198 Exploration of various avenues in diagnostic and treatment modalities in the management of horizontal crown-root Fractures : Case reports Vibha Hegde # * Esha Chandawalla # * Introduction Horizontal root fractures are uncommon lesions accounting for 0.5-7% of all the traumas that occur in the permanent teeth while the frequency of occurrence in deciduous teeth is about 2-4% 1-4 . Root fractures occur mainly in maxillary central incisors (68%) followed by maxillary lateral incisors (27%) and mandibular incisors (5%). Horizontal fractures occur most commonly in the middle-third of the root and rarely in the apical- third 5-7 . A single fracture occurs in most cases while multiple root fracture is a rare finding. Case Report 1 A 34 year old male patient reported to the Department of Conservative Dentistry and Endodontics, giving a history of a traumatic accident ABSTRACT Management of crown-root fractures presents a formidable challenge for clinicians because of the difficulty in achieving a stable union of the fractured fragments. Root fractures in permanent teeth are uncommon injuries among dental traumas accounting for 0.5-0.7% of the cases. These case reports describe the various clinical presentations of horizontal crown-root fractures and the different treatment modalities that we as clinicians can offer to these patients. An attempt to treat these horizontal oblique fractures at various levels with these different diagnostic and treatment approaches has been solicited. Stabilization of these fractures was achieved by intra-radicular splinting and MTA as well as re-attachment of the fractured fragments. Short term follow up results showed successful management of these cases using the treatment modalities mentioned above. Keywords : Intra-radicular splinting, MTA, Fracture Re-attachment, CBCT and Horizontal Root fractures. Case Report # Dept. of Conservative Dentistry and Endodontics, * Yerla Dental College and Hospital, Navi Mumbai while playing a sport. The accident had occurred 3 days ago. Patient chiefly complained of discomfort, pain and mobility of the front teeth in the upper arch. On careful intra-oral examination, left central incisor showed grade II mobility and extreme pain on percussion. Upper right central incisor showed a vertical fracture from the incisal edge, the apical extent of which could not be determined clinically. (Fig. 1-A and 1-B). A pre-operative peri-apical radiograph of the upper central incisors revealed the presence of a comminuted fracture at the junction of the middle and coronal thirds of the upper left central incisor. (Fig. 1-C) However, no confirmatory diagnosis could be drawn from these radiographs for upper right central incisor in which a vertical fracture had been suspected. Hence, a decision to go in for cone beam computed ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY Volume: 26 Issue 1 June 2014 194
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198
Exploration of various avenues in diagnostic and treatmentmodalities in the management of horizontal crown-rootFractures : Case reports
Vibha Hegde # *Esha Chandawalla # *
IntroductionHorizontal root fractures are uncommon
lesions accounting for 0.5-7% of all the traumas
that occur in the permanent teeth while the
frequency of occurrence in deciduous teeth is about
2-4% 1-4. Root fractures occur mainly in maxillary
central incisors (68%) followed by maxillary lateral
incisors (27%) and mandibular incisors (5%).
Horizontal fractures occur most commonly in the
middle-third of the root and rarely in the apical-
third5-7 . A single fracture occurs in most cases while
multiple root fracture is a rare finding.
Case Report 1A 34 year old male patient reported to the
Department of Conservative Dentistry and
Endodontics, giving a history of a traumatic accident
ABSTRACTManagement of crown-root fractures presents a formidable challenge for clinicians because of the difficulty
in achieving a stable union of the fractured fragments. Root fractures in permanent teeth are uncommon
injuries among dental traumas accounting for 0.5-0.7% of the cases. These case reports describe the various
clinical presentations of horizontal crown-root fractures and the different treatment modalities that we as
clinicians can offer to these patients.
An attempt to treat these horizontal oblique fractures at various levels with these different diagnostic and
treatment approaches has been solicited. Stabilization of these fractures was achieved by intra-radicular
splinting and MTA as well as re-attachment of the fractured fragments.
Short term follow up results showed successful management of these cases using the treatment modalities
Figure 2-C: Pre-operative radiograph with arch-bar
Figure 2-D: Checking the fit of F1 Protaper
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VIBHA HEGDE, ESHA CHANDAWALLA
203
Figure 2-E : Intra-radicular splinting with the file and MTA
Figure 2-F & 2-G : Clinical & radiographic follow up after 10 monthsFigure 2-F
Case Report 3
Figure 3-A : Pre-operative clinical photograph with 12,11and 21
Figure 3-B : WL determination with 12
Figure 3-C: Removal of the fractured fragment with 12
Figure 3-D : Fibre post selection post obturation
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EXPLORATION OF VARIOUS AVENUES IN DIAGNOSTIC AND TREATMENT MODALITIESIN THE MANAGEMENT OF HORIZONTAL CROWN-ROOT FRACTURES : CASE REPORTS
204
Figure 3-E : Temporary splinting after re-attachment with 12
Figure 3-F and 3-G : A 6 month clinical and radiographic follow-up with 12 and 11
Figure 3-F Figure 3-G
showed the presence of fracture line and periapical
abscess with upper right central incisor. A diagnosis
of a Ellis class VI subgingival horizontal oblique
root fracture traversing in the coronal thirds of the
root was made.(Fig 2-B,C)
Treatment plan
After taking the informed consent, the
endodontic therapy of upper right central incisor
was initiated. The use of an intra-radicular splint
similar to case 1 was carried out using a F1 Protaper
file. A 10 month follow up showed no pathologic
mobility or any signs of endodontic or restorative
failure. (Fig. 2D-G)
Case Report 3A 15 year old patient reported to the Dept. of
Conservative Dentistry & Endodontics with a
history of a frontal traumatic impact while playing
at school. Patient complained of pain and mobility
with upper left lateral incisor and severe pain on
biting with upper right central incisor. (Fig. 3-A).
On clinical examination a through and through
horizontal crown fracture was seen with upper left
lateral incisor at the cervical thirds of the crown.
Upper right central incisor showed severe pain on
percussion while left central incisor showed a Ellis
class II fracture. This was all confirmed via radiographic
examination.
Treatment plan
A non-surgical fragment re-attachment
procedure was undertaken with upper right lateral
incisor similar to the first case. A root canal
treatment was initiated with upper right central
incisor and a composite build up for upper left
central incisor was completed. Splinting was then
done from upper right canine to canine using a
stainless steel wire and composite resin. At the 6
month follow up patient was completely
asymptomatic and no mobility was seen with any
of the above teeth. (Fig. 3B-G)
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VIBHA HEGDE, ESHA CHANDAWALLA
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DiscussionRoot fracture is one of the consequences of
dental trauma. The treatment principles for
horizontally fractured teeth mainly involve
maintaining pulp vitality by immobilizing the coronal
segment. According to Hjorting-Hansen, there are
four healing patterns that can affect the prognosis
and tissue response to dental trauma- healing with
calcified tissue, healing with interproximal
connective tissue, healing with interproximal bone
and connective tissue, Interproximal inflammatory
tissue without healing 8-10 .
In these cases, an endodontic instrument was
used to fix the separated root fragments. This is
uncommon in literature. Intraradicular splinting is
indicated in cases in which the fracture line is in
the middle or coronal segment. This technique is
known to correct the mobility of the coronal
segment and aid in the healing of periodontal tissue
around the fracture site11 . The technique involves
connecting the tooth fragments through the root
canal using a metal pin, together with a root canal
sealer. For the same purpose, others have used a
metallic or dental post, which was placed passively
inside the root canal together with endodontic
cement12.
As seen in a series of recent case reports,
central incisors were treated for horizontal root
fractures with the use of Ni-Ti protaper file / H -file
as an intra-radicular splint. In all the case reports
excellent healing was seen in follow-ups up to
4 years12-14 .
According to Andreason, splinting should be
applied within a week. Nowadays, splinting for
1-3 months is recommended, but no study on the
effects of splinting period on the prognosis has been
carried out yet. Studies questioning the usefulness
of rigid fixation in horizontal root-fractured teeth
did not find any advantage in terms of healing over
no-splinting9,12,15. In all the above cases, the
maxillary central incisors had severe mobility and
dislocation, therefore a prolonged duration of the
fixed appliance was considered safe and viable for
healing.
Although literature supports maintaining the
vitality of the apical fragment, considering the
mobility and increased chances of infection of the
affected teeth, endodontic treatment was initiated
to maximize the prognosis of the teeth. Dental pulp
necrosis may be reported from 20-44% of root
fracture cases whereas in luxated teeth without
fracture, necrosis occurs in about 43.5% cases16,17.
Earlier studies have used AH26 and
polycarboxylate cement as the sealer. In this case
MTA was used as a sealer due to the established
advantages of MTA in Endodontics. The
disintegration of AH26 and polycarboxylate cement
by tissue fluids may cause a foreign body reaction
at the fracture site. The use of MTA as a sealer in
order to fill the fractured root is due to the excellent
biological and physical properties of MTA and the
fact that it can set even in the presence of moisture
and blood12,14.
The use of modern diagnostic modalities can
actually affect the prognosis of a given tooth. As
in the first case, the central incisor with the
horizontal oblique fracture was initially indicated
for extraction when a vertical fracture was
suspected. However, after CBCT imaging it was
eventually salvaged when the fracture line was
detected to end supra-osseously.
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EXPLORATION OF VARIOUS AVENUES IN DIAGNOSTIC AND TREATMENT MODALITIESIN THE MANAGEMENT OF HORIZONTAL CROWN-ROOT FRACTURES : CASE REPORTS
206
A study concluded that limited CBCT imaging
offers the clear advantage over conventional imaging
(PA & OC) as traumatized teeth can be visualized
in all three dimensions- especially the oro-facial
dimension18-21.
Reattachment of the fractured fragment was
considered a favourable option in the cases above
as the approximation of the fractured fragment
subgingivally on the palatal aspect seemed to be
satisfactory which otherwise to restore with the
current technique sensitive restorative materials
would be challenging. Aesthetics and strength can
be restored to a great extent with this technique.
Chosack and Eildeman described for the first time in
1964, reattachment of tooth fragment after traumatic
injury of a 12 year old child. Using the good
experience of published articles, there are more often
scientific reports of successfully followed up clinical
cases of reattached fractured teeth without pulp
involvement or of endodontically treated teeth22-24.
ConclusionWithin the limitations it can be concluded that
treatment of horizontal root fractures in the coronal
and middle thirds with intra-radicular splinting and
use of MTA as a sealer can be an alternative for
managing such cases.
Also, CBCT as a diagnostic aid in selected cases
can greatly influence treatment planning.
Reattachment of fractured fragments can help to
achieve the best anatomical approximation than
most restorative materials available today.
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