case rep.management of vertically … of vertically fractured maxillary second molar volume 1 issue...

Management of Vertically Fractured Maxillary Second

Molar Volume 1 Issue 2

September 2010

45 Journal of Dental Sciences and Research

Case Report


Molar

Dr. Jyothi K.N.

Professor and H.O.D., Department of Conservative Dentistry and, Endodontics, Sri

Siddhartha Dental College, Agalakote, Tumkur, Karnataka.

Abstract:

Vertical tooth fractures are longitudinal fractures of crown and /or root

which are caused by trauma, heavy occlusal forces and dental procedures.

There is little research on longitudinal tooth fractures related to diagnosis

and treatment out come. There are few reports where fractured tooth can be

salvaged intact and fully healthy when repositioned early and stabilized. This

case report explains the management of vertically fractured maxillary

second molar by intra coronal splinting and full coverage restoration.

Key Words: Vertical tooth fracture, Intracoronal splinting, Adhesive

technique, Full coverage restoration.

Journal of Dental Sciences & Research 1:2: Pages 45-50

Introduction:

Cracked teeth and their

related entities, as well as vertical

root fractures are longitudinal

fractures of the crown and / root.

These fractures occur in all tooth

groups and are caused by occlusal

forces and dental procedures.

There is relatively little research on

longitudinal tooth fractures,

particularly on clinical outcome

related to diagnosis and treatment.

Most treatment modalities are

based on opinion and anecdotal

information1.

When a vertical tooth

fracture extends below the gingival

attachment the recommended

treatment has been extraction. As

asserted by Walton after the



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diagnosis of a split tooth is

confirmed saving the tooth is not

an option. But the literature also

reveals long term case studies by

David A Hall upto 20 years where a

fractured tooth can be completely

salvaged, intact and fully healthy

when repositioned early and

stabilized. The healing was

observed by cementum

deposition2.

Masaka in 1980 and Aouate

developed a technique for

preserving vertical root fractures

using 4 META adhesive extra orally

and then with replantation. But

they do not address the issue of

potential biological cementum

repair3.

The present case report

explains the management of

vertical fracture in maxillary

second molar by intracoronal

splinting using advanced adhesive

technique followed by a full

coverage restoration.

Case Report:

A female patient aged 35

years was referred to the

department of conservative

dentistry and Endodontics from

out-patient department Sri

Siddhartha Dental college, Tumkur.

Patient c/o pain on chewing in the

right posterior tooth region. She

gave h/o trauma one month ago

due to fall and was hurt on the

chin. On examination there was

vertical fracture of tooth 17, the

fracture line running mesio distally

splitting the tooth into 2 halves.

The fragments were intact and

were in position without any

displacement, but could be

separated by wedging with a

probe. The fracture line had

extended subgingivally involving

the furcation and passing through

the pulp chamber. There was no

sign of periodontal pocket. The

tooth was tender on percussion. It

was diagnosed as complicated

crown-root fracture of 17 (split

tooth). The sequence of treatment

planned was – splinting the tooth

with orthodontic band, root canal

treatment, intra coronal splinting of

fragments with self etching


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adhesive and composite resin,

crown preparation followed by

cementation of metal crown.

Immediately after the examination

& diagnosis of vertical tooth

fracture in relation to 17 pa

was referred to orthodon

department for cementation

orthodontic band to hold the

fragments in position (fig.1&2)

Fig1:Fractured Maxillary Second

Splinted with Orthodontic Band

Fig 2: Pre-Operative radiograph

In the next appointment

root canal opening was done

fracture line was clearly seen

running mesiodistally involving

both the marginal ridges and

f Vertically Fractured Maxillary Second Volume 1 Issue 2

September 2010

Journal of Dental Sciences and Research

adhesive and composite resin,

crown preparation followed by

cementation of metal crown.

Immediately after the examination

of vertical tooth

fracture in relation to 17 patient

ed to orthodontia

department for cementation of

hold the

(fig.1&2)

Maxillary Second Molar

with Orthodontic Band

Operative radiograph

In the next appointment

root canal opening was done. The

fracture line was clearly seen


both the marginal ridges and

through the pulp chamber and the

palatal canal( fig.3). The root canal

treatment was completed and

temporary restoration was given.

Fig3:Fractured line running mesiodistally

shown under magnification

In the subseq

appointment temporary

was removed, access cavity was

thoroughly debrided with saline

and dried. Self etching adhesive

(Multilink) was applied to the

cavity according to manufacturer’s

instructions and the cavity was

restored with packable light cured

composite resin (Tetric ceram

Ivoclare vivadent)

Orthodontic band was removed and

the tooth was prepared to receive

a metal crown(fig.6).

crown was cemented initiall

followed by full metal crown(fig.7).

Volume 1 Issue 2

September 2010

p chamber and the

The root canal

treatment was completed and

temporary restoration was given.

Fractured line running mesiodistally

shown under magnification

In the subsequent

appointment temporary restoration

was removed, access cavity was

thoroughly debrided with saline

and dried. Self etching adhesive

(Multilink) was applied to the

manufacturer’s

instructions and the cavity was

restored with packable light cured

composite resin (Tetric ceram –

(fig.4&5).

Orthodontic band was removed and

epared to receive

ig.6). Temporary

crown was cemented initially

followed by full metal crown(fig.7).


Molar


Fig4: Post Obturation Radiograph.

Fig5: Access cavity restored with

composite resin splinting the buccal &

Lingual fragments.

Fig6: Tooth Preparation done to Receive a

Metal Crown.

Fig7: Metal Crown Cemented on Maxillary

Second Molar.

f Vertically Fractured Maxillary Second Volume 1 Issue 2

September 2010

Journal of Dental Sciences and Research

Fig4: Post Obturation Radiograph.

Access cavity restored with

splinting the buccal &

h Preparation done to Receive a

Fig7: Metal Crown Cemented on Maxillary

Tooth is periodically

evaluated once in a month.

Tenderness to percussion has

gradually reduced and the patient

is able to chew on the tooth.

Periodontal attachment is intact

without pocket formation. IOPA

radiograph does not show any sign

of bone loss in the furcation or

interdental area. Further periodic

evaluation is planned once in three

months till one year and later once

a year to know the long term

success of the treatment.

Discussion:

Tooth fractures include

trauma related crown, crown

fractures and a broad group of

cracked teeth. American

association of Endodontists classify

cracked teeth as4 –

Cuspal fractures

Cracked teeth

Split tooth

Vertical root fracture.

Split tooth fractures are

primarily mesio distal fractures

that cross both marginal ridges and

extend deep to shear onto the root

Volume 1 Issue 2

September 2010

Tooth is periodically

evaluated once in a month.

Tenderness to percussion has

gradually reduced and the patient

is able to chew on the tooth.

ontal attachment is intact

ormation. IOPA

radiograph does not show any sign

bone loss in the furcation or

interdental area. Further periodic

evaluation is planned once in three

months till one year and later once

a year to know the long term

success of the treatment.

Tooth fractures include

a related crown, crown-root

and a broad group of

cracked teeth. American

association of Endodontists classify

Craze lines

Cuspal fractures

Vertical root fracture.

Split tooth fractures are

primarily mesio distal fractures

that cross both marginal ridges and

extend deep to shear onto the root



September 2010


surface. The more centered the

fracture is occlusally, the greater

the tendency to extend apically.

These fractures are more

devastating. Mobility of one or both

segments will be present. These

fractures usually include the pulp.

Maintaining an intact tooth is

challenging if not impossible.

Prognosis is variable. When the

fracture extends to and surfaces in

the middle to cervical third of the

root, there is reasonable chance of

successful treatment and

restoration.

There are various treatment

modalities in the literature to bind

cracked teeth together, like the use

of adhesives, amalgam with

retention on both sides of the

infractions and full coverage

crowns, and experimental

approaches using lasers CO2, Nd-

YAG.

The outcome of the

treatment is not extensively

reported for teeth with infractions.

Cameron reported a 75% success

after 10 years following the

placement of the crowns. Guthrie

and Defiore found that 24 of 25

teeth restored with acrylic crowns

were asymptomatic after one year.

Brynjulfsen et al achieved pain

relief in 90% of their patients after

protective restorations including

endodontic treatment. Tan etal

showed an 85% survival rate of 2

years after protective crowns were

placed. According to Leif K Bakland

a 5 year survival prediction

appears reasonable in most cases.

Dr.David A Hall has followed his

cases upto 20 years where a split

tooth can be completely salvaged,

intact and fully healthy when

repositioned early and stabilized

where the healing was observed by

cementum deposition5.

In the present case report

the fracture in maxillary right

second molar was almost centered


both the marginal ridges and the

pulp cavity similar to one of the

case reports by Dr David A Hall.

Root canal treatment was carried

out under orthodontic band



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cementation. Later the tooth

fragments were splinted with self

etching adhesive, restored with

light cured composite resin and a

full metal crown was cemented.

The tooth is followed up for 6

months with no signs of failure.

Treating longitudinal

tooth fractures is challenging and

long term follow up is necessary.

References:

1. Eric M Rivera, Richard E Walton.

Longitudinal tooth fractures. In:

Endodontics principles and

practice. 4th ed. Saunders :

Elsevier. Inc. 2009.p 108-28.

2. David A Hall, Sergio A M

Qurique, Guilherme H Itikawa.

Brazilian dental journal Jan-Feb

2004. p 10-15.

3. Masaka N. Long term

observation of fractured tooth

roots preserved by adhesion.

Adhesive Dentistry.

1995;13:156-70.

4. Leif K Bakland. Tooth

infractions. In: Endodontics. 6th

ed. Hamilton:B C Decker Inc.

2008. p 660-75.

5. Hall D A. Restoration of a

shattered tooth – report of a

case. Jour. Americ. Dent. Assoc.

1998; Jan : 129-35.

Corresponding author address:

Dr. Jyothi K.N.

No: 101, Swajyothi, 2ND Cross, 4TH

Main, Income Tax Layout, Near

Attiguppe Vijayanagar, Bangalore.-

560040.

PH. 080-23396000, 9845184346.

E- Mail: [email protected]

case rep.management of vertically … of vertically fractured maxillary second molar volume 1 issue...

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