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CASE REPORT

Reattachment of endodontically treated lateralincisor with supragingivally complicated crown

fracture using ber-reinforced post

The long-term functional survival of initial endodonti-cally treated permanent teeth was reported as 97.1%after 8 years in a large epidemiologic survey (1);however, coronal and/or radicular tooth fractures con-tinue to remain important reasons for postendodontic

tooth repairs and extractions (2, 3).Re-restoring endodontically treated teeth with com-plicated crown or crown root fracture is a majorchallenge for dental practitioners because it requiresprofound knowledge in endodontics, periodontics andoperative dentistry. The treatment modalities can bechanged depending on the level of the fracture line andthe amount of the remaining root. In cases where thefracture line extends down along the long axis of theroot, extraction of the root is indicated. If the fractureinvolves at maximum, which means the coronal third of the root and the remaining root structure is long enoughto support the subsequently applied restoration, only thefractured portion is extracted and root canal therapy is

performed. If the fracture extends further subgingivally,ap surgery combined with osteoplasty/osteotomy pro-cedures, and surgical or orthodontic extrusion of theapical fragment is necessary to convert the subgingivalfracture to a supragingival one in order to restore thefracture either with a postcore covered by a porcelain ormetal crown (46). Using the original tooth fragment torestore a fractured tooth, makes it possible to achievegood esthetics with original tooth contours, texture andradiolucency and function. Furthermore this technique issimple, faster, cost-effective and less complicated com-pared with other invasive prosthetic procedures (7, 8).

Nowadays a number of successful reattachment casesand studies of the crown fragment with or without using

intra-canal metal anchorage are reported in the literature(913); however, there are only two published casereports of complicated crown root fractures that weresuccessfully treated by the reattachment of the originaltooth fragment using an intra-canal ber post (14, 15).

The following case report describes a conservativeapproach for the treatment of the supragingivally com-plicated crown fracture of an endodontically treatedmaxillary lateral incisor.

Case report

A 25-year-old female patient with a non-contributorymedical history was referred to our clinic immediatelyafter she was involved in a crown fracture of rightmaxillary lateral incisor while biting into hard bread(Fig. 1a,b). The patient had stated that the tooth hadreceived a conventional root canal treatment with a non-vital bleaching procedure 5 years earlier. A radiograph

taken immediately after the accident showed no evidenceof a periapical lesion, root or alveolar fracture and a wellcondensed root lling that appeared to reach a reason-able radiographic standard (Fig. 2). The tooth wasasymptomatic and not tender to percussion or palpationtests. The adjacent teeth responded within normal limitsto vitality testing. The patient was very apprehensiveabout her fractured teeth. She was assured and thecondition was explained to her. Of the various treatmentoptions explained to the patient, she preferred to retainthe fractured fragment. Upon direct inspection, wedetermined that the fracture line of the maxillary rightlateral incisor was horizontal, not extending in apicaldirection, from labial to palatinal surface with no visible

Dental Traumatology 2011; 27 : 305308; doi: 10.1111/j.1600-9657.2011.01002.x

2011 John Wiley & Sons A/S 305

M. Kemal Cal s kan, K. TolgaCeyhanl

Department of Restorative Dentistry andEndodontics, Ege University School ofDentistry, Bornova, Izmir, Turkey

Correspondence to: M. Kemal Cals kan,Department of Restorative Dentistry andEndodontics, Ege University School ofDentistry, 35100 Bornova, Izmir, TurkeyTel.: +90 232 388 03 28Fax: +90 232 388 03 25e-mail: [email protected]

Accepted 16 March, 2011

Abstract Re-restoring endodontically treated teeth with complicated crown orcrown root fractures is a major challenge for dental practitioners, because theycan present difculties for successful treatment. This report describes themanagement of supragingivally complicated crown fracture of an endodonti-cally treated maxillary lateral incisor. The involved tooth was restored with thereattachment procedure using light transmitting ber post. After 11 months, thereattached tooth had a satisfying function, favorable physiological and estheticoutcomes and healthy surrounding periodontal structures.


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damage on the marginal periodontal tissue. The marginon the labial surface was just located above the freegingival margin while 3 mm of sound tooth structure

above the palatinal margin was observed. When thecoronal fragment was positioned to verify t, it wasconcluded that ap surgery was not needed.

Based on the clinical and radiographic ndings, adiagnosis of the supragingivally complicated horizontalcrown fracture was achieved. Once the fragment wasproperly cleaned from any remaining old resin composite,it was stored in distilled water to be used at a later stage.Isolation was achieved using cheek retractor, cotton rolls,and saliva enjector placed in position. The postspace of previously adequately completed root canal treatmentwas prepared with a Unicor #3 drill (Ultradent ProductsInc., South Jordan, UT, USA) and was then irrigatedwith EDTA, 5.25% NaOCl and distilled water respec-tively. After drying the postspace with sterile paperpoints, a light-transmitting ber post (Ultradent ProductsInc.) was tried in the canal and cut at the desired length.The fractured fragment was tried on the cut end of theber post. A groove was made on the fractured fragmentuntil it tted comfortably on the post and the fracturedtooth. Once the desired t was conrmed, it was againstored in distilled water. After acid etching of thepostspace with 37% phosphoric acid (Total Etch; IvoclarVivadent, Liechtenstein), Syntac primer and adhesive(Ivoclar Vivadent) was applied to the root canal walls,and Heliobond (Ivoclar Vivadent) was applied to bothroot canal walls and the ber post, following this the postwas cemented with the help of a dual-cure resin cement(Variolink II; Ivoclar Vivadent). Any excess resin cementoozing out of canal was removed with an explorercompromising the t of the coronal fragment. The postwas then light-cured for 40 s (Elipar Freelight 2; 3MEspe, St Paul, MN, USA). After cleaning the coronalfragment with pumice and a brush, the internal aspect of the fragment was etched, rinsed, coated with Syntacprimer and adhesive, lightly dried to evaporate thesolvent, and light-cured. Then a resin composite (FiltexZ350 Universal Restorative; 3M Espe) was inserted onthe inner lingual surface groove of the fragment and onthe cervical portion of the remaining tooth. The crownfragment was carefully repositioned to the fracturedtooth with rm nger pressure. After removing the excesscomposite, the reattached crown was light-cured for 60 sfrom both labial and palatal surfaces. Composite materialwas incrementally added to the lingual surface toreestablish natural anatomy and contour. Flame-shapedcarbide burs and BP blades were used to remove excess of material and nish the restoration. The occlusion was

carefully checked and adjusted. Polishing was done usingSoft-Lex polishing system (Soft-Lex; 3M Espe). Routinepost-treatment instructions were given in writing andpatient was recalled periodically.

Clinical and radiographic examinations after11 months revealed a stable reattachment of the frag-ment, excellent esthetics, satisfying function and peri-odontal health with no bleeding on probing (Fig. 3ac).

Discussion

Endodontically treated teeth have traditionally beenconsidered to be weaker. In fact, when being extractedthey have greater tendency to break during extraction

(b)

(a)

Fig. 1. (a) Preoperative frontal extra-oral view of supragingi-vally complicated crown fracture of maxillary right lateralincisor. (b) Fractured crown fragment.

Fig. 2. The periapical radiographshowing previously completedadequate rootcanal treatmentand absence ofperiapicalpathosis.

306 C al s kan & Ceyhanl

2011 John Wiley & Sons A/S


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maneuvers (16). Although endodontic treatment mightcontribute in the compromising biomechanical proper-ties of the teeth (17), Sedgly & Messer (18) demonstratedthat the physical properties such as hardness, shearresistance and breaking strength of endodonticallytreated teeth are similar to those of vital teeth. Thesolidity and breaking strength of the endodonticallytreated teeth weaken due to the loss of the tooth

structure and this has greater importance than anypossible changes affecting the proportion of collagen orthe moisture content (1820).

Maximal removal of remaining sound tooth structureduring the endodontic access cavity preparation, overinstrumentation of the root canal and postspace prepa-ration might lead to higher occurrence of fractures inendodontically treated teeth. Furthermore, prolongeduse of high concentrations of different root canalirrigants, bleaching agent and type of coronal restorationmight increase the risk for root fracture (21, 22). In thepresent case, the supragingivally complicated crownfracture occurred during biting of a hard bread. Thecause of this fracture might be the extensive loss of

coronal hard tissue structure and non-vital bleaching.The goal of endodontic and restorative dentistry is to

retain natural teeth with maximum function and pleasingesthetics. Traditionally, custom-cast post and cores,covered by metal or porcelain fused to metal crowns,were the restoration choices of this type of complicatedcrown fractures. Recently, there has been a clearlyobservable transition from the use of metal alloy poststoward the use of ber-reinforced resin-based compositeposts with resin composite build-ups especially with teethin the esthetic zone such as maxillary anterior incisors.Fiber-reinforced resin-based composite posts have adentin-like modulus that allows a more even distributionof occlusal stresses in the root dentin (23), which usually

have lead to fewer and less severe in vitro root fracturefailures (2426).

When compared to alternative treatment options suchas direct or indirect composite restorations with fullcoverage crown, tooth fragment reattachment is a moreconservative, affordable, less time-consuming treatmentoption with favorable psychological and esthetic out-comes. It is difcult to determine how long the restora-

tion presented in this case report will provide areasonable degree of esthetics and function. Variouscase reports of even subgingivally crown-root fractureswere treated successfully by fragment reattachmentwithout using intra-canal anchorage with different fol-low-up periods ranging from l month to 6 years (7, 11 13). The present case report shows that coronal fragmentwithout visible damage can be used with a ber post evenif the fracture is complicated but the margins areaccessible. This provided a good adaptation of thefragment, associated with the sealing effect of therestorative material used, and also a proper t andcontour of the margins as recently demonstrated in casereports (14, 15). By using a prefabricated ber post used

in conjunction with a resin based composite in endodon-tically treated tooth may reinforce the weakened root-canal walls, increase the fracture resistance and may alsosupport the retention of the crown fragment.

Although a well-controlled, long-term, multicenterclinical study showed less optimistic outlook (7); it isexpected that, with the improvements in composites andadhesives, these retention rates of reattached teeth wouldbe higher today.

Conclusion

Complicated crown fractures also occur in endodonti-cally treated teeth. Reattachment of the coronal frag-

(a)

(b)

(c)

Fig. 3. (a) Frontal intra-oral view of reattached tooth 11 months after the reattachment. Note the excellent adaptation between thecrown fragment and involved tooth at the cervical aspect. (b) Palatal view of restoration. (c) Periapical radiograph showing nopathological alteration in the periapical region.

Reattachment of an endodontically treated lateral incisor 307



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ment to an endodontically treated tooth requires aslightly different technique which focuses on maintainingthe tooths structural integrity, while ensuring that thereis enough retention form for the fragment reattachment.In the present case, fragment reattachment using intra-canal ber postsystem of supragingivally complicatedcrown fracture of an endodontically treated tooth wasfound to be successful clinically 11 months after thetreatment.

References

1. Salehrabi R, Rotstein I. Endodontic treatment outcomes in alarge patient population in the USA: an epidemiological study.J Endod 2004;30:84650.

2. Hansen EK, Asmussen E, Christiansen NC. In vivo fractures of endodontically treated posterior teeth restored with amalgam.Endod Dent Traumatol 1990;6:4955.

3. Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factorsrelated to extraction of endodontically treated teeth. Oral SurgOral Med Oral Pathol Oral Radiol Endod 2008;106:e315.

4. C al s kan MK, Tu rku n M, Gomel M. Surgical extrusion of crown-root fractured teeth: a clinical review. Int Endod J1999;32:14651.

5. C al s kan MK. Surgical extrusion of cervically root-fracturedtooth following apexication treatment. J Endod 1999;25:509 13.

6. Andreasen FM, Andreasen JO. Crown fracture. In: AndreasenJO, Andreasen FM, Andersson L, editors. Textbook and coloratlas of traumatic injuries to the teeth, 4th edn. Copenhagen:Munksgaard; 2007.

7. Andreasen FM, Noren JG, Andreasen JO, Engelhardtsen S,Lindh-Stromberg U. Long-term survival of fragment bondingin the treatment of fractured crown: a multicenter clinical study.Quintessence Int 1995;26:66981.

8. Macedo GV, Ritter AV. Essentials of rebonding tooth frag-ments for the best functional and esthetic outcomes. Pediatr

Dent 2009;31:1106.9. Turgut MD, Go nu l N, Altay N. Multiple complicated crown-root fracture of a permanent incisor. Dent Traumatol 2004;20:28892.

10. Koparal E, Ilgenli T. Reattachment of a subgingivally fracturedcentral incisor tooth fragment: report of a case. J Clin PediatrDent 1999;23:1135.

11. Cengiz SB, Kocadereli I, Gu ngo r HC, Altay N. Adhesivefragment reattachment after orthodontic extrusion: a casereport. Dent Traumatol 2005;21:604.

12. Eden E, Yanar SC, So nmez S. Reattachment of subgingivallyfractured central incisor with open apex. Dent Traumatol2007;23:1849.

13. Ertugrul F, Eden E, Ilgenli T. Multidisciplinary treatment of complicated subgingivally fractured permanent central incisors:two case reports. Dent Traumatol 2008;24:e616.

14. Rajput A, Ataide I, Fernandes M. Uncomplicated crownfracture, complicated crown-root fracture and horizontal rootfracture simultaneously treated in a patient during emergencyvisit: a case report. Oral Surg Oral Med Oral Pathol OralRadiol Endod 2009;107:e4852.

15. Oliveira GMS, Oliveira GB, Ritter AV. Crown fragmentreattachment: report of an extensive case with intra-canalanchorage. Dent Traumatol 2010;26:17481.

16. Chen S-C, Chueh L-H, Hsiao CK, Wu H-P, Chiang C-P. Firstuntoward events and reasons for tooth extraction afternonsurgical endodontic treatment in Taiwan. J Endod 2008;34:6714.

17. Reeh ES, Messer HH, Douglas WH. Reduction in toothstiffness as a result of endodontic and restorative procedures.J Endod 1989;15:5126.

18. Sedgley CM, Messer MM. Are endodontically treated teethmore brittle? J Endod 1992;18:3325.

19. Huang TJ, Schilder H, Nathanson D. Effects of moisturecontent and endodontic treatment on some mechanical prop-erties of human dentin. J Endod 1992;18:20915.

20. Rivera EM, Yamouchi M. Site comparisons of dentine collagencross-links from extracted human teeth. Arch Oral Biol1993;38:5416.

21. Attin T, Mu ller T, Patyk A, Lennon AM. Inuence of differentbleaching system on fracture toughness and hardness of enamel.Oper Dent 2004;29:18895.

22. Tang W, Wu Y, Smales RJ. Identifying and reducing risk forpotential fractures in endodontically treated teeth. J Endod2010;36:60917.

23. Nakamura T, Ohyama T, Waki T, Kinatu S, Wakabayashi K,Mutobe Y et al. Stressanalysis of endodontically-treated ante-rior teeth restored with different types of post material. DentMater J 2006;23:25.

24. Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NHJ. Astructural analysis of in vitro failure loads and failure modes of ber, metal and ceramic post-and-core systems. Int J Prosth-odont 2004;17:47682.

25. Salameh Z, Sorrentino R, Ounsi HF, Goracci C, Tashkandi E,Tay FR et al. Effect of different all-ceramic crown system onfracture resistance and failure pattern on endodontically treatedmaxillary premolars restored with and without glass ber posts.J Endod 2007;33:84851.

26. Salameh Z, Sorrentino R, Ounsi HF, Sading W, Atiyeh F,Ferrari M. The effect of different full-coverage crown systemson fracture resistance and failure pattern of endodonticallytreated maxillary incisors restored with and without glass berposts. J Endod 2008;34:8426.

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