Introduction: tried and discarded. Progress was halting, often

Introduction:

Change was inevitable. Awakened to beauty by the media, the public became aware of the importance of a beautiful smile. The dental profession conscious of this growing demand, began a search for cosmetic restorations. Change came gradually. Many techniques and materials were tried and discarded. Progress was halting, often two steps forward and one step back.1

Dentoalveolar fracture is the most well-known type of head and neck trauma. Dental trauma may happen because of a sports mishap, a fall while playing, or other causes. Traumatic injuries to teeth and their supporting tissues can occur in any age group, but children are most common candidate followed by adolescents; with boys considered at being at higher risk than girls, mainly because of increase in participation of children in dangerous sports and activities.2,3 Damage may vary from enamel fracture to avulsion, with or without pulpal involvement or bone fracture.3

The teeth most commonly affected by trauma are the maxillary incisors with a report shared of 96% of all the crown fractures of which 80% central incisor and 16% lateral incisor are seen.4 Anterior anatomic crown fractures are a common site of injury. Uncomplicated crown fracture of the permanent teeth has an intense effect not only on the patient’s appearance but also in speech defects, psychological and social effects.5 The treatment for such trauma depends upon the type of injury and whether the injured tooth is a primary or permanent tooth. Management of the patient with anterior tooth fracture provides a great challenge to the clinicians both from a functional and aesthetic perceptive.6 Definitive treatment is essential for the well-being of the dentoalveolar fracture.

This case report describes an innovative technique in rehabilitating an uncomplicated fractured maxillary central incisors tooth in a young patient with composite, which is easily available, economical and requires less operating time with direct technique.

Case Report:

 A 12-year-old male was reported to the Department of Paediatric Dentistry, Pacific Dental College & Hospital, and Udaipur, with chief complaint of broken upper front teeth. The history revealed of trauma to upper front teeth about 6 days back, due to a fall during playing. Extraoral examination revealed no gross facial abnormality nor any wound. Intraoral examination revealed Ellis class II (uncomplicated) fractured 11 and Ellis class I fractured 21 (Figure 1). The teeth were asymptomatic without any associated soft or hard tissue injuries to the supporting tissues and responded well to electric pulp tester, indicating positive teeth vitality. Intraoral periapical radiograph confirmed the absence of pulpal or periapical pathology (Figure 2). Thus, it was planned to rehabilitate the fractured teeth using composite restorative material, with a direct technique using the template.

A 45°bevel was given to remove the unsupported enamel and increase the surface area. Primary impressions of the maxillary and mandibular arches were made using alginate material (Chromatic Jeltrate, Dentsply, Gurgaon). Study models were made in Type III dental stone (Neelkanth, Jodhpur) and mock build-up of the lost teeth structure with modeling wax (Y-Dents, MDM Corporation, New Delhi) was done. After the build-up of the lost segment, the cast was duplicated by using the template of putty impression material (Aquasil, Dentsply, Germany). Labial surface of the putty template was removed up to the middle third of the crown, to aid in the reconstruction of the lost tooth structure (Figure 3).  A clinical try-in of the template was done to ensure adequate fit. After appropriate shade selection of the composite material (Spectrum®, Denstply, Germany), this crown former was used to restore the fractured tooth quickly with minimal post-restoration finishing (Figure 4).

Discussion:

Trauma with accompanying fracture of a permanent incisor is a terrible experience for the young patient and creates a psychological impact on both the parents and children.2 If the injury involves the loss of extensive tooth structure, it alters the child’s appearance and makes him the target for teasing by peers.

Treatment objectives may vary depending on the age of the patient, socioeconomic status of the patient and intraoral status at the time of treatment planning.7 There are various treatment modalities for restoration of fractured teeth like composite restoration, fixed prosthesis, reattachment of the fracture fragment (if available) followed by post and core supported restorations.7-9 Common restorative management such as full-coverage restoration or  laminate veneers can be considered after multiple fragment rebonding/ composite resin restorations have been done and this option is no longer functional. These methods might tend to sacrifice the healthy tooth structure and challenge the dental professional to match with the adjacent healthy teeth.

Management of the young patient with anterior tooth fracture provides a great challenge to the dental professional both from an aesthetic and functional perceptive. The predictable esthetic restoration of the broken incisal edge of maxillary incisors is a demanding and technique sensitive procedure. Its success is dependent on clinician skills and knowledge and also on adhering to a systematic and problem-solving approach.6 A logical method is used to build-up morphologically correct composite restorations by careful selection of composite shades, tints and opaquers in accurate combinations, an illusion of varying translucencies and opacities become visible over natural tooth structure.10

 In patients with fractured dentition, satisfactory results were reported with anterior composites offering a cost-effective treatment alternative where esthetics is a major concern. With further improvements in bonding chemistry, the success rate of composites is speculated to improve.9 A good polishing system including polishing paste, cups and wheels is recommended to achieve appropriate luster.

In the present case, an innovative technique which includes both direct and indirect method of restoring was designed by using Polyvinyl siloxane (PVS) rubber base impression material (putty) as a template. This method is simple, quick and economic, when compared to other invasive procedures. The usage of the PVS template allowed incremental layering of the composite material, optimal depth of cure, accurate reproducibility of the anatomic contours and minimal polishing and finishing procedures.11,12

Conclusion:

Direct composite resin bonding agents successfully deal with the aesthetic issue of maxillary anterior teeth along with a painless approach providing a successful outcome for the dental professional and greater satisfaction for the patients. As restoring a fractured tooth is a complex procedure, this technique can prove as a simple, effective and appropriate technique that will fulfill all the requirements of dental personnel.