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Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 79

AbStrAct
Trauma to the anterior teeth is relatively common in
young children and teenagers. Traumatized anterior
teeth require quick functional and aesthetic repair,
and poses a challenge to the dental practitioner owing
to the lack of co-operation ceded and the longer time
invested. Reattachment of tooth fragment should
be the frst choice to restoring teeth when a usable
fragment is available, since it gives a psychological
and aesthetic advantage over the conventional
technique. With the vast improvement in adhesive
technology, reattachment is defnitely a predictable
treatment option for very young children. This paper
describes the treatment of a 2 year old female
child who sustained crown-root fracture, extending
subgingivally, in primary upper central incisor.
KEYWOrDS: Crown-root fracture, primary tooth,
reattachment, toddler
Biologic restoration of a traumatized maxillary central
incisor in a toddler: A case report
Sheen Ann John, Anandaraj S, Sageena George
Department of Pedodontics and Preventive Dentistry, PMS College of Dental Science and Research, Thiruvanthapuram, Kerala, India
Introduction
Injury to a young childs teeth and face is a traumatic
experience for the child and parents. It is not only
traumatic in the physical sense but also in an emotional
and psychological sense.
[1]
Maxillary incisors are most
frequently injured in the primary and permanent
dentition. Traumatized anterior tooth requires quick
functional and aesthetic repair. Therefore, if a broken
fragment is available, the restoration of a tooth with
its own fragment has been suggested as an alternative
treatment. Such a biologic restoration.
[2]
provides
excellent results regarding surface smoothness and
aesthetics. This clinical report describes reattachment of
tooth fragment of deciduous maxillary central incisor
in a 2 year old with extensive fracture involving pulp
following trauma.
Case Report
A 2 year old female child reported to the department
of Pedodontics and Preventive dentistry, P.M.S
College of dental Science and Research, Kerala with
the complaint of fractured maxillary deciduous central
incisor in the left quadrant. History revealed trauma
about 1week back and there was no relevant medical
history.
Intra-oral clinical examination revealed a fractured,
mobile tooth segment in relation to the left deciduous
maxillary central incisor [Figure 1]. Closer examination
revealed extensive fracture involving the enamel,
dentin and pulp. Tooth was fractured in a vertical
Address for correspondence:
Dr. Sheen AJ,
Department of Pedodontics and Preventive Dentistry,
PMS College of Dental Science and Research,
Thiruvanthapuram - 695 028, Kerala, India.
E-mail: drann78@hotmail.com
Case Report
Access this article online
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Website:
www.jisppd.com
DOI:
10.4103/0970-4388.127068
PMID:
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Figure 1: Pre-op
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Sheen, et al.: Biologic restoration of a traumatised tooth
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 80
plane that extended subgingivally. The tooth exhibited
no mobility. There was little injury associated with the
soft tissue, but none with the alveolar bone.
Radiographic examination revealed that there was no
associated root fracture, no resorption of the root and
no damage to the permanent tooth bud [Figure 2]. After
obtaining parental consent for the treatment procedure,
physical restraints were used as the child was emotionally
immature and lacking co-operative behavior.
Under local anesthesia, the fractured tooth segment
was carefully removed taking care not to damage either
the fragment or the remaining tooth [Figure 3]. The
fractured fragment was stored in saline [Figure 4].
[3]
Endodontic therapy was done for the fractured tooth
and obturated with metapex. The entrance of the root
canal was plugged with a glass ionomer plug. The
pulp chamber, dentin and enamel and the fractured
tooth segment was etched with 37% phosphoric
acid gel, rinsed and coated with bonding agent,
simultaneously, and light cured. The fragment was
then aligned and fowable composite used to reattach
the segment to the tooth surface. After excess resin
removal, the area was cured for 40 seconds. Finishing
and polishing were done [Figures 5 and 6]. The
patient was given instructions to avoid any heavy
function on this tooth and to follow regular home
care instructions.
On subsequent follow-up visits at 1, 2 and 6 months
[Figure 7], the tooth was found to be asymptomatic.
Discussion
Trauma to anterior teeth is relatively common among
young children and teenagers. Many of the accidents
that affect the primary teeth occur during the frst
three years as the child is moving from a state of total
dependence, with respect to movement, to one of
independence and stability.
[1]
In the primary dentition,
luxation injuries are more common than fractures due
to the spongy nature of the bone and also the lower
root/crown ratio in comparison to that of permanent
dentition.
[4]
But in this case it was a complicated
subgingival fracture involving the pulp also.
Figure 2: Pre-op IOPAR Figure 3: Mid treatment
Figure 4: Fractured Segment Figure 5: Post treatment
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Sheen, et al.: Biologic restoration of a traumatised tooth
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 81
The psychological impact of such a trauma should
be taken into consideration and must be restored to
normal as soon as possible to relieve the consciousness
of being different from other children. Moreover,
the major consequence of early loss of maxillary
primary incisors is most likely the delayed eruption
of permanent successors as reparative bone and dense
connective tissue covers the site. This would lead to
adverse consequences like unattractive appearance,
development of deleterious habits such as tongue
thrust, forward resting posture of the tongue and also
the improper pronunciation of frictative sounds, such
as s and f.
[5]
To compensate, there are various treatment options
to restore a fractured segment ranging from direct
resin restoration to extraction of the tooth followed
by an artifcial appliance. But given the demands for
co-operation in wear and frequent appliance loss or
damage, such removable appliances can be problematic
in pre-schoolchildren.
[5]
Hence, the primary teeth
should be restored provided it is not damaging the
permanent successor.
It has also been found that there is a positive emotional
and social response from the patient to the preservation
of natural tooth structure.
[6]
Hence, considering
advantages like:
1. Regaining color and size of the original tooth
2. The proportion of wear similar to adjacent tooth
without trauma
3. Giving an emotionally and socially positive
response due to the protection of natural tooth
structure
4. Rapid and conservative nature of the treatment
5. Economical aspect of a one-visit treatment,
[7]
the
decision to reattach the fractured segment was
considered.
Reattachment techniques such as direct reattachment of
the fragment, internal enamel groove, internal dentinal
groove and external enamel groove in the shape of a
Figure 6: Post-op IOPAR Figure 7: After six months
V have been used.
[ 8,9,10]
Reis et al., and Demarco et al.,
pointed out that reattachment without any extra
preparation or retention results in fracture strength
lower than that of an intact tooth. On the other hand,
some research
[11]
has shown that introduction of such
bevels does not enhance fracture strength. Another
factor infuencing fracture strength is the hydration of
tooth fragment. Prolonged dehydration causes change
in color of the fragment
[12]
and also the collapse of the
collagen fber net, preventing adequate penetration of
the resin monomer and resulting in a poor resin-dentin
bonding.
[13]
But in our case, the patient presented to
the clinic with the tooth fragment is still in the oral
cavity. Hence, with all the above advantages and
moreover considering the amount of tooth structure in
a primary tooth the direct reattachment procedure was
performed.
An endodontic treatment is recommended in cases
of complicated fractures to eliminate bacterial
contamination and pulp remnants within the root
canal.
[6]
Patient education about treatment limitations may
enhance clinical success as reattachment failures may
occur with new trauma or para functional habits.
[14]
Conclusion
Thus with the remarkable advancement of adhesive
systems and resin composites, reattachment of tooth
fragments has become a procedure that is no longer
a provisional restoration, but rather a restorative
technique offering a favorable prognosis, especially in
very young patients.
References
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Sheen, et al.: Biologic restoration of a traumatised tooth
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 82
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How to cite this article: John SA, Anandaraj S, George S.
Biologic restoration of a traumatized maxillary central incisor
in a toddler: A case report. J Indian Soc Pedod Prev Dent
2014;32:79-82.
Source of Support: Nil, Conflict of Interest: None declared.
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