MANAGEMENT OF HORIZONTAL AND MULTIPLE CROWN-ROOT FRACTURES - DENTAL BOOKS

MANAGEMENT OF HORIZONTAL AND MULTIPLE CROWN-ROOT FRACTURES

Case Report                                                                                                                                                                                                                                     
                                                                                                                                                                                                                                
One feature common to all patients with acute dental trauma is the fact that they come to us unexpectedly. Traumatic injuries of teeth are the main causes of emergency treatment in dental practice. The dental health and appearance marred by an unsightly injury must be restored to normal as early as possible. Among dental trauma, root fractures are relatively uncommon and comprise 0.5 to 7% of all injuries affecting permanent dentition. They are defined as fractures involving dentin, cementum and pulp. Commonly seen in maxillary anterior teeth and are more frequent at the middle third of the root. Crown-root fracture is a fracture involving enamel, dentin and cementum, comprising 5% of injuries to permanent dentition. Complicated crown root fractures present a treatment challenge because of pulp involvement in fully erupted anterior teeth. This report records the case of intraalveolar horizontal root fracture with subluxation of coronal segment, treated with Mineral Trioxide Aggregate (MTA) barrier and effective management of crown-root fracture using custom cast post.

A 24-year-old male patient was presented to the Department of Conservative Dentistry and Endodontics, Bangalore Institute of Dental Sciences and Research Center, after 15 days of traffic accident with a chief complaint of multiple front teeth fracture. On clinical examination, tooth 11 showed Ellis class I fracture with grade III mobility. Probing depth was 2 mm and demonstrated no response to vitality test (thermal and electric pulp testing). Teeth 12 and 21 showed complicated oblique crown-root fracture with shattered crown and grade III mobility of palatal fragments. Intraoral periapical radiograph showed intraalveolar horizontal root fracture, at the junction of middle and apical third of the root with subluxation of coronal fragment in relation to 11. With respect to teeth 12 and 21, the fracture line extended below CEJ and alveolar crest.

The treatment plan comprised of reduction and rigid splinting in relation to 11 and removal of mobile palatal fragments in relation to 12 and 21, followed by root canal treatment. Tooth 11 was splinted using 0.6 mm stainless steel orthodontic wire bonded with composite resin. Root canal treatment was performed in relation to 12 and 21. A decision of endodontically treating only the coronal fragment in relation to 11 was taken, as the fracture fragments were not approximated and due to the possibility of the apical fragment retaining pulp vitality. Working length determined was about 17 mm. MTA (Proroot MTA, Dentsply, India) plug was placed into the apical 4 mm of the coronal fragment after cleaning and shaping, using endodontic pluggers. After 24 hours, rest of the canal was obturated with warm vertical compaction of gutta percha. Four days later, the access cavity was restored with composite resin.

The patient’s postoperative course was uneventful. Rigid splint was removed after 2 months of follow-up. Mobility was within normal limits. After performing crown lengthening to expose the fracture line, teeth 12 and 21 were restored with custom cast post and core. Chamfer finish line was placed on the cast core. Final restorations of porcelain fused to metal crown were given.

At recall visits of 3 months and 1 year, teeth were asymptomatic and responded normally to palpation and percussion. There was evidence of healing at the fracture line in relation to 11 with normal periapical features.