Case ReportBiological Restoration of a Fractured Anterior Tooth with theUse of Dentine Pin (Biopins)

Lilian Capanema Nogueira,1 Karine Taís Aguiar Tavano,1,2,3 Nayara Kelly Lyrio Ferraz,1

José Cristiano Ramos Glória,3 and Adriana Maria Botelho3,4

1The Federal University of Minas Gerais, Belo Horizonte, MG, Brazil2The Pontifical Catholic University of Minas Gerais, Belo Horizonte, MG, Brazil3The Federal University of the Jequitinhonha and Mucuri Valleys (UFVJM), Diamantina, MG, Brazil4The Bauru Dental College, Federal University of Sao Paulo, Sao Paulo, SP, Brazil

Correspondence should be addressed to Karine Taıs Aguiar Tavano; ktavano@gmail.com

Received 13 October 2015; Revised 22 November 2015; Accepted 23 November 2015

Academic Editor: Andrea Scribante

Copyright © 2015 Lilian Capanema Nogueira et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

This case study describes the esthetic and functional reconstruction of a fracturedmaxillary central incisor. Due to the requirementfor additional retention, treatment was performed using the homogenous technique of biological restoration associated withcementation of posts made from human dentin (biopins). This type of treatment is a new alternative to conventional techniquesand favors the dental esthetic and function, as well as biocompatibility, and is an inexpensive procedure.

1. Introduction

Dental trauma occurs quite frequently and principally affectschildren and adolescents [1, 2].Themaxillary central incisorsare the most susceptible teeth to fractures because of theirvulnerable position in the dental arch [3, 4]. Traumaticinjuries cause a significant impact on the quality of life ofchildren in terms of physical and psychological discomfortand have the potential to negatively affect social relationships[5, 6].

Depending on the type and extent of the trauma, thereestablishment of the esthetic and function of a fracturedtooth can be performed using a number of restorative meth-ods: composite resin restorations and ceramic restorations,with or without additional retentions (intracanal or dentalposts) [7, 8]. Whenever possible, the most commonly recom-mended technique is autogenous or homogenous fragmentbonding [9, 10]. Fragment bonding is a procedure that canbe labeled as “biological restoration,” consisting of the useof fragments of the fractured tooth (autogenous bonding) orfragments obtained from an extracted tooth (homogenousbonding) [11, 12]. This technique allows reestablishment of

the dental element with its original characteristics and themaintenance of occlusion in natural teeth and is inexpensiveand has a positive psychological effect, since the socialand emotional well-being of the patient and their family isrestored [13–15].

Restorative dental materials have reached high levels ofdevelopment and stability although there is no material inexistence that completely meets the requirements to restorethe loss of tooth structure in terms of plastics, esthetics, andfunctionality [16, 17]. Whenever possible, fragment bondingis the most adequate restoration technique for fracturedanterior teeth. The result is esthetically satisfactory in termsof translucence, opalescence, fluorescence, and the texture ofthe natural surface [18, 19].

When the remainder of the tooth is not sufficient to retainthe fragment or the restorative material, it is necessary to useadditional resources for retention in both vital anddevitalizedteeth [20]. It is possible to use prefabricated cemented,rubbed, or screwed interdental posts for devitalized teeth [21].Cement posts are the most commonly used as they do notcause tension in the dentin [21]. Interdental posts of humandentin or “biopins” are one possible option for permanent

Hindawi Publishing CorporationCase Reports in DentistryVolume 2015, Article ID 138474, 9 pageshttp://dx.doi.org/10.1155/2015/138474

2 Case Reports in Dentistry

(a) (b)

Figure 1: (a) Initial clinical aspect. (b) Initial radiographic aspect.

(a) (b)

(c) (d)

Figure 2: (a), (b) Initial clinical aspect, close-up. (c) and (d) Malocclusion in laterality.

anterior vital teeth that require additional retention [22].Biopins provide a greater level of retention and stability invital teeth and also have the following advantages: biocom-patibility; resilience; coefficient of thermal expansion similarto dental element; being esthetically favorable; production offewer cracks in the dentin; and being inexpensive [23].

An ex vivo study demonstrated a significant increase infracture resistance among teeth restored with experimentaldentin posts in comparison to teeth restored with fiber-reinforced composite posts. This suggests the possible rein-forcing potential of the dentin post. However, there are noexisting studies that test the effectiveness of dentine pins [24].

The aim of the present case study was to describea new homogenous fragment bonding technique for vitalteeth, associated with the cementation of interdental postsproduced with human dentin (biopins).

2. Case Study

A nine-year-old girl attended the dental clinic of the Univer-sidade Federal dos Vales do Jequitinhonha eMucuri (UFVJM),Diamantina, MG (Brazil), exhibiting a fracture in the middlethird of the crown of tooth 21 (Figures 1(a), 2(a), and 2(b)).

The guardian reported that the child had undergone previ-ous unsuccessful treatments. The restorations had loosenedduring protrusive movements in the two years since thetreatment. Clinical and radiographic examinations revealedfractured enamel and dentin without pulp involvement.

Since the child did not have the original fragment, ahomogenous biological restoration procedure was proposed,associated with the use of dentine pins (biopins) in order toincrease the retention of the fragment to the remainder ofthe tooth. The technique was explained in terms of esthetics,functional, and hygienic characteristics, and the guardiansigned an informed statement of consent.

The technique was executed during two separate sessions.After anamnesis and clinical and radiographic examination,an assessment of the color and the incisal guides (Figures2(c) and 2(d)), upper and lower archmolding was performed,as well as casting of the mold with a special type of plaster(Durone Tipo IV, Dentsply, Brazil) to enable the cutting of thetooth fragment and the production of the dentine pins in thelaboratory.

An extracted tooth of the same size, shape, and coloras tooth 21 (Figure 3) was used to cut the dental fragmentand in the subsequent homogenous bonding.The tooth to be

Case Reports in Dentistry 3

(a) (b)

(c) (d)

(e)

Figure 3: (a) Selected extracted central incisor. (b), (c) Mesiodistal measurement of the extracted tooth. (d), (e) Mesiodistal measurement ofthe remaining tooth in the laboratory.

used in the homogenous restoration was sterilized in moistheat at 121∘C for 15 minutes [16]. The cutting of the dentalfragment and the “biopins” was performed under extremerefrigeration with diamond burs (Figure 4). Figure 5(a)displays the production process of the “biopins,” which wasperformed by cutting a coronal slice, following the transversedirection of the tooth, in order that the dentinal tubules wereperpendicular along the axis of the pin. These were thenseparated until a cylindrical shape of approximately 1mmdiameter and 4mm length was obtained (Figure 5(b)).

After the cutting and adaptation of the restorative frag-ment to the model (Figure 4), a drilling simulation wasperformed to place the biopins in the plaster die (Figure 6(a))and in the fragment (Figure 6(d)), using a spherical bur (1mmdiameter and a depth of 2mm) with a low rotation. This wasto simulate what would be performed at a later stage with theremainder of the tooth.

In the second clinical session, perforation of the remain-der of the tooth was conducted, through absolute isolation,for the cementation of the “biopins” with a spherical burof 1mm diameter (Figure 7(a)). Subsequently, conditioningtreatment with phosphoric acid (37%) was performed for 30seconds in enamel and for 15 seconds in dentin from thefragment, from the remainder of the tooth, and from the“biopins” (Figure 7). This was followed by application of theadhesive system (Adper Single Bond 2, 3M ESPE, Brazil)and photopolymerization for 20 seconds (Figure 7). Afterconditioning, the “biopins” were cemented to the dentin withFLOW resin of color A2 (Vigodent, 3M ESPE, Rio de Janeiro,Brazil) and photopolymerized for 40 seconds (Figures 8(a)and 8(b)). Subsequently, the dental fragment was embeddedin the dentine pins, cemented with FLOW resin A2 (Figures8(c) and 8(d)), and photopolymerized for 40 seconds on allsides (Figure 8(f)).

4 Case Reports in Dentistry

(a) (b)

(c) (d)

Figure 4: (a) Cut of the dental element to obtain the restorative fragment. (b) Cut of dental fragment. (c) Adaptation of the fragment to theplaster model, vestibular view. (d) Adaptation of the fragment to the plaster model, palatal view.

(a) (b)

Figure 5: (a) Dental slice cut to obtain the dentinal pins, with outline showing the area from which they were obtained. (b) Dentinal biopins.

After the cementation of the dental fragment (Figure 9),occlusal adjustment was carried out. Seven days after theconclusion of the homogenous bonding of the fragment,the bevel was constructed at the apparent bond line, withspherical diamond bur number 1014. This was done usinglight-cured composite resin A1 (Z250, ESPE, USA) in orderto produce a satisfactory esthetic result. The newly restoreddental surface was then finished and polished (Figure 10).

The child and their guardian were instructed regardinghygiene, diet, and the need for regularmonitoring to preservethe esthetics and functional conditions. Figure 10(c) displays

the aspects of the restoration after one year of clinical follow-up (Figure 11).

3. Discussion

The clinical decision regarding the restorative procedureselected for fractured teeth directly affects the treatmentprognosis and requires a careful assessment of differentfactors, such as the extent and pattern of the fracture,the endodontic involvement, and the possibility of usingthe fragment in the bonding process [25]. In the present

Case Reports in Dentistry 5

(a) (b)

(c) (d)

(e) (f)

Figure 6: (a) Simulated holes in themodel for placement of the biopins. (b) Biopins in place, incisal view. (c) Biopins in place, vestibular view.(d) Holes made in the fragment for adaptation of the biopins. (e) Laboratory sample of the fragment to the biopins. (f) Fragment suitablyadapted to the plaster model.

case study, homogenous bonding was selected since it wasimpossible to perform autogenous bonding as the patient nolonger had the dental fragment. The association of biopinswith homogenous bonding was conducted in an attemptto improve retention of the fragment to the remainderof the tooth. The shape, location, and number of biopinsfundamentally depend on the extent of the cavity preparation,the vestibulolingual volume, and the position of the tooth inthe arch [8].The alternative to biopinswould bemetallic poststhreaded in dentin. However, there are disadvantages in usingthese metallic posts, such as the greater risk of perforatingthe pulp chamber, inflammatory responses of the pulp, andcracks in the dentin [26].

In previous studies, the dentin post closely resembledroot dentin in all physical properties, such as the modulusof elasticity, viscoelastic behavior [24], compressive strength[25], and thermal expansion [26]. Furthermore, dentin hasbeen found to be tougher than most of the other currentrestorative materials [27]. A dentin post forms a microme-chanical homogenous unit with the root dentin, resultingin uniform stress distribution [28, 29]. The similarity inelasticity of a dentin post to root dentin may allow postflexion to mimic tooth flexion so that the post acts as a shockabsorber, transmitting only a fraction of the stresses placedon the tooth to the dentinal walls [30]. It is possible that theseproperties are also applicable to biopins. However, laboratory

6 Case Reports in Dentistry

(a) (b) (c)

(d) (e) (f)

Figure 7: (a) Sample of the biopins in the holes made in the remaining tooth. (b) Acid conditioning of remaining tooth. (c) Acid conditioningof dental fragment. (d) Acid conditioning of the biopins. (e) Application of the primer/adhesive on the remaining teeth. (f) Application ofthe primer/adhesive in the biopins and dental fragment.

(a) (b)

(c) (d)

Figure 8: Continued.

Case Reports in Dentistry 7

(e) (f)

Figure 8: Cemented biopins in the remaining tooth. (a) Vestibular view. (b) Incisal view. (c) Clinical sample of the dental fragment. (d)Fragment adapted to the remaining tooth. (e) Vestibular aspect after bonding the vestibular fragment. (f) Palatal aspect after bonding thefragment.

(a) (b)

(c) (d)

Figure 9: (a) Clinical aspect of the restoration after removal of the absolute isolation. (b) Clinical aspect in protrusion. (c) and (d) Clinicalaspects in laterality.

studies should be performed to test the fracture resistance offragments and of composite resin restorations associatedwithbiopins.

In the present case study, it was confirmed that thechild had already undergone a number of composite resinrestorative procedures. These were unsuccessful due to thefact that the patient did not yet have complete permanentdentition. The guides and occlusion were not mutuallyprotected, which led to pressure during jaw movements thatcould have compromised the stability of prior restorations.After one year of monitoring, the fragment and tooth hadcorrectly adapted their functionality with excellent results interms of smoothness, esthetic, andmaintenance of the incisor

guide, as well as physiological and natural characteristics ofthe dental structure.

In the present case study, the pulp chamber was obliter-ated with reactionary dentin, which improved the possibilityof success of the retention technique using “biopins.”The useof this technique in young patients is significant, since thevolume of pulp is an important contraindication [25].

In spite of the previously mentioned advantages of using“biopins,” it is important to refer to a number of theirlimitations: there is the difficulty of acquisition of extractedteeth; they are difficult to create due to the reduced size; andthere is a possibility of perforating the pulp chamber duringcompletion of the technical preparation of the pin hole.

8 Case Reports in Dentistry

(a) (b)

(c)

Figure 10: (a) Initial clinical aspect. (b) Clinical aspect shortly after bonding. (c) Final radiographic aspect.

Figure 11: Clinical aspect after 12 months.

With regard to the ethical aspect, it is necessary to clarifyto the patient and/or the parents/guardians that the post ismade from duly donated and properly sterilized extractedteeth, thus preventing biosecurity risks. However, a toothfragment obtained from another patient may be rejected,which is a disadvantage of this technique. The teeth usedin biological restoration procedures can be obtained fromhuman teeth banks or from nonprofit institutions, whichstore and provide teeth for didactic, clinical, and scientific use[31]. The low number of human teeth banks and the limiteddissemination of the technique make this an uncommonroutine in dental practice [15].

The technique of biological restoration associated withthe use of pins created from human dentin (biopins) isanother alternative among the different treatment optionsfor vital teeth. This technique is inexpensive and exhibitsexcellent biocompatibility, as well as maintaining the char-acteristics of tooth structure such as smoothness, surfacebrightness, texture, hardness, size, shape, color, resistance,and, consequently, functionality and esthetic.

However, this is a little known technique, and there arevery few studies reporting its use in the literature. Therefore,further studies are necessary which demonstrate themechan-ical properties of biological restorations and biopins, as wellas assessing and monitoring long-term clinical cases.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgment

The authors would like to thank Professor Dr. Maria LetıciaRamos Jorge for assistance in drafting the present study.

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