen treating patients with coronal fractures of the ante-rior teeth.Key Words. Complicated crown root fracture; rebonding;fiber post; reattachment; trauma.JADA 2011;142(6):646-650.

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To Add On page 12 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 7, Page 790-792 On page 20 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 612-620 On page 30 add: © 2011American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 658-665 On page 39 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 668-671 On page 43 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 635-645 On page 55 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 651-653 On page 58 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 654-656 On page 62 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 646-650 10 JADA Middle East vol 2 No 4 July-August 2011

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sound tooth structure and unfavorable anatom-ical conditions may render the direct restorationthe first choice in many clinical situations.6,7

Techniques that speed and simplify treatment,restore esthetics and improve long-term successrates, therefore, are of potential value, and clini-cians should consider them.8

Developments in restorative materials andtechniques have facilitated reattachment offractured teeth. Tooth-colored fiber posts wereintroduced in the 1990s and offer several advan-tages, such as esthetics, a strong bond to toothstructure and a modulus of elasticity similar tothat of dentin. However, fiber posts still requiredentin preparation to fit into the canal.6,9

In this article, we will address the treatmentregimen for crown-root fracture at a level belowthe free gingiva that offers the advantages ofsimplicity, esthetics and conservation of toothstructure in cases of dental trauma.

CASE REPORTA 22-year-old male patient reported to theDepartment of Conservative Dentistry andEndodontics, the Academy of Medical Educa-tion’s Dental College and Hospital, Raichur Dis-trict, Karnataka, India. The patient complainedof mobile and broken teeth in the maxillaryanterior region. He had experienced trauma 10days previously. His medical history was non-contributory. On extraoral and intraoral exami-nation, the clinician (V.B.) found no apparenttrauma to the soft tissues.

On clinical (Figure 1) and radiographic(Figure 2) examination, the clinician diagnoseda chisel type of crown root fracture of the maxil-lary right central and lateral incisors. The frac-ture lines of both teeth were supragingival onthe labial aspect and below the gingival marginon the palatal aspect. The clinician determinedbiological width by measuring probing depthand conducting intrasulcular bone soundingafter administering local anesthetic. Probingdepth measured 3 millimeters palatally. Palatalgingiva and interdental papilla were inflamedand edematous. There was no apparent peri-apical pathosis. The clinician planned directreattachment of the crown fragments, a planthat the patient accepted.

An endodontist (S.K.R.) removed the frac-tured coronal fragments without incurringdamage by using a forceps. He cleaned the pulpchambers in the coronal fracture fragments andstored the fragments in saline to prevent discol-oration and dehydration. A periodontist thenperformed external bevel gingivectomy, markingthe depth of the sulcus with a pocket marker.

He used a no. 12 surgical blade to excise 2 mmof the inflamed and edematous gingiva, thusexposing the margins and at the same timemaintaining the biological width (Figure 3).

The endodontist then extirpated theremaining pulp tissue in the root portions bymeans of a barbed broach. He used the radio-graphic method to determine the workinglength and cleaned and shaped the canal bymeans of the step-back method. Then heselected and confirmed the master cones byusing intraoral periapical radiographs and obtu-rated the canal by means of the lateral com-paction method, using AH Plus Root CanalSealing Material (Dentsply, York, Pa.). Theendodontist used Peeso reamers and the preci-sion drill provided with the Radix Fiber Postsystem (Dentsply) to prepare the post space,leaving the apical 5 mm of gutta-percha intact,and obtained a radiograph by which to evaluatethe work. He selected a Radix fiber post (Figure4) of a size corresponding to that of the precisiondrill. The endodontist etched the surface of thepost and the canal by using 37 percent phos-

Figure 1. Preoperative photograph showing fractured maxillaryright central and lateral incisors.

Figure 2. Preoperative intraoral periapical radiograph.

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sound tooth structure and unfavorable anatom-ical conditions may render the direct restorationthe first choice in many clinical situations.6,7

Techniques that speed and simplify treatment,restore esthetics and improve long-term successrates, therefore, are of potential value, and clini-cians should consider them.8

Developments in restorative materials andtechniques have facilitated reattachment offractured teeth. Tooth-colored fiber posts wereintroduced in the 1990s and offer several advan-tages, such as esthetics, a strong bond to toothstructure and a modulus of elasticity similar tothat of dentin. However, fiber posts still requiredentin preparation to fit into the canal.6,9

In this article, we will address the treatmentregimen for crown-root fracture at a level belowthe free gingiva that offers the advantages ofsimplicity, esthetics and conservation of toothstructure in cases of dental trauma.

CASE REPORTA 22-year-old male patient reported to theDepartment of Conservative Dentistry andEndodontics, the Academy of Medical Educa-tion’s Dental College and Hospital, Raichur Dis-trict, Karnataka, India. The patient complainedof mobile and broken teeth in the maxillaryanterior region. He had experienced trauma 10days previously. His medical history was non-contributory. On extraoral and intraoral exami-nation, the clinician (V.B.) found no apparenttrauma to the soft tissues.

On clinical (Figure 1) and radiographic(Figure 2) examination, the clinician diagnoseda chisel type of crown root fracture of the maxil-lary right central and lateral incisors. The frac-ture lines of both teeth were supragingival onthe labial aspect and below the gingival marginon the palatal aspect. The clinician determinedbiological width by measuring probing depthand conducting intrasulcular bone soundingafter administering local anesthetic. Probingdepth measured 3 millimeters palatally. Palatalgingiva and interdental papilla were inflamedand edematous. There was no apparent peri-apical pathosis. The clinician planned directreattachment of the crown fragments, a planthat the patient accepted.

An endodontist (S.K.R.) removed the frac-tured coronal fragments without incurringdamage by using a forceps. He cleaned the pulpchambers in the coronal fracture fragments andstored the fragments in saline to prevent discol-oration and dehydration. A periodontist thenperformed external bevel gingivectomy, markingthe depth of the sulcus with a pocket marker.

He used a no. 12 surgical blade to excise 2 mmof the inflamed and edematous gingiva, thusexposing the margins and at the same timemaintaining the biological width (Figure 3).

The endodontist then extirpated theremaining pulp tissue in the root portions bymeans of a barbed broach. He used the radio-graphic method to determine the workinglength and cleaned and shaped the canal bymeans of the step-back method. Then heselected and confirmed the master cones byusing intraoral periapical radiographs and obtu-rated the canal by means of the lateral com-paction method, using AH Plus Root CanalSealing Material (Dentsply, York, Pa.). Theendodontist used Peeso reamers and the preci-sion drill provided with the Radix Fiber Postsystem (Dentsply) to prepare the post space,leaving the apical 5 mm of gutta-percha intact,and obtained a radiograph by which to evaluatethe work. He selected a Radix fiber post (Figure4) of a size corresponding to that of the precisiondrill. The endodontist etched the surface of thepost and the canal by using 37 percent phos-

Figure 1. Preoperative photograph showing fractured maxillaryright central and lateral incisors.

Figure 2. Preoperative intraoral periapical radiograph.

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phoric acid for 15 seconds. Herinsed the surfacewith water, driedit with air andapplied Prime & Bond NT(Dentsply Caulk,Milford, Del.) byusing a microtipapplicator. Helight cured theadhesive for 10 seconds afterremoving theexcess by usingpaper points.Later, he spread

Calibra (Dentsply) esthetic resin cement mix onthe surface of the post and into the post prepa-ration with a syringe tip and a lentulo spiralinstrument, cured it for 10 seconds and stabi-lized the post for six minutes until the cementset. Isolation was maintained throughout theprocedure by means of cotton rolls, a salivaejector and gingival retraction cord.

The original clinician (V.B.) prepared reten-tion boxes by using a straight fissure bur inboth coronal fragments to accommodate theheads of the posts. She etched the fracturedcrown segments and the teeth with 37 percentphosphoric acid etchant gel for 15 seconds. Sheapplied Prime & Bond NT on the surface of thetooth structure (enamel and dentin) with anapplicator brush and light cured it for 10 sec-onds. After applying Calibra around the postsand the retention boxes of the fragments, theclinician reattached the fragments to the teeth(Figure 5). She removed excess material along

the margins by using a No.12 Bard Parker blade(Aspen Surgical Products, Caledonia, Mich.) andlight curing the material with a light-emittingdiode curing light for 40 seconds from bothbuccal and palatal directions. She polished thetooth surface to remove excess cement.

One month later, clinical and radiographicexamination revealed a stable reattachment ofcrown fragments. After 12 months, the clinicianfound a 1-mm palatal probing depth, nobleeding on probing and normal mobility, andradiographic examination showed a stable re-attachment of the fragments and good perio-dontal health (Figure 6).

DISCUSSIONThe treatment of complicated crown-root frac-tures in many cases is compromised by toothfractures that are well below the gingivalmargin or bone. Today, dentists have a numberof different approaches from which to choosewhen treating fractured teeth, depending on thelocation of the fracture.10 If the fracture line issupragingival, the procedure for reattachmentwill be straightforward. However, when thefracture site is subgingival or intraosseous,orthodontic extrusion with a post-retainedcrown may be necessary. Alternatively, surgicaltechniques such as electrosurgery, elevation of atissue flap, clinical crown-lengthening surgerywith removal of alveolar bone and removal ofgingival overgrowth for access to the fracturedsite all are viable methods.11

The reattachment of the crown fragment to afractured tooth is the best method of reinstatingthe fragment’s natural shape, contour, surfacetexture, occlusal alignment and color. It elimi-nates the problems of differential wear ofrestorative materials and offers excellent

Figure 3. Fracture fragment removal and gingivectomy performed to expose the margins.

Figure 4. Intraoral periapical radiograph showing the selectionof fiber posts.

Figure 5. Intraoral periapical radio-graph showing reattached fragments.

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esthetic and functional results in a singleappointment while maintaining healthy perio-dontal attachment.12,13 Also, this procedure isrelatively simple, atraumatic and inexpensive.14

However, because the findings of few long-termstudies regarding this topic have been reportedin the literature, the patient should be informedof the possible interim nature of the treatment.

Factors that influence the success of reattach-ment include the site of fracture, the size of frac-tured remnants, the patient’s periodontal status,pulpal involvement, maturity of the root forma-tion, biological width invasion, occlusion, timesince the initial trauma, the material used forreattachment and the type of post used.15 Exten-sive damage of the tooth structure and reattach-ment of the fragment warrants reinforcementwith fiber posts. Tooth-colored fiber posts haveseveral advantages. Their main proposed advan-tage is that they are esthetically pleasing, aremore flexible than metal posts and have approxi-mately the same modulus of elasticity asdentin.16 When such posts were bonded in placewith resin cement, researchers thought, forceswould be distributed more evenly in the root,resulting in fewer root fractures.16 In addition,the fiber-reinforced posts can be used with min-imal preparation because resin cement uses theundercuts and surface irregularities to increasethe surface area for bonding. Thus, it reducesthe possibility of tooth fracture during functionor traumatic injury.17 In addition, they are rela-tively easy to remove.18 In theory, a post thatflexes together with the tooth during functionshould result in better stress distribution andfewer fractures.19-21

With advancements in dental bonding tech-nology, the clinician now can achieve excellentresults with reattachment of dislocated tooth

fragments provided that he or she assesses andmanages the biological factors, materials andtechniques in a logical manner. Extensivelyfractured fragments have to be restored in con-junction with placement of a resin. In one study,researchers achieved the highest fracture resist-ance by using chemically cured composite fol-lowed by light-cured and resin cement; thelowest fracture resistance they achieved byusing only dentin bonding agent.22 They usedthe pulp chamber for increasing the surfacearea for composite bonding. In 1986, Amir andcolleagues23 found that when endodontictherapy was required, the space provided by thepulp chamber could be used as an inner rein-forcement, thus avoiding any excess preparationof teeth.

The recent trend has been toward use of resincements because they increase retention,24,25 tendto leak less than other cements26-28 and provideat least short-term strengthening of the root.24,29

Junge and colleagues30 reported that postscemented with resin cements were moreresistant to cyclic loading than were thosecemented with zinc phosphate or resin-modifiedglass-ionomer cement. Some investigators haverecommended bonded resin cements for theirstrengthening effect in roots with thin walls.31-33

Resin may be bonded to some types of posts, so,theoretically, the dentin, resin and post can bejoined via resin adhesion into a single unit, atleast for a time. Unfortunately, resin cementshave some disadvantages. They are more “tech-nique sensitive” than are most of the otherluting cements. They require extra steps such aspreparing the canal walls with an acid such asethylenediaminetetraacetic acid and placing adentin-bonding agent. Contamination of thedentin or post can be a problem. Predictabledelivery of etchants and adhesive materials deepinto the canal space also can be problematic.

With the materials available today, in con-junction with an appropriate technique, the cli-nician faced with reattaching a tooth fragmentcan achieve esthetic results with predictableoutcomes. Thus, the reattachment of a toothfragment is a conservative option that restoresfunction and esthetics, and clinicians shouldconsider it when treating patients with coronalfractures of the anterior teeth.

CONCLUSIONSeveral aspects govern the choice of techniqueand selection of materials for reattachment offractured fragments. The reattachment of atooth fragment is a viable, conservative tech-nique that restores function and esthetics. The

Figure 6. Photograph taken one year after surgery.

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clinician should assess the potential treatmentof each trauma case on an individual basis.However, because the findings of few long-termstudies regarding reattachment of tooth frag-ments have been reported in the literature, thepatient should be informed that the treatmentmay be only of an interim nature. �

Disclosure. Drs. Badami and Reddy did not report any disclosures.

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2. Malmgren O, Malmgren B, and Frykholm A. Rapid orthodonticextrusion of crown root and cervical root fractured teeth. Endod DentTraumatol 1991;7(2):49-54.

3. Ehrmann EH. Restoration of a fractured incisor with exposedpulp using original tooth fragment: report of case. JADA 1989;118(2):188-185.

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8. Murchison DF, Burke FJ, Worthington RB. Incisal edge reat-tachment: indications for use and clinical technique. BDJ 1999;186(12):614-619.

9. Qualtrough AJ, Mannocci F. Tooth-colored post systems: areview. Oper Dent 2003;28(1):86-91.

10. Andreasen JO. Traumatic Injuries of the Teeth. 2nd ed. Copen-hagen, Denmark: Munksgaard; Philadelphia: Saunders; 1981:151-195.

11. Baratieri LN, Monteiro Júnior S, Cardoso AC, de Melo FilhoJC. Coronal fracture with invasion of biologic width: a case report.Quintessence Int 1993;24(2):85-91.

12. Arhun N, Ungor M. Re-attachment of a fractured tooth: a casereport. Dent Traumatol 2007;23(5):322-326.

13. Zorba YO, Ozcan E. Reattachment of coronal fragment usingfiber-reinforced post: a case report. Eur J Dent 2007;1(3):174-178.

14. Deliperi S, Bardwell DN, Congiu MD. A clinical challenge:reconstruction of severely damaged endodontically treated andbleached teeth using a microhybrid composite resin—two-year casereport. Pract Proced Aesthet Dent 2003;15(3):221-226.

15. Wadhwani CP. A single visit, multidisciplinary approach to themanagement of traumatic tooth crown fracture. Br Dent J 2000;188(11):593-598.

16. Schwartz RS, Robbins JW. Post placement and restoration of

endodontically treated teeth: a literature review. J Endod 2004:30(5)289-301.

17. Trabert KC, Caput AA, Abou-Rass M. Tooth fracture: a com-parison of endodontic and restorative treatments. J Endod 1978;4(11):341-345.

18. de Rijk WG. Removal of fiber posts from endodontically treatedteeth. Am J Dent 2000;13(spec no):19B-21B.

19. Cormier CJ, Burns DR, Moon P. In vitro comparison of the frac-ture resistance and failure mode of fiber, ceramic, and conventionalpost systems at various stages of restoration. J Prosthodont 2001;10(1):26-36.

20. Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fractureresistance of endodontically treated teeth restored with compositeposts. J Prosthet Dent 2003;89(4):360-367.

21. Ferrari M, Vichi A, García-Godoy F. Clinical evaluation of fiber-reinforced epoxy resin posts and cast post and cores. Am J Dent2000;13(spec iss):15B-18B.

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23. Amir E, Bar-Gil B, Sarnat H. Restoration of fractured imma-ture maxillary central incisors using the crown fragments. PediatrDent 1986;8(4):285-288.

24. Mezzomo E, Massa F, Libera SD. Fracture resistance of teethrestored with two different post-and-core designs cemented with twodifferent cements, part I: an in vitro study. Quintessence Int 2003;34(4):301-306.

25. Nissan J, Dmitry Y, Assif D. The use of reinforced compositeresin cement as compensation for reduced post length. J ProsthetDent 2001;86(3):304-308.

26. Reid LC, Kazemi RB, Meiers JC. Effect of fatigue testing oncore integrity and post microleakage of teeth restored with differentpost systems. J Endod 2003;29(2):125-131.

27. Bachicha WS, DiFiore PM, Miller DA, Lautenschlager EP,Pashley DH. Microleakage of endodontically treated teeth restoredwith posts. J Endod 1998;24(11):703-708.

28. Mannocci F, Ferrari M, Watson TF. Microleakage of endodonti-cally treated teeth restored with fiber posts and composite cores aftercyclic loading: a confocal microscopic study. J Prosthet Dent 2001;85(3):284-291.

29. Mannocci F, Ferrari M, Watson TF. Intermittent loading ofteeth restored using quartz fiber, carbon-quartz fiber, and zirconiumdioxide ceramic root canal posts. J Adhes Dent 1999;1(2):153-158.

30. Junge T, Nicholls JI, Phillips KM, Libman WJ. Load fatigue ofcompromised teeth: a comparison of three luting cements. Int JProsthodont 1998;11(6):558-564.

31. Saupe WA, Gluskin AH, Radke RA Jr. A comparative study offracture resistance between morphologic dowel and cores and a resin-reinforced dowel system in the intraradicular restoration of struc-turally compromised roots. Quintessence Int 1996;27(7):483-491.

32. Katebzadeh N, Dalton BC, Trope M. Strengthening immatureteeth during and after apexification. J Endod 1998;24(4):256-259.

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To Add On page 12 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 7, Page 790-792 On page 20 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 612-620 On page 30 add: © 2011American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 658-665 On page 39 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 668-671 On page 43 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 635-645 On page 55 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 651-653 On page 58 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 654-656 On page 62 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 6, Page 646-650 10 JADA Middle East vol 2 No 4 July-August 2011