Case report: laser-assisted rebonding of a central incisor tooth due to a severe trauma--4 years of follow-up.
BACKGROUND: The success of reattaching fractured tooth crowns
fragments, as a result of trauma, has improved as a result of the
introduction of lasers in dental care. This case report documents a 4
year follow-up of a re-bonded tooth fragment on a maxillary first
permanent incisor. CASE REPORT: An 8-year-old girl presented with a
fractured maxillary might first permanent incisor (II) as a result of a
severe trauma. The child's parents had preserved the tooth fragment
in a glass of milk immediately after the injury. TREATMENT: An
Er,Cr:YSGG Laser with a wavelength of 2,780nm was used with 20Hz, 5W
(250 mJ), 90 % air, 80% water for etching of the enamel and 20 Hz, 3W
(150 mJ), 65% air, 55% water for dentine etching with a G6 (600 micron,
sapphire, 6mm long) tip. For conditioning the enamel and dentine no
additional acid etching was used. Only a 2 step self-etched adhesive
system Clearfil Protect[R] (Kuraray Medical, Japan) was applied. Then a
flowable composite resin, Grandi Flow[R] (Voco, Cuxhaven, Germany) was
applied in order to bind the broken fragment onto the tooth. FOLLOW-UP:
The re-bonded tooth fragment has been retained in place and symptom
free, as assessed by clinical examination, intraoral photographs and
radiographs for a period of 4 years. CONCLUSION: Laser-assisted
re-bonding of a tooth fragment was found to be successful.
Key words: Laser, Er., Cr:YSGG, rebonding, tooth fragment, fractures.
Crowns (Dentistry) (Health aspects)
Lasers in medicine (Health aspects)
Tooth diseases (Care and treatment)
|Publication:||Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300|
|Issue:||Date: April, 2011 Source Volume: 12 Source Issue: 2|
|Product:||Product Code: 3832848 Lasers for Medicine NAICS Code: 334510 Electromedical and Electrotherapeutic Apparatus Manufacturing SIC Code: 3845 Electromedical equipment|
|Geographic:||Geographic Scope: Turkey Geographic Code: 7TURK Turkey|
Crown and crown-root fractures of anterior primary or permanent teeth of children are the most common dental accidents during childhood. Bonding of the permanent tooth fragment is a logical restorative treatment option when the trauma results in no or minimal damage to the biological tissues surrounding the tooth. Reattachment of crown tooth fragments can provide favourable and long-lasting aesthetics because the tooth's original anatomic form, colour, and surface texture are maintained [Macedo and Ritter, 2009].
If the crown fragments of a fractured tooth remain within the dentinal region, several different treatments can be used after the necessary radiological and clinical evaluations. If a fragment is small, it can be restored with suitable composite resin (CR) restorations. But the stability of the CR restoration is limited. Due to nutritional habits and oral hygiene of an individual, CR restorations can change colour and have to be renewed over time. If the tooth fragment is large, consisting of half or more of the tooth crown, the best treatment is to consider restoring the fractured tooth using the original displaced fragment. This approach gives a good aesthetic result and colour match [Andreasen et al., 1995. Burden, 1995; Kania et al., 1996; Cortes et al., 2001]. If a patient is more than 17 years old, however, porcelain laminate veneers can also be used.
The use of lasers is becoming more common in paediatric dentistry [Martens, 2011; Olivi and Genovese, 2011]. The major advantages of hard tissue lasers such as Er:YAG and Er,Cr:YSGG are essentially that the use of providing a smear-free surface, good adhesion, lack of vibration and lack of need for local analgesia in most cases. Both Er:YAG and Er;Cr:YSGG lasers have FDA approval (Government of USA) for hard tissue applications and both laser wavelengths have the highest absorption in water of any dental wavelength and have a high affinity for hydroxyapatite. The laser energy couples into the hydroxyl radical in the apatite crystal and into the water that binds to the crystalline structures of the tooth. The vapourisation of the water within the mineral substrate causes the surrounding material to literally explode away [Eversole et al., 1997].
One of the basic advantages of the laser cavity preparation compared with conventional techniques is the temperature change of the pulp. It had been reported that the use of a bur preparation, with an insufficient cooling, may lead to a temperature rise of over 15[degrees]C when the critical temperature rise lies at about or above 5.5[degrees]C, at which a high percentage of the pulp cells are killed. But for Er:YAG or Er;Cr:YSGG laser prepared cavities, with the suggested cooling settings, a decrease in the temperature of the pulp has been recorded [Moritz, 2005].
Laser prepared enamel has a chalk-like appearance that is similar to the acid etched characteristic of enamel and enamel rods [Trajtenberg et al., 2004]. Laser etching is painless and does not involve vibration or heat, making it very useful for routine use. Furthermore, laser etching of enamel or dentine has been reported to yield a fractured and uneven surface and open dentine tubules, both apparently ideal for adhesion [Secilmis et al., 2009]. The Er,Cr:YSGG laser can also etch enamel for orthodontic purposes. It was stated that the mean shear bond strength and enamel surface etching obtained with an Er,Cr:YSGG laser (operated at 1W or 2W for 15 seconds) is comparable to that obtained with acid etching [Basaran et al., 2007].
An 8-year-old girl was brought a our paediatric dental clinic after a severe trauma to her face and maxilla. Due to the trauma she had minor soft tissue contusions but also a broken right maxillary first permanent incisor (tooth II). The patients' mother had been advised to immediately keep the piece of broken tooth in a glass of milk while bringing her child for treatment. After the child arrived, intra-oral pictures (Fig. 1a) and digital periapical radiograph (Fig. 1b) of the tooth II were taken. There were no sign of broken bone or other pathological findings and the apexification of II almost complete of II.
[FIGURE 1 OMITTED]
An Er;Cr:YSGG laser (Waterlase, Biolase, CA, USA, wavelength of 2,780 nm) was used for etching the fractured tooth crown and the broken fragment before re-bonding without any analgesia. The laser parameters were as follows:
* 20Hz, 5W (250 mJ), 90 % air,
* 80% water for etching of the enamel and 20 Hz, 3W (150 mJ),
* 65% air, 55% water for dentine etching with a G6 (600 micron, sapphire, 6mm long) tip.
After air-drying both tooth and fragment surfaces, a chalk-like appearance of the enamel on both surfaces was observed (Fig. 2). No additional acid etching was used for conditioning the enamel and dentine, but a 2 step-self etched adhesive system (Clearfil Protect[R], Kuraray Medical, Japan) was applied. Then a flowable CR, (Grandi Flow[R], Voco, Cuxhaven, Germany) was used in order to bind the broken fragment to the retained tooth. Polishing discs were used to remove the excess CR and for polishing the surface. Then post-operative pictures of the patient were taken (Fig. 2b). Application of ice was recommended to prevent the swelling of the injured soft tissues.
[FIGURE 2 OMITTED]
The patient was recalled 1 week after initial treatment. She only had to take analgesics for the first 3 days after the trauma, due to her soft tissue contusions. At the time of the first follow-up appointment a digital radiograph was taken and a recall appointment was scheduled for one month, two months then every following 6 months.
On every appointment, digital radiographs and intra-oral pictures (Fig. 3 a and b) were taken and evaluated for any signs of internal or external resorption of the root surfaces. The latest follow-up appointment was performed 4 years post-trauma (Fig. 4 a and b). Periodic pulp vitality tests showed that the tooth was still healthy and remained vital.
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
Of all the dental hard tissue traumas 18-22% are coronal fractures of permanent incisors. There are many different techniques described in the literature for re-bonding of tooth fragments [Mader, 1978; Ludlow and LaTurno, 1985; Croll, 1988; Baratieri et al., 1991]. If a tooth fragment fits exactly back into place, then it can be re-bonded provided that the endodontic, periodontal and occlusal evaluations are normal. Some researchers, however, do not support this technique because the re-bonded surface cannot withstand the occlusal forces that occur during protrusive movements [Baty et al., 1994; Chu et al., 2000; Vilela et al., 2003]. Traumatic forces affecting the teeth and periodontium can cause damage in different ways and degrees.
Re-bonding of a tooth fragment with acid-etch and adhesive system technique has been used for many years [Andreasen and Ravn, 1972; Mader, 1978; Baratieri et al., 1990]. Baratieri et al.  introduced the 'Sandwich Technique' for rebonding of tooth fragments whereby the advantages of glass ionomer cements (GIC) and CR were combined. As this treatment technique gives an opportunity to treat cases with patients' own dental tissue, it has many advantages. Treatment with the original tooth fragment has better aesthetic than CR or porcelain restorations. Anterior guidance will be truer due to the similar physical appearance with a neighbouring tooth. Also, as a patient has the opportunity to use his or her own tooth, psychological and sociological status will be better. For many cases this technique is easy and quick to do [Simonsen, 1979; Simonsen 1982; Baratieri et al., 1990].
Due to the development of bonding agents there are some case reports concerning re-bonding of tooth fragments by using only bonding agents without using additional CR [Baratieri et al., 1994; Kanca, 1993]. On the other hand, laser-assisted bonding systems have also given promising results. But there is not sufficient evidence-based research about the shear bond strength of enamel surfaces prepared by lasers compared with surfaces prepared by burs. In none of the previous studies, the laser prepared surfaces was found to be less successful when compared with conventionally prepared enamel surfaces [Moritz, 2005; Basaran et al., 2007; Secilmis et al., 2009]. In most of the previous investigations laser prepared enamel surfaces with specific wavelengths with suitable settings for enamel etching were found to be more successful than with a bur preparation [Moritz, 2005].
Re-bonding of a broken tooth fragment, following trauma, with an Er,Cr:YSGG laser was found to be very successful, maintaining stability and vitality of the affected tooth.
Andreasen FM, Noren JB, Andreasen VO, Engelardtsen S, Lind-Stromberg U. Long-term survival of fragment bonding in the treatment of fractured crowns: a multicenter clinical study. Quintescence Int. 1995;26 660-81.
Andreasen JO, Ravn JJ. Epidemiology of traumatic dental in-jury to primary and permanent teeth. Int J Oral Surg 1972;1:235-239.
Baratieri LN, Monteiro S Jr, Andrada MAC. Tooth fracture re-attachment: Case reports. Quintessence Int 21: 261-270, 1990.
Baratieri LN, Monteiro S, Andrada MA. The 'sandwich' technique as a base for reattachment of dental fragments. Oper Dent 1991;22:81-8.
Baratieri LN, Monteiro S Jr, de Albuquerque FM, et al. Reattachment of a tooth fragment with a 'new' adhesive system: A case report. Quintessence Int 1994;25:91-96.
Basaran G, Ozer T, Berk N, Hamamci O. Etching enamel for orthodontics with an erbium, chromium:yttrium-scandium-gallium-garnet laser system. Angle Orthod. 2007;77(1):117-23.
Baty DL, Storie DJ, von Fraunhofer JA. Synthetic elastomeric chains: a literature review. Am J Orthod Dentofacial Orthop. 1994;105(6):536-42.
Burden DJ. An investigation of the association between overjet size, lip coverage, and traumatic injury to maxillary incisors. Eur J Orthod. 1995;17:513-7.
Chu FCS, Yim TM, Wei S. Clinical considerations for reattachment of tooth fragments. Quintessence Int. 2000;31: 85-91.
Cortes MI, Marcenes W, Sheiham A. Prevalence and correlates of traumatic injuries to the permanent teeth of school-children aged 9-14 years in Belo Horizonte, Brazil. Dent Traumatol. 2001;17:22-6.
Croll, TP. Repair of severe crown fracture with glass ionomer and composite resin bonding. Quintessence Int 1988;19: 649-654.
Eversole LR, Rizoiu I, Kimmel AI. Pulpal response to cavity preparation by an erbium, chromium: YSGG laser-powered hydrokinetic system. J Am Dent Assoc 1997;128:1099-1106.
Franzen R, Esteves-Oliveira M, Meister J, et al. Decontamination of deep dentine by means of erbium, chromium:yttrium-scandium-gallium-garnet laser irradiation. Lasers Med Sci. 2009 Jan;24(1):75-80.
Gordon W, Atabakhsh V, Meza F, et al. The antimicrobial efficacy of the erbium, chromium:yttrium-scandium-gallium-garnet laser with radial emitting tips on root canal dentine walls infected with Enterococcus faecalis. J Am Dent Assoc, 2007;138(7):992-1002.
Kanca J. Replacement of a fractured incisor fragment over pulpal exposure: A case report. Quintessence Int 1993;24:81-84.
Kania MJ, Keeling SD, McGorray SP. Et al. Risk factors associated with incisor injury in elementary school children. Angle Orthod. 1996;66:423-32.
Ludlow JB, LaTurno SA. Traumatic fracture-one-visit endodontic treatment and dentinal bonding reattachment of coronal fragment: Report case. J Amer Dent Assoc 1985;110:314-343.
Macedo GV, Ritter AV. Essentials of rebonding tooth fragments for the best functional and esthetic outcomes. Pediatr Dent. 2009;31(2):110-6.
Mader O. Restoration of fractured anterior tooth. J Amer Dent Assoc 1978;96:113-115.
Martens LC. Laser physics and a review of laser applications in dentistry for children. Eur Arch Paediatr Dent 2011;12:61-67
Moritz A. Oral Laser Application. Berlin: Quintessenz Verlag, 2005.
Olivi G, Genovese MD. Laser restorative dentistry in children and adolescents. Eur Arch Paediatr Dent 2011; 12:68-78
Roeland JG. De Moor, Katleen I.M. Delme. Erbium Lasers and Adhesion to Tooth Structure. J Oral Laser Applications 2006; 6:7-21.
Schoop U, Kluger W, Moritz A, et al. Bactericidal effect of different laser systems in the deep layers of dentin. Lasers Surg Med. 2004;35(2):111-6.
Secilmis A, Usumez A, Usumez S, Berk G. Evaluation of mineral content of enamel prepared by erbium, chromium:yttrium-scandium-gallium-garnet laser. Lasers Med Sci. 2009; DOI 10.1007/s10103-009-0656-5.
Simonsen RJ. Traumatic fracture restoration an alternative use of acid-etch technique. Quintessence Int 1979;10:15-21.
Simonsen RJ. Restoration of fractured central incisor using original teeth fragment. J Amer Dent Assoc 1982;105: 646-648.
Trajtenberg CP, Pereira PN, Powers JM. Resin bond strength and micromorphology of human teeth prepared with an Erbium:YAG laser. Amer J Dent. 2004 Oct;17(5):331-6.
Vilela Maia EA, Baratieri LN, Andrada MA, et al. Tooth fragment reattachment: fundementals of the technique and two case reports. Quintessence Int. 2003;34:99-107.
N. Berk *, G. Berk **, S. Ulucam **
* Orthodontist, Private practice, ** Paediatric Dentists, Private practice, DENTA FORM, Ankara, Turkey.
Postal address: Dr. N. BERK, Denta Form, Mahatma Gandi Cad. No:34 06700 G.O.P.-Ankara, Turkey.
|Gale Copyright:||Copyright 2011 Gale, Cengage Learning. All rights reserved.|