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CASE REPORT
Acta Marisiensis - Seria Medica 2022;68(3):136-139 DOI: 10.2478/amma-2022-0027
Reattachment of coronal tooth fragments:
Aesthetic management of a complicated anterior
maxillary crown fracture
Preethesh Shetty1, Raksha Bhat1*, Arjun Kini2
1. Nitte (Deemed to be University), AB Shetty Memorial Institute Of Dental Sciences (ABSMIDS), Department of Conservative Dentistry and Endodontics,
Mangalore, India
2. New York University College of Dentistry, New York, NY, USA.
The trauma of anterior teeth is a frequent occurrence in young patients. Reattachment of fractured fragments is one of the various treatment
modalities proposed in anterior tooth coronal fractures. The reattachment of fractured fragments grants the advantage of immediate aesthetic
rehabilitation and restoration of function, which is a relatively rapid and less arduous procedure. The manuscript presents a case report depict-
ing the management of a complicated crown root fracture of anterior maxillary teeth first treated endodontically, followed by reattachment of
the same fragment with a cast post-reinforcement. Reattachment of fractured coronal tooth fragments is a feasible restorative option, rapidly
restoring the function and aesthetics of the tooth by a conservative and inexpensive approach.
Keywords: tooth fractures, endodontics, trauma, incisors, esthetics
Received 18 June 2022 / Accepted 10 September 2022
Introduction
e most prevalent consequences of traumatic injuries are
coronal fractures in the permanent dentition, primarily
seen in the anterior maxillary teeth. Literature advocates
that coronal fractures of the anterior teeth are seen in one-
fourth of the population in the young age group, mainly
accredited to falls, high-impact sports injuries, and auto-
mobile accidents [1,2]. Of all coronal tooth fractures, the
prevalence of trauma to maxillary central incisors accounts
for nearly 37%, attributed to the anterior positioning and
protrusion of the tooth due to the eruptive pattern during
tooth morphogenesis [3]. Coronal fractures of the maxil-
lary incisors usually present with an oblique fracture line
labiolingually [4].
Traumatic injuries to the anterior maxillary teeth are
commonly seen in clinical practice. Management of such
coronal fractures is a challenge as several treatment modali-
ties must be considered. Successful management strategies
necessitate immediate functional and aesthetic repair, sup-
ported by endodontic treatment followed by a post-endo-
dontic restoration, namely, access restorations, cast posts,
bre posts, veneering, and full coverage crowns when indi-
cated. However, with the availability of the fractured tooth
fragment and no or minimal violation of the biological
width, reattachment of the dental fragment is one of the
comprehensive options for managing coronal tooth frac-
tures [5]. Reattachment of a fractured coronal tooth frag-
ment yields long-lasting aesthetics as the tooth regains its
anatomic form, colour, and surface texture. e procedure
restores ecient function in addition to a denitive psy-
chological response. Patient cooperation, understanding of
the benets and limitations of this treatment modality and
postoperative care are essential for a good prognosis [4,5].
Chosack and Eidelman reported the rst case on reat-
tachment of fractured maxillary incisor fragment manag-
ing a complicated tooth fracture with endodontic treat-
ment followed by a post endodontic restoration of cast
post and core [6]. e success of the reattachment proce-
dure is based on specic factors such as the fracture site,
size of remnants of fracture, fracture of the alveolar bone,
fracture pattern, presence of root fracture, secondary trau-
ma, soft tissue injuries, periodontal and pulpal involve-
ment, the extent of the root formation, biological width
invasion, occlusion, time-lapse and material used for reat-
tachment, post-endodontic restoration and prognosis[7].
Reattachment is a treatment modality helping restore the
natural shape, contour, translucency, surface texture, oc-
clusal alignment, and colour of the tooth with a positive
emotional and social response from the patient, preserving
the natural tooth structure. It is also a conservative and
economical procedure [8]. However, in case of signicant
periodontal damage or biological width invasion, the man-
agement of coronal fractures should follow the protocol
concerning the associated issues. e approach to coronal
tooth fractures must be systematic to achieve a successful
result [6].
e article presents a case of a complicated maxillary an-
terior coronal fracture treated with endodontic treatment
and reattachment of the fractured segment with a cast post
and core as a post endodontic restoration to provide ad-
ditional support for the restoration’s success and longevity.
Case presentation
A 23-year-old male patient reported the chief complaint of
broken upper front teeth following trauma a day prior due
* Correspondence to: Raksha Bhat.
E-mail: rkshabhat@gmail.com
137Acta Marisiensis - Seria Medica 2022;68(3)
to a fall from a bike (Figure 1). Intraoral clinical examina-
tion revealed a horizontal fracture involving enamel and
dentin with exposure of the pulp, i.e. Ellis Class III fracture
extending obliquely from the incisal edge to the middle-
third region of 11 and 12; the left maxillary central and
lateral incisor. e fractured fragment was loosely attached
to the tooth. Soft tissue examination revealed minimal lac-
eration of the upper lip. Also, an Ellis Class II fracture was
seen on the 21 right maxillary central incisor. Radiograph-
ic examination conrmed the presence of horizontal tooth
fracture in 11, 12 (Figure 2). e orthopantomagram also
conrmed the presence of the horizontal fractures in 11,
12 with the absence of any other traumatic injuries (Fig-
ure 3). e patient reported harmonious functional dental
status prior to the trauma, without any dysfunctions or
parafunctions aecting the positions of the maxillary inci-
sors. e patient was given a detailed explanation of the
dierent treatment modalities, including reattachment,
which included the rst removal of the fractured fragment,
secondly performing endodontic treatment of the tooth,
reattachment of the tooth crown fragment using a cast post
and nally the long term monitoring associated with the
treatment option. e patient was also briefed about the
risks of failure associated such as dental hygiene practices
and restriction on sports activities. On understanding the
benets and limitations of treatment, the patient commu-
nicated their inclination to maintain the integrity of the
tooth in its original form. Written informed consent was
obtained from the patient.
Under aseptic conditions, local anaesthesia was admin-
istered with anterior inltration and nasopalatine nerve
block techniques with 2% lidocaine containing 1:100,000
epinephrine. e fractured segment was separated from the
tooth and stored in a physiological saline solution to pre-
serve it from dehydration and discolouration of the tooth
fragment. e fracture site was examined in detail, disin-
fected and cauterised with a diode laser using a high power
908 nm diode laser (Kavo Gentle Ray) with a 200 μm -
beroptic tip and set at a power of 2.5 W and evaluated for
the t of the broken fragment (Figure 4). Following access
cavity preparation with an Endoaccess bur #q (Dentsply
Maillefer, Switzerland), working length was determined
with an apex locator (RootZX II, J.Morita, USA). e root
canal system was cleaned and shaped using #15 size K les
initially followed by rotary instrumentation with ProTa-
per les (Dentsply Maillefer, Ballaigues, Switzerland) up to
size F2. Disinfection of the root canal system was achieved
by initially ushing with 3% sodium hypochlorite (Py-
rex, Prime dental products, Mumbai, India), 17% EDTA
solution (Dent Wash, Prime Dental Products, Mumbai),
normal saline and a nal rinse with 2% Chlorhexidine
solution. e root canal was dried with paper points and
obturated with corresponding F2 gutta-percha cones with
calcium hydroxide-based sealer (Sealapex, SybronEndo,
Orange, CA, USA) with a down pack using heated plug-
gers (System B, SybronEndo, Orange, CA, USA).
Fig 1. A. Pre-operative photograph. B. Close-up view.
Fig. 2. Radiographic evaluation of the fractured site depicting
horizontal fracture lines in 11,12.
Fig. 3. OPG depicting the horizontal fracture lines in 11,12
Fig. 4. Fragment removal and crown lengthening (LASER)
138 Acta Marisiensis - Seria Medica 2022;68(3)
Following completion of the endodontic therapy, the
root canal system was prepared to receive the cast post by
removal of gutta-percha from the coronal two-thirds of the
canal with peeso-reamers (drill size 2). Subsequently, bevels
were placed on the tooth and on the fractured tooth frag-
ment for enhanced retention. A wax pattern was prepared
in the canal with the help of Inlay Wax (Figure 5). e cast
post was fabricated using a type II Gold alloy followed by
a try-in the root canal and adjusted to the required length
(Figure 6). Accordingly, minimal adjustments were made
in the fractured crown fragments’ pulp chamber to receive
the post’s coronal portion. Once the adjustments were con-
rmed, the alignment of the coronal tooth fragments was
veried with the post in situ. Following isolation with liq-
uid dam(Vistaapex), the post was luted in the canals using
dual-cured resin luting cement (Ivoclar Vivadent) (Figure
7). e coronal fractured fragments were reattached (Fig-
ure 8). e teeth were nished and polished with polishing
discs (Soex discs, Shofu) (Figure 9) Anterior and posterior
occlusion was veried, and postoperative instructions were
given to the patient to prevent functional loading in the
anterior teeth. e patient was recalled for follow-up after
a month, and then a year, the tooth was observed to be in
normal form, function and aesthetics.
Conclusion
e case report presents the management of complicated
crown-root fractures by a comprehensive multidisciplinary
approach, thereby preserving the natural anatomy of tooth
structure. Reattachment procedures provide a conserva-
tive, inexpensive, and aesthetic result depending on frag-
Fig. 5. Post Wax pattern preparation.
Fig. 6. Cast post core - fragment Trial.
Fig. 7. Luting of the Post and core
Fig. 8. A. Fragment reattached. B. Palatal View. C. Frontal View.
Fig. 9. Postoperative photograph.
139Acta Marisiensis - Seria Medica 2022;68(3)
ment availability. Nonetheless, relief from pain and imme-
diate restoration of aesthetics and functions accomplishes
the treatment goal in trauma.
Authors'contribution
PS: Conceptualization; Data curation; Formal Analysis;
Writing – review & editing.
RB: Supervision; Validation; Visualization; Writing – orig-
inal draft.
AK: Investigation; Supervision; Writing – review & edit-
ing.
Conflict of interest
None to declare.
References
1. Andreasen JO, Andreasen FM. Classification, etiology and epidemiology,
inTextbook and Color Atlas of Traumatic Injuries to the Teeth: Mosby,
Munksgard, Copenhagen, Denmark,1994:151–179.
2. Andreasen FM, Andreasen JO. Luxation injuries of permanent teeth:
General findings, In: Andreasen JO, Andreasen FM, Andersson L,
editor. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th
ed. Oxford, UK: Blackwell Munksgaard; 2007:372-403.
3. Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured
teeth: a review of literature regarding techniques and materials. Oper
Dent. 2004;29(2):226-33.
4. Mojirade AD, Funmilayo A-SIM, Olaide GS. Reattachment of fractured
anterior tooth: a 2-year review of a case. Int J Prosthod Restorat Dent.
2011;1(2):123–127.
5. Macedo GV, Diaz PI, De O Fernandes CA, Ritter AV. Reattachment
of anterior teeth fragments: a conservative approach. J Esthet Restor
Dent. 2008;20(1):5-18; 19-20.
6. Chosack A, Eidelman E. Rehabilitation of a fractured incisor using
the patient’s natural crown. Case report. Journal of Dentistry for
Children.1964;31:19–21.
7. Wadhwani CPK. A single visit, multidisciplinary approach to the
management of traumatic tooth crown fracture. British Dental
Journal.2000; 188(11):593–598.
8. Baratieri LN, Júnior SM, Cardoso AC, and Filho JCD.Coronal fracture
with invasion of the biologic width: a case report. Quintessence
International.1993;24(2):85–91.
9. Deliperi S, Bardwell DN, Congiu MD. A clinical challenge: Reconstruction
of severely damaged endo/bleached teeth using a microhybrid
composite resin. Two year case report. Pract Proced Aesthet
Dent.2003;15:221–226
10. Caliskan MK, Turkun M, Gomel M. Surgical extrusion of crown-root-
fractured teeth: a clinical review.Int Endod J.1999;32:146–151.
11. Johnson RH. Lengthening clinical crowns. J Am Dent
Assoc.1990;121:473–476.
12. Kocadereli I, Tasman F, Güner SB. Combined endodontic-orthodontic
and prosthodontic treatment of fractured teeth. Case report.Aust Dent
J.1998;43:28–31.
13. Hayashi M, Takahashi Y, Imazato S, Ebisu S. Fracture resistance
of pulpless teeth restored with post-cores and crowns. Dent
Mater.2006;22:477–485.
14. Christensen GJ. When to use fillers, build-ups or posts and cores.J Am
Dent Assoc.1996;127:1397–1398.
15. Christensen GJ. Posts: necessary or unnecessary? J Am Dent
Assoc.1996;127:1522–1524.
16. Rajput A, Ataide I, Fernandes M. Uncomplicated crown fracture,
complicated crown-root fracture, and horizontal root fracture
simultaneously treated in a patient during emergency visit: a case
report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009
Feb;107(2):e48-52.
