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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 219-227

Contemporary restorative strategies for root canal-treated traumatized maxillary incisors – Case series report


1 Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, Madurai, Tamil Nadu, India
2 Department of Endodontics, Nova Southeastern University College of Dental Medicine, Davie, FL, USA

Date of Submission21-Jun-2020
Date of Decision27-Jul-2020
Date of Acceptance02-Jul-2020
Date of Web Publication1-Dec-2020

Correspondence Address:
I Anand Sherwood
Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_65_20

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  Abstract 


This article aims to present about the restorative strategies to be adopted for the management of root canal-treated traumatized maxillary incisors incorporating the contemporary minimal invasive options. Each root canal-treated tooth poses a unique challenge to be addressed in an individual manner. This presentation highlights the restorative assessment and technique to be adopted for restoring the root canal-treated maxillary incisor.

Keywords: Composite restoration, posts, restoration of root canal-treated teeth, traumatized maxillary incisors


How to cite this article:
Sherwood I A, Gutmann JL, Divyameena B, Nivedha V, Ramyadharshini T, Asit JJ, Subashri V, Valliappan C T, Pavula S, Pradeepa M R, Rahul B. Contemporary restorative strategies for root canal-treated traumatized maxillary incisors – Case series report. J Dent Res Rev 2020;7:219-27

How to cite this URL:
Sherwood I A, Gutmann JL, Divyameena B, Nivedha V, Ramyadharshini T, Asit JJ, Subashri V, Valliappan C T, Pavula S, Pradeepa M R, Rahul B. Contemporary restorative strategies for root canal-treated traumatized maxillary incisors – Case series report. J Dent Res Rev [serial online] 2020 [cited 2021 Jan 16];7:219-27. Available from: https://www.jdrr.org/text.asp?2020/7/4/219/302058




  Introduction Top


Many clinicians opt for full-coverage crowns for root canal-treated maxillary incisors irrespective of the tooth structure loss. When the loss of tooth structure has been extensive treatment of choice would be fabrication of cast post or fiber post followed by full-coverage crowns. Contemporary literature evidence states that when there is relatively minimal loss of tooth structure in anterior teeth, tooth-colored composite restoration would be sufficient.[1],[2],[3] Assessment of the tooth structure loss as a guide to establish about postplacement has been reported with varied techniques.[4],[5],[6],[7],[8],[9] Petti et al.[10] reported that traumatic dental injuries could rank fifth if it was included in the list of the world's most frequent acute/chronic diseases and injuries. Such high incidence of injuries, especially in younger individuals, requires restorative dentist to conservatively manage them with long-term optimal clinical outcome.

Present literature evidence is unclear about the selection of direct composite or fiber postrestoration for fractured root canal-treated maxillary incisors with tooth structure loss >50%. This case series aims to outline the optimal minimally invasive treatment strategies available for restoring an uncomplicated crown fracture in root canal-treated maxillary incisors based on the amount of tooth structure lost. All patients in this report are part of ongoing two clinical trial registered with clinical trial registry of India (CTRI/2020/01/023019 [Registered on: 28/01/2020]) and CTRI/2020/02/023417 [Registered on: 18/02/2020]) and informed written consent has been obtained for publication of their photographs.

Coronal tooth structure loss assessment

All the fractured were photographed preoperatively using DSLR camera (Nikon D5300, Nikon Corp., Tokyo, Japan). Each fractured maxillary central and lateral incisors was superimposed with a 3 × 3 and 2 × 2 grid of equal dimensions, respectively [Figure 1]. The pretreatment photographs were opened in Adobe Photoshop CS5 (“Ctrl + O”) (Adobe Inc., San Jose, CA, USA). ''View > show > grid'' was used to superimpose a grid on the photographs. ''Edit > preferences > guides > grids, and slices > grid line every'' was chosen, and values between 4000 and 6000 and 1 were input into the ''gridline every'' and ''subdivision,'' respectively, to change the size of the grid.
Figure 1: (a-d) Tooth structure loss <50%-When <4.5 and 2 squares are having tooth structure loss in maxillary central and lateral incisors respectively – Treatment option suggested composite restoration with/without internal bleaching (Arrows mark the tooth classified). (e-g) Tooth structure loss >50% to <75%-When tooth structure loss is >4.5 to <6 squares in maxillary central incisor and >2 to <3 squares in lateral incisors– Treatment option suggested is cornoradicular composite restoration (Arrows mark the tooth classified). (h-k) Tooth structure loss >75%-when tooth structure loss is >6 and >3 squares for maxillary central and lateral incisors respectively – Treatment option suggested is surgical crown lengthening if required followed by fiber postcomposite restoration and full coverage ceramic crowns (Arrows mark the tooth classified)

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Depending upon the amount of tooth structure lost, it was categorized as follows [Figure 1]:

  1. Tooth structure loss <50%: When <4.5 and 2 squares are having tooth structure loss in maxillary central and lateral incisors, respectively
  2. Tooth structure loss >50% to <75%: When tooth structure loss is >4.5 to <6 squares in maxillary central incisor and >2 to <3 squares in lateral incisors
  3. Tooth structure loss >75%: When tooth structure loss is >6 and >3 squares for maxillary central and lateral incisors, respectively.


Discolored maxillary incisors with tooth structure loss <50% and both the proximal contact intact

Discoloration of a nonvital traumatized maxillary incisor is a common situation requiring clinical intervention. Full-coverage crowns, veneers, and walking bleaching are the most recommended management options. Full-coverage crowns [Figure 2] have an advantage of immediate change in the appearance, and several clinical studies have established their long-term esthetic and functional stability but require significant tooth structure removal. Ceramic veneers are another option for these teeth, but they have a drawback of poor adhesion in this tooth substrate. Direct composite veneers with/without prior internal bleaching (walking bleaching) are another minimal tooth structure removal exercise. Direct composite veneers in discolored fractured teeth without bleaching procedure could require application more tooth structure removal, opaque masking agents, and multiple shade usage [Figure 3]. Walking bleaching was described during the middle part of the 19th century has been extensively researched with various bleaching materials.[11] Main disadvantage with walking bleaching is it requires multiple sittings and if the access seal restoration is dislodged in-between the appointments then efficacy of the lightening the shade becomes delayed. Clinical results achieved with walking bleach (96% sodium perborate (Lobe Chemie Pvt. Ltd., Mumbai, India and 30% hydrogen peroxide [NICE Chemicals Pvt. Ltd., Kochi, India]) with/without direct composite restorations is the least invasive postendodontic restorative treatment option [Figure 4]. Furthermore, walking bleaching is an effective procedure when triple antibiotic paste has been used as an intra-canal medicament in open apex management case, because of extensive discoloration encountered [Figure 4].
Figure 2: (a) Fractured (tooth structure loss <50%) discolored right and left root canal treated maxillary central incisors due to triple antibiotic intra-canal medicament. (b) Tooth preparation for full coverage crowns. (c) Lithium di silicate full coverage ceramic crowns

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Figure 3: (a-h) Two cases of fractured (tooth structure loss <50%) discolored root canal treated maxillary incisors restored with composite restorations. Arrows denote the amount of tooth removal required to mask the discoloration

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Figure 4: (a-c) Discolored root canal treated right maxillary central incisor without any fracture demonstrating satisfactory color change after three sittings of walking bleach. (d-f) Fractured (tooth structure loss <50%) root canal treated discolored right and left maxillary central incisors managed with walking bleach procedure followed by composite restoration of fractured left maxillary central incisor. Arrows denote minimal tooth preparation required for composite restoration. (g-m) Two cases of fractured (tooth structure loss <50%) root canal treated discolored right maxillary central incisors managed by intra-coronal bleaching followed by composite restoration with minimal tooth preparation

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Fractured maxillary incisors with tooth structure loss <50% and both proximal contact intact

This condition warrants the same approach described earlier with the exception of bleaching procedure. Furthermore, because of absence of discoloration, tooth preparation is less extensive [Figure 5].
Figure 5: (a-f) Two cases of fractured nondiscolored root canal treated left maxillary central incisors (tooth structure loss < 50%) restored with composite restoration. Arrows denote minimal tooth preparation

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Rationale of composite restoration for fractured maxillary incisors with tooth structure loss <50%

Some of the tooth showed in [Figure 3], [Figure 4], [Figure 5] if observed has similar amount of tooth structure loss to teeth restored by direct composite restorations having intact pulp [Figure 6]. The only differences between the both sets of teeth are discoloration and necrotic pulp managed by root canal treatment. [Figure 7] illustrates same patients in the present case report having similar amount of tooth structure loss in two different maxillary incisors with one tooth requiring root canal treatment for necrotic pulp and other one with intact pulp, both of them restored with direct composites. Thus, the protocol for the selection of composite restoration in the cases presented were based upon the amount of tooth structure loss and not influenced by whether tooth has undergone root canal treatment or discoloration.
Figure 6: (a) Fractured (tooth structure loss <50%) discolored root canal treated left maxillary central incisor restored with direct composite [Figure 3a-d]. (A1 and A2) Fractured (tooth structure loss <50%) right maxillary central incisor similar to tooth in Figure 6a with intact pulp restored with direct composite restoration. (b) Fractured (tooth structure loss <50%) discolored left maxillary central incisor restored with direct composite [Figure 3e-h]. (B1 and B2) Fractured (tooth structure loss <50%) right maxillary central incisor similar to Figure 6b restored with direct composite. (c) Fractured (tooth structure loss <50%) discolored root canal treated right maxillary central incisor managed by internal bleaching followed by direct composite restoration [Figure 4g-i]. (C1 and C2) Fractured (tooth structure loss <50%) left maxillary central incisor similar tooth in Figure 6c with intact pulp restored with direct composite restoration. (d) Fractured (tooth structure loss <50%) discolored root canal treated right maxillary central incisor managed by internal bleaching followed by direct composite restoration [Figure 4j-m]. (D1 and D2) Fractured (tooth structure loss <50%) left maxillary central incisor similar to tooth in Figure 6d with intact pulp restored with direct composite restoration

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Figure 7: (a-c) Two maxillary central incisors with similar amount of tooth structure loss (tooth structure loss <50%) with root canal treated right maxillary central incisor displaying slight discoloration and left maxillary central incisor with intact pulp both restored with direct composite restoration (arrows denoting tooth restored). (d-g) Two maxillary incisors with similar tooth structure loss (tooth structure loss <50%). (d) Fractured (tooth structure loss <50%) discolored root canal treated left maxillary central incisor and fractured (tooth structure loss <50%) right maxillary lateral incisor with intact pulp (arrows denoting tooth restored). (e) Right maxillary central incisor after internal bleaching. (f and g) Both the maxillary incisors restored with direct composite resin with same technique [Figure 4d-f]. (h-l) Two maxillary central incisors with similar amount of tooth structure loss (tooth structure loss <50%) restored with direct composite restoration. (h) Fractured (tooth structure loss <50%) slightly discolored root canal treated right maxillary central incisor and fractured (tooth structure loss <50%) left maxillary central incisor with intact pulp. (i-l) Both maxillary central incisor restored with direct composite resin (arrows denote tooth restored)

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Restoration for root canal-treated maxillary incisors with 50%–75% tooth structure loss and one proximal contact has been lost

Current recommendations prescribe for fiber postrestorations for maxillary incisors with crown structure loss of >50% with supragingival ferrule availability.[9] In the present report, composite restoration placement is advocated as an alternative to fiber post for maxillary incisors with tooth structure loss of >50% with effective use of pulp chamber anatomy and coronal/middle 3rd of root canal space. This approach allows for a minimally invasive restorative option.

[Figure 8] illustrates a 14-year-old female patient with right maxillary central incisor fracture with >50% and <75% tooth structure loss restored with coronoradicular composite restoration utilizing pulp chamber and coronal third of root canal space for composite retention. [Figure 9] shows a 30-year-old male patient with left maxillary central incisor fracture with >50% and <75% tooth structure loss restored with fiber postcomposite restoration. [Figure 10] is a 22-year-old male patient with right maxillary central and lateral incisor fracture with >50% and <75% tooth structure loss. Fiber post composite restoration for maxillary central incisor and coronoradicular composite restoration for the maxillary lateral incisor. Both the cases in [Figure 9] and [Figure 10] display maxillary incisors with tooth structure loss >50% and <75% can be successfully managed with both fiber post and coronoradicular restoration. However, with fiber post restoration, because of the palatal inclination of the roots in maxillary incisors, the post tends to have a labial inclination which is reflected in the final composite restoration.
Figure 8: (a-f) Fractured (tooth structure loss >50% and <75%) root canal treated right maxillary central incisor restored with coronoradicular composite restoration. (g) Postrestoration radiograph displaying composite placement utilizing the pulp chamber and coronal 3rd of root canal space

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Figure 9: (a-i) Fractured (tooth structure loss >50% and <75%) root canal treated left maxillary central incisor restored with fiber post composite restoration. (f) Postrestoration radiograph displaying placement of fiber post in the root canal space. Arrows denote labial inclination of the fiber post and composite restoration

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Figure 10: (a-f) Fractured (tooth structure loss >50% and <75%) root canal treated right maxillary central; lateral incisor restored with coronoradicular composite in left maxillary lateral incisor; central incisor restored with fiber post composite. Arrows in (c and e) denoted the labial proclination of fiber post compared to coronoradicular composite restoration

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[Figure 11] depict two cases of maxillary central incisors restored with coronoradicular composite restoration with 1-year follow-up. Case # 2 in [Figure 11] had a fractured coronoradicular composite restoration after 3 months of placement and composite repair was accomplished by removal of composite from pulp chamber and coronal 3rd of the root canal space.
Figure 11: Case # 1 (a-e) Coronoradicular restoration for fractured (tooth structure loss >50% and <75%) root canal treated right and left maxillary central incisors. Arrows denote tooth restored. (f and g) 1-year recall clinical and radiograph picture of the coronoradicular restoration. Case # 2 (h and i) Fractured coronoradicular composite restoration in maxillary left central incisor placed 3-months before. (j) Arrow indicates the fractured composite restoration. (k) Composite restoration removed from pulp chamber and root canal space. (l and m) Replaced coronoradicular composite restoration in left maxillary central incisor; radiographs displaying presence of composite placement in root space

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Rationale for coronoradicular restoration in maxillary incisors with 50% to 75% tooth structure loss and one proximal contact has been lost

These teeth do not have enough crown surface area for satisfactory bonding of the composite resin, therefore as an alternative to fiber post, pulp chamber, and coronal/middle 3rd of root canal space is utilized for additional bonding surface area. Previousin vitro report from authors' department has shown that coronoradicular restoration had significantly higher fracture resistance than compared to conventional direct composite and fiber post restorations.[12]

Both the condition described above do not require full-coverage ceramic crowns as the amount of supragingival bonding tooth structure and composite material is greater than or equal to the crown volume of the tooth structure.

Restoration for root canal-treated maxillary incisors with more than 75% tooth structure loss with both proximal contacts lost

In these fractures there could be partial absence of circumferential supragingival ferrule tooth structure which may require surgical crown lengthening to expose the tooth structure. [Figure 12] and [Figure 13] depict restoration of maxillary incisors with more than 75% tooth structure loss with fiber post and cast post restorations combined with laser crown lengthening, respectively. This should be followed up with full-coverage ceramic crowns. Results obtained with fiber post restoration are far better than achieved with cast post. These tooth that could be taken for fiber post rehabilitation should have some evidence of crown structure presence coronal to alveolar bone crest level in the periapical radiograph [Figure 14].
Figure 12: (a-h) Case #1 Fractured (tooth structure loss >75%) right maxillary central incisor with part of tooth structure present subgingivally managed by fiber post and full coverage lithium di silicate ceramic crown. Crown lengthening accomplished using diode laser to expose tooth structure (c and d). Radiograph evidence show supra-alveolar tooth structure (e). (i-o) Case #1 Fractured (tooth structure loss >75%) right maxillary central incisor with part of tooth structure present subgingivally managed by fiber post and full coverage lithium di silicate ceramic crown. Crown lengthening accomplished using diode laser to expose tooth structure (l and m). Lithium di silicate ceramic crown as final definitive restoration (o). Arrows indicating exposed supra-gingival ferrule achieved with diode laser crown lengthnening

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Figure 13: Case #1: (a-f) Fractured (tooth structure loss >75%) right maxillary central incisor with part of tooth structure present subgingivally. Crown lengthening accomplished using diode laser to expose tooth structure (b and c). Cast postluted (d and e). Metal-ceramic crown placed as final definitive restoration (f). Case #2: (g-j) Fractured (tooth structure loss >75%) right maxillary central incisor with part of tooth structure present subgingivally. Crown lengthening accomplished using diode laser to expose tooth structure (h). Cast post luted (i). Radiograph of cast post luted with evidence of tooth structure above the alveolar crestal bone level (j). Arrows indicating exposed supra-gingival ferrule achieved with diode laser crown lengthnening

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Figure 14: Case # 1 (a-e) Fractured (tooth structure loss > 75%) right maxillary central and lateral incisors with part of tooth structure present subgingivally. Radiograph with arrows indicating presence tooth structure above the alveolar bone crest level (b). Fiber post composite core build up done for ceramic crown placement (c and d). Radiograph indicating placement of fiber post (e). Case # 2: (f-i) Fractured (tooth structure loss > 75%) right maxillary central incisor with part of tooth structure present subgingivally. Radiograph with arrows indicating presence tooth structure above the alveolar bone crest level (g). Cast postluted with radiograph evidence (H and I). This is the same case depicted in Figure 13 g-j

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Rationale for fiber postrestoration in maxillary incisors with >75% tooth structure loss and both proximal contacts lost

These teeth will not have sufficient supragingival tooth structure, and also the pulp chamber space is also compromised for satisfactory bonding of coronoradicular composite restoration. Therefore these teeth are best managed using fiber post restorations for additional retention from the deeper part of the root canal space. As supragingival ferrule is minimum compared to the length of crown, a full-coverage ceramic crown is recommended for the protection of the tooth structure.


  Discussion Top


Present report suggests a practical approach to the assessment of tooth structure loss in root canal treated uncomplicated crown-fractured maxillary incisors. The approach was based on the current available scientific data on the principles of restoring root canal-treated teeth.[4],[5],[6],[7],[8],[9] The categorization formulated is along the principles of minimal invasive restoration. Schwendicke[13] published a report on “Tailored Dentistry” and describes about treatment strategies according not only to individual patients but also to specific tooth and condition presented. Furthermore, he outlined that this concept prevents unnecessary high treatment costs and decreased tooth longevity. In accordance to this concept, the present report takes into consideration of a specific condition and tooth, i.e., uncomplicated crown fracture of root canal root canal-treated teeth and maxillary incisors, respectively. Schwendicke[13] recommended treatment plan based on stratification of patients or teeth, sites or lesions which can allow for tailored decision making. Therefore, restoration of endodontically treated teeth can also not be based on one universal protocol but will certain be based on each individual tooth condition presentation to provide optimized long-term benefits for each patient. Coronal tooth structure assessment using Adobe Photoshop computer software is a modification of the methodology earlier adopted by the authors for color change analysis in stained dental fluorosis management for maxillary central and lateral incisors.[14] All the cases in this presentation have finished 9-months follow-up without any fracture or loss of restorations except for cases mentioned in [Figure 11]. Long-term follow-up of the patients presented is part of the clinical trial. However, the protocol followed in this report has been adhered for past 12 years in the authors' department for restoring root canal-treated traumatized maxillary incisors.

The present categorization in the report has a drawback such as it is based on the authors' 15-year experience in restoring root canal treated and nonroot canal treated fractured maxillary incisors. But with advent of artificial intelligence (AI) allowing for incorporation of photographic evidence from each stratified tooth with its clinical presentation along its long-term survival outcome can provide dentists a more scientific and precise treatment choices in betterment of patients' oral health longevity. This report is a step towards customization in restoration of root canal treated tooth and about application of AI in this field of endodontics through stratified photographic relevant data recording.


  Conclusion Top


This article describes a protocol for the assessment of tooth structure loss in a specific clinical condition, i.e., fractured root canal-treated maxillary incisors which could be utilized for making a restorative treatment option. The protocol described incorporates the principles of minimal invasive restoration and also the current universal prescription for restoration of root canal-treated tooth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Goodacre CJ, Kan KY. Restoration of the endodontically treated tooth. In: Ingle IJ, Bakland KL, editors. Endodontics. 5th ed. Ontario. Canada: BC Decker Inc.; 2002. p. 914-5.  Back to cited text no. 1
    
2.
Baba NZ, Goodacre CJ. Contemporary restoration of endodontically treated teeth. In: Rotstein I, Ingle IJ, editors. Ingle's Endodontics. 7th ed. North Carolina. United States: PMPH USA Ltd.; 2019. p. 1080-2.  Back to cited text no. 2
    
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Gulabivala K, Ng YL, editors. The restorative-endo interface. In: Endodontics. 4th ed. Edinburgh. United Kingdom: Mosby Elsevier Ltd.; 2014. p. 338-42.  Back to cited text no. 3
    
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Peroz I, Blankenstein F, Lange KP, Naumann M. Restoring endodontically treated teeth with posts and cores – A review. Quintessence Int 2005;36:737-46.  Back to cited text no. 4
    
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Esteves H, Correia A, Araújo F. Classification of extensively damaged teeth to evaluate prognosis. J Can Dent Assoc 2011;77:B105.  Back to cited text no. 5
    
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Baba NZ, Goodacre CJ. Restoration of endodontically treated teeth: Contemporary concepts and future perspectives. Endodontic Topics 2014;31:68-83.  Back to cited text no. 6
    
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Mannocci F, Cowie J. Restoration of endodontically treated teeth. Br Dent J 2014;216:341-6.  Back to cited text no. 7
    
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Eliyas S, Jalili J, Martin N. Restoration of the root canal treated tooth. Br Dent J 2015;218:53-62.  Back to cited text no. 8
    
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Zarow M, Ramírez-Sebastià A, Paolone G, de Ribot Porta J, Mora J, Espona J, et al. A new classification system for the restoration of root filled teeth. Int Endod J 2018;51:318-34.  Back to cited text no. 9
    
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Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis-One billion living people have had traumatic dental injuries. Dent Traumatol 2018;34:71-86.  Back to cited text no. 10
    
11.
Plotino G, Buono L, Grande NM, Pameijer CH, Somma F. Nonvital tooth bleaching: A review of the literature and clinical procedures. J Endod 2008;34:394-407.  Back to cited text no. 11
    
12.
Subashri V, Sherwood IA, Samran A, Gutmann JL, Subramani KS. Fracture resistance of teeth with direct composite restorations reflecting different restorative designs in fractured root canal treated anterior teeth: Anin vitro study. Endo Pract Today 2020;14:53-61.  Back to cited text no. 12
    
13.
Schwendicke F. Tailored dentistry: From “one size fits all” to precision dental medicine? Oper Dent 2018;43:451-9.  Back to cited text no. 13
    
14.
Divyameena B, Sherwood IA, Rathinapiriyanka R, Deepika G. Clinical performance of enamel microabrasion for esthetic management of stained dental fluorosis teeth. Oper Dent 2020. Doi: https://doi.org/10.2341/19-248-C.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]



 

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