Guidelines for Restoring Fractured Central
Imen Kalghoum, Ines Azzouzi, Hadyaoui Dalenda*, Belhssan Harzallah and Mounir Cher
Department of Fixed Prosthodontics, University of Monastir, Tunisia
Submission: January 05, 2018; Published: February 22, 2018
*Corresponding author: Hadyaoui Dalenda, Department of Fixed Prosthodontics, Research Laboratory of Occlusodontics and Ceramic Prostheses LR16ES15, Faculty of Dental Medicine, University of Monastir, Tunisia, Email:email@example.com
How to cite this article: Imen Kalghoum, Ines Azzouzi, Hadyaoui Dalenda, Belhssan Harzallah, Mounir Cherif. Guidelines for Restoring Fractured Central
Incisors. Adv Dent & Oral Health. 2018; 7(5): 555724. DOI:10.19080/ADOH.2018.07.555724
Faced with fractured central incisors, many solutions are available and the practitioner has to choose the appropriate one. Rehabilitation of the compromised teeth number 11 and 21 was performed with lithium discilcate veneers. The purpose of this clinical case is to outline the treatment approach and to highlight the different guidelines to establish function and esthetic using ceramic veneers.
Keywords: Ceramic veneers; Dental trauma; Central incisors; Function; Esthetic
Traumatic dental injury has been confirmed as a current health problem in many recent studies. Now a day’s [1,2]. First, trauma of the oral region occurs frequently and makes up 5% of all injuries for which people seek treatment in all dental clinics and hospitals in a country .
High-risk age groups for dental and facial trauma were 10-18 years and 19-28 years, which may be attributed to the fact this age-group usually has more intense social interaction and sports activities 
The teeth most commonly affected by trauma are the maxillary central incisors [3,4]. There are many causes for these such as falls, sports injiolenceuries, and vehicle accidents; other causes may also exist, depending on a country’s development and local habits [3-5]. The most frequent types of permanent teeth fractures are enamel fractures, enamel and dentine fractures, and enamel and dentine fractures with pulp involvement .
The conservative dental esthetic reestablishment treatments has been improved and evaluated with the development of adhesive materials. The adhesive dentistry allowed minimally invasive preparation through direct treatments with composite resin and indirect ceramic laminates veneers [7,8]. Despite the contribution of this treatment modality in terms of esthetic outcome, restoration of a fractured tooth in the anterior maxilla remains a challenge for even the most experienced dental practitioner. Several approaches for recovery of the esthetics and the function are available [7,8]. Currently, The clinician must consider all diagnostic parameters before making a decision or
recommendation to the patient. Direct resin is suitable when compromised structures is minimal allowing a natural look , However, Indirect restorations are indicated for greater strength and longevity but they add a layer of complexity when communication with the laboratory technician is required for an esthetic outcome .
A range of dental ceramic materials is presently available on the market for these treatments, though with very different characteristics in terms of the composition, optic properties and manufacturing processes involved. In fact, A.A Font et al created a classification based on the objectives of treatment: esthetic and/or functional problems Because of their predictable results and conservation of tooth structure,  ceramic veneers are indicated for the esthetic rehabilitation of fractured anterior teeth with anomalous position and appearance. The aim of this paper is to highlight the steps of dental rehabilitation in a 19-year-old patient with fractured central incisors which had been directly restored by composite resin and because of repetitive fracture of the resin. The patient restrained herself from smile due to self-consciousness. Seeking for a permanent restoration, the alternative solution was a fixed restoration using ceramic veneers, who restrained herself from smile due to self-consciousness, using ceramic veneers.
H.F was a 19-year-old female patient reported to the department of prosthetic dentistry, with a chief complaint of unattractive smile because of her fractured tooth number 11 and defective composite restoration in tooth number 21. Complete
history of the patient along with preoperative photograph was
taken (Figure 1). Medical history was non-contributory. Extra oral
examination showed an ovoid face with a convex profile.
Intraoral examination revealed that the right central incisor
was fractured in the middle-third of the crown, involving enamel
and dentin without pulp exposure (Figure 2) and without
symptoms of concussion or contusion, The left central incisor
was restored by composite but she complained from it repetitive
loss.. Oral prophylaxis was done and dental hygiene maintenance
instructions were given. Radiographic examination and tooth
vitality tests were positive. Anterior guid¬ance was evaluated.
Several approaches for recovery of the esthetics and the
masticatory function depend on the type and extent of tooth
fracture; In this case, the fracture is located in enamel a dentin
with a loss of much tooth structure, the use of ceramic veneers is
an excellent and suitable alternative.
In order to facilitate the treatment planning, a wax-up and
cosmetic mock-up is recommended. The wax-up is a study model
that present build- up wax teeth and the mock-up is obtained from
silicon matrix filed with bis-acrylic resin  which provided a real
three dimensional in situ visualization of the final result of the
Various techniques for accurate tooth reduction have been
proposed, including silicone matrices, depth limiting burs and
free hand preparation (Cherukara et al. 2005). It is important
that whatever tooth reduction guide method is used, it is based
on the definitive wax up and not the original tooth. Failure to do
this may result in excessive and unnecessary removal of tooth
enamel. Tooth should be prepared within the enamel whenever
possible. In this case depth limiting burs were used to prepare
directly through the bis-acryl mockup, as described by Gurel
(2003) (Figure 3). The teeth were prepared with a marginal
chamfer labially and interproximally, and a butt fit margin palatoincisally
with wrap around onto the palatal aspect as described
by Castelnuovo et al. 2000 (Figure 4). Contact points were not
preserved, in order to allow freedom for the technician to change
the width and shape in the final restoration. Ensure smooth finish
lines and surfaces, using 40 micron diamond abrasives. A smooth
surface avoids stress under the veneer and also a more uniform
thickness of cement. This also leads to better adhesion.
After adequate gingival retraction (Figure 4), a two step dual
impression was made and sent to the laboratory for fabrication of
lithium dislocates (IPS e max cad) veneers.
Lithium desiccate veneers were aided by computer (CAD), by
copying the contours from the diagnostic wax-up (Figure 5 & 6).
Veneers were individually checked intra-orally to control gingival
margins adaptation, the complete seating and embrasure opening,
and occlusion. Then, shade and esthetics were well checked to
minimize contamination from saliva and blood, the application of
rubber dam is strongly recommended. In fact blood can change the
completely the color of final restoration and because of esthetic
failure. Currently maintaining clean tooth with water and pumice
during bonding is very important for the success of this step. Light
curing composite resin was used for bonding.
At the end of the treatment, the patient was pleased with the
results and no longer hides her smile (Figure 7 & 8). Periodic
follow-up was scheduled to evaluate the gingival health and
patient comfort and satisfaction. (Figure 9 & 10)
Unlike dental caries that have been declining over the last
decades, Dental fractures are considered an increasing public
health problem compromising aesthetic and function. If this
trauma is not treated, personal problems can occur, such as
difficulties in eating, laughing, and smiling, as well as emotional
problems associated with public contact . Aesthetic dentistry
has expanded dramatically in the last two decades and reestablishing
dental aesthetic appearance is a very important
clinical challenge .
Currently, based on the type and the extent of tooth fracture,
there are many treatment options and it is possible to restore
function and esthetics using very conservative restorative
techniques. In our case, the use of composites was well suited for
our young patient because it is a very conservative technique for
performing repairs without reduction in healthy tooth structure
, Final restoration using nanoparticles-based composite resin
was performed, allows restorations with shades and nuances
similar to the adjacent dental structures. However, to achieve
good results, this technique requires knowledge of the field of
restorative material, dental anatomy, and the skills to reproduce
all the characteristics of the tooth . After a short time, there was
a repetitive loss of restoration, because the restoration probably
doesn’t support the masticator efforts, mainly because of the
insufficient area for bonding, Furthermore, those restorations
should be limited for fractures limited in dental enamel or in
enamel and dentin without loss of much tooth structure [8,9].
Currently, the use of ceramic veneers was indicated, It was
introduced into dentistry as Hollywood veneers by Pincus 
with a survival rates ranged from 92% at 5 years to 64% at 10
years [15,16]. On another hand, According to a recent systematic
review Composite and ceramic veneers were found to have
statistically similar survival rates. Indirect composites showed
87% survival rate compared with 100% for ceramic veneers,
with all failures occurring within 13 months of placement. No
secondary, Caries were seen with either material. Temporary
postoperative sensitivity developed with both ceramic (9%) and
composite (26%) .
According to some cli¬nicians, provisionalization is not
necessary because tooth reduction is minimal, but in reality, it’s an
important step in the treatment plan as it gives to both patient and
clinician the opportunity to access the final planned result 
preparation, cementation, and finishing procedures adopted are
considered key factors for the long-term success and aesthetical
result of the veneer restorations. In addition with improved
mechanical properties of dental ceramics and the optical qualities
of these materials have allowed the use of ceramics with esthetic
The success of minimally invasive restoration of fractured
teeth dependent on the detailed planning and correct selection
of dental materials. Ceramic veneers provided good treatment
outcomes and allowed long-lasting functional and esthetic