IDRR APRIL -MAY -JUNE 2020 - Flipbook - Page 74
ESTHETIC DENTISTRY
The treatment options available in this scenario are:
1. Composite buildup of fractured tooth
2. Reattachment of fractured fragment
Reattachment procedure was the treatment of
choice because it was the easiest and most conservative treatment option. It is the least time-consuming
treatment option and since incisal edge effects are
already present in the fractured fragment there is no
need to recreate them. The only problem with the reattachment procedure is a high chance of debonding and treatment failure and the difficulty to hide the
fracture line for a good aesthetic outcome.
Shade selection is the first and foremost procedure in
any aesthetic case and it is the first step to be carried
out before any dehydration occurs to the tooth during
any operative procedures. Hence prior to rubber dam
isolation, the shade of the composite resin to be used
was confirmed with button technique and A3 body
shade from 3M ESPE was selected (Figure 3). The
shade of the fractured segment was not altered as it
was kept well hydrated in milk and brought to OPD. In
a case where the fragment was kept dry, we can
consider reattachment. In such cases, the shade will
not match initially but rehydration of the fragment will
happen in 3 or 4 days after reattachment leading to
a better shade match.
Prior to any adhesive procedure, rubber dam isolation
is a mandatory step. The surfaces to be bonded are
first thoroughly cleaned and polished with a non-fluoridated prophylactic paste. This is done to remove biofilm. Here, Clinpro (3M ESPE) prophy paste was used
(Figure 4 & 5). Alternatively, sand-blasting can also be
done.
The adjacent teeth are covered with teflon so as to
protect it while etching. Selective etching of enamel
was carried out for 20 seconds with 37% orthophosphoric acid (Figure 6). The dentin surface is not
etched. Etching procedure was followed by washing
with a gentle stream of water for one minute followed
by blot drying. Now the enamel is ready to be bonded
July-August-September 2019
(Figure 7).
Meanwhile, the fractured piece was removed from
milk and was disinfected with 2% chlorhexidine solution (Asep-RC from Anabond Stedman) for one to two
minutes (Figure 8).
The fractured piece was attached to OptraStick (Ivoclar Vivadent) as it is difficult to carry with finger (Figure 9). The fit of the fractured fragment to the tooth
was checked and confirmed (Figure 10). Selective
etching of enamel was done with 37% orthophosphoric acid for 20 seconds followed by washing with the
gentle steam of water for 1 minute followed by air dry
(Figure 11). Single bond universal (3M ESPE) was gently
massaged onto the etched tooth surface as well as
fractured piece for 20 seconds followed by gentle air
dry for 10 seconds to remove the solvent. Light curing
was not done. Heated packable composite A3 shade
from 3M ESPE was injected onto the tooth surface and
the fractured fragment was bonded into place(Figure
12). The excess was removed and light cured for 40
seconds.
Now there are two potential problems. The first one
being the inability to mask the fracture line. The second problem is that the shear bond strength of the attached piece is very low irrespective of the material
used.
Based on the study published by Chazine et al, Dent
Traum 2011, the influence of the material and the
technique used to reattach the fragment was evaluated using a shear bond strength test. Pure adhesive,
flowable composite, regular packable composite
and dual cure resin cement were used to reattach 80
fragments. Another variable was the use or not of a
post reattachment procedure as demonstrated in this
article. The choice of material seems to have no influence on the test whereas a bevel performed on the
buccal and palatal surfaces could significantly improve the shear bond strength of the reattached fragment (Figure 13).
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