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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

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

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tomography (CBCT) was made to obtain a detailed

and a three-dimensional picture on the exact location

and extent of these fractures. Images obtained by

CBCT (Fig. 1D-H) revealed an Ellis class VI

horizontal oblique fracture with the right central

incisor in which a vertical fracture was suspected

initially.

Treatment plan

After taking the informed consent, a rigid

splinting of upper central incisors with a 21 gauge

stainless steel wire and photopolymerizable

flowable composite was carried out and the

occlusion was relieved anteriorly. The endodontic

treatment of upper left central incisor was initiated

first under local anesthesia. The endodontic

instrumentation was limited to size F2 protaper to

prevent further displacement of the fragments. The

canal was then filled with MTA using the butt end

of the gutta percha point and a F1 size protaper file

was then inserted into the canal filled with MTA. It

was segmented approximately at the cervical level.

Thus the F1 protaper file coated with MTA was used

as an intra-radicular splint to stabilize the fragments.

(Fig. 1-I)

A surgical approach was planned to reattach

the fragment palatally with the upper right central

incisor. The fractured fragment was separated under

local anesthesia. (Fig.1-J) Pulp extirpation and

cleaning and shaping procedures were carried out.

Sectional obturation was done followed by checking

the fit of an appropriate size fibre post. (Fig. 1-L)

The palatal flap was raised first to gain access

to the fractured site. (Fig. 1-M) The fractured

fragment was adjusted to fit the head of the fibre

post and the approximation of the fibre post and

the fractured fragment was checked. (Fig. 1-O)

Under isolation the surfaces were prepared for

bonding and the fibre post and the fractured

fragment were all cemented simultaneously using

self adhesive rein based cement Rely-X (3M ESPE).

The flap was then sutured back and the

approximation was checked radiographically. The

fracture line in the crown was prepared with a deep

chamfer and flowable composite was used to

achieve acceptable esthetics. (Fig. 1-P). The tooth

was then build up with restorative composite and

kept under observation.

At the 8th month follow up, patient was

asymptomatic. The radiographic follow up showed

no periapical pathology with any of the upper central

incisors. However, further follow-up is required

with upper left central incisor considering the

multiple fracture lines seen with this tooth. A longer

healing period can be expected. (Fig. R-S)

Case Report 2A 30 year old male patient was referred to the

Department of Conservative Dentistry and

Endodontics, from the Dept. of Oral and

Maxillofacial Surgery for the endodontic treatment

of the upper central incisor. Patient gave a history of

a frontal traumatic impact on his face during a road

accident. The trauma had occured 2 weeks ago.

Patient complained of discomfort and mobility of the

affected tooth in the upper front region of the mouth.

An ERICH’S arch bar was splinted across the

upper arch as a part of the treatment plan in

response to the dento-alveloar fracture in the pre-

maxillary region.(Fig. 2-A). The upper right central

incisor had suffered intrusion injuries and showed

grade 1 mobility and pain on percussion. It gave a

variable pulp response to vitality tests. A pre-

operative radiograph of the upper central incisors

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EXPLORATION OF VARIOUS AVENUES IN DIAGNOSTIC AND TREATMENT MODALITIESIN THE MANAGEMENT OF HORIZONTAL CROWN-ROOT FRACTURES : CASE REPORTS

200

ILLUSTRATIONS & LEGENDS :

Case Report 1

Figure 1-A :

Figure 1-B :

Fig. 1A & 1B : Pre-operative clinical photograph after temporary splinting11 and 21 - Labial view and Palatal view

Figure 1-C : Intra-oral periapical radiograph

Figure 1-D and 1-E : CBCT- 11,21- MESIO- DISTAL VIEW

Figure 1-F : CBCT- 11 and 21 - PALATAL VIEW

Figure 1-G : CBCT- 21 - BUCCOLINGUAL VIEW

Figure 1-H : CBCT- 11 - BUCCOLINGUAL VIEW

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VIBHA HEGDE, ESHA CHANDAWALLA

201

Figure 1-I : Intra-radicular splinting withF1 Protaper file and MTA with 21

Figure 1-J : Removal of the fractured fragment with 11

Figure 1-K : WL determination with 11

Figure 1-L : Sectional obturation and fibre post fit with 11

Figure 1-M : Raising the palatal flap with 11

Figure 1-N : Fractured fragment adjusted to fit the fibre post

Figure 1-O: Checking the fit of fractured fragment with 11

Figure 1-P : Sealing the fracture line with flowable composite

Figure 1-Q : Composite build up - 11

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Case Report 2

Figure 1-R and 1-S : A 8 month clinical and radiographic follow up

Figure 1-R Figure 1-S

Figure 2-A: Pre-operative clinical photographafter arch-bar placement

Figure 2-B: Pre-operative radiograph

Figure 2-C: Pre-operative radiograph with arch-bar

Figure 2-D: Checking the fit of F1 Protaper

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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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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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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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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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