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Management of the fractured incisor
T r e a t m e n t of th e incisal fra c tu re by th e m e th o d d e s c rib e d in this re p o rt pro v id e s im m e d ia te a n d lo n g -te rm repair, seals th e fra c tu re site, and restores e sthetics at th e initial visit.
Managem ent of the fractured incisor
G.A. Crim, DMD, M ilton, KyWIÊÊÊÊÊIKÊÊÊIÊÊIÊÊÊÊÊlÊÊÊÊÊÊÊÊlÊÊ^KÊllÊÊÊÊÊÊimÊÊiÊÊÊÊÊÊÊÊÊÊÊÊKIÊÊÊÊÊIÊÊIKÊÊÊÊÊKKÊIÊÊÊÊL
T h e m a n a g e m e n t o f a fra c tu re d in c is o r h a s b e e n g re a tly fa c ilita te d s in c e th e in tro d u ctio n o f th e
ity p re p a ra tio n is n e c e s s a r y fo r u se o f th e a cid e tc h p ro c e d u re , th e re a re s e v e ra l fa c to r s w h ich
a c id -e tc h c o m p o s ite s y s te m s .1 H o w e v e r, th is r e sto ra tiv e te ch n iq u e re q u ires m u ch a tte n tio n and sk ill. T h e te c h n iq u e m u st m e e t th e e ss e n tia l r e q u ire m e n ts o f m e c h a n ic a l re te n tio n , fu n ctio n a l e s th e tic s , and n atu ral c o n to u r, w h ile rem ain in g as a tra u m a tic to th e pulp a s p o ss ib le . T h e u se o f p in -re tain e d c o m p o s ite re s to ra tio n s has b e e n a d v o ca te d b y s o m e o p e ra to rs in th e tre a tm e n t o f in cisa l fr a c tu r e s . T h is p ro c e d u re , w h ile a ttain in g goo d e s th e tic re s u lts , re q u ire s an e x a c tin g te ch n iq u e to avo id fu rth e r pulpal d am a g e .2 T h e fo llo w in g p ro c e d u re m in im iz es pulpal tra u m a s in c e all o f th e p re p a ra tio n is co n fin e d to th e e n a m e l. F o r th o s e te e th w h ere th e re h a s b e e n m inute pulp e x p o s u re , th e a c id -e tc h te c h n iq u e h a s n o t a b le p u lp -tre a tm e n t c a p a b ilitie s . I t p ro v id e s an
c o n tra in d ic a te th is o m is s io n . A m o d ified b e v e l p re p a ra tio n aro u n d th e fra c tu re site a ffo rd s c o r r e c t a n a to m ica l c o n to u r c o n trib u tin g to gingiv al h e a lth and e s th e tic s (w ith o u t th e re m o v a l o f som e e n a m e l th e re s to ra tio n will b e o v e r c o n to u re d ); c o n tro l o f m arg inal lea k a g e p ro v id ed b y th e fe a th ered g e fin ish o f th e c o m p o s ite m a te ria l3; g re a te r
im p ro v ed m eth o d o f sea lin g in th e ra p e u tic ag e n ts and iso la tin g th e pulp fro m o ral flu id s th rou g h b e tte r m arg in al ad a p ta tio n .
R a tio n a le
b u lk o f m a te ria l to re s is t fr a c tu r e ; in c re a se d su r fa c e a re a fo r b on d in g to im p ro v e re te n tio n ; and rem o v a l o f o u te r “ m a tu re d ” e n a m e l w h ich m ay re s is t e tch in g . H o lm e s and R a k o w 4 re p o rted th a t m o st fa ilu re s
AUTHOR
Dr. Crim is an assistant professor in the departm ent of restorative dentistry at the University of Louisville S chool of D entistry in Louisville, Ky 40232. Address re quests fo r re prints to Dr. Crim. CRIM
A lth o u g h m o st m a n u fa c tu re rs im ply th a t n o c a v JADA, Vol. 96, January 1978 ■ 99
in th e e tch in g te c h n iq u e resu lte d fro m th e v a ria tio n s in d ire c tio n o f en a m e l ro d s, p re s e n c e o r a b s e n c e o f in te rp rism a tic s u b s ta n c e , o r th e p re s e n c e o f an e n am e l p e llic le . T o help e lim in a te th e lo ss o f in cis a l r e s to ra tio n s , th e y su g g ested th e in itial re d u ctio n o f th e e n a m e l o f all te e th th a t a re to b e re sto re d w ith th is te c h n iq u e .
M e th o d and m a te ria ls T h e s e le c tio n o f th e sh ad e o f th e c o m p o site -m a te rial is m ad e b e fo re th e to o th is iso la te d w ith e ith e r a ru b b e r dam o r c o tto n ro lls. A dry field is e s s e n tial to th e s u c c e s s fu l union o f th e re sin and the e tc h e d e n a m e l. T h e p re p a ra tio n is d on e w ith a n o . 250-7V i or 2 6 0 -8 d iam on d b u r u sin g a w a te r c o o la n t sp ra y .
Facial view of m odified bevel preparation (left); Incisal view of prepared fractured incisor (right).
T h e m od ified b e v e l is e x te n d e d 2 to 3 m m b ey o n d th e fra c tu re site to a d ep th o f a third to a h a lf o f the to tal e n a m e l th ic k n e s s . T h e tip o f th e d iam ond in stru m en t p ro v id e s th e b ev el to aid in fe a th e re d g in g, w h ile th e rem ain in g p o rtio n p ro v id e s th e re d u ctio n in b u lk (Illu s tra tio n ). I f th e o p e ra to r c h o o s e s to u se a ce llu lo id cro w n fo rm to p la ce th e c o m p o s ite m a te ria l, it m ay be s e le c te d and trim m ed a t th is tim e . A b a se o f c a l ciu m h y d ro x id e m u st b e p la ced o v e r any e x p o s e d d en tin b e fo re e tch in g . A so lu tio n o f 3 5 % p h o sp h o ric a cid on a c o tto n p e lle t is p laced on th e en am el w alls fo r 1 to 2 m in u tes. B e c a u s e th e a cid is a p o ten tia l irrita n t to th e pu lp, it should b e c o n fin e d to the p rep ared e n am e l o n ly . T h e a cid is rin sed o f f th e to o th and th e site is th o ro u g h ly d ried w ith an o il-fre e air sp ra y . P ro p e rly p rep ared en a m el shou ld h a v e a “ fr o s te d ,’ ’ ch a lk y -w h ite a p p e a ra n c e .5T h e c a lciu m h y d ro x id e lin e r shou ld b e in ta c t. I f th e lin e r is not in ta c t, it shou ld b e re p la c e d . C a r e sh ou ld b e ta k e n to av o id an y c o n ta m in a tio n o f th e e tch e d e n a m e l. T h e unfilled resin b on d in g a g e n ts a re m ixed and p la ced o v e r th e p rep a red e n a m e l w ith a sm all b ru sh o r sp on g e p e lle t. T h e c o m p o s ite m ate ria l is th e n m ixed a cc o rd in g to th e m a n u fa c tu re r’ s in s tru ctio n s and im m e d ia te ly p la ced w ith th e aid o f a ce llu lo id m a trix strip o r cro w n fo rm . A fte r th e c o m p o s ite h a s s e t, re m o v a l o f th e g ro ss e x c e s s m ay b e a c c o m p lis h e d w ith tu n g sten c a rb id e b u rs and c o a r s e sa n d p a p er d isk s. A n o. 12 sca lp e l b lad e m ay b e u sed in te rp ro x im a lly to re m o v e sm all a re a s o f fla s h . C a r e should b e ta k e n to av o id th e u se o f pryin g fo r c e s th a t co u ld d islod ge th e re s to ra tio n . F in a l p o lish in g is d on e w ith fine c u ttle fis h d isk s and strip s g e n e ro u sly lu b rica ted w ith s ilic a te lu b ric a n t.6 100 ■ JADA, Vol. 96, January 1978
C o n c lu s io n T h e m a n a g e m e n t o f th e in cisa l fra c tu re b y the m eth o d d e sc rib e d p ro v id e s b o th im m ed iate and lo n g -term re p a ir, s e a ls th e fra c tu re s ite , and re sto r e s e s th e tic s a t th e initial v is it. T h e d esign o f th is p re p a ra tio n in c o rp o ra te s s e v e ra l s c h o o ls o f th o u g h t. T h e r e is th e a d v a n ta g e o f th e sh o u ld er p re p a ra tio n 7 fo r p rovid ing b u lk o f m a terial fo r b e tte r stre n g th , re te n tio n , and c o r r e c t c o n to u r. T h e sea lin g p ro p e rtie s o f th e b ev el p re p a ra tio n to e sta b lis h a fe a th e re d g e m a rg in 8 a re a lso in clu d ed in th is te c h n iq u e .
1. Baharloo, D., and Moore, D.L. E ffect of acid etching on mar ginal penetration of com posite resin restorations. J Prosthet Dent 32:152 Aug 1974. 2. Scheer, B. The restoration of injured an terior teeth in children by etch-retained resin. A long itudin al study. Br Dent J 139:465 Dec 16, 1975. 3. Al Rafei, S., and Morre, D.L. Marginal penetration of com po site resin restorations as indicated by a tra cer dye. J P rosthet Dent 34:435 Oct 1975. 4. Holmes, L.W., and Rakow, B. Trouble-shooting acid-etch fa il ures. J NJ Dent Assoc 47:20 Fall 1975. 5. Mink, J.R., and McEvoy, S.A. Acid etch and enamel bond com posite restoration of perm anent an te rio r teeth affected by enamel hypoplasia. JADA 94:305 Feb 1977. 6. M cLundie, A.C. and Murray, F.D. Com parison o f m ethods used in fin ish in g com posite resin— a scanning electron m icro scope study. J P rosthet Dent 31:163 Feb 1974. 7. Rule, D.C., and E lliott, B. Seml-perm anent restoration of fra c tured Incisors in young patients. Br Dent J 139:272 Oct 7, 1975. 8. B uonocore, M.G.; Sheykholeslam , Z.; and Glena, R. Evalua tio n of an enamel adhesive to prevent m arginal leakage: an in vitro study. J Dent C hild 40:119 M arch-A pril 1973.
Managem ent of the fractured incisor
G.A. Crim, DMD, M ilton, KyWIÊÊÊÊÊIKÊÊÊIÊÊIÊÊÊÊÊlÊÊÊÊÊÊÊÊlÊÊ^KÊllÊÊÊÊÊÊimÊÊiÊÊÊÊÊÊÊÊÊÊÊÊKIÊÊÊÊÊIÊÊIKÊÊÊÊÊKKÊIÊÊÊÊL
T h e m a n a g e m e n t o f a fra c tu re d in c is o r h a s b e e n g re a tly fa c ilita te d s in c e th e in tro d u ctio n o f th e
ity p re p a ra tio n is n e c e s s a r y fo r u se o f th e a cid e tc h p ro c e d u re , th e re a re s e v e ra l fa c to r s w h ich
a c id -e tc h c o m p o s ite s y s te m s .1 H o w e v e r, th is r e sto ra tiv e te ch n iq u e re q u ires m u ch a tte n tio n and sk ill. T h e te c h n iq u e m u st m e e t th e e ss e n tia l r e q u ire m e n ts o f m e c h a n ic a l re te n tio n , fu n ctio n a l e s th e tic s , and n atu ral c o n to u r, w h ile rem ain in g as a tra u m a tic to th e pulp a s p o ss ib le . T h e u se o f p in -re tain e d c o m p o s ite re s to ra tio n s has b e e n a d v o ca te d b y s o m e o p e ra to rs in th e tre a tm e n t o f in cisa l fr a c tu r e s . T h is p ro c e d u re , w h ile a ttain in g goo d e s th e tic re s u lts , re q u ire s an e x a c tin g te ch n iq u e to avo id fu rth e r pulpal d am a g e .2 T h e fo llo w in g p ro c e d u re m in im iz es pulpal tra u m a s in c e all o f th e p re p a ra tio n is co n fin e d to th e e n a m e l. F o r th o s e te e th w h ere th e re h a s b e e n m inute pulp e x p o s u re , th e a c id -e tc h te c h n iq u e h a s n o t a b le p u lp -tre a tm e n t c a p a b ilitie s . I t p ro v id e s an
c o n tra in d ic a te th is o m is s io n . A m o d ified b e v e l p re p a ra tio n aro u n d th e fra c tu re site a ffo rd s c o r r e c t a n a to m ica l c o n to u r c o n trib u tin g to gingiv al h e a lth and e s th e tic s (w ith o u t th e re m o v a l o f som e e n a m e l th e re s to ra tio n will b e o v e r c o n to u re d ); c o n tro l o f m arg inal lea k a g e p ro v id ed b y th e fe a th ered g e fin ish o f th e c o m p o s ite m a te ria l3; g re a te r
im p ro v ed m eth o d o f sea lin g in th e ra p e u tic ag e n ts and iso la tin g th e pulp fro m o ral flu id s th rou g h b e tte r m arg in al ad a p ta tio n .
R a tio n a le
b u lk o f m a te ria l to re s is t fr a c tu r e ; in c re a se d su r fa c e a re a fo r b on d in g to im p ro v e re te n tio n ; and rem o v a l o f o u te r “ m a tu re d ” e n a m e l w h ich m ay re s is t e tch in g . H o lm e s and R a k o w 4 re p o rted th a t m o st fa ilu re s
AUTHOR
Dr. Crim is an assistant professor in the departm ent of restorative dentistry at the University of Louisville S chool of D entistry in Louisville, Ky 40232. Address re quests fo r re prints to Dr. Crim. CRIM
A lth o u g h m o st m a n u fa c tu re rs im ply th a t n o c a v JADA, Vol. 96, January 1978 ■ 99
in th e e tch in g te c h n iq u e resu lte d fro m th e v a ria tio n s in d ire c tio n o f en a m e l ro d s, p re s e n c e o r a b s e n c e o f in te rp rism a tic s u b s ta n c e , o r th e p re s e n c e o f an e n am e l p e llic le . T o help e lim in a te th e lo ss o f in cis a l r e s to ra tio n s , th e y su g g ested th e in itial re d u ctio n o f th e e n a m e l o f all te e th th a t a re to b e re sto re d w ith th is te c h n iq u e .
M e th o d and m a te ria ls T h e s e le c tio n o f th e sh ad e o f th e c o m p o site -m a te rial is m ad e b e fo re th e to o th is iso la te d w ith e ith e r a ru b b e r dam o r c o tto n ro lls. A dry field is e s s e n tial to th e s u c c e s s fu l union o f th e re sin and the e tc h e d e n a m e l. T h e p re p a ra tio n is d on e w ith a n o . 250-7V i or 2 6 0 -8 d iam on d b u r u sin g a w a te r c o o la n t sp ra y .
Facial view of m odified bevel preparation (left); Incisal view of prepared fractured incisor (right).
T h e m od ified b e v e l is e x te n d e d 2 to 3 m m b ey o n d th e fra c tu re site to a d ep th o f a third to a h a lf o f the to tal e n a m e l th ic k n e s s . T h e tip o f th e d iam ond in stru m en t p ro v id e s th e b ev el to aid in fe a th e re d g in g, w h ile th e rem ain in g p o rtio n p ro v id e s th e re d u ctio n in b u lk (Illu s tra tio n ). I f th e o p e ra to r c h o o s e s to u se a ce llu lo id cro w n fo rm to p la ce th e c o m p o s ite m a te ria l, it m ay be s e le c te d and trim m ed a t th is tim e . A b a se o f c a l ciu m h y d ro x id e m u st b e p la ced o v e r any e x p o s e d d en tin b e fo re e tch in g . A so lu tio n o f 3 5 % p h o sp h o ric a cid on a c o tto n p e lle t is p laced on th e en am el w alls fo r 1 to 2 m in u tes. B e c a u s e th e a cid is a p o ten tia l irrita n t to th e pu lp, it should b e c o n fin e d to the p rep ared e n am e l o n ly . T h e a cid is rin sed o f f th e to o th and th e site is th o ro u g h ly d ried w ith an o il-fre e air sp ra y . P ro p e rly p rep ared en a m el shou ld h a v e a “ fr o s te d ,’ ’ ch a lk y -w h ite a p p e a ra n c e .5T h e c a lciu m h y d ro x id e lin e r shou ld b e in ta c t. I f th e lin e r is not in ta c t, it shou ld b e re p la c e d . C a r e sh ou ld b e ta k e n to av o id an y c o n ta m in a tio n o f th e e tch e d e n a m e l. T h e unfilled resin b on d in g a g e n ts a re m ixed and p la ced o v e r th e p rep a red e n a m e l w ith a sm all b ru sh o r sp on g e p e lle t. T h e c o m p o s ite m ate ria l is th e n m ixed a cc o rd in g to th e m a n u fa c tu re r’ s in s tru ctio n s and im m e d ia te ly p la ced w ith th e aid o f a ce llu lo id m a trix strip o r cro w n fo rm . A fte r th e c o m p o s ite h a s s e t, re m o v a l o f th e g ro ss e x c e s s m ay b e a c c o m p lis h e d w ith tu n g sten c a rb id e b u rs and c o a r s e sa n d p a p er d isk s. A n o. 12 sca lp e l b lad e m ay b e u sed in te rp ro x im a lly to re m o v e sm all a re a s o f fla s h . C a r e should b e ta k e n to av o id th e u se o f pryin g fo r c e s th a t co u ld d islod ge th e re s to ra tio n . F in a l p o lish in g is d on e w ith fine c u ttle fis h d isk s and strip s g e n e ro u sly lu b rica ted w ith s ilic a te lu b ric a n t.6 100 ■ JADA, Vol. 96, January 1978
C o n c lu s io n T h e m a n a g e m e n t o f th e in cisa l fra c tu re b y the m eth o d d e sc rib e d p ro v id e s b o th im m ed iate and lo n g -term re p a ir, s e a ls th e fra c tu re s ite , and re sto r e s e s th e tic s a t th e initial v is it. T h e d esign o f th is p re p a ra tio n in c o rp o ra te s s e v e ra l s c h o o ls o f th o u g h t. T h e r e is th e a d v a n ta g e o f th e sh o u ld er p re p a ra tio n 7 fo r p rovid ing b u lk o f m a terial fo r b e tte r stre n g th , re te n tio n , and c o r r e c t c o n to u r. T h e sea lin g p ro p e rtie s o f th e b ev el p re p a ra tio n to e sta b lis h a fe a th e re d g e m a rg in 8 a re a lso in clu d ed in th is te c h n iq u e .
1. Baharloo, D., and Moore, D.L. E ffect of acid etching on mar ginal penetration of com posite resin restorations. J Prosthet Dent 32:152 Aug 1974. 2. Scheer, B. The restoration of injured an terior teeth in children by etch-retained resin. A long itudin al study. Br Dent J 139:465 Dec 16, 1975. 3. Al Rafei, S., and Morre, D.L. Marginal penetration of com po site resin restorations as indicated by a tra cer dye. J P rosthet Dent 34:435 Oct 1975. 4. Holmes, L.W., and Rakow, B. Trouble-shooting acid-etch fa il ures. J NJ Dent Assoc 47:20 Fall 1975. 5. Mink, J.R., and McEvoy, S.A. Acid etch and enamel bond com posite restoration of perm anent an te rio r teeth affected by enamel hypoplasia. JADA 94:305 Feb 1977. 6. M cLundie, A.C. and Murray, F.D. Com parison o f m ethods used in fin ish in g com posite resin— a scanning electron m icro scope study. J P rosthet Dent 31:163 Feb 1974. 7. Rule, D.C., and E lliott, B. Seml-perm anent restoration of fra c tured Incisors in young patients. Br Dent J 139:272 Oct 7, 1975. 8. B uonocore, M.G.; Sheykholeslam , Z.; and Glena, R. Evalua tio n of an enamel adhesive to prevent m arginal leakage: an in vitro study. J Dent C hild 40:119 M arch-A pril 1973.