Fractured First Upper Pre-Molar Restored with

Resin Composite
CASE REPORT
Mireille Feghali BDS, DU
Assistant, Department of Restorative and Esthetic Dentistry, Lebanese University, Beirut - Lebanon
Emilie Mouchantaf BDS, DU
Assistant, Department of Restorative and Esthetic Dentistry, Lebanese University, Beirut - Lebanon
Paul Nahas BDS, CES
Chief of Services, Department of Restorative and Esthetic Dentistry, Lebanese University, Beirut - Lebanon
CES from Claud-Bernard University, Lyon-France

ABSTRACT
The lack of knowledge of the biomechanical response of a vital tooth restored with composite makes the practitioners
tend for full coverage instead of a partial restoration. The purpose of this article is to show that a large composite
restoration on a vital tooth is always possible. Although the risk of fracture of the remaining enamel walls, even if they
are well supported, is relatively high. The line of the fracture, because the tooth is still vital, should stay above the pulp
chamber. No other fracture at the root level was observed. Three years later the tooth is still functional.

KEYWORDS
Cracked tooth, Dental restoration, Bonding composite.

INTRODUCTION CASE REPORT

Unlike what is known, teeth are not rigid structures; they
undergo deformation during normal loading, and lead
in some situations to weaken or even to lose parts. The
main factors that contribute to common tooth fracture
are: masticatory accidents, such as biting on a hard, rigid
object with unusually high force, or excessive removal
of tooth structure during cavity preparation, extensive
composite restorations placed without due care for
incremental technique, as well as large Class II OM and
MOD restorations that produce obvious deformation.
By definition, tooth fracture is a fracture plane of
unknown depth and direction passing through tooth
structure,1 while infraction is when the crack line is
limited only to the enamel2 the most commonly affected
teeth are mandibular second molars, followed by
mandibular first molars and maxillary premolars.3
J. Edward Ailor JR has classified fractures into vertical or
oblique. Vertical fractures are located midtooth, usually
running in a mesiodistal direction, although buccolingual
vertical fractures do occur. Oblique fractures normally
originate at the internal line angles of intracoronal
preparations and result in cuspal fracture, with or without
root involvement.1
According to Lynch C et al. management options
of a cracked tooth vary according to clinical need,
from replacement of the fractured cusp with a simple
restoration to placement of an extracoronal restoration
with adequate cuspal protection.4
This article is a case report of a fractured first upper
pre-molar that held a critically composite restoration for
almost 5 years.
The following case compared the bonding resistance
throughout the years between dentin and enamel.
A 41-year-old female exhibited discomfort at the upper
left maxillary region.
She was having pain especially when chewing tough
foods and often something as innocuous as salad, and
sudden onset of acute sensitivity to thermal changes,
always to cold and sometimes to heat.
The clinical examination revealed a horizontal line of
crack at the palatal side of the tooth (Fig 1).
No other fracture was detected after a circumferential
periodontal probing of the sulcus. The gum around the
tooth looked healthy.
Although various fracture detection devices test individual
cusps to localize fractures, biting on cotton rolls is
considered the simplest method and it revealed the same
pain described by the patient. X-ray under magnifying
loupes clarifies the diagnosis by exposing the fracture
line and its extent (Fig 2) even though a radiograph is
not the primary diagnostic aid for locating fractures.
Primary Treatment
Like any other treatment, the fractured part should be

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eliminated in order to relieve pain.

It is well known that Pressure applied to the crown

of a cracked tooth leads to separation of the tooth
components along the line of the crack.4 As a result, the
whole crown, while removing the existing old restoration
with a regular-grit diamond bur (Diamond Point FG,
#104R, Shofu, Kyoto, Japan) in a high-speed hand piece
under copious water spray, is detached taking off the
buccal cusp with it (Fig 3).

Less than 25% of the detached fragment is composed

of enamel and the rest is resin composite (Fig 4). The
enamel is fractured before it can detach from the
residual composite.
(Fig 1) Cervical crack line of the palatal cusp
On the other hand, the rest of the tooth shows a sclerotic
pigmented dentin due to an old amalgam restoration
(Fig 5). No evidence of any caries or residual composite
material is visible. The fracture pattern shows a complete
debonding of the restoration from the dentin.

Since partial restoration of the tooth with a composite

is not feasible anymore; the patient is referred to a (Fig 2) X-ray showing the
extent of the fracture line
prosthodontist for full crown coverage.

Two weeks later endodontic treatment was performed

and a metal screw was cemented. Then one month later
the final crown was placed.

Figure 6 shows a 3 years follow up of the adaptation of

the crown. The tooth is still functional.

DISCUSSION
Posterior teeth, particularly maxillary premolars, have an
anatomic shape that makes them more susceptible to cusp
fractures when under occlusal load.5 Premolars are more
brittle when subjected to lateral forces during mastication.

The type and quality of the remaining structure also has

an influence on fracture resistance when the tooth is
submitted to load application.

When the width of the intracoronal preparation of a

posterior tooth exceeds one third of the intercuspal
width, the tooth becomes significantly more susceptible
to cuspal fracture and the concern becomes not only (Fig 3) Detached crown at the fracture line
restoration failure but also tooth fracture.6

Cavities of large size (a facio-lingual dimension of more

than two thirds of the distance between cusps) had been
judged to require cusp covering.7

Thus, direct composite restorations are commonly

used for small posterior restorations and are not
recommended for large ones especially in regions with
high masticatory forces.8

Although a cusp reduction of at least 1.5mm is

recommended in extensive premolar restorations.9 The
fractured tooth shows no reduction of the buccal cusp (Fig 4) Detached Fragment detail

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 chewed.10 Finally, it holds the fracture location above the
pulp chamber at the lowest resistant wall which is in our
case the floor of the restoration. No other fracture was
observed in the remaining tooth especially at the level of
the root for the last 3 years following the placement of
the crown, means that the original fracture of the cusp
was limited above the pulp chamber (Fig 7).

In this case the failure mode observed was the

(Fig 5) Sclerotic pigmented dentin
debonding of the restoration at the dentin bonding
interface, this could be explained by the difference in
the resistance fatigue with time of the bonding agent
between enamel and dentin. Moreover, the resistance
fatigue of the bonding agent with enamel is much
better than the glasslike dentin (Fig 5), because it has a
morphological and structural transformations, induced
by physiologic and pathologic processes, resulting in
a dentinal substrate that is less receptive to adhesive
treatments than is normal dentin.6

CONCLUSION
Diagnosing discomfort sometimes could be tricky. The
practitioner must take into consideration among the
other causes of pain the possibility of a tooth fracture,
especially when patients complain of pain or discomfort
while chewing or biting. A typical examination starting
with the history to the clinical and radiographic
inspection, finalized with specialized tests could be
conclusive. Dependent on the type of the fracture,
treatment could vary from partial (Composite, amalgam)
to a full covered tooth restoration mainly when no more
healthy residual structures are left. Based on a systematic
examination and the awareness of the problem, the
practitioner should have no difficulty diagnosing and
managing pain caused by a fractured tooth.
(Fig 6) Three years later the crown is still functional
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