Making the Most of an Emergency Appointment: A Class IV Fracture Repair

The dental office should view emergency patients as an opportunity to strut its stuff. If these patients feel they have been treated in a caring, professional manner by a friendly staff in a relaxed atmosphere, it is a distinct possibility that they and their families will become patients. One of the most stressful situations for an emergency patient who is not a patient of record in any office is a fractured anterior tooth. Instilling confidence in the patient by providing an aesthetic result in a timely manner can turn a one-time patient into an often-time patient.
For the clinician, the class IV fracture can present many challenges, including issues related to shade, shape, texture, luster, durability, and creating an invisible margin.1 The following case describes how to overcome the aforementioned difficulties in a timely and efficient manner.

CASE REPORT

Figure 1. Preoperative view of the class IV fracture of the upper right central incisor (tooth No. 8).

A 9-year-old male reported with a distal-facial-lingual-incisal fracture of the upper right central incisor (Figure 1). Incidentally, a majority of class IV fractures occur in this age group.2,3 A standard periapical radiograph was taken to verify that there was no pulpal involvement and/or fracture of the root or surrounding structures.
Although the fracture was substantial, there was no pain and little temperature sensitivity. A conservative approach utilizing direct bonding was appropriate. Therefore, the patient did not require anesthetic for the procedure.

SIMPLIFIED SHADE AND LAYERING TECHNIQUE

Because of the durability, lifelike characteristics, and ease of handling, a microhybrid composite resin was chosen (Amelogen Plus [Ultradent Products]), and a simplified shade selection and layering technique was used. The simplified layering technique provides optical characteristics associated with a natural tooth, using only one enamel shade, one dentin shade, and one universal opaque shade. In a natural tooth, it is the exchange in the thicknesses of dentin and enamel from gingival to incisal that is primarily responsible for its polychromatic nature. A natural tooth in cross-section exhibits thin enamel and thick dentin in the gingival third, resulting in more saturation of color in this area. The opposite occurs at the incisal third, where thicker enamel and thinner dentin is found, resulting in a lighter and more translucent area. The middle third of the tooth serves as a transitional area.

Figure 2. Note the exposed dentin and enamel layers of the fractured tooth.	Figure 3. A direct composite mock-up is done without etching/bonding.

Figure 4. An undulated, starburst-like bevel provides an invisible margin.

The simplified shade selection technique is a common sense method, matching the exposed cross-section of the tooth to be restored (Figure 2). The dentin body shade and the enamel facial shade are selected by direct comparison of the composite shade tabs to the actual dentin and enamel layers of the fractured natural tooth to be restored. An opaque shade is recommended for the lingual enamel layer to prevent intraoral show-through.1 This technique differs from the more complicated methods, where a recipe of shades is used to create the average hue of the tooth. Shade selection should always be performed as one of the first steps while the tooth is still hydrated.
Immediately after shade selection, the decision must be made as to whether the procedure can be freehanded or if a stent/guide would be required to speed up the bonding portion of the case. Generally, when more tooth structure is missing, there is greater need for a stent. The stent has proven valuable in proper placement of composite restorations because it provides mesial distal width, gingival incisal height, and facial lingual depth.4
There are two methods for creating a stent. The first method involves placing composite on the unetched, unprimed tooth to be restored. The composite is then light-cured once the proper shape and dimensions are achieved (Figure 3). A roll of heavy-bodied putty PVS impression material is then placed on the opposing arch, and the patient is instructed to close down partially while pushing the material forward with the tongue until the material sets. The set silicon and the composite resin from the tooth are then removed. The facial aspect of the silicon is then trimmed, resulting in a guide/stent to aid in the proper placement of the definitive composite resin restoration. The question may arise that if a mock-up can be done in the mouth, why not skip this extra step and freehand the definitive restoration? The layering technique is more easily accomplished when you have a stent to push against and to keep the composite in place while working with thin layers. The second method involves taking an alginate impression of the fractured tooth in order to build up the desired shape on a stone model, followed by the creation of the silicone putty stent on the model. In this case, the first method was utilized for better time efficiency.
To achieve an invisible facial margin, it is recommended that an undulated bevel be placed on the facial fractured edge.1,5,6 Create long fingers into the remaining enamel to make a starburst-like effect (Figure 4). This will later facilitate the blending of the resin and the enamel so that light transmission through the resin mingles with that of the enamel, thus hiding the fractured edge.
To isolate the fractured tooth, a small piece of Teflon tape was cut and placed around the adjacent teeth. The tape was stretched and pulled tight over the dried teeth. A depth-limiting 35% phosphoric acid-etch gel (Ultra-Etch [Ultradent Products]) was then placed using the total-etch technique over the enamel and dentin for 15 seconds, which was subsequently rinsed off and air-dried. This was followed by an application of a chlorhexidine gluconate solution (Consepsis [Ultradent Products]), which was then air-dried. (Consepsis is an antimicrobial agent with an ethanol carrier that does not interfere with bond strengths.)

Figure 5. Silicone putty stent in position. Note anatomical landmarks provided by the stent that will aid in proper composite placement.	Figure 6. The lingual enamel wall is fabricated with Opaque White composite to prevent intraoral show-through.

Figure 7. Postoperative view taken 13 months after placement of restoration. Note color stability and surface luster.

The bonding agent was then applied, air-thinned, and light-cured for 10 seconds (PQ1 [Ultradent Products]). Next, the preformed silicone putty stent was put into place (Figure 5). To reiterate, note that the gingival-incisal length, mesial-distal width, and facial-lingual depth can be seen in the stent, providing a reliable guide for restoring the proper morphology of the tooth. Additionally, the stent offers a stable surface on which to shape the lingual resin and subsequent layers. The lingual enamel wall was created by applying shade OW composite resin (Opaque White, Amelogen Plus; Figure 6). This layer should approximate the thickness of the lingual enamel. To provide a translucent incisal edge that matched the adjacent tooth, an explorer was used to create irregularities or small scallops in the edge of the OW prior to light-curing, enhancing the optical dimension. Nature abhors a straight line, therefore anytime it is possible to create irregularities in the restoration, the better it is. Dentin shade A1 was used to replace the missing dentin, as indicated by the dentoenamel junction of the fractured tooth. It is important to use the cross-sectional guide that appears on the fractured teeth to know where and how much material will be needed. If the dentin is placed too thick, the overall color of the restoration will be too dark, and vice-versa if too little ma-terial is used. The enamel shade EW (Enamel White, Amelogen Plus) was placed facially and interproximally to finish the bonding procedure. The facial material was carried onto the enamel past the fracture line, filling in the starburst pattern of the undulated bevel.
The silicone putty stent and the Teflon tape were removed, and the restoration was shaped using a combination of carbide finishing burs (48L, H379, ETS7 [Brasseler USA]). Care was taken to ensure that all scratches were eliminated from the surfaces while at the same time preserving microanatomy. The tooth was polished using a white Jiffy Polisher Cup followed by a Jiffy Polisher Brush (Ultradent Products). Polishing protocol dictates that if at any step in the polishing process scratches are still observed, then it is prudent to back up one step and eliminate these. However, this simple polishing scheme is extremely effective. The interproximal surface was smoothed using ultra-fine Vision Flex abrasive strips (Brasseler USA) followed by blue Epitex Finishing and Polishing Strips (GC America). With the use of Teflon tape, however, only minimal polishing of the adjacent resin is necessary. An important tip: stretching the tape smoothly over the interproximal surface without creating creases or wrinkles will eliminate interproximal issues completely.

CONCLUSION

The final result is a restoration that is not only aesthetically pleasing, but also durable (Figure 7). The conservative nature of this direct bonded composite resin restoration allowed preservation of the remaining natural tooth structure. This young patient was also appreciative that, because this was a minimally invasive procedure, it did not require any anesthetic. Although this patient started out with us as an emergency patient, he is now a patient of record, along with his entire family.

References

Dr. Morgan graduated from the University of Texas Dental School at San Antonio. She has been heavily involved in research in association with the Division of Esthetic Dentistry at the University of Texas. In conjunction with her research, she has presented numerous scientific papers, and she has had several articles published in the leading dental journals. Dr. Morgan lectures internationally on aesthetic and restorative dentistry as well as orthodontics. She has been touted as one of the most practical speakers heard in that she focuses on “real dentistry for real people” and offers practical solutions to everyday problems. Dr. Morgan practices orthodontics and cosmetic and restorative dentistry in Salt Lake City, Utah, and can be reached at (801) 561-9999 or morganjaimee@hotmail.com.

Disclosure: Dr. Morgan is a consultant for Ultradent Products.

Dr. Presley received his doctorate from Baylor College of Dentistry in 1977. He attended The Pankey Institute, which provided him with a sound cosmetic treatment philosophy. Dr. Presley was one of the founding members of the South Texas Chapter of the AACD; he also served as secretary and vice president. Recognizing the need to provide an alternative to porcelain restorations in his practice, Dr. Presley focuses his attention on conservative aesthetic restorations combined with orthodontic treatment. He is a co-developer of the Simplified Layering Technique and lectures internationally using both didactic and hands-on courses. He also writes articles and lectures on realistic and learnable procedures for general practitioners, including direct composite resins and orthodontics. He currently practices orthodontics and cosmetic and restorative dentistry with his wife, Dr. Jaimeé Morgan, in Salt Lake City, Utah, and can be reached at
(801) 561-9999 or by visiting presleyorthodontics.net.