Clinical management of a complicated crown-root fracture using autogenous tooth fragment: A biological restorative approach
A 10-year-old girl reported seeking treatment for her traumatized upper front tooth. Patient had trauma due to accidental fall in the school 1 week ago. They immediately reported for medical assistance, received immediate treatment for lip lacerations, medications to relive pain and tetanus-toxide coverage. Her medical and family histories were non-contributory. On examination, lip lacerations were healing, no other extraoral injuries were detected. Intraoral examination revealed the patient was in mixed dentition stage. Maxillary left central incisor was fractured bucco-lingually and a small portion of the tooth was missing. The second fracture fragment was mobile and attached to the gingival tissue []. It was a crown-root fracture involving enamel, dentin, pulp and a small portion of cementum. The fracture line was subgingival and involving the biologic width. There was no associated mobility of the affected tooth. Intra oral periapical (IOPA) radiograph exhibited the extent of the fracture subgingivally []. The fracture line was extending slightly apical to the level of crest of the interdental alveolar bone, on the mesial half of the tooth. Apex of the involved tooth was nearer to its completion. Patient was unable to maintain the oral hygiene due to pain associated with the fractured tooth.\nThe fractured fragment was separated from the gingival tissue after administration of local anesthesia. The tooth fragment was preserved in distilled water until reattachment. As patient reported 1 week after the trauma, preservation of the tooth vitality was difficult. Hence, root canal treatment for the involved tooth was planned. Access was gained to the root apex after isolation. The working length of the root canal was determined using IOPA radiographs, after eliminating the magnification factor. Shaping and cleaning of the canal was performed using endodontic K-files and H-files (MANI, INC. Utsunomiya, Tochigi, Japan). Irrigation of the root canal at every step was done with 5.2% sodium hypochlorite and normal saline. The canal was finally flushed with normal saline and dried with absorbent paper points. The root canal was filled with a paste of calcium hydroxide powder mixed with saline (Deepashree products, Ratnagiri, India) for 1 week. After 1 week as the tooth was asymptomatic, final obturation was done using endodontic sealer (Endoflux, Ammdent, Mohali, India) with gutta-percha (Dentsply, France, SAS) by rolled cone technique. After root canal filling the access cavity was sealed by glass ionomer cement (Ketac™ Molar Easymix, 3M ESPE AG, Seefeld, Germany).\nAfter completing the endodontic procedure, it was planned for orthodontic extrusion of the tooth, to facilitate access to the fracture line. Orthodontic traction was applied by a bracket fastened to the labial surface of the fractured tooth and elastics anchored to the orthodontic appliance []. As gingiva followed the path of extruding tooth, crown lengthening by gingival re-contouring (gingivectomy) was performed, for better esthetics and to gain access to the fracture line.\nBiological restoration was carried out under rubber dam isolation. The proper position and the fit of the fragment were checked on the fractured tooth. Internal grooves were prepared on the coronal aspect of both fragment and the fractured tooth to enhance the bond strength. The tooth fragment and the remaining tooth structures were etched with 37% phosphoric acid gel, followed by rinsing. After removal of the excess water, dentin bonding agent (Adper™ Single bond 2, adhesive; 3M ESPE AG, Seefeld, Germany) was applied to both bonding surfaces, in accordance with the manufacturer's instructions. A small layer of A2 shade composite resin material (Filtek Z250; 3M ESPE AG, Seefeld, Germany) was then applied to the fractured area of the tooth to which the fragment was reattached. The fragment was properly positioned on the fractured tooth surface, excess resin was removed and the area was light cured for 40 s, while the fragment was held in place under pressure. On the coronal aspect of the fractured tooth, a double chamfer margin was created 1 mm coronally and apically to the fracture line using a round diamond bur. After acid etching, single bond adhesive was applied to the chamfer area, followed by composite resin (Filtek Z250, shade A2) application and light curing was done, according to the manufacturer's instructions. The reconstruction of lost tooth structure was also carried out using the same composite resin in an incremental manner. Final finishing and polishing of the margins and composite resin restoration was done using finishing burs and composite finishing kit (SHOFU, SHANK CA, PN 0306, Shofu Dental Corporation, USA) [Figures and ].\nPatient was followed-up for 1 year at bimonthly intervals; the patient was asymptomatic throughout the period and the tooth was serving both esthetics and function.