One case of complicated crown root fracture of upper anterior teeth managed by multidisciplinary joint approaches.

Complicated crown root fracture is a serious combined fracture of the enamel, dentin, and cementum in dental trauma. The treatment method is complicated. During the procedure, the condition of pulp, periodontal, and tooth body should be thoroughly evaluated, and a multidisciplinary approach combined with sequential treatment is recommended. This case reported the different treatment and repair processes of one case of two affected teeth after complicated crown root fracture of upper anterior teeth, including regrafting of broken crown after flap surgery at the first visit, direct resin repair to remove broken fragments, and pulp treatment and post-crown repair at the second visit. After 18 months of follow-up, the preservation treatment of the affected teeth with complicated crown root fracture was achieved. Therefore, fragment reattachment and post-crown restoration are feasible treatment options for children with complicated crown root fracture.

Restoration of Complicated Crown-Root Fracture in a Primary Incisor with Fragment Reattachment.

In traumatic dental injuries in children, due to a lack of maturity to cope with the situation, pain intolerance, amount of treatment procedure, and parental anxiety, simplified and non-invasive treatment procedures, such as biologic restorations, are useful. Using advanced adhesive material for fragment reattachment provides excellent esthetic results and a positive attitude from the patient and family. The purpose of this case report is to describe the biological restoration of a complicated crown-root fracture of a primary maxillary central incisor with the fragment reattachment technique.

Polychromatic Restoration of Anterior Fractured Teeth Using a Custom-made Silicone Matrix.

When restoring anterior teeth using resin composites, the use of silicone guide matrices obtained from diagnostic wax-ups is recommended, as this technique facilitates layering and optimizes working time. This is particularly important in polychromatic layering and when more than one anterior tooth is to be restored with resin composites. However, in cases of fractured anterior teeth, it is often not feasible to perform a previous impression and waxing. In these cases, due to trauma and related psychological aspects, patients usually seek immediate esthetic solutions. Therefore, an interesting restorative approach that can simplify the restorative technique is the creation of a silicone guide matrix obtained from the patient's fractured tooth, without the need for prior waxing. This type of personalized matrix was initially proposed by Bertholdo, Ricci, and Barrote. Thus, the purpose of the present work is to demonstrate a modification of the technique for making this type of custom-made matrix for the restoration of two upper central incisors of a 14-year-old patient who fractured his teeth in a bicycle accident.

Review of Approaches to the Management of Vertical Dental Root Fractures and Tooth Preservation.

A vertical root fracture (VRF) is a complex condition in which the fracture lines can be partial or complete and extend along the long axis of the tooth. Considering the nature of the damage and the low likelihood of a successful outcome, such fractures can be difficult to manage. Their management typically involves complex endodontic or surgical procedures, which can be technically challenging for general dentists. Recent advancements introduce promising techniques, such as intentional replantation, adhesive methodologies, and regenerative procedures, showcasing potential in salvaging teeth affected by VRFs. Nonetheless, the imprecise nature of symptoms necessitates meticulous case evaluation by clinicians. Comprehensive patient counseling regarding diverse treatment options and potential ramifications remains crucial to preserving the affected tooth. Preserving a vertically fractured tooth aids in improving both function and aesthetics while safeguarding the arch's integrity by maintaining the height of the alveolar bone. It is important to note that the success of the treatment procedures depends on the extent and location of the fracture, the condition of the tooth and fragment, and the skill of the dental professional performing the treatment. This review highlights the complexity of VRF management, emphasizing the necessity for precise evaluation, patient education, and the exploration of innovative techniques. It aims to review the treatment of VRFs, ranging from classical to contemporary methods, with a focus on tooth preservation. The establishment of standardized protocols and conduct of further research to ascertain long-term efficacy are imperative in optimizing outcomes and retaining natural dentition in cases of VRFs.

Long-Term Outcome of Horizontal Root Fractures in Permanent Teeth: A Retrospective Cohort Study.

INTRODUCTION: Horizontal root fracture (HRF) is a complex traumatic dental injury that affects the pulp, dentin, cementum, and periodontal ligament. This retrospective cohort study evaluated treatment outcomes in permanent teeth with HRF. METHODS: We analyzed clinical and radiographic data from a dental trauma center (2006-2022). Permanent teeth with HRF with a follow up of ≥12 weeks were considered for outcome assessment (defined as clinical normalcy and radiographic healing at the fracture line). Prognostic factors were identified through multivariable logistic regression analyses (P value ≤ .05). RESULTS: 125 teeth from 103 patients were included. After a median follow-up of 79 weeks, the overall favorable outcome was 92%. This includes teeth that received emergency splinting/repositioning at baseline (62.2%) and those that received subsequent endodontic intervention for the coronal fragment (baseline: 85%; subsequent follow-ups: 91.8%). Being male and incomplete root development were both significantly associated with a better outcome of splinting/repositioning (OR = 2.58; 95% CI, 1.06-6.24 and OR = 4.37; 95% CI, 1.16-16.41, respectively) and a reduced likelihood of requiring endodontic treatment (OR = 0.44; 95% CI, 0.20-0.96 and OR = 0.24; 95% CI, 0.08-0.76, respectively). Treatment delays surpassing one week were significantly associated with an increased likelihood of requiring endodontic treatment compared to timely presentations within 24 hours (OR = 3.06; 95% CI, 1.07-8.77; P value < .05). CONCLUSION: With timely diagnosis and treatment, and close monitoring, HRF cases can achieve a 92% favorable outcome. Male sex and incomplete root development correlate with improved baseline outcomes and a reduced need for endodontic treatment. Conversely, delayed presentation increases the likelihood of requiring endodontic intervention.

[The quality of dental care in children with permanent teeth trauma according to analysis of medical records in an emergency unit of a municipal dental clinic]. / Kachestvo okazaniya neotlozhnoi pomoshchi detyam s travmami postoyannykh zubov po dannym analiza dokumentatsii otdeleniya neotlozhnoi pomoshchi gorodskoi stomatologicheskoi polikliniki.

THE AIM OF THE STUDY: Was to assess the efficacy and timing of emergency dental care in children with permanent teeth trauma according to analysis of medical records in an emergency unit of a municipal dental clinic. MATERIAL AND METHODS: The study involved 320 medical records of pediatric patients admitted to emergency dental care unit of a municipal dental clinic in 2021 because of maxillofacial trauma from which 221 records of children with acute dental trauma were extracted. The quality of documentation of the medical records, rationale for diagnosis and adequacy of emergency dental treatment were analyzed. RESULTS: No records included diagnosis code according to ICD-10. Trauma history was described in the majority of records by in 67% of them no trauma time was stated with proper precision. In 67.6% of permanent teeth trauma cases emergency aid was carried out inadequately. All patients with uncomplicated crown fractures were dismissed with no treatment. In complicated crown fractures needing pulp vitality preservation the pulp was devitalized or just anesthetized. Tooth replantation in avulsion cases was not performed. In 13.5% of records the treatment was not properly described. In 67.6% of records there were no recommendations for follow-ups. CONCLUSION: There is a strong need for the improvement of knowledge of traumatic dental injuries management among Russian pediatric dentists by elaboration and implementation of protocols for dental traumas treatment.

[Application of bioactive ceramics iRoot BP Plus® in pulpotomy for complicated crown fracture of immature permanent anterior teeth in children].

OBJECTIVE: To analyze the clinical and radiographic effectiveness of a calcium silicate-based bioactive ceramic iRoot BP Plus® pulpotomy of immature permanent teeth with complicated crown fracture and to evaluate the factors influencing its long-term success rate. METHODS: The digital medical records of patients under 13 years old who had undergone iRoot BP Plus® pulpotomy in the Department of Oral Emergency or the First Clinical Division, Peking University School and Hospital of Stomatology from March 2017 to September 2022 due to complicated crown fracture of anterior teeth, and had taken at least one post-operation apical radiograph were reviewed. The clinical and radiographic information at the initial examination and follow-up period were obtained, including crown color, mobility, percussion, cold test (partial pulpotomy teeth), dental restoration, fistula, swelling or inflammation of the gingival tissue, the formation of apical foramen, pathologic radiolucency and calcification of pulp chamber or root canal obliteration. Data were tested by Fisher exact test and a multiple comparison. RESULTS: In the study, 64 patients including 37 males (57.8%) and 27 females (42.2%) with a mean age of 9.1 years : ere finally enrolled. The total number of permanent teeth that received pulpotomy was 75, and the average follow-up time was 19.3 months. The success rate was 93.1% with the time interval between dental injury and treatment in 24 h, while the success rate dropped to 88.2% with the time intervals beyond 24 h. The time intervals did not significantly affect the pulp survival rate (P=0.61) after pulpotomy (partial or coronal). The success rate 6 months after pulpotomy was 96. 0%, and one-year success rate was 94. 7%. A total of 23 cases were reviewed for more than 2 years after pulpotomy, and 6 cases failed. The mobility had no significant effect on the success rate (P=0.28). Pulp chamber calcification and pulp canal obli-teration were not observed in all the post-operative radiographs. CONCLUSION: The one year clinical and radiographic success rates obtained in this study indicate that iRoot BP Plus® is an appropriate pulp capping material option for pulpotomy treatment of complicated crown fracture in immature permanent teeth without displacement injuries. This technique has broad promotional value.

Comparative evaluation of three materials used for fragment reattachment in uncomplicated crown fracture-An in vitro study using bovine teeth.

BACKGROUND/AIMS: The recommended treatment for uncomplicated crown fractures is bonding the fractured fragment or the fragment reattachment. A paucity was identified regarding the studies comparing the efficacy of micro-hybrid and nanohybrid composites in fragment reattachment. Hence, the present study aimed to evaluate and compare three materials for bonding of fragments rehydrated by humidification in teeth with uncomplicated crown fractures. MATERIAL AND METHODS: Eighty mandibular bovine incisors with similar dimensions and free of any structural deformities were fractured similar to the technique followed in previous studies. Fracture was simulated, fragments, and stumps were coded, stumps were stored in artificial saliva and the fragments were dehydrated at room temperature and pressure. They were randomly assigned to Group-1 (no rehydration), Group-2 (rehydrated and bonded by flowable nanohybrid composite-3M Filtek Supreme Syringe Flowable Composite Resin-A2, Sao Paulo, Brazil), Group-3 (rehydrated and bonded by flowable micro-hybrid composite- Ruby Flow, InciDental, England, United Kingdom), and Group-4 (rehydrated and bonded by light-cured Glass-Ionomer-Cement-Voco Ionoseal, Cuxhaven, Germany). The samples were subjected to a universal testing machine to evaluate the force required to fracture the bonded fragments. RESULTS: The highest median value of the force required to fracture was recorded for Group 2 (208.4 N) followed by Group 3 (195.2). The force required to fracture the bonded fragments was lowest in Group 4 (67.2 N) which was lower than the negative control (131.4 N). The differences between the observations in Groups 2 and 3 were not found to be statistically significant. CONCLUSION: The nano and micro-hybrid composites showed greater force required to fracture than fragments bonded by LC-GIC. Dehydrated fragments bonded using nanocomposites performed better than rehydrated fragments bonded by using LC-GIC.

The fracture strength and the failure mode of lithium disilicate or resin nano ceramics as a crown, overlay, or endocrown restoration on endodontically treated teeth.

INTRODUCTION: Different materials and restorative concepts have been proposed over the years to restore endodontically treated teeth (ETT). Monolithic ceramic and composite restoration can be lute to the tooh, without the use of a post. However, little is known how the material stiffness and presence of a composite core will affect the survival and failure mode. The objective of this in-vitro study was to evaluate the fracture strength and failure mode of endodontically treated molars, restored with ceramic or hybrid composite monolithic restoration, in the presence of absence of a composite core. MATERIALS AND METHODS: Sixty depulped molars were restored with a lithium-disilicate (e.max CAD) or hybrid composite (Cerasmart) restoration. Both materials were used in a monolithic approach, but with 3 different designs: (a) monolithic endocrown, (b) crown with a separate composite core, and (c) overlay without core buildup or pulpal extension. Ten sound teeth were used as control group. All groups were thermocycled (10,000 cycles), subsequently loaded in a chewing simulator (100,000 cycles) and finally loaded until fracture. RESULTS: Peak fracture loads and failure modes were registered. No significant differences were seen between the groups in terms of fracture load. Failure modes were statistically significantly different among groups with significant correlation between restoration type and material. (p < 0.001 and p = 0.033, respectively). No group presented significantly higher fracture resistance. Although ceramic crowns and overlays presented the highest repairability, all restored ETT were within the range of the intact tooth' fracture strength. CONCLUSION: No restoration presented significant different fracture loads. However, the type of restoration and material choice were correlated to the fracture mode.

Are Tooth and Ceramic Fractures Different Sides of the Same Coin? A Report of Two Clinical Cases.

Two clinical cases involving the fracture of a natural tooth and one of a ceramic crown are presented and discussed based on fractography principles. In the first case, a patient reported intense pain in a sound third molar where a longitudinal fracture was identified, and the tooth was extracted. In the second case, a posterior rehabilitation using a lithium silicate ceramic crown was carried out, and the patient returned after 1 year with a fractured piece of the crown. Both were analyzed under microscopy to identify the origins of fractures and their causes. The fractures were critically analyzed so that relevant information could be generated from the laboratory to the clinic.

Indications for root canal treatment following traumatic dental injuries to permanent teeth.

The dental pulp may respond favourably or unfavourably to traumatic dental injuries. The most serious unfavourable responses are pulp necrosis and infection of the root canal system. These cause apical periodontitis and/or external inflammatory resorption of the tooth. The following injuries require root canal treatment as part of their emergency management-(A) complicated crown fractures (but some may be suitable for conservative pulp treatments, such as pulp capping, partial pulpotomy or pulpotomy), (B) complicated crown-root fractures, (C) supra-crestal coronal third root fractures and (D) injuries where pulp necrosis is predictable or highly likely to occur AND where there has been damage to the root surface and/or periodontal ligament with the aim of preventing external inflammatory resorption. This latter group of injuries are avulsion, intrusion, lateral luxation with a crown fracture, extrusion with a crown fracture (all in fully developed teeth) plus avulsion with a crown fracture and intrusion with a crown fracture (both in incompletely developed teeth). All other injuries should not have root canal treatment commenced as part of the emergency management, but they must be reviewed regularly to monitor the pulp for any adverse changes to its status, particularly pulp necrosis and infection of the root canal system.

Traumatic dental injuries over an 8-year period at a German dental center: a retrospective overview and cross-sectional analysis.

BACKGROUND/AIM: The aim of this study was to analyze a population of patients who had suffered from traumatic dental injuries (TDIs) by using different patient-, trauma- and treatment-related parameters. MATERIAL AND METHODS: All dental records of patients ≥ 3 years old who had presented at the dental emergency service between Jan 1, 2009 and Dec 31, 2016 for the treatment of dental trauma were analyzed. A total of 2758 patients were invited for a recall examination at the Department for Dental Surgery and Implantology, ZZMK Carolinum, Goethe University Frankfurt, Germany; of these, 269 patients attended their recall appointments. RESULTS: The enrolled patient population consisted of 1718 males and 1040 females, with a mean age of 19.63 years (median 12.00 ± 17.354 years). A total of 4909 injured teeth were assessed, with a mean of 1.78 injured teeth per patient (median 2.00 ± 1.279). Males were found to be more frequently affected by TDIs compared to females (1.65:1). The majority of these injuries occurred in the first two decades of life (66.1%; n = 1824). The majority of the patients presented for initial treatment within 24 h of their accident (95.7%). The most frequent TDIs were isolated luxation injuries 49.4% (n = 2426) and isolated crown fractures 30% (n = 1472). Combination injuries were diagnosed in 20.6% of the cases (n = 1011). CONCLUSIONS: Based on the findings of the present analysis, it can be concluded that males were more frequently affected by TDIs than females. Most patients had suffered from TDI before they had turned 10 years of age. Overall, the enamel-dentin fracture was found to be the most frequent injury, followed by concussions and lateral luxations.

Dental trauma: assessment and acute management of fractures.

Acute dental trauma is unscheduled and presents infrequently to the majority of practitioners. Therefore, a consistent, logical and systematic process for examination, prioritisation and management is imperative for all sustained injuries to have an optimal outcome. Fractures are a frequent sequela to dental trauma and can involve any aspect of the tooth structure or supporting alveolar bone. While some minor crown fractures may initially seem inconsequential, they may be a subtle indication to a more serious underlying root fracture. Concomitant injuries and injuries that have been initially missed are generally associated with poorer outcomes. The time sensitive management of traumatic dental injuries aims to preserve pulpal and periodontal health where possible. The follow up period for tooth or alveolar fractures are important to allow for early intervention if pathology develops.

Short fiber reinforced composite on fracture strength of immature permanent anterior teeth with simulated regenerative endodontic procedures: an in vitro study.

The aim of the present study was to evaluate the effect of short fiber reinforced composite on the fracture strength of anterior immature teeth treated with regenerative endodontic procedures. A total of 120 permanent maxillary central incisors were selected, and root lengths were standardized. Except for the positive control group (n = 20), the root canals were instrumented to simulate immature teeth with incomplete root development, and the regenerative endodontic procedure was performed. Twenty instrumented teeth acted as negative controls (n = 20), and the remaining 80 teeth were randomly divided into 4 groups according to the chosen coronal restoration material: bulk fill, short fiber reinforced composite (SFRC), polyethylene fiber (Ribbond Ultra), and flowable composite resin. Each specimen was then subjected to fracture testing using a universal testing machine (AGS-X, Shimadzu, Japan). The load to fracture was recorded. Data were subjected to statistical analysis using analysis of variance and the Tukey Honestly Significant Difference test. A significant difference was detected between the groups (p < 0.05), with the positive control group showing the highest mean fracture strength. The SFRC group had significantly higher values than the bulk fill, polyethylene fiber, flowable composite resin and negative control groups. In conclusion, SFRC has a relatively high fracture strength compared to other materials used in regenerative endodontic procedures. The use of SFRC enhanced the fracture strength of immature permanent teeth.

Dental and Dentoalveolar Injuries in the Pediatric Patient.

Dental and dentoalveolar injuries are common in the pediatric population. Management is predicated on the type of tooth injured (primary or permanent), extent of injury, the dental and behavioral age of the patient, and ability of the patient to tolerate treatment. Although many dental injuries occur in isolation, a systematic evaluation of the patient is mandatory to confirm the absence of basal bone fractures of the maxilla or mandible, traumatic brain injury, cervical spine injury, and/or facial soft tissue injury. Long-term follow-up is paramount to achieving a functional occlusion and optimal dental health following injury.

Critical appraisal of the 2020 IADT Guidelines: A personal commentary.

The 2020 International Association of Dental Traumatology (IADT) Guidelines feature several important changes in the treatment recommendations for traumatic dental injuries (TDIs) from the previous 2012 iteration of these Guidelines. This evidence-based narrative review aims to provide a detailed appraisal of five specific changes incorporated in the 2020 IADT Guidelines, based on the available literature evidence that may have prompted these changes. The paper discusses three excellent additions/changes to the new Guidelines: (i) inclusion of a core outcome set for reporting TDIs; (ii) more conservative management of primary dentition TDIs including the changed recommendations for radiation exposure and managing primary dentition luxation injuries; and (iii) the changes in the treatment recommendations for permanent dentition avulsion injuries. The paper further debates whether two other changes made in the current IADT Guidelines for-(i) intrusion injuries in immature teeth; and (ii) complicated crown-root fractures in mature teeth-have sufficient evidence to support the changed recommendations.

Evaluation of the Fracture Resistance of Conservative and Ultraconservative Access Cavity Designs with Different Treatment Modalities: An In Vitro Study.

Introduction: The aim of this study was to evaluate the fracture resistance of endodontically treated mandibular molars using traditional and conservative access cavity preparation. Materials and Methods: In this in vitro study, 100 extracted healthy human mandibular molars were selected and divided into 10 groups (n = 10). Healthy teeth in one group were considered the control group. In three groups, traditional access cavity preparation was done (groups A) without two marginal ridges (A1), with one marginal ridge (A2), and with two marginal ridges (A3). In three groups (group B), two separate access cavities with a dentinoenamel roof without two marginal ridges (B1), with one marginal ridge (B2), and with two marginal ridges (B3) were prepared. In three other groups (groups C), two separate access cavities were prepared only with a dentinal roof without two marginal ridges (C1), with one marginal ridge (C2), and with two marginal ridges (C3), on which root canal treatment was performed afterward. Then, these teeth were subjected to force until fracture. The fracture force and fracture mode of each tooth were recorded and compared between groups by ANOVA, Tukey's post hoc, and chi-square tests using SPSS ver. 23 (IBM, Somers, NJ, USA). Results: The control teeth had the highest mean fracture force (2804.5 ± 338.5 N), followed by a conservative access cavity with a dentinoenamel roof and two marginal ridges (2360.4 ± 181.72 N) and a conservative access cavity with a dentinoenamel roof and one marginal ridge (1812.8 ± 263.9 N), respectively. The lowest mean fracture force was found for the conventional access cavity group without two marginal ridges (399.4 ± 95.2 N). Conclusion: In the condition of this study, with two separate access cavities in mandibular molars and maintenance of the marginal ridges, it is possible to provide teeth with higher fracture resistance against occlusal forces.

Fragment Reattachment: A 4-Year Case Report of Uncomplicated Dental Fractures.

Two fractured maxillary central incisors were restored via the crown fragment reattachment technique with adhesive systems and composite resin material. A long-term successful outcome was achieved after 4 years of follow-up. The patient presented with fractured maxillary central incisors, and a comprehensive intraoral and radiographic examination revealed that both teeth had extended crown fractures with no pulpal exposure (Class II, Ellis and Davey). The tooth fragments were thoroughly cleaned and inspected before being repositioned. Both fragments were in excellent condition with almost no pieces missing. Therefore, the proposed treatment was fragment reattachment. After verifying the repositioning and adaptation of the fractured fragments, a flowable composite was used to perform the reattachment procedure under rubber dam isolation. With modern dental adhesives, the reattachment of tooth fragments in good condition is considered a more conservative option for restoring tooth morphology, esthetics, and function. Although one tooth showed signs of irreversible pulpitis and required root canal treatment 2 weeks after the restoration, the clinical and radiographic evaluations at the 4-year follow-up visits confirmed the success of the restorative treatment. The restorations showed good functional and esthetic outcomes after 4 years of follow-up.

Forced surgical extrusion using an axial tooth extraction system as a practicable technique for preserving severely destroyed teeth? - Clinical outcomes up to 4.8 years.

OBJECTIVE: Several extrusion techniques have been described to restore teeth with insufficient coronal tooth structure and to avoid their extraction. Still, there is little evidence for a treatment concept combining surgical extrusion using an atraumatic axial extraction system. MATERIALS AND METHODS: A total of nine patients, each with an iso- or subgingival fractured tooth, were retrospectively examined. Treatment of the damaged tooth comprised an atraumatic forced surgical extrusion performed with an axial tooth extraction system and a more coronal positioning within the socket. The teeth were initially splinted and subsequently restored. The follow-up period was up to 57.1 months and averaged 36.5 (SD: ±13.5) months. RESULTS: All nine teeth were still in situ, without signs of inflammation. During the period of the provisional restoration, six prosthetic complications occurred, which were resolved with little effort, whereas, success rate for the definitive restoration was 100%. No biological complications were observed concerning the root apex or soft tissue. The radiographically measured mean extrusion distance was 3.4 (SD: ±1.0) mm, so that a sufficient prosthetic ferrule could be reestablished. CONCLUSIONS: Surgical extrusions using an axial tooth extraction system demonstrate low biological and prosthetic complications rates over observation time. CLINICAL SIGNIFICANCE: The presented extrusion approach preserves soft and hard tissue and is an efficient treatment option for severely destroyed teeth. Saving hopeless teeth by this relatively predictable and feasible procedure has hardly any disadvantages for patients, and in case of failure, an implant or fixed partial denture are still an option.

Managing a Deep Subgingival Cusp Fracture: Case Reports.

Cuspal fractures are relatively common. Fortunately for esthetics, when a cuspal fracture occurs in a maxillary premolar, it most commonly involves the palatal cusp. Fractures with a favorable prognosis may be approached with a minimally invasive treatment to successfully retain the natural tooth. This report describes 3 cases of "cuspidization" to treat maxillary premolars with cuspal fractures. After identifying a palatal cusp fracture, the fractured segment was removed, resulting in a tooth that closely resembles a cuspid. Depending on the extent and location of the fracture, root canal treatment was indicated. Subsequently, conservative restorations sealed the access and covered exposed dentin. Full coverage restorations were neither required nor indicated. The resulting treatment provided practical and functional treatment with a good esthetic outcome. When indicated, the described cuspidization technique can conservatively manage patients with subgingival cuspal fractures. The procedure is minimally invasive and cost-effective and can be done conveniently in routine practice.