Treating Fractured Teeth With Composite Resin

Written by Jaime Morgan, DDS, and Stan Presley, DDSWednesday, 10 August 2011 14:17

INTRODUCTION
Over the years, one of the most challenging restorations to place has been on a tooth presenting with a Class IV
fracture. Dentists have universally experienced difficulty in providing a long-lasting restoration that exhibits all of the
color properties necessary for a successful shade match, as well as harmonious texture and polish. Due to their past
experiences, many clinicians have regarded a direct-bonded Class IV restoration as a temporary solution. They will
often advise their patients that the affected tooth will require a porcelain restoration as the definitive treatment.
However, there has been a flurry of progress in the research and development of composite resins during
the first decade of this millennium. New techniques have been introduced, and an improved protocol has been
developed in the clinical environment to maximize these advances. Because of this, there should no longer be a
reason to regard composite resin restorations as temporary or substandard. It is, however, important to update your
knowledge on the properties of the composite resin material that you are utilizing in order to consistently create
beautiful restorations. In order to realize long-lasting results, adhering to protocol is even more important. The
following case study represents a typical emergency appointment dealing with a fractured central incisor in an
adolescent patient.
CASE REPORT
Diagnosis and Treatment Planning

Figure 1. Facial view of fractured

Figure 2. Lingual view of fractured

upper central incisors.

upper central
incisors.

Figure 3. Note the band of incisal

Figure 4. Vit-l-escence (Ultradent

translucency.

Products) enamel-enhancing
shades.

Figure 5. Vit-l-escence basic enamel Figure 6. An undulating (scalloped)

shades.

margin was prepared to create an

invisible margin once the microhybrid
composite resin was placed.

Figure 7. Opaque Snow was used

Figure 8. Dentin shade A1 was used

for the lingual layer.

to replace the missing dentin.

A 15-year-old male was seen in response to an athletic trauma inflicted upon teeth Nos. 8 and 9 (Figure 1).
Incidentally, a majority of Class IV fractures occur in this age group.1,2 The mesial-incisal angle of tooth No. 8 was
fractured at the incisal one third, and only involved the enamel. Tooth No. 9 was fractured in the middle one third at
the mesial-incisal as well as the distal-incisal angle and involved both dentin and enamel (Figure 2). A standard
periapical radiograph was taken to verify that there was no pulpal involvement or fracture of the root or surrounding
structures.
There was enough sensitivity to temperature changes to necessitate performing the procedure under local
anesthetic. Prior to beginning the procedure, the resin shades were chosen while the teeth were still hydrated. In this
case, a narrow translucent incisal zone was evident, accompanied by the incisal halo (Figure 3). To deem this
restoration an aesthetic success, these subtle nuances would need to be duplicated, and thus we chose Vit-l-escence
(Ultradent Products) for this case. In most situations, this requires only 2 shades: one dentin and one enamel shade,
in conjunction with a universal lingual opaque shade that prevents intraoral show-through. The dentin shade required
for this restoration, as determined by utilizing the specific resin shade tab, was A1. This composite resin system, as
well as other "super systems" offer numerous enamel shades. However, most of the enamel shades are in fact
enamel enhancing shades, which are generally not used on a daily basis. In the Vit-l-escence system, the enamel
enhancing shades are designated as "Trans" shades; the true enamel shades are designated as "Pearl" shadesof
which there are only 4 (Figures 4 and 5).
Of the 4 Pearl shades, the authors use only 2 of them based on whether the patient has bleached his or her

teeth or not. If the patient has bleached, Pearl Frost is used. If the patient has not bleached, Pearl Neutral is used.
Since our patient had not bleached his teeth, Pearl Neutral was used for the facial enamel layer, while Opaque Snow
was used as the universal lingual opaque layer.
Preparation and Composite Resin Placement Protocol
Local anesthetic (3% Isocaine plain [Septodont]) was administered and the fractured teeth were prepared with a long
star-burst shaped bevel (48L bur [Brasseler USA]) (Figure 6).3-5 Teflon tape would have been necessary to cover the
enamel of the adjacent tooth if an interproximal contact had been present. In this case, the adolescent had diastemas
present, which were left open in anticipation that future orthodontic treatment would be able to properly position the
teeth.
Beginning with the right central incisor, the teeth were restored. Tooth No. 8 was etched (UltraEtch [Ultradent
Products]) and bonding agent applied (PQ-1 [Ultradent Products]). To ensure an invisible margin, both the etchant
and the bonding agent were applied well beyond the fracture line in a gingival direction. Longevity of the restoration
depends upon utilizing a maximum amount of the remaining facial enamel. The increase in surface area improves the
bonding anchorage value of the restoration to such an extent that this restoration should rival the cosmetic life of any
all-ceramic counterpart. Since the fracture in tooth No. 8 only involved the enamel, and occurred at the line of
translucency, no dentin shade or lingual opaque shade was needed. Therefore, only Pearl Neutral was used, thus
preserving the translucent zone as well as continuing the incisal halo of the natural tooth.

Figures 9 and 10. After placing Pearl Neutral as the facial layer, adjusting
and polishing. The completed aesthetic and strong composite resin
restorations.
After preliminary shaping of No. 8, the enamel and dentin surfaces of No. 9 were prepared with UltraEtch
and PQ1 bonding agent, again extending in a gingival direction well beyond the fracture line. The lingual enamel layer
was placed using a universal lingual opaque shade (Opaque Snow). It is important to note that it was left short of the
final distal and incisal edges of the tooth, allowing for the creation of a thin band of translucency that was required for
optimal aesthetics in this case (Figure 7). Following the simplified layering technique protocol, the dentin-enamel
junction (DEJ) was used as a guide for the placement of the dentin layer. Dentin shade A1 was placed to restore the
portion that was missing from the fracture. This was placed directly over the lingual enamel layer (Figure 8). The final
facial enamel layer was then placed using Pearl Neutral.

Sorry! It's Part of the Restoration

Tom M. Limoli, Jr
As the authors have repaired teeth Nos. 8 and 9 with direct resin-based composite restorations, the appropriate code that identifies the
procedures is D2335. A 4 or more surface anterior restoration is one in which both the lingual and facial margins extend beyond the line
angle and the incisal angle is involved. This restoration may also involve all 4 surfaces of an anterior tooth and not involve the incisal
angle.
If the case so dictated that the direct restorative technique would not provide the needed prognosis, then a true temporary
crown for a fractured tooth identified with code D2970 would be the order of the day. This code is not intended as a reimbursement
mechanism to be used in conjunction with the routine delivery of fixed crown and bridge therapy.
If the patient is, or will, become a patient of record in your office and you complete the chamfer/shoulder outline on the date of
treatment and make the preparation ready for the final impression, the use of this code would be fraudulent.
If you are placing a treatment crown for a patient who will not return to you for the fabrication of a finished crown, the use of this
code is appropriate, provided this tooth has been involved with accidental injury. When such injury is reported, reimbursement may be
canceled by the dental insurance plan, with further submissions being made to the liability carrier, automobile insurer or workers'
compensation plan. Coordinating benefits with these insurers would result in enhancing the current benefits available for the injured
tooth as well as providing for future replacements.

Table. Laser Codes and Fees

Code

Description

Low

Medium High

National
Average National RV

D2335

Resin-based composite
4 or more surfaces involving inisal
angle (anterior)

$175

$206

$376

$269.20

5.85

D2970

Temporary crown

$182

$290

$372

$256

5.57

CDT-2011/2012 copyright American Dental Association. All rights reserved. Fee data copyright Limoli and
Associates/Atlanta Dental Consultants. This data represents 100% of the 90th percentile. The relative value is
based upon the national average and not the individual columns of broad-based data. The abbreviated code
numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for
your individual office is available for a charge from Limoli and Associates/Atlanta Dental Consultants at (800)
344-2633 or limoli.com.
Finishing and Polishing
Finishing and defining of the facial anatomy were completed using a 48L bur (Brasseler USA). An egg-shaped
finishing bur (H379 [Brasseler USA]) was used for lingual anatomy reproduction and for the occlusal adjustments.
Polishing was carried out using Jiffy cups (yellow and white) (Ultradent Products), ending with a Jiffy brush (Ultradent
Products). Interproximal polishing was done using Epitex (GC America) polishing strips.
The final clinical result (Figures 9 and 10) showcases the remarkable manner in which modern resin
chemistry has allowed dentists to duplicate color and light-handling capabilities of natural teeth, while be confident of
restorative longevity.
DISCUSSION
The resin utilized in this case (Vit-l-escence) is a microhybrid resin. It is indicated for use in both anterior and posterior
teeth. The authors chose this resin because of the ease in shade matching to the natural tooth, the manner in which

the material handles, and the finishing and polishing results that it produces. The shade tabs are fabricated out of the
actual Vit-l-escence resin (other systems use dissimilar materials) and are divided into the individual enamel and
dentin shades. This unique feature allows the clinician to directly match a resin shade tab to exposed dentinand the
same with the enamel.
Most of the information on shade matching is based on determining an average hue by placing a shade tab
on the facial of the tooth to be restored or on the adjacent intact tooth. The problem with this method is that it does not
take into account the individual contributions of the dentin and the enamel. On most fractures, the DEJ can be seen,
which clearly separates the dentin and enamel components as well as indicates the thickness of each layer. The
interplay between the thickness of each layer and how they change from gingival to incisal provides the polychromatic
effect visually perceived by the human eye. The authors based their simplified layering technique on this unique
anatomical characteristic of the tooth: thinner enamel at the gingival third and thicker enamel at the incisal third.
CONCLUSION
The case example presented here, involving the successful repair of a tooth with a Class IV fracture, demonstrates
how the utilization of a proper protocol and suitable composite resin materials can ensure both beauty and longevity.

References
1.

Gutz DP. Fractured permanent incisors in a clinic population. ASDC J Dent Child. 1971;38:94-95.

2.

Summitt JB, Robbins JW, Schwartz RS. Fundamentals of Operative Dentistry: A Contemporary Approach.
2nd ed. Chicago, IL: Quintessence Publishing; 2001:243.

3.

Morgan J. Successful management of class IV fractures: Direct bonding and finishing procedures. In: The
New Face of Aesthetics; The AACD Monograph. 2004; 1:8186.

4.

Vargas M. Conservative aesthetic enhancement of the anterior dentition using a predictable direct resin
protocol. Pract Proced Aesthet Dent. 2006;18:501-507.

5.

Morgan J, Presley S. Conservative treatment of dental trauma in adolescents with malocclusion. J Am

Orthodont Soc. 2008;8:34-37.

Dr. Morgan received her dental degree from the University of Texas Health Science Center at San Antonio. She
divides her professional career between clinical practice of cosmetic restorative and orthodontic treatment with her
husband, Dr. Stan Presley in Salt Lake City, Utah and teaching. She regularly contributes articles to dental periodicals
and journals on cosmetic dental techniques for the general practice. Dr. Morgan has served as a founding member of
the South Texas Chapter of the American Academy of Cosmetic Dentistry. She has served on the board of directors
of the American Orthodontic Society. She also lectures internationally. She can be reached at (801) 561-9999, via email at morganjaimee@hotmail.com , or by visiting the Web sitepresleyorthodontics.net.

Disclosure: Dr. Morgan is a consultant for Ultradent Products and other dental companies.
Dr. Presley received his dental degree from Baylor College of Dentistry in 1977. He currently practices orthodontics
and cosmetic and restorative dentistry with his wife Dr. Jaime Morgan in Salt Lake City, Utah. His training at the L.D.

Pankey Institute and Dr. Bob Gerety's straight wire continuum has provided him with a sound cosmetic treatment
philosophy. Dr. Presley was one of the founding members of the South Texas Chapter of the American Academy of
Cosmetic Dentistry where he served as secretary and vice-president. He is co-developer of the Simplified Layering
Technique for composites along with Dr. Morgan. Dr. Presley lectures internationally and has contributed numerous
articles demonstrating realistic and learnable procedures for general practitioners. He can be reached at (801) 5619999 or by visiting the Web site presleyorthodontics.net.
Disclosure: Dr. Presley is a consultant for Ultradent Products and other dental companies.