Treatment and prognosis of a vertically fractured ...

Prosthodontics

Treatment and prognosis of a vertically fractured maxillary molar withwidely separated segments: A case report

T. Takatsu*/H. Sano**/M. F. Burrow**--

This is a report of ¡he ireciiineni and prognosis of a maxillary second mohr exhibiUnga complete vertical crown-rooi fraciiire. The buccal and palatal seginenis were widelyseparated by as much as 2 mm and were immobile. To restore this tooth, it was essentialto bring the segments into dose apposition. This was accomplished by application oforthodontic elastics to the tooth crown in combination with a wire splint. After approximatelyI month of continuous use of the orthodontic elastics, the disiodged segments were suitablyrepositioned close to their original positions. The tooth was then endodontically treated andrestored with a cast complete crown. The restored tooth has been functioning well, withperiodic periodontal maintenance, for more than 3.5 years, indicating a promisingprognosis. (Quintessence Int 1995:26:479-484.)

Introduction

Molars suffering from vertical crown-root fractures aretisually believed to require either partial removal, atbest, or total extraction at worst.'' To salvage such afractured molar in an emergency, the authors previ-ously developed a simple technique, the wire-bindingrepositioning technique.' The essence of this techniqueis to preserve the vertically separated segments bytightly binding them together with a loop made fromorthodontic wire and then to restore the tooth with acast complete crown.

A few years ago, a patient presented with a toothfracture in which the buccolingual segments of a maxil-

* Professor and Chairman. Deparlmenl urPeriodomies and Reslora-(iveDemislry, Ohu University, School of Dentislry, 31-1, Tomila-choa¡a Misumido, Koriyama, Japan.

*' Instructor, Dcpartmeni of Operative Dentislry, Tokyo Medical andDenial Unjveraty, Fdcully of Dentistry, Tokyo, Japan.

" * Honorary Lecturer, Department of Operative Dentistry, ToityoMedical and Dental University, Faculty of Dentistry, Tokyo,Japan.

Reprint requests: Dr T. Takatsti, Department of Perlodontics andRestorative Dentistry, Ohii University, Sciiool of Dentistry, 31-1, Tomita-cho aza Misumido, Koriyama. Japan.

lary right second molar were markedly separated andimmobile. This case report describes the treatmentprocedures and the clinical result of this case, in whichminor orthodontic movement was used in combina-tion with the wire-binding repositioning technique atthe initial stages of treatment.

Case report

A 41-year-old man exhibited a severe vertical fractureof the maxillary right second molar. Clinical examina-tion revealed that the touth was vertically fracturedmesiodistally. The buccal and lingual segments wereseparated from each other by approximately 2 nun ( Fig1), Both segments elicited slight pain when subjectedto vertical percussion, although they were immobilewhen subjected to fairly strong digital pressure.

Localized periodontal pockets adjacent to thefracture site, measuring about 6 mm in depth, weredetected. The occlusal surface of the opposing mandi-bular tooth exhibited occlusal faceting, indicatingevidence of a heavy occlusion. From the analysis of theclinical symptoms and the history reported by thepatient, the molar was diagnosed as having suddenlyfractured more than 4 months previously. It had

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Prosthodontics

Fig 1 Vertically fractured maxillary second molar. Thebuccal and lingual segments ate separated from each otherby approximtely 2 mm.

Fig 2 Model showing the preparation of narrow grooves inthe cervical regions of Ihe tooth, as marked in black, with around diamond stone.

Fig 3 Model showing the positioning of the doubled andtwisted looped orthodontic wire in the location ot theprepared grooves. The wire is then tightly wound.

Fig 4 Model tooth, illustrating the suitably repositionedtractured segments, which have been tightly splinted

Fig 5 Maxillary second molar after placement of the wiresplint using the wire-binding repositioning technique. Alarge gap remains after placement ol the splint.

Fig 6 Cpening and cleansing of the pulp chamber.

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Fig 7 Obturation of the pulp chamber with a soft rootsealer and application of two orthodontic elastics.

Fig 8 Segments of the fractured molar almost brought intocontact and suitably repositioned affer 24 days of elasticsappiication

been left untreated, allowing Ihe fractured segments tureadily move apart.

Repositioning ofthe separated segments by acontinuous binding force

It was decided to attempt to bring the two segments ofthe tooth back to their original position. In accordancewith the wire-binding repositioning technique, narrowgrooves were prepared in the cervical region aroundthe angles ofthe facial and lingual siitfaces ofthe tooth,with a round diamond stone approximately 1,2 mni indiameter (Fig 2). Then, a doubled and twisted ortho-dontic wire, 0,25 nini in diameter, was looped aroundthe tooth, positioned at the grooves, and tightly woundto close the gap (Fig 3), In this way, the dislodgedsegments can usually be suitably repositioned andtightly sphnted (Fig 4),

In the present patient, however, both segmentscotild only be slightly reapposed; a gap of more than1 mm still remained (Fig 5), To bring the separatedsegments into close contact, a continuous bindingforce was considered essential. The gap was provi-sionally obturated with cotton pledgets to prevent foodimpaction.

At the next appointment, the pulp chamber ofthefractured tooth was opened and cleansed to removeany remaitiing pulpal tissue and debris (Fig 6), Afterthis, the pulp chamber was obturated with an experi-mental root sealer" composed of soft polymers toprevent food impaction and seal the access cavity. Thiselastic material was used so that the two segments

could be brought together but would not be interferedwith by a hard scaling material. Two orthodonticelastics, 5 mm in diameter, were applied to the segmentsin combination with the wire splint (Fig 7). After 14days, the elastics were replaced and the loosened wiresplint was retightened to facilitate gap closure. Conse-quently, after 24 days of application of elastics, thedislodged segments were almost brought into contactwith each other and suitably repositioned (Hg 8),

Endodontic treatment and restoration

Prior to etidodontie treatment, the narrow gap leftbetween the segments was sealed with a photocuredadhesive resin liner (Clearfil Liner Bond System,Kuraray), Endodontic treatment was then completeduneventfully with gutta-percha and eugenol cement(Fig 9), and a resin core was placed.

To add support to the tooth, screw posts wereinserted horizontally into the pulp chamber from thewalls of the buccal and lingual segments (Hg 10)following the technique described by Mondelli et al̂and then ernbedded with a chemically cured adhesiveresin eornposite (Clearfil Core New Bond, Kuraray),This procedure was petformcd to mechanically strength-en the union between both segments. Preparation andfabrication of a cornplete cast crown proceededfollowing routine clinical procedures (Figs 11 and 12),

Clinical restilts aitd prognosis

Since restoration, the tooth has elicited no masticalorypain and has exhibited normal mobility. To evaluate

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Prosthodontics

Fig 9 Periapicai radiograph taken alter compiefion ofendodonfic treatment.

Fig 10 Horizontal insenion ot screw posts into the pulpchamber from the waiis of buccai and iinguai segmentsThis was done prior to placement of an adhesive resincomposite used as a core.

Fig 11 Tooth prepared for a compiete cast crown. Fig 12 Tooth immediately foiiowing resforation.

•Pl IIMi .<|il|MJFig 13 Tooth 3.5 years after restoration. Fig 14 Periapicai radiograph of the tooth and surrounding

hard tissues 3.5 years affer resforation, showing theabsence of severe periodontal breakdown.

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Prosthodontics

the extent ofthe functional rehabilitation, the bitingforce was measured 1 week after restoration with astrain gauge (MPM-3Û0, Nihon Kohden), The re-stored tooth could bite to a masticatory load of asmuch as 59 kg. while an unrestored control tooth (themaxillary left second molar) produced a force of 61 kg,indicating close-to-normai ioad function.

The patient was also unaware of any differencebetween the restored and the control tooth duringmastication. This suggests that the tooth and peri-odontal tissues promptly recovered from the fracturedamage. The localized periodontal pocketing that wasinitially present around the fracture line slightlydecreased to measure 3 to 4 mm in depth. The peri-odontal discharge that had been present initally wasconsiderably reduced, indicating some healing ofthesurrounding tissues. However, the value of gingivalcrevicular fluid measured by an electronic device(Periotron, Harco) 2,5 years after treatment indicatedthe presence of slight gingival inflammation, requiringperiodical periodontal maintenance care.

Since restoration, more than 3 years has passed, andthe tooth flinctions well, indicating a promisingprognosis (Figs 13 and 14).

Discussion

The extent and direction of fractures of posterior teethvary widely. According to the fracture classification ofSilvestri and Singh,^ this tooth had a vertically directedcomplete fracture. As a rational treatment for this typeof posterior fracture, Silvestri and Singh- suggestedthat extraction followed by prosthetic replacement ispreferable and that, on very rare occasions, one ofthesegments of a multirooted tooth is retained to serve asan abutment for a prosthesis. This idea seems to havebeen widely recognized as a basic treatment principle,with some refinements for vertical crown-root frac-tures of posterior teeth.'^-^

In the case presented here, the fracture passedthrough the furcation and the segments became widelyseparated. The subgingival location of the fracture,which was determined from a silicone impression ofthe pulp chamber, is schematically illustrated in Fig 15.However, despite such a condition, both segments hadbecome immobile. Considering the merits and demer-its of various treatment alternatives, the decision wasmade to attempt to reposition the segments first andthen to restore the tooth. Thus the need to make aprosthetic replacement and the development of sub-sequertt interferences with the occlusion were eliminated.

Fig 15 Distal 1A| and occlusal (B) views of the fracture siteand pattern (arrows), which was determined Irom a siiiconeimpression of the pulp chamber.

The restored tooth still has a fracture line passingthrough the furcation, although it was reduced as muchas possible by tight binding and sealing with anadhesive resin before endodontic treatment. BecauseAndreasen and Andreasen^ histopathologicallyshowedthat inflamed granular tissue can proliferate into afracture line when a fracture communicates with thegingival crevice, it is difficult to determine what theoutcome of this treatment will be. Long-term evalua-tion is required to answer this question. The results inother patients in whom tliis method has been employedare quite promising. At present, more than 20 crown-root fractures have been repaired with this techniqueover the past 10 years. If this technique is used, it isvitally important to ensure that periodic maintenanceis ongoing and that radiographie follow-up is per-formed at regular intervals,

Leubke' stated that "there are many times in today'spractice of dentistry' when heroics are indicated," Thistechnique could perhaps be considered overtreatment.However, perhaps in the case of young patients, thistechnique may provide a way to avoid or postpone theplaeement ofa fixed partial denture. It is well acceptedthat fixed partial dentures are not a lifetime form oftreatment, and that replacement of such prostheses eanbe extremely difficult, often with a poor long-termprognosis. Hence, the technique described may beconsidered as one possible alternative to placing apatient into a situation of "no return" with toothextraction and a prosthesis. This technique may also beusefial tor those patients who, for various reasons, maynot be able to wear a removable prosthesis.

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Summary

A clinical case describing the rehabilitation ofa verti-cally fractured maxillary molar was presented. First,the buccal and palatal fracture segments, which hadbecorne widely separated over time, were repositionedby application ofa continuous binding force exerted byorthodontic elastics in combination with a wire splintaroundthe tooth crown. Afterapproximately 1 month,the dislodged segments were suitably reposilioned.The tooth was endodontically treated and restoredwith a complete cast crown. The rehabilitated toothhas been ilinctioning well under periodic periodontalobservation for more than 3 years since completion oftreatment.

References1. Talim ST, Gohil KS. Management of coronal fractures of permanent

posterior teetii.J I'rosthet Dent i974i3i:172-i7S.

2. Silvestri AR Jr, Singh J. Treatment rationale of fractured posteriorteeth. J Am DenL Assüc I978;97;8O6-8IO.

,1. TakatsLi T, Husoda H. Preservation and rehabilitation uflhe crown-root fractured molar. Acta of 79th Annuai World Dental Congress ofthe FDI 1991:1:77-81.

4. Daidoh H. Stud y on a newly designed dentin adhesive system for rooteanai fiiiing. Jpn J Conserv Dent i992^35:162-Í9I.

5. Münddii J, IshikJriama A. Perdra JC, Francishone CE, NavarroMFL, Galan J, Cordaz£j JL. Cross-splinting a weakened looth with ahoriïuntal pin: A tiew method. J Prosthet Dent i987;57:442-445.

6. Pitts DL. NatkinE. Diagnosis and treatmenL of vertical root fraclure.JEndod ¡9%:Í-.9 338-346.

7. Luebke RG. Vertical crown-root fractures in postetior teeth DentClin North Am 1984:28:883-894.

8. Andreascn JO, Andreasen FM. Root fractures. In: Andreasen FM,Andrcasen JO (eds). Textbook and Coior Atias of Traumatic Injuriesto the Teeth, ed 3. Copenhagen, Munksgaard, 1994:279-3i4. •

Proceedings of the

1st European Workshopon PeriodontologyEdited by Prof, Dr. Niklaus P. Langand Prof, Dr. Thorkild Karring

At the Ist European Workshop oti Periodontnlogy, held February 1-4, 1993, in Thurgau,Switzerland, periudontists from al! over Europe came together to discuss basic aspects ofperiodoiitology as weil as the clinical practice of periodontics. These proceeditigs containthe reports of a!l five sessions, including ail of the position papers and consensus reports.This collection serves as an excellent resource to keep pace with the latest issues andresearch in periodontology.

Cotitents• Diagnostics: Prevalence and classification; disease progression; di.iease activity and

risk assessment; diagnostic tests and predictors• Therapy: Motivation and plaque controi; mechanical debridement of ruut surfaces;

surgical treatment modalities; adjunctive pharmaco-therapeutic approaches; regenera-tive modaiitiesi mucogingival surgery

• Prevention: Mechanical and chemical plaque control; atttibiotics; supportive peri-odontal care

• Implant Dentistry: Materials and healing patterns; petiodontal tissues and their coun-terparts; criteria for success; maintenance and supportive therapy; peri-implantlesions; role of occlusion; regenerative techniques

• Systemic Diseases: Periodontal manifestations; role of systemic factors in etiology andpathogènes is; acute periodontal lesions; HlV-associated gingivitis and periodontitis;treatment of the medically compromised patient; geriatric patients

Proceedings of the1st European Workshopon Periodontolo<)vLang/Karri ng

^&l iMim.

478 pages; 52 illus;

ISBN 1-S5097-035-1; US $58.50

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484 Quintessence International Volume 26, Number 7/1995