Treating Fractured Incisors

An 11-year-old boy was, in the words of his mother, "horsing around in the kitchen with his sister when he lost his balance, fell, and struck his mouth on the counter." A piece of tooth No. 9 was fractured off at nearly the mid-tooth level (exposing the pulp), and a small piece of tooth No. 8 was fractured off of the incisal third (Figure 1 and Figure 2). His mother was able to find the larger fragment of tooth No. 9, but was unable to locate the smaller piece from tooth No. 8. Because the accident occurred on a Saturday, she contacted the after-hours emergency number and was instructed to put the recovered tooth fragment in milk (to prevent desiccation) and come immediately to the office.

Upon arrival, radiographs were taken to check for any tooth or root fractures and the teeth were evaluated for mobility. In addition, the lip trauma was assessed and palpated to make certain that the unrecovered fragment of tooth No. 8 had not been imbedded there. Next, the recovered fragment of tooth No. 9 was rinsed off and tried back in to make sure that it fit seamlessly. After it was determined that it did, the benefits of fragment reattachment were explained to the boy's mother, and she elected to go ahead with the procedure. She was also informed that because of the trauma to the tooth and exposure of the pulp, root canal therapy could become necessary in the future.

To begin, a local anesthetic was given, the teeth were isolated with a rubber dam, and the pulp exposure was covered with a pulp-capping agent (TheraCal LC^®, Bisco Dental Products). Next, the tooth was etched with a 37% phosphoric acid gel (Select HV^® Etch, Bisco Dental Products), rinsed, and dried, followed by an application of a universal adhesive (All-Bond Universal^™, Bisco Dental Products), which was light cured after solvent evaporation. Universal adhesives not only offer high bond strengths but also have a thin film thickness (ie, less than 10 um), which helps to keep the adhesive layer on both the tooth and the fragment from interfering with complete seating. After first relieving a small area in the center of the fragment to allow for the thickness of the pulp cap, it was prepared in the same way as the tooth (Figure 3 and Figure 4). Following confirmation that the fragment fit tightly with no gaps, it was bonded into place with a universal flowable/sculptable composite (Beautifil Flow Plus^®, shade A-1; Shofu Dental), which is available in two viscosities: low flow and zero flow. Because it would provide less resistance and make it easier to completely seat the fragment, the low flow option was chosen. Due to its patented GIOMER technology, Beautifil Flow Plus also provides fluoride release (as well as other ions that recharge in the oral environment) in addition to its strength and durability. First, a thin layer of the flowable composite was applied to the tooth and fragment, and the fragment was seated. While holding the piece firmly in place, the excess flowable was removed with brushes and the tooth was light cured for 40 seconds from the facial and lingual aspects (Figure 5).

During treatment planning, the boy's mother also agreed to restore tooth No. 8 with composite resin because it was the most conservative option available, especially considering the age of the patient. A bioactive, nanohybrid composite material (Beautifil^® II LS, Shofu Dental) was chosen due to its excellent handling properties, shade-matching chameleon effect, polishability, and fluoride ion release. Another advantage of this material is that the new "low shrink" formulation offers even less polymerization shrinkage and stress. First, bevels were made on the facial and lingual aspects of the tooth, the enamel was etched, and universal adhesive was applied. Next, the composite was applied in two layers, forming a lingual shelf in shade A-2 and a facial layer in shade A-1. Following this, the incisal shade was added to create mamelon effects and add translucency. After the final shape and contours were achieved, the restoration was polished with aluminum oxide points (OneGloss^® PS, ShofuDental) and discs (Super-Snap^® X-Treme, Shofu Dental) (Figure 6 through Figure 8).

Fractures of anterior teeth among children and adolescents are ideally treated in the most conservative manner possible that restores the natural form and function of the affected tooth or teeth. If the fractured piece is available, fragment reattachment offers a conservative approach that is cost-effective and results in an ideal shade and surface texture match. When fragment reattachment is not possible, composite bonding is also a conservative treatment option that can yield excellent results, especially in young patients.

Thomas E. Dudney, DMD
Alabaster Aesthetic Dentistry
Alabaster, Alabama