A 24 year old male patient, a basketball professional player, suffered a traumatic crown fracture of the upper right central incisor (11), with the fracture line being located in the middle third of the tooth. The patient reported promptly to the clnician with the fractured fragment. The tooth involved showed no evidence of pulpal exposure or of periodontal lesions consequent to the dental injury. Our operative protocol, preliminarily to any restorative step, started with a clinical examination in order to evaluate the traumatic injury, and the condition and the margins of the fragment. The fractured tooth was evaluated by trans-illumination in order to rule out the presence of enamel fissures. In the radiographic assessment, there was no fracture of the root or the alveolar bone [Figure 1].
The fractured portion was disinfected with 0.2% chlorhexidine, and stored in physiologic solution (Ogna Sodiomu Clorum 0.9 % ) to maintain the hydration. Tooth vitality test was performed by giving thermal stimulus to the tooth (cold) and it responded as vital. The first step of the operative procedure, after administration of local anaesthesia, was the isolation of the operating field with a rubber dam. Prior to the reattachment procedure, the fractured tooth was cleansed and polished; and, the fractured portion was "tried-in" to check for any presence of disruptions or defects between the remaining tooth structure and the fragment. To facilitate its handling, the fragment was fixed on its vestibular aspect to a holder with an adhesive tip (Pic-n-stic, Pulpdent Corp.)
We decided to proceed with the attachment of the fractured fragment with no additional tooth preparation as there was no loss of dental hard tissues and the edges matched without any disruptions.
The fragment was treated with an "etch and rinse" technique using 37% phosphoric acid (The acid time application was related to the different tooth surface. It was 30 seconds for enamel, 1s seconds for dentine), followed by a separate application of priming and bonding agents (Scotchbond MP, 3M ESPE), and the fragment was kept away from light or heat sources until the reattachment phase. The fractured tooth was etched and treated with the same adhesive system (Scotchbond MP, 3M ESPE). The fragment was thus placed in its proper position on the tooth paying attention to the perfect fit between the two parts and only after this point was the bonding agent photopolymerized. The polymerization was carried out on both the vestibular and lingual aspects using a 60 seconds for each surface light-emitting diode (LED) light-curing unit (Elipar Freelight 2, 3M Espe). The restored tooth was then finished and polished using silicon points immediately after the fragment reattachment (HiLuster Plus Identoflex, KerrHawe).
Patient was then recalled for a follow up control at 6 and 12 months. All the clinical evaluation demonstrated a good maintaining of the previous treatment with good aesthetics and function.
25 months later the patient injured the same tooth during a sport activity and sustained a small enamel fracture at the incisal margin of the fragment reattached [Figure 2]. The other maxillary central incisor (21) was involved by a small enamel lesion too caused by the same traumatic event. At this time vitality test by giving thermal stimulus to the tooth (cold) was performed again and the tooth was still vital. The clinicians observed the stability of the fragment. Therefore, a direct restoration of both of the fractured teeth was performed using Scotchbond MP (3M Espe) and composite resin (Filtek Supreme, 3M Espe). Patient was recalled for follow up control at 3 months and no function, clinical or aesthetic problems were recorded. However, 4 months later a new trauma caused the detachment of the fragment. After clinical evaluation the treatment plan of choice was the same one used on the occasion of the first fracture [Figure 3]. After 3 years (5.5 years from the first injury) a follow-up control was performed. Aesthetics and pulp vitality were confirmed clinically. A radiographic control showed no evidence of periapical pathology [Figure 4].