Restoring Anterior Aesthetic Using Template Method

Dentoalveolar fracture is the most common form of trauma. Dental trauma may occur as a result of a sports mishap, an altercation, a fall inside of the home, or other causes. Traumatic injuries to teeth and their supporting tissues, usually occur in children and adolescents and damage may vary from enamel fracture to avulsion, with or without pulpal involvement or bone fracture.

Anterior crown fractures are a common form of injury. Uncomplicated crown fracture of the permanent teeth has an intense effect not only on the patient’s appearance but also in function and speech. The treatment for dental injuries depends upon the type of injury and whether the injured tooth is a primary (baby) or permanent (adult) tooth. Prompt treatment is essential for the long-term health of an injured tooth.

The case report describes a new-fangled technique in restoring an uncomplicated fractured maxillary anterior tooth in a young patient with direct composite, which is economical and requires less chairside time.

Case Report: A 12-year-old boy was reported to the Department of Paediatric Dentistry for the treatment of a fractured upper front tooth with esthetic concern. The patient gave a history of trauma 6 days back due to falling on the ground while running. Clinical examination revealed Ellis class II (uncomplicated) fracture irt 11 and Ellis class I with 21. The teeth were asymptomatic without any associated soft or hard tissue injuries to the supporting tissues and responded to Electric Pulp Tester indicating tooth as vital. Intraoral periapical radiograph confirms the absence of pulpal or periapical pathosis. So, it was planned to restore the fractured segment using direct composite restoration technique.

The preliminary impression of the upper and lower arches was made using fast alginate(). Study models were made in dental stone() and mock preparation of the lost tooth structure with modeling wax() was done. After crown builds up, the cast was duplicated by using the template of putty impression material. Labial surface of the putty template was removed up to the middle third of the crown, to aid in the reconstruction of the lost tooth structure. On labial aspect, groves were made and unsupported enamel was removed. A clinical try-in of the template was done to ensure adequate fit. After appropriate shade selection of the composite material, this crown former was used to restore the fractured tooth quickly with minimal post-restoration finishing.

Discussion:

Trauma with accompanying fracture of a permanent incisor is a tragic experience for the young patient and creates a psychological impact on both the parents and children.1 If the injury involves the loss of extensive tooth structure, it alters the child’s appearance and makes him the target for teasing by peers.

Treatment objectives may vary depending on the age of the patient, socioeconomic status of the patient and intraoral status at the time of treatment planning.2 There are various treatment modalities for the restoration of fractured teeth like composite restoration, fixed prosthesis, reattachment of the fracture fragment (if available) followed by post and core supported restorations.2-4 Common restorative treatments such as laminated veneers or full-coverage restoration may be considered after multiple fragment rebonding/ composite resin restorations have been done and this option is no longer functional. They also tend to sacrifice the healthy tooth structure and challenges the clinician to match with the adjacent un-restored teeth. Management of patient’s with anterior tooth fracture provides a great challenge to the clinicians both from a functional and anesthetic perceptive. The predictable esthetic restoration of the broken incisal edge of maxillary incisors is a demanding and technique sensitive procedure. Its success is dependent on operator’s skills and knowledge and also on adhering to a systematic and problem-solving approach.5 A logical method is used to build up morphologically correct composite restorations by careful selection of composite shades, tints and opaque. Inaccurate combinations, an illusion of varying translucencies and opacities become visible over natural tooth structure.6

In patients with fractured dentition, satisfactory results were reported with anterior composites offering a cost-effective treatment alternative where esthetics is a major concern. With further improvements in bonding chemistry, the suc¬cess rate of composites is speculated to improve.5 A good polishing system including polishing paste, cups, and wheels is recommended to achieve appropriate luster.

In the present case new-fangled technique which includes both direct and indirect method of restoring was designed by using Polyvinyl Siloxane (PVS) Rubber base impression material (putty) as a template. This method is simple quick and economic when compared to other invasive procedures. The usage of the PVS template allowed incremental layering of the composite material; optimal depth of cure; accurate reproducibility of the anatomic contours and minimal polishing and finishing procedures.7,8

Direct composite resin bonding agents successfully deal with the esthetic issue of maxillary anterior teeth along with a painless approach providing a successful outcome for the dentist and greater satisfaction for the patients. As restoring a fractured tooth is a complex procedure, this technique can prove as simple, effective and appropriate technology that will fulfill all the requirements of dental personnel.