As a private practitioner trained in advanced aesthetic techniques, it is common to overlook simple solutions to what may initially appear to be a complex problem. At times, the temptation is to present a comprehensive aesthetic treatment plan when a patient presents with a traumatized or otherwise damaged tooth. If the remaining dentition is unsightly, the jump to an aesthetic rehabilitation seems the natural solution.
The purpose of this article is to describe a procedure recently performed on a 76-year-old female patient. The patient presented with what she described as a front tooth that was “broken in half.” Upon examination, it was determined that tooth No. 9 had fractured both vertically through what appeared to be an internal stress fracture, and mesio-distally through the DEJ. These vertical fractures are commonly observed in elderly patients, but I had never seen a total separation (Figures 1 through 4).
Given the patient’s inability to proceed with a comprehensive aesthetic rehabilitation, she was presented with four treatment options: (1) full-coverage PFM; (2) all-porcelain crown; (3) porcelain veneer; and (4) reattachment of the fractured portion of the tooth. I felt that the fourth was a viable choice, and it was decided to attempt reattachment of the separated portion. This course of treatment was the least invasive and guaranteed the most accurate match to her remaining dentition.
|Figure 1. Patient presentation.||Figure 2. Tooth No. 9 with fragment removed.|
|Figure 3. Dentin surface of fragment.||Figure 4. Facial surface of fragment.|
|Figure 5. Optibond placed on segment.||Figure 6. Cord placed to isolate.|
|Figure 7. Seek placed.||Figure 8. Seek rinsed off.|
|Figure 9. Tooth restored.|
After establishing that the separated fragment was indeed intact, it was coated with Seek (Ultradent) and rinsed to verify that there was no decay present. The internal surface was then microetched (Danville Engineering), rinsed, etched for 15 seconds with 35% phosphoric acid (Patterson), rinsed for 20 seconds, coated with Optibond Solo Plus (Kerr), and isolated to avoid premature curing (Figure 5).
The anterior teeth were isolated with a rubber dam, and a small piece of retraction cord (GingiBraid, Van R) was placed to control any seepage from the gingival sulcus, as the fracture terminated precisely at the gingival margin (Figure 6). Again, Seek (Ultradent) was used (Figures 7 and 8), and then the dentin surface of the tooth was scrubbed with Concepsis (Ultradent) as a cleansing medium and to help decrease any potential sensitivity. The tooth was then etched with 35% phosphoric acid (Patterson), rinsed for 20 seconds, and lightly wetted with SuperSeal (Phoenix Dental) to again decrease the possibility of sensitivity as well as to enable a wet dentin bond. Optibond Solo Plus (Kerr) was applied, thinned, and cured twice. After placement of the third coat, the severed portion of the tooth was placed into position, any excess Optibond Solo Plus was removed with a thin brush, and the tooth was cured (Jetlite 2000, J. Morita) for a total of 3 minutes—1 minute each on the facial, palatal, and incisal surfaces. After establishing that the occlusion had not been altered, the tooth was polished with Enhance Cups (DENTSPLY Caulk) (Figure 9).
The patient was extremely grateful that her front tooth could be repaired in a rapid and economic fashion. Prior to the development of current bonding materials and techniques, this patient would have had to endure a different experience, probably with a less-than-satisfactory result.
The author wishes to acknowledge the Las Vegas Institute for Advanced Dental Studies for its progressiveness and guidance.
Dr. Levy currently maintains a private practice in Columbus, Ohio, and is a clinical instructor at the Las Vegas Institute and the Ohio State University College of Dentistry. He can be contacted at (614) 476-6696.