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International Dental Journal (2007) 57, 13-18

Fractured incisors: a judicious


restorative approach part 1
G.P.M. Brambilla
Milan, Italy

E. Cavall

Monza, Italy
Aim: To consider different conservative options in the literature to restore fractured anterior
teeth. Materials and methods: Only anterior tooth fractures not involving the pulp were
considered, without limitation on age. Treatment options were chosen depending on the
clinical situation of patients at rst visit. The authors considered 15 cases each of: reattachment; porcelain veneers; direct composites. Results and conclusions: The techniques
analysed were revealed to be valid during the period of observation. No failures were
recorded with vital teeth keeping their vitality and no radiographic signs of apical or root
pathology. With reattachment, two cases have shown the visibility of fracture line after 2
years, depending on the angle of light incidence on the tooth surface. For direct restorations, three adult cases have shown partial discolouration at 24, 28 and 40 months. No
fractures or debonding have occurred among porcelain veneers. The authors suggest,
whenever possible, to utilise the reattachment technique. Direct restorations are suitable
for young patients: they have a higher chance of sustaining further trauma than adults,
and composites have a favourable failure mode compared to ceramics. In adults, where
long-lasting restorations are needed, restoration with porcelain veneers is the treatment
of choice.
Key words: Fractured incisors, dental trauma, reattachment, direct composites, porcelain
veneers

In recent years scientic literature has reported an


increasing number of cases of dental trauma with the
presence of fractures in particular in children and young
people due to the higher frequency of engaging in risky
habits and sports1,2.
Despite different classications of dental trauma
most authors concur on the following points3-6:
Most recurrent trauma involves crown fractures
uncomplicated by pulpal exposure
Children and young people, in particular males, are
mostly affected
Fractures involve especially the upper anterior
teeth
Fractures are mainly caused by road accidents and
risky sports activities.
The need for intervention, even in uncomplicated
and asymptomatic cases, can be linked to psychological
needs: even in young people between 12 and 14 years,
2007 FDI/World Dental Press
0020-6539/07/01013-06

the fracture of one or more teeth has a signicant


impact on daily life3. Treatment options for traumatic
dental fractures are chosen depending on various factors including the extent of the trauma, the quality and
timing of the initial intervention and the presence or
absence of dental fragments4.
The aim of this paper is to consider different conservative techniques and materials present in the scientic literature and to analyse their clinical advantages
and disadvantages.
Materials and methods

The study is conned to simple fractures without pulpal and/or periodontal involvement as complicated
fractures are limited in incidence and clinically more
complex from the point of view of the prognosis and
technique. There has been no limitation of age and
treatment options have been chosen depending on the

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clinical situation of the patients during the rst visit.


Forty-ve cases of anterior tooth fractures have
been considered and divided into three equal groups
of 15 cases:
Reattachment of the fragment
Indirect restorations with feldspatic porcelain veneers
Direct restorations with composite resin.
The reattachments were performed within one
week after the fracture; with the fragments having been
kept in water solution5; materials used for the reattachment were a one-bottle dentin-enamel adhesive system
(Optibond Solo Plus, Kerr)(OSP) according to the
total-etch technique (3M Etchant Gel, 3M) (EG) and
photo-polymerising resin cement (Nexus, Kerr; Calibra,
Dentsply)(N)(C) or composite resin (Enamel Plus HFO,
Micerium)(EP).
Reattachment of fragments

Fragments and teeth were treated in the same way: selective etching of enamel for 30 seconds and of dentine
for 15 seconds6,7, rinsing with water8 for 30s, drying
with cotton pellets9,10, application of the adhesive with
Microbrush (Microbrush) rubbing for 30s and thinning
of the adhesive with lightly blown oil-free air. When
Enamel Plus was used, the composite was warmed to
37C to give a temporary increase in its uidity. When N
or C were chosen, no catalyst was used to prevent colour
change linked to amine11. Adhesive and composite resin
/ resin cement were polymerised with a LED lamp for
60s on each side simultaneously to prevent undesired
thickness of the adhesive layer12. The nal restorations
were accurately polished rst with rubbers (Brownie and
Greenie, Shofu) and then with shining brushes (Occlubrush, Have Neos). The occlusion was tested, keeping
incisal guides, with articulation paper progressively from
200m, 40m, 20m and shimstock.
Indirect restorations

For indirect restorations, the choice was for feldspatic


porcelain (Creation Dental Porcelain, Klema), onebottle adhesive system (OS) following the total-etch
technique (EG) and light curing resin cement (N) or
composite resin (EP). This type of porcelain has a
low abrasivity towards dental enamel13. Polyether was
used for impressions (Permadyne + Garant, 3M) and
gingival retraction was obtained with the double-cord
technique, the rst retraction cord not soaked and the
second soaked in Hemodent and kept in the gingival
sulcus for 4 minutes (the dimension of the cords varied
in relation to the deepness of the sulcus; no patients
had gingival inammation.) The teeth were treated like
reattachments and the internal surface of the porcelain
treated with hydrouoric acid at 9.7% for 90s, washed
with water for 60s, kept in ultrasound with alcohol
International Dental Journal (2007) Vol. 57/No.1

for 5 mins and rinsed with water for 60s. Silane was
then applied and evaporated under hot air. After try-in
procedures, veneers were treated with phosphoric acid
for 60s to prevent possible salivary contamination and
a further silane coat14 was applied. The adhesive agent
(OPS) was brushed with Microbrush and made thinner with a light jet of oil-free air. When EP was used,
composite was warmed to 37C to temporarily increase
its uidity. When N was chosen, no catalyst was used
to prevent colour changes caused by the amines in
the catalyst11. Everything was polymerised at the same
time to prevent undesired thickness of the bond layer
with a LED lamp at 450mW for 20s for each area of
irradiation of the lamp and then polymerised for 60s
at 1100mW for each area15. The resin of the interface
was thoroughly polished with rubbers (Brownie and
Greenie, Shofu) rst and then with shining brushes
(Occlubrush, Have Neos), paying attention not to touch
the surrounding gingival tissue. A nal polymerisation
was made under glycerine to eliminate the oxygen on
the external surface of composite resins. The occlusion
was tested as above.
Direct restorations

For direct restoration a two-bottle self etching primer


adhesive system (Clearl SE Bond, Kuraray)(SEB) was
used by treating the enamel selectively with phosphoric
acid gel at 37% (EG) according to the manufacturers
instructions, or with a one-bottle bond system (OSP)
according to the total-etch technique (EG), and composite resin (EP). Layering was performed with a slight
increase at every layer (< 1mm) to minimise composite contraction. The nal restoration was thoroughly
polished with rubbers (Brownie and Greenie, Shofu)
rst and then with shining brushes (Occlubrush, Have
Neos). The occlusion was tested as above.
Every case was isolated with rubber dam to reduce
the possibility of contamination and the cases were
observed for a minimum of six months to a maximum
of four years.
Discussion on the techniques
Reattachment

If a fragment has been maintained, it can be reattached


to the remaining tooth providing it has been well preserved16. The literature about these cases is very recent
as retention between fractured teeth and fragments is
difcult to obtain. Before bond techniques were available, it was impossible to think about conservative
treatment of such dental fractures and one of the few
possibilities was the prosthetic approach.
The rst case of reattachment goes back to the year
1964, when Chosack and Eidelman published a case
report involving luting the dental fragment to an endo-

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dontic post. Then there is a gap in time until the end


of the 1970s before there is any documentation about
bonding systems17.
When possible, reattachment is a good technique
as it is aesthetically more predictable for translucency,
opalescence, uorescence, characterisations and texture
of the surface18-21. Moreover, it is less time consuming
compared to direct restoration. The rate of abrasion
and abrasiveness is the same as for the intact tooth,
whilst composite resin will be abraded more quickly than
enamel by the opposing dentition22. The technique also
restores stress comparable to intact tooth tissue and, in
case of further dental trauma, is preferable to composite
restorations23.

the fracture-line is prepared for about 2.5mm apically


and coronally and then restored with composite. This is
useful to hide the junction of the fragment. A middle to
long-term aesthetic decit is possible due to composite
deterioration32,33.

Reattachment techniques17

The choice of technique should be based on its capacity


to restore the original fracture resistance. The literature
has few case reports in which such a parameter has been
considered: the results are discordant and principally
linked to the laboratory techniques that have been used
for testing.
Some authors report regaining a fracture resistance
of 50-60% with the reattachment technique36,37. Others
have found statistically similar values between intact
tooth and reattached fragment as far as fracture resistance is concerned38. In other words, should the tooth
with the reattachment have a second traumatic incident
it will break in the same way as an intact tooth39.
Others have demonstrated that a circumferential
chamfer gives better recovery40, together with over
contour or internal reinforcement. The major difference
in the results depends on how the laboratory samples
have been produced: the cases where the samples have
been produced through a cut with diamond disks have
shown superimposable values in the different reattachment techniques (approx 60%); the cases where a real
fracture was present have shown dissimilar values in
the reattachment techniques. However, recovery rates
at 50-60% of the fracture resistance are likely to be
sufcient17.
Reattachment technique should be chosen in relation
to the specic case, considering variables such as pulp
exposure, need of endodontic treatment, extension of
the fracture, t of fragments and fracture direction. In
cases in which the pulp is involved, the need for direct
pulp-capping eliminates the possibility of reinforcement, if not only in the fragment. In cases of direct
pulp-capping, attention should be paid when using
calcium hydroxide as it can signicantly lower fracture
resistance when using dentin bonding agents41.
In the case of endodontic treatment, the pulp chamber can be used to give greater support to the fragment,
paying attention to aesthetics (non-vital teeth lose translucency and can change colour). If fragments have a
perfect t, techniques with composite exposure could
be avoided (internal preparation, simple reattachment),
whilst, in cases of discrepancies it will be preferable to

Enamel bevel

This technique has been successful thanks to the increase in retention due to the cut angle of the enamel
prisms, which favours adhesion and provides short-term
improved aesthetics. In some case reports the bevel was
only vestibular, in others circumferential. The risk is the
loss of precision when the two parts are joined.
Internal enamel V- preparation

The V-incision is performed into the inner portion of


the fragment and lled with composite. This technique
is difcult to carry out due to the thin layer of enamel.
Enamel on a central incisor is 0.3-0.4mm thick in the
gingival third, 0.6-0.9mm in the middle third and 0.91.1mm in the incisal third of the tooth24. The risk is the
loss of precision when the two parts are joined.
Internal dentine preparation

This technique has been initially used as reinforcement25,26, exploiting the composite adherence and
resistance and in endodontically treated teeth using the
pulp chamber. It can be utilised for pulp covering27,28.
Some authors have reported an aesthetic decit due to
the different refraction of light due to the composite
insertion29, but this can be changed according to materials and thickness.
The risk is the loss of precision when the two parts
are joined.
External chamfer

This technique is based on a chamfer preparation after


reattachment of the fragment, to be done in particular if
fracture line is still visible after one week30,31. A middle to
long-term aesthetic decit is possible due to composite
deterioration.
Over contouring

This technique is similar to the external chamfer: after


reattachment of the fragment, the enamel adjacent to

Simple reattachment

Simple reattachment is a more recent technique linked


to the better dentin-enamel bonding systems that have
been recently produced. If fragments have a good t
no preparation is needed and the fragment is directly
cemented34,35.
Discussion on reattachment techniques

Brambilla and Cavall: Fractured incisors

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choose a tooth-reinforcing technique that re-establishes


a correct aesthetics (circumferential chamfer, over contour). As far as the fracture direction is concerned, about
80% of the cases are from buccal to palatal and from
coronal to apical42: this direction is adverse to buccalpalatal forces, and is in a perpendicular direction to the
major tooth axis.
The dental fragment should be kept in water solution. Statistical analysis has shown that an exposure of
up to one hour in the air of the dental fragment before
adhesion does not jeopardise resistance, but further
drying lowers fracture resistance. Fragments kept in a
dry area for 24h and then put into water for about 1 day
regain the potential they had lost43.
Clinical case: reattachment of tooth fragments

The15-year-old male patient presented with trauma


to his anterior teeth, causing fracture of 11 and 21
(Figure1).
The trauma had occurred the day before he presented and the fragments had been recovered and kept

in water. Clinical and radiographic examination did not


show periodontal disease, root or alveolar bone injury
and the teeth gave positive vitality tests. The case was
diagnosed as simple trauma, without pulpal exposure
and the treatment chosen was fragment reattachment.
Firstly, the teeth were polished and cleaned with a slow
handpiece with prophylaxis brush and water, and then
isolated with a rubber dam (Figure 2).
The fragments were tried in to establish their t
(Figure 3) and a transparent try-in paste was used to
keep them in position. In this case the t was good and
reattachment could be performed without the need for
closing any large gaps with composite. The teeth were
etched with 35% phosphoric acid (Scotchbond Etchant Gel, 3M ESPE) following the total-etch technique.
The enamel was selectively etched for 30 seconds and
dentin for 15 seconds, isolating each tooth so as not to
contaminate other surfaces (Figures 4-6). The teeth were
then rinsed with water for 30 seconds and dried with
cotton pellets (Figure 7).

Figure 1. Patients smile with fractured teeth

Figure 2. Isolation of front teeth after plaque removal

Figure 3. Fragments try-ins

Figure 4. Buccal view of enamel etching with phosphoric


acid: note the over-contour of etched area

Figure 5. Palatal view of enamel etching: the etched


over-contour is at 360

Figure 6. Dentin etching for 15s with phosphoric acid

International Dental Journal (2007) Vol. 57/No.1

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Adhesive was applied (Optibond Solo Plus Unidose,


Sds Kerr) with a Microbrush (Microbrush), attentively
rubbing for 20-30 seconds each, to give time for the
adhesive solution to penetrate into the dentin tubules
and to form a correct hybrid-layer (Figure 8). The adhesive layer was gently blown with oil-free air and then
polymerised for 20 seconds (Figure 9).
The composite (Enamel Plus HFO, Micerium) chosen for reattachment has previously been warmed to
increase uidity and then applied to the tooth (Figure 10).
Treating the fragments in the same way as the teeth, they
were then luted with a thin layer of enamel composite to
cover the fracture line, polymerised and nished (Figure
11). The nal polymerisation was made with glycerine
gel to avoid oxygen inhibition on the composite surface
(Figures 12-15). After rubber dam removal, occlusion and
incisal guidance were checked and the composite was
polished (Figure 16).

Follow up

After six months, the fractured teeth had kept their vitality and the contouring of the composite contributes to
the tooth and fragment reinforcement. The patient was
satised with the aesthetic result, particularly because
he felt that the restoration was part of himself and
not a foreign body, as could be the case with direct or
indirect restorations. The positive psychological impact
was even greater for his parents, who were pleased with
the possibility that their son could have his own teeth
reattached (Figures 17- 20).
References

The full reference list will be published at the end of


Part 2 of this article in the April 2007 issue of the International Dental Journal.

Figure 7. Rinsing with water for the same time as for


etching

Figure 8. Adhesive application

Figure 9. Polymerisation for 20s

Figure 10. Thin layer of composite (B3) is applied on the


fracture line. Notice the shine of the tooth: meaning that the
adhesive layer is correctly applied for good adhesion.

Figure 11. Luted and rened fragment on 21


Brambilla and Cavall: Fractured incisors

18

Figure 12. Enamel etching of 11 for 30s with 35%


phosphoric acid

Figure 13. Dentin etching for 15s with 35% phosphoric


acid

Figure 14. Tooth is rinsed with water for 30s

Figure 15. Final polymerisation with glycerine gel

Figure 16. Patients smile after occlusal checking and


polishing procedures. Teeth are dehydrated.

Figure 17. Patients smile after six months. Aesthetics


are re-established with the fracture-lines well hidden.

Figure 18. Intraoral left side view

Figure 19. Intraoral right side view

Correspondence to: Dr. G. P. M. Brambilla, V.le Vitt. Veneto 22,


20124 Milan, Italy. Email: gregory.brambilla@tiscali.it .
Dr E. Cavall, V. Mentana 43, 20052 Monza (MI), Italy.
Email: edocav@tin.it

Figure 20. Detail of upper anterior teeth


International Dental Journal (2007) Vol. 57/No.1