A novel surgical treatment approach for the vertical root fracture of posterior teeth: a case report with 24-month review.

BACKGROUND: Up to 25% of the tooth extraction after root canal treatment could be attributed to the vertical root fracture (VRF). The treatment choice for teeth with VRF would mostly be the extraction despite some repairing methods were also reported. The repairing treatment result of VRF would mostly depend on the fixation strength and the bioactivity of the repairing materials, especially for the posterior teeth with high masticating stresses. This case report designed a novel surgical treatment approach for the VRF of posterior teeth. METHODS: a maxillary premolar with buccal-palatal complete VRF was treated with a new dual-layered repairing approach using adhesive resin + iRoot BP Plus bioceramic cement to fill the modified fracture line with retention forms through the intentional replantation. RESULTS: At the 24-month review, the tooth showed desirable periodontal healing and normal function. CONCLUSIONS: This case report indicated that the dual-layered repairing approach might be effective for saving the posterior teeth with VRF. Nevertheless, further clinical trials are needed for its long-term result.

7.5- to 11.5-Year Follow-up of the Fracture Removal Treatment for Propagated Crown Fractures.

A definitive method to predictably treat propagated longitudinal fractures remains elusive. A proof-of-concept case report series documenting nonsurgical removal of propagated longitudinal fractures has shown up to 5 years of clinical and radiographic success. This installment of the case report series further documents these teeth with 7.5-year to 11.5-year recall evaluations. Three previously reported cases of fracture removal were followed at 11.5 years (1 case), 9.75 years (1 case), and 7.5 years (1 case) after treatment to determine the long-term clinical and radiographic success of nonsurgical fracture removal. This case report series has demonstrated 10-year success (clinically and radiographically) for the treatment of progressive longitudinal fractures. Propagated fractures can be nonsurgically removed and the iatrogenic defect repaired with long-term success providing a foundation for treatment and further investigation.

[How long does a tooth last after a surgical crown lengthening?] / Hoe lang gaat een gebitselement mee na een chirurgische kroonverlenging?

The presence of subgingival pathology, such as a deep secondary caries lesion, a fracture, an already existing restoration that needs to be replaced or the presence of a resorption defect, can constitute a difficult starting situation for the preservation of a tooth. How to deal with such a situation has been a topic of discussion for years. Surgical crown lengthening is one of the first and classic treatment options that is often chosen in such cases. Crown lengthening is a periodontal surgical technique to obtain extra supra crestal clinical crown length. The question is, what is the long-term prognosis of teeth after surgical crown lengthening. To answer this question, a review of the literature was carried out looking for clinical studies examining survival. Four studies with a follow-up of at least 5 years were included. The factors that adversely affect survival of the tooth after the crown lengthening are an unfavourable crown-root ratio, insufficient plaque control and moderate ability to keep the restoration clean.

[Surgical extrusion, an alternative to a dental implant?] / Chirurgische extrusie, een alternatief voor een tandheelkundig implantaat?

Unfortunately, accidents do happen. Dentoalveolar injury to the front teeth resulting from trauma can sometimes be so problematic that an (adhesive) restoration seems almost impossible to make, let alone saving the tooth. In this contribution the case of a 17-year-old patient whose upper incisor suffered severe dentoalveolar trauma in a traffic accident is presented. His upper incisor was fractured deeply subgingivally, at bone level, and at first glance, appeared to be lost. Surgical extrusion, however, in this patient represents a full alternative to a prosthetic solution, such as a dental implant.

Prevalence of and Factors Associated With Vertical Root Fracture in a Japanese Population: An Observational Study on Teeth With Isolated Periodontal Probing Depth.

INTRODUCTION: Previous studies on the prevalence of vertical root fractures (VRFs) were based on extracted teeth, or teeth referred for apical surgery. This study examined teeth with an isolated periodontal probing depth (PD) as an indicator of VRF. The primary aim of this study was to investigate the prevalence of vertical root fracture (VRF) and non-VRF among teeth with an isolated probing depth (PD) ≥ 5 mm. The secondary aim was to assess factors associated with VRF by comparing the teeth with and without VRF in the Japanese population. METHODS: A total of 288 teeth with an isolated PD ≥ 5 mm were grouped pathologically into 8 groups comprising VRF and non-VRF conditions. A descriptive analysis for age, sex, tooth type, endodontically treated teeth (ETT) versus non-ETT, proximal contacts, PD (depth), PD (broadness and location), restoration type, and presence of a post was performed. Moreover, the associations between these factors and VRFs were investigated using the Chi-square test. RESULTS: The prevalence of VRF was 32%. Lower first molars were the most common tooth type in both VRF (31.5%) and non-VRF groups (29.7%), while premolars were exclusively frequent in VRF (30.2%) and not frequent in non-VRF (7.8%). Narrow buccolingual PD was common in VRF (78.1%) whereas wide PD was frequent in non-VRF (67.1%). ETT, narrow buccolingual PD, tooth type (premolars), restoration type (crown), and the presence of a post showed significant associations with VRF (P ≤ .001). CONCLUSIONS: VRFs may be more prevalent in ETT among the Japanese. Careful assessment is necessary to differentiate VRFs from other conditions when the lower first molars show an isolated PD ≥ 5 mm. When an endodontically treated premolar with a post shows a narrow buccolingual PD, the probability of a VRF may be greater than in other tooth types.

Effect of apical root resection, orthodontic extrusion, and surgical crown lengthening on load capability.

OBJECTIVES: This study aims to investigate the load-to-fracture of procedures changing crown-to-root ratio (RCRR) aimed to restore severely damaged upper central incisors to avoid tooth extraction compared to implant placement. There is no evidence on load capability after apical root resection (AR), orthodontic extrusion (OE), and surgical crown lengthening (SCL) in respect to RCRR, respectively. MATERIAL AND METHODS: Human maxillary central incisors were endodontically treated, decoronated, and divided into 4 groups (n = 48). The following specimen preparation was performed: (I) adhesive core-and-post build-up (control), (II) as (I) and 2 mm apical root resection (AR), (III) before adhesive core-and-post build-up teeth were shortened 2 mm coronally (OE) (IV) as (I), but specimens were embedded 4 mm instead of 2 mm below the CEJ (SCL), group (V) implant-borne restoration with individual all-ceramic abutments (n = 12; ∅4.1/l = 12 mm) (IBR). All specimens received all-ceramic crowns, thermo-mechanical (TML), and subsequent linear loading (LL) until failure. RCRR were calculated and log-rank, Kruskal-Wallis, Mann-Whitney U, ANOVA, and chi-square tests applied (p = 0.05). RESULTS: Fracture loads after subsequent LL differed significantly (p = 0.001) between groups, while implants showed the highest values. Fmax median (min/max) were as follows: (I) 252 (204/542), (II) 293 (243/443), (III) 253 (183/371), (IV) 195 (140/274), and (V) 446 (370/539). Pair-wise comparison showed significant differences (p = 0.001) between group I/IV and group V, I, and IV (p = 0.045), II and IV (p = 0.001), and III compared to IV (p = 0.033), respectively. RCRR below 1 significantly increased load capability compared to RCRR = 1. CONCLUSIONS: OE appears to preferably ensure biomechanical stability of teeth that are endodontically treated and receive core-and-post and crown placement compared to SCL. AR has no adverse biomechanical impact. RCRR < 1 is biomechanically beneficial. CLINICAL RELEVANCE: For endodontically treated and restored teeth, orthodontic extrusion should be preferred compared to surgical crown lengthening prior single-crown restoration. As orthodontic extrusion, apical root resection has no adverse effect on load capability. Single-crown implant-borne restorations are most load capable.

Management of Crown-root Fracture with 180-degree Rotation Replantation: a Report of 2 Cases.

Intentional replantation involves a combination of periodontics, endodontics, prosthodontics and oral surgery. Crown-root fracture management is still complicated nowadays. A fracture line extending longitudinally to the subgingival area and intruding bioogical width could affect infection control, gingival health and crown restoration. In the present study, we present two cases. Case 1 involved a 23-year-old man who presented at our hospital with crown-root fracture of the maxillary left central incisor. A radiographic image of the tooth revealed a fracture line under the alveolar crest. The fractured tooth was treated with intentional replantation with 180-degree rotation, root canal treatment and veneer restoration. The patient was followed up for 60 months. The replanted tooth functioned well, and no symptoms of resorption or ankylosis were observed by radiographic examination. Case 2 involved a 20-year-old woman who was referred to our hospital for crown-root fracture of her maxillary teeth. A radiographic examination revealed complicated crown-root fracture of the maxillary right lateral incisor and both maxillary central incisors. The central incisors were treated with intentional replantation with 180-degree rotation. At the 48-month follow-up, the fractured teeth were found to have regained normal function based on clinical and radiographic examination. Limited case reports are available on a long-term follow-up of intentional replantation with 180-degree rotation. These two cases, particularly case 2, presented optimal healing after 4 years with unideal crown-root ratios. This case report suggests that this old method of preserving teeth with crown-root fractures can be used as a last resort to save teeth owing to its timesaving and microinvasive procedure.

Tooth in the line of a mandibular fracture: Retain it or remove it? Clinical case report.

Defining the prognosis and treatment plan for teeth in the line of a mandibular fracture is a challenge for the maxillofacial surgeon. The periodontal ligament may provide a communication with the oral cavity and become a pathway for infection. There is currently no consensus on the management of teeth in mandibular fracture lines. This report outlines a case where a tooth was successfully retained in the line of fracture as well as providing a review of the literature on the best-accepted treatments for this scenario.

Abordagem multidisciplinar no tratamento de incisivo lateral com fratura oblíqua e lesão periapical: relato de caso clínico / Multidisciplinary approach in the treatment of lateral incisor with oblique fracture and periapical injury: clinical case report

Casos de fraturas dentárias oblíquas muitas vezes possuem um prognóstico desfavorável, geralmente com indicação da extração do elemento dental. O presente artigo visou relatar o tratamento do caso clínico de um paciente do sexo masculino, 12 anos, que compareceu à Unidade de Saúde Bucal do Hospital Universitário de Brasília com encaminhamento de extração do dente 12, apresentando fratura oblíqua que se estendia subgengivalmente na face vestibular. O trauma havia ocorrido há três anos e o paciente havia sido submetido a diversas intervenções endodônticas, apresentando no momento da consulta inicial por nossa equipe uma lesão periapical extensa. Após a realização da anamnese, exame clínico e radiográfico, foi adotada uma abordagem multidisciplinar conservadora com a manutenção do dente e a realização da enucleação da lesão periapical por meio de intervenção cirúrgica e posterior reabilitação. Em uma mesma sessão, foi realizada a obturação do conduto com cone de guta percha e cimento sealer 26 e a cirurgia parendodôntica juntamente com a apicoplastia. Uma semana após a intervenção cirúrgica foi realizada restauração classe IV com resina composta baseada no enceramento dos modelos de diagnóstico montados em articulador. Com base em uma avaliação criteriosa e multidisciplinar, foi possível adotar uma abordagem conservadora no caso em questão, com a manutenção e reabilitação de um dente permanente em um paciente jovem, evitando a indicação de exodontia(AU)

Cases of oblique dental fractures often have an unfavorable prognosis, usually with the indication of extraction of the dental element. The present article aimed to report the treatment of the clinical case of a 12-year-old male patient, who attended the Oral Health Unit of the Hospital Universitário de Brasília with a referral for extraction of tooth 7, presenting an oblique fracture that extended subgingivally on the labial surface. The trauma had occurred three years ago and the patient had undergone several endodontic interventions, presenting an extensive periapical lesion at the time of the initial consultation by our team. After anamnesis, clinical and radiographic examination, a conservative multidisciplinar approach was adopted with the maintenance of the tooth and the enucleation of the periapical lesion through surgical intervention and subsequente rehabilitation. In the same session, the conduit was filled with gutta-percha cone and sealer cement 26 and parendodontic surgery was performed together with apicoplasty. One week after the surgical intervention, class IV restoration was performed with composite resin based on the waxing of the diagnostic models mounted on an articulator. Based on a careful and multidisciplinary evaluation, it was possible to adopt a conservative approach in the case in question, with the maintenance and rehabilitation of a permanent tooth in a young patient, avoiding the indication of extraction(AU)

Prosthetic restoration after atraumatic surgical extrusion: a report of two cases.

Preservation and restoration of teeth with little coronal tooth structure due to crown-root fractures or caries lesions, ensuring restoration margins do not encroach on the biologic width, constitute a challenge. Available treatment options include surgical crown lengthening and orthodontic or surgical extrusion. This report presents two patients in which teeth were restored by surgical extrusion with an atraumatic extraction system and prosthetic therapy.

Success rate of fractured teeth receiving modified crown lengthening surgery and restorations.

BACKGROUND: Whether to preserve a structurally compromised tooth or remove it is a dilemma often encountered by clinicians. The aim of this study was to assess the long-term success rate of fractured teeth preserved by modified crown lengthening surgery and restorations. METHODS: Thirty-nine patients with a total of 45 fractured teeth who had received modified crown lengthening surgery were recruited and examined. Numbers of teeth lost were recorded, and the criteria for successful teeth were defined. Kaplan-Meier estimator was used to determine the success rate. Possible risk factors were compared between successful and unsuccessful groups by a Cox regression analysis to explore the potential predictors of failure with a significant level at α = 0.05. RESULTS: The mean ± SD of success time without considering variants was 6.2 ± 0.6 years (95% CI 5.1-7.7). The mean survival rates ± SD at 1.0-, 2.0-, 3.0-, 5.0-, 7.0-, and 9.0-year intervals was 97.8 ± 2.2%, 92.2 ± 4.4%, 72.8 ± 7.9%, 68.2 ± 8.6%, 60.7 ± 10.5%, and 40.4 ± 13.6%, respectively. Failure cases in teeth with poor plaque control and step-shaped fracture margin were significantly more than those with good plaque control and knife-shaped fracture margin (HR = 7.237, p = 0.011; HR = 15.399, p = 0.006; respectively). CONCLUSIONS: Fractured teeth treated with modified crown lengthening surgery are anticipated to have a high clinical success rate for 6.2 ± 0.6 years. Plaque control and fracture morphology appeared to be significantly associated with the success of the multidisciplinary treatment approach.

Multidisciplinary Approach to Complicated Crown-root Fracture Treatment: A Case Report.

Treatment of complicated crown-root fractures is one of the most challenging within the various types of dental trauma and requires a multidisciplinary approach. This paper reports the complicated crown-root fracture of a maxillary right central incisor, in which there was esthetic, functional, and biologic (endodontic and biologic width invasion) involvement. A 15-year-old male patient presented to the dental clinic one month after suffering trauma with a complicated crown-root fracture on tooth 8. The patient had previously undergone endodontic treatment and was sent to have periodontal surgery to reestablish the biological width on the palatal surface. Following the surgery, a fiberglass post was cemented, and the fragment was reattached. This approach allows the exposure of the cervical margin, adequate isolation, and subsequent fragment reattachment in the same clinical appointment. Fragment reattachment is a viable approach as it is a simple and conservative procedure that restores the natural esthetic of the tooth and has superior resistance compared to a composite restoration. The patient's cooperation in understanding the limitations of the treatment and maintaining adequate oral hygiene are very important to achieving a good prognosis of the case. After a 2-year clinical and radiographic follow-up period, the clinical protocol was found to be successful, and the tooth remained functional, esthetically favorable and asymptomatic.

Intentional Replantation of a Second Premolar with Internal Resorption and Root Fracture: A Case Report.

AIM: This case aims to detail intentional replantation as a last resort to save an otherwise hopeless premolar with perforated internal resorption and root fracture. BACKGROUND: Internal root resorption, progressive destruction of intraradicular dentin, is a condition that sometimes renders a tooth non-restorable. In the rare cases reported where severe internal resorption leads to root fracture, extraction of the tooth seemed to be a common treatment of choice, and a few literatures had reported endodontic surgery as an alternative treatment option. To date, there had been no report of treating internal root resorption using intentional replantation. CASE DESCRIPTION: A 20-year-old male presented swelling at the buccal region of his left maxillary second premolar (#13). Clinical examination revealed a sinus tract and fractured dens evaginatus at the occlusal surface of the tooth. Radiographically, a large area of radiolucency was detected within the middle third of the root, where root fracture was present, leaving a triangular-shaped mature root apex. The condition was diagnosed as internal root resorption and root fracture. Endodontic surgery was excluded from treatment choices due to potential damage of periodontal bone. Instead, intentional replantation was performed, with the application of biomaterials including mineral trioxide aggregate (MTA) and platelet-rich fibrin (L-PRF). The tooth achieved satisfactory healing and remained asymptomatic after 2 years of follow-up. CONCLUSION: The successful outcome of the case suggests that intentional replantation could preserve a fractured tooth caused by internal root resorption. Incorporated application of biomaterials, such as MTA and L-PRF, might as well improve the chances of saving this otherwise hopeless tooth. CLINICAL SIGNIFICANCE: Through careful planning and execution, intentional replantation is a viable alternative treatment option to preserve a fractured tooth caused by internal root resorption, while leaving periodontal bone architecture almost intact. How to cite this article: Yang Y, Zhang B, Huang C, et al. Intentional Replantation of a Second Premolar with Internal Resorption and Root Fracture: A Case Report. J Contemp Dent Pract 2021;22(5):562-567.

El reto del abordaje quirúrgico en la rehabilitación sobre un implante unitario en un caso de alto requerimiento estético del sector anterior. Descripción a propósito de un caso / The challenge of the surgical approach in the rehabilitation of a unitary implant in a case of high aesthetic requirements of the anterior sector. Case report

Objetivo: Describir de forma detallada el abordaje clínico basado en la evidencia científica actual de un implante postextracción con carga y provisionalización inmediata. Caso clínico: Se presenta el caso de una paciente mujer de 32 años de edad, que acude por presentar una posible fractura radicular del incisivo central superior izquierdo (ICSI), acompañada de la aparición de un absceso periodontal en la región del fondo de vestíbulo de dicho diente. Tras llevar a cabo la exploración clínica y radiológica, se establece que el pronóstico del ICSI es desfavorable para llevar a cabo un tratamiento conservador del mismo. Tras la valoración de las características clínicas del caso presente, el plan de tratamiento se inclinó por la realización de la exodoncia del ICSI con la colocación simultánea de un IOI postextracción y la carga inmediata con una prótesis provisional del mismo. Conclusiones: La rehabilitación sobre implantes en situaciones de pérdida dental en el sector anterior estético y en especial, en pacientes jóvenes, requiere un plan de tratamiento multidisciplinar en cuanto a la extracción del diente y colocación del IOI en la posición tridimensional correcta, existiendo diferentes aspectos a tener en cuenta para ello, especialmente el remanente óseo residual, la posición del margen gingival, así como la preservación y acondicionamiento de los tejidos duros y blandos periimplantarios mediante injertos y un manejo correcto de una prótesis provisional hasta conseguir un perfil de emergencia y contorno gingival ideal antes de la corona definitiva. (AU)

Objective: To describe in detail the clinical approach based on current scientific evidence for a post-extraction implant with immediate loading and provisionalisation. Clinical case: We present the case of a 32-year-old female patient who presented with a possible root fracture of the upper left central incisor (ULCI), accompanied by the appearance of a periodontal abscess in the region of the bottom of the vestibule of said tooth. After carrying out the clinical and radiological examination, it is established that the ULCI prognosis is unfavourable for carrying out conservative treatment of the tooth. After assessing the clinical characteristics of the present case, the chosen treatment plan was to extract the ULCI with the simultaneous placement of a post-extraction osseointegrated implant (OII) and immediate loading of a provisional prosthesis on the implant. Conclusions: Rehabilitation on implants in situations of tooth loss in the aesthetic anterior sector, especially in young patients, requires a multidisciplinary treatment plan in relation to tooth extraction and placement of the OII in the correct three-dimensional position. There are various aspects to be taken into account, particularly the residual remaining bone, the position of the gingival margin, as well as the preservation and conditioning of the peri-implant hard and soft tissues by means of grafts and proper handling of a provisional prosthesis until an ideal emergence profile and gingival contour is achieved before the final crown. (AU)

The management of a complicated crown-root fracture incorporating modified crown-lengthening surgery.

Anterior teeth with subgingival fractures require a multidisciplinary management approach with regards to biological, functional and aesthetic factors. This case report emphasises the use of a minimally invasive technique combined with a sequence of therapies to treat a complicated crown-root fracture and reviews the critical factors to ensure predictable outcomes. Endodontic treatment was undertaken due to exposure of the pulp in a complicated crown-root fracture of the maxillary right central incisor. Extrusion of the fractured fragment was performed to expose the fracture margin under the alveolar bone. Modified crown-lengthening surgery was used to reconstruct the biologic width. The traumatised tooth was restored with a glass fibre post and resin core, which fit the biological requirements. Finally, an all-ceramic crown fulfilled biomimetic aesthetics. This multidisciplinary approach achieved a good long-term prognosis with regards to periodontal and periapical healing.

A conservative approach for an adult patient with a fractured tooth and crowding: Autotransplantation at the fracture site.

Autotransplantation of a mature premolar in adults can be a treatment of choice for tooth replacement when combined with well-planned orthodontic treatment. This case report describes the successful treatment of a 39-year-old patient with severe crowding and a hopelessly fractured tooth on the maxillary left side. Maxillary dental crowding was relieved by extraction of a premolar on the right side, and this extracted tooth was autotransplanted to replace the fractured tooth. A mandibular incisor was extracted to correct anterior crossbite. The total treatment period was 20 months. The treatment results showed a good long-term prognosis after transplantation of a mature premolar with normal surrounding alveolar bone level for over 6 years of follow-up. Occlusion and periodontal health were excellent in the long term.

Intentional replantation and Biodentine root reconstruction. A case report with 10-year follow-up.

AIM: To describe the innovative use of intentional replantation for Biodentine root reconstruction of a previously treated immature maxillary central incisor with vertically extended crown root fracture and root detachment. SUMMARY: In the present case, the intentional replantation of a failing, previously treated maxillary central incisor with a vertical crown/root fracture in a 12-year-old male patient is reported. The gross extrusion of gutta-percha points beyond the apex and the pre-existing extensive, trauma related, distal cervical dentinal detachment justified the intentional replantation treatment plan as an option for tooth retention. After controlling the infection by oral administration of antibiotics, the immature tooth was extracted atraumatically and kept in gauze embedded with tooth replantation medium. The apical third of the immature fractured tooth was treated with ultrasonics and an MTA plug (MTA Angelus White, Londrina, Brazil). The distal cervical dentinal root defect was reconstructed with Biodentine (Septodont, St. Maur-des-Fosses, France). The tooth was reinserted and stabilized to the adjacent teeth for 2 weeks. The total extraoral time before replantation was 25 min. In the 10 years since the initial trauma (9 years after the intervention) radiographic and clinical evaluation revealed uneventful healing of the periapical lesion, normal mobility and no detectable signs of external replacement resorption. KEY LEARNING POINTS: Intentional replantation may provide a viable treatment alternative in cases of severe complicated crown/ root fractures Biodentine may be useful in the reconstruction of external root defects in crown root fractured traumatic dental injuries.

Surgical extrusion to provide a ferrule for restoring a tooth with a compromised prognosis: A clinical report.

A surgical extrusion technique was used to provide a ferrule for a tooth with significant tooth structure loss and an oblique coronal fracture. The maxillary lateral incisor was surgically repositioned coronally to provide sufficient dentinal wall for a good prognosis of the restorative treatment. The procedure is conservative and relatively straightforward and can be performed rapidly with minimal patient discomfort.

Severe Case of Delayed Replantation of Avulsed Permanent Central Incisor: A Case Report with Four-Year Follow-Up.

Avulsion is one of the most serious dental traumatic injuries with a reserved prognosis. This case report describes multiple trauma lesions in permanent central incisors of an eight-year-old girl and a four-year follow-up. The right upper incisor suffered avulsion, remained 16 h extraorally, and was replanted after extraoral endodontic therapy. The left maxillary central incisor suffered a noncomplicated crown fracture with concomitant subluxation. The present case adds to the literature a rare occurrence of success in a severe case with poor prognosis. For this reason, the International Association for Dental Traumatology (IADT) guidelines should be followed and, even in extreme situations, replantation should always be considered.