Esthetic Management of a Reattached Tooth Fragment by Abelardo Báez, DDS, MS; Gerardo Dúran, DDS; Diego De Nordenflycht, DDS

A 27-year-old woman presented a main complaint of a recently non-complicated tooth fracture of the maxillary right central incisor. After a thorough clinical examination, all possible facial, root or alveolar bone traumatic injuries were discarded. At the examination it was noted that her tooth also had a palatal surface aged composite resin restoration, altered gingival zenith position, unsatisfactory shade and color of the remaining tooth, and attrition of the incisal edge. The patient brought the tooth fragment to first appointment, which presented a clearly dehydration and whitish appearance due to having been wrapped in dry paper for two days.

The tooth fragment; note its white appearance due to dehydration.

Because the fragment adapted correctly to the remaining tooth, the decision was made to reattach it and correct the esthetics of both maxillary central incisors.

The operating field was isolated with a rubber dam using a split dam technique and a gingival retraction cord.
Adhesive technique used on the intact portion of #8: etching, rinsing, adhesive application, and light-curing.
Once the adhesive was set, a universal dentin composite resin was applied on the treated surface of the fragment and then taken to the prepared tooth with a placement instrument.
The tooth fragment mounted on the placement device.

"One concern regarding the esthetics of tooth fragment reattachment is dehydration, which can result in the fragment being whiter than the remaining dental structure."

The composite resin was pre-heated at 55°C to improve its flowability. The excess of composite resin was gently removed and adapted with a brush and then light-cured.
Image immediately after the fragment was reattached.

The patient returned the next day, at which time a radiograph was taken and improvement in the reattached fragment's color was noted. A gingivoplasty (external bevel incision technique using a No. 15 scalpel correcting only soft tissue) was performed at the same appointment to raise the gingival zenith to the level of #9.

Two weeks later, a direct veneer of #8 was completed and a mesial correction of #7 performed. After the application of a gingival retraction cord in both teeth, a 0.3-mm minimal chamfer preparation was made supragingivally in the cervical aspect of #8

Twelve hours after reattachment the improvement in the fragment’s color is noticeable. Composite resin excess can be seen in the buccal aspect of #8.

Two weeks after the gingivoplasty.

Minimal and conservative preparation of #8.

A two-step etch-and-rinse adhesive system was applied following manufacturer’s instructions over the prepared surface of #8 and the unprepared surfaces of #7. A first layer of dentin composite resin (UD 0.5) was used on #8 was applied over the cervical zone of the vestibular surface, and light-cured for five seconds. A universal enamel composite resin (UE2) was then applied all over the vestibular area until the tooth’s shape was completed, and light-cured under a small layer of glycerin gel for 60 seconds. UE2 alone was used for characterization and esthetic corrections on #7. At the same appointment, a first polishing was done using a diamond silicone point at 4,000 rpm.

The adhesive technique used on #8 and #7.
Dentin composite resin application.
Enamel composite resin application.
Final light-curing through the glycerin layer.

Definitive finishing and polishing procedures were performed 48 hours later. After drawing the transitional angles on the vestibular surfaces to mimic the visual effects of natural teeth, final shaping of the restored teeth was accomplished with abrasive discs.

Finishing procedure for definitive details; note the lines drawn to emulate the transitional angles of #9.

Diamond polishing pastes were applied in descending order of particle size using a goat hair brush. Final gloss was achieved using aluminium oxide paste with a felt wheel. Finally, interproximal surfaces were polished with diamond strips.

Diamond strips were used to polish the interproximal surfaces.
Immediately after finishing and polishing, showing a minimal difference in color.
One month later, the restorations are successfully integrated.

This case presents a conservative approach for the management of maxillary front teeth that have been functionally and esthetically impaired by an uncomplicated dental fracture, mismatched shades, and asymmetrical gingival zenith. Particularly interesting about this case was the integration of multiple conservative esthetic procedures. The direct freehand veneer played a fundamental role in achieving the right shape and color after the reattachment and the clinician was able to achieve optimized esthetics without laboratory procedures. When a case requires restoration of only one tooth it is easier to mimic the shape and color of the adjacent tooth and the need for subsequent adjustments is less likely. It should be noted, however, that even with these advantages, esthetic correction after fragment reattachment requires a clinician well trained in esthetic layering techniques.

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