| Abstract|| |
The post endodontic fracture of a tooth is a common occurrence, when the full coverage restoration is delayed or not at all given. It could be a perplexing situation to the magnitude, where extraction is second to none. This case report is about the reattachment of the fractured, endodontically treated premolar tooth followed by composite crowning. This led to the conservation and reinforcement of the brittle tooth, overcame the need of post and core and aided in delivering a crown of good esthetics and mechanical properties in one appointment at a lesser cost and time.
|How to cite this article:|
Vivekananda Pai A R, Kamath M P. Reattachment and composite crowning of a fractured, endodontically treated tooth - a case report. J Conserv Dent 2005;8:19-26
|How to cite this URL:|
Vivekananda Pai A R, Kamath M P. Reattachment and composite crowning of a fractured, endodontically treated tooth - a case report. J Conserv Dent [serial online] 2005 [cited 2020 Sep 25];8:19-26. Available from: http://www.jcd.org.in/text.asp?2005/8/1/19/42701
| Introduction|| |
An endodontically treated tooth becomes brittle with passing time, for biomechanical reasons, which jeopardise the integrity of the tooth. The fracture of the root canal treated tooth is one common cause for the post Endodontic failure, particularly when the splinting of occlusal cusps (by onlay) or Coverage of the crown Enmasse is delayed. The Treatment modalities for the post Endodontic fracture depends on the affected tooth, type, location, extent of the fracture and its relationship with the gingiva and alveolar crest  . The clinical management varies from full crown with or without allied procedures like bonding, post and core, Crown lengthening, hemisection, bicuspidisation, radisection to Extraction, if given to a hopeless prognosis. To prove a worthwhile, guarded procedures like reattachment of the fractured fragments using adhesives (4 - META / MMA-TBB), lasers and Intentional replantation have been attempted , .
Adhesive composite resins are capable of bonding micromechanically to tooth, hence they are used for binding the fragments together in reattachment procedure and reinforcing an endodontically treated tooth ,,, . Esthetics, Indirect mode of fabrication and advanced formulation in composite resins showing improved physical properties and wear resistance have promoted them as crown material ,,, . The following case report is about the reattachment of a fractured fragment of an endodontically treated maxillary left first premolar using adhesive composites and its full coverage using the same for crowning.
| Cash report|| |
A 50 years old male patient reported, with a fractured 2 4 which was root canal treated but not crowned. Hard and soft tissue examination revealed a mobile palatal fragment, which was barely attached to rest of the tooth gingivally along with Class II amalgam restoration sealing the pulp chamber and other failing amalgam fillings. Radiographically the root canal obturation was found satisfactory. Since there was no tooth structure loss, the positioning of the fragment in close approximation to the tooth remnant was possible. Hence a reattachment followed by ferruling of the tooth using a composite crown which would be made and luted in the same appointment by applying the concept of indirect-direct resin restoration was compiled.
| Clinical Technique|| |
The mobile fragment was severed under local anesthesia [Figure 1] and stored in saline. The fracture was found to be oblique, chisel type, involving enamel, dentin and cementum [Figure 2]. Keeping biologic width in mind, palatal gingivectomy was carried to expose the tooth structure around the fracture line which was fading out subgingivally [Figure 3]. After maintaining a dry field and confirming the approximation of the fragment to the fracture line, without any further mechanical preparation the surface of the tooth remnant was acid etched and bonded (Single Bond, 3M). The fragment was similarly surface treated but extra orally, followed by its simple reattachment using the dual cure resins cement (Rely X ARC, 3M). The existing amalgam restoration was used to orient and position the fragment. Following reattachment the tooth was ground out of occlusion [Figure 4], banded and the amalgam restoration was removed. The resultant cavity was first filled with GIC (Fuji II, GC corp) to cover the exposed gutta percha in the pulp chamber and chemically bind the fragment further, followed by the composite resin (Zl00, 3M). Early in the next appointment, following shade selection, the tooth preparation was carried out with the reduction similar for a PFM crown but with a lmm chamfer margin circumferentially followed by polyvinyl siloxane impressioning (Reprosil, Dentsply) and die making. A layer of bonding resin cured on the die acted as a spacer and following the application of separating media, the crown form was built by incremental technique using selected dentin and enamel shades of the composite resin (Tetric Cerarn, Ivoclar/ Vivadent). To maximize contacts, the proximal surfaces of the crown were slightly over built. The recovered crown was cleaned off any debris and was further exposed for additional degree of conversion using the light box (Translux EC, Kulzer) for 7 minutes to optimize its mechanical properties. After intraoral try-in and confirmation of the fit, esthetics and color match of the crown, it was finished and polished. Soon, the prepared tooth was acid etched, followed by bonding of its surface (Single Bond, 3M). The fitting surface of the crown was mechanically abraded, cleansed using phosphoric acid followed by its bonding and luting using the resin cement (Rely X ARC, 3M) in the same appointment. Mylar matrices were placed between the crown and the adjacent teeth to minimize interdental overhangs and excess cement was removed by flash curing of the margins for 2-3 seconds before its final light curing. The minor occlusal adjustment was followed by intraoral finishing and polishing of the crown [Figure 6]. In the subsequent appointment the failing amalgam restorations were replaced by the composite resin (Z100, 3 M) and the patient has been under observation ever since the treatment (2 years).
| Discussion|| |
This patient apart from RC treated and fractured 2 4, had multiple fail-ing amalgam restorations and desired for tooth colored, service- able, affordable treatment but taking less time. The delay in occlusal coverage and consequent fracture of embrittled 2 4, signifies the vital role played by the post endodontic restora-tions, which is proved times and again  . Since the patient was optimistic and could appreciate the intentions, not a routine but an experimental procedure of reattachment and composite crowning for 24 was suggested. Apart from esthetics, factors like reinforcement of the tooth by micromechanical bonding, cost effectiveness, strategic position of 24 with both esthetics and occlusion at moderation and the concept of indirect - direct resin restoration  , played a decisive role in selecting composite resins which befitted the restorative needs of this patient.
Direct resins like Microfilled and hybrid resins, indirect resins like Art glass and Belle glass, and recently ceramic optimized polymer and fibre reinforced composite resins are used for making the composite crowns. Extra oral, Post-cure hardening by means of light, heat (by dry heat oven), pressure (using autoclave or in laboratory), nitrogen gas and combinations have been suggested to optimize mechanical properties and minimize the wear and functional deformation of the crown under occlusal load , . Paradoxically, high degree of conversion may lessen the chemical reactive monomeric sites, affecting the resin luting and bonding of the crown  .
The severed fragment was stored in saline to prevent dehydration and collapse of the dentinal collagen  . A simple reattachment of the fragment to the tooth remnant was carried out without any mechanical preparation of either, as it would allow proper positioning and no differences have been found in the retention of a prepared and an unprepared fragment reattached to its counterpart  . Apart from favourable physical and flow properties, the dual cure resin cement shows complete setting even if depth of light cure is less, hence it was used for an effective reattachment  .
The reattached fragment of an anterior tooth ensures better and long lasting esthetic than any tooth colored restoration, because it displays optical properties similar to rest of the tooth and restores its former shape and contour. Functionally, it wears at a rate similar to the adjacent tooth surface and biologically more acceptable as it would contact the soft tissues to which it is native by its smooth enamel surface. Also it elicits positive psycho - social response for the preservation of the natural tooth structure  . For this patient, since the RC treated, reattached 2 4 needed a crown, the above said merits were of no significance. However, by reattachment objectives like conservation and strengthening of brittle tooth by bonding and avoidance of post and core with its draw backs were met  . This simplified the remaining treatment reducing the time and cost.
For the composite crowning, the tooth was prepared with a Chamfer margin. The fracture strength of a composite crown is greater with Chamfer finish when compared to shoulder ones. Unlike ceramic crowns, a butt- fit is easily obtained at a Chamfered margin for the composite crowns, as there is no firing shrinkage. However, polymerization shrinkage related marginal gaps are shown to be more with Chamfer but luting of the crown using resin cements, provide good marginal adaptation apart from increasing its fracture resistance ,,, . The , metal free composite crown can be made with or without fibres or fibrous ,substructure  .
In this case, the composite crown was made using Tetric Ceram (Ivoclar/ vivadent) which is a ceramic optimized polymer, highly dispersed, micro-hybrid composite and due to its physical properties indicated for indirect restorations like inlays and onlays. The crown form was built without any fibres or fibrous structure, as no statistically significant differences were found in the fracture resistance of a crown with and without fibre reinforcement, and few specific problems like discoloration, fracture and debonding of the composite from the fibrous substructure, have been reported , . But a recent study has shown that the fibre reinforcement can significantly increase the fracture resistance of a composite crown  . Post -cure hardening using the light box, was carried to maximize the mechanical properties for serving as a crown, which would be chemically active and bonds strongly, when there is less lapse of time between its making and luting. Hence the crown was luted in the same appointment using the resin cement.
For the patient, composite crown achieved good esthetics, further at a lesser cost and time, as the crown lacked metal coping, procedure was devoid of any laboratory involvement and was completed in one appointment. The absence of metal coping and the amount of tooth reduction, similar for a PFM crown, provided more space for the bulk of composite to increase its longevity, serviceability and functioning as a crown. Using composite for both crown and restorations any possibility of electrogalvanism was also prevented.
Composite crown is not yet a perfect substitute for conventional PFM and cast metal ones, especially regarding its use in high stress bearing areas. However, its functioning in selected cases can have certain advantages over the latter ones. The composite crown lacking metal, will be esthetically most pleasing as there is no chance of metal showing through or its exposure due to the surface loss (as in PFM crown) or its excessive display (as in metal crown). When a composite crown is adhesively luted on an endodontically treated or weakened tooth using the resin cement, the resistance to fracture and flexural strength of such a tooth increases (by 50%) due to the reinforcement by micromechanical bonding of the crown to it, added to the full coverage protection given by the crown itself ,, . Since both the crown and cement are basically composite resins, the luted and bonded crown will be strong both cohesively and adhesively with an increase in its fracture strength. This also leads to the maximum integrity in the restoration, reducing the number of interphases and consequent micro leakage , .
When compared to ceramic crown the easiness of polishability of a composite crown, allows the obtaining of its desired smooth surface, following an occlusal adjustment or altered surface due to functioning and it cause less wearing of the opposing teeth or restorations. Regarding slightly hyper occluding crown, a composite crown is less damaging to the TMJ apparatus than a cast a metal one, as the high point gets corrected by the preferential wearing of the crown itself. For the same reason in contrast to a PFM crown, a high spot on the composite crown is less abrasive to the antagonistic tooth or restoration ,, Since composite crown is better resilient than brittle ceramic crowns, it absorbs masticatory stresses well and withstands any impact forces during finishing, polishing, seating or occlusal loading of the crown ,, .
On the other hand, if a re-entry into the root canal is needed, it can be accessed through the metal free composite crown without its removal, as it is not prone to chipping and do not damage the rotary burs. The access opening or any intraoral repair of the composite crown and adding its contacts can be easily carried out using the same material , .
Given time, space, facility with moderate sophistication and based over the concept of indirect - direct resin restoration, the procedure of making a composite crown can be restricted to the chairside so that it is directly under control of the operating specialist and with assistance of an in-house technician, it is possible to do away with crowning of the tooth in one appointment. This eliminates any need of the laboratory involvement and there on any chances of misinterpretation due to improper communication. Since there is no possibility of tooth movement or drifting in this single appointment procedure, the need of a provisional crown and there by any contamination of the prepared tooth by the temporary luting cements is excluded. Also since the time lost between the making and luting of the composite crown is less, a large number of reactive monomeric sites will be available on the fitting surface. This leads to a strong resin luting and bonding of the crown to the tooth  . The application of this concept would be useful for making a provisional crown on an endodontically treated tooth of a young patient in whom definitive crowning of the tooth would be deferred until the passive eruption ceases  .
Regarding the survival rate, it has been concluded that crowns and FPDs made of composites could be a viable alternative to those based on cast metal and ceramics , . The composite crown and restoration of this patient, which have been under observation since 2 years have not shown any abnormal wear or changes in the shade and soft tissue health in its vicinity [Figure 7].
| Conclusion|| |
The indirect mode of using and post - cure hardening of a regular composite resin assisted in over coming most of its drawbacks and moulding it into a well functioning crown, while successfully restoring a fractured, endodontically treated premolar tooth by its full coverage following the reattachment. Composite crowns are due as a right alternative to PFM or cast metal ones, because of their inherent material related limitations and lack of time tested basis. However, in selected patients after careful evaluation regarding occlusion, caries risk, parafunctional habits and age, composite crown for its esthetics and cost effectiveness can be used in lieu of a metal crown when there is a possibility of metal allergy, display, galvanism or debonding of the facing if given and where PFM crown is not affordable. Future developments in the composite resin and its clinical implications may help it in gaining a strong foothold as a crown and bridge material, particularly for high stress bearing areas.[Figure 5]
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A R Vivekananda Pai
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Light House Hill Road, Mangalore - 575001
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]