Effects of new adhesive resin root canal filling materials on vertical root fractures

The aim of this study was to compare the fracture resistance of roots following root canal therapy using the RC Sealer system, the Epiphany system and the conventional system of gutta-percha and Sealapex. Fifty-six maxillary central incisors were divided into eight groups of seven teeth each, according to master apical file size and obturation systems. Obturation materials in the root canal were vertically loaded using a universal testing machine. Fracture loads were analysed by anova and Tukey comparison, and fracture patterns were analysed with ordinal logistic regression. Master apical file size 80 had a significantly lower fracture load than size 40 (P < 0.05). The groups obturated using the Resilon Cone and the Epiphany Sealer had significantly lower fracture loads than the other groups (P < 0.05). There was no significant improvement in resistance to vertical root fractures using the examined adhesive resin root canal filling systems, compared with conventional gutta-percha and sealer.     

Resorption and mineralization processes following root fracture of permanent incisors

Abstract The records of 85 patients treated for 95 root fractures of permanent incisors and followed regularly for up to 11 years were studied with respect to healing events after injury. The radiographic exposure best suited for disclosing root fractures in the apical third of the root was a steep occlusal exposure, while a conventional bisecting angle periapical exposure was optimal for revealing fractures in the cervical third. It is concluded that both exposures should, therefore, be used at the initial examination at the time of injury. Root resorption processes were observed in 60% of the material and could usually be detected within one year after injury. These preceded fracture healing and obliteration of the apical and/or coronal root canals. The changes observed represented one or more of four resorption entities: 1) external surface resorption, characterized by the rounding of the fracture edges mesially and/or distally; 2) internal surface resorption, manifested as rounding of the fracture edges centrally, in the apical and coronal root canals, at the intersection between the pulp canal and fracture line; 3) internal tunneling resorption, going behind the predentin layer and burrowing along the root canal walls of the coronal fragment; and 4) transient apical breakdown of the apical lamina dura. While the resorption processes were self-limiting and required no treatment, the pattern of resorption and pulp canal obliteration appeared to be decisive for the type of fracture healing. Thus, all resorption entities collectively and internal tunneling resorption particularly were significantly related to healing at the fracture site by interposition of connective tissue. However, when seen alone, internal surface resorption was significantly related to fracture healing by hard tissue union. The different root resorption entities may represent osteoclastic activity connected with the ingrowth of new vascularized connective tissue into the fracture site or the coronal part of the root canal.     

Different clinical outcomes following root fractures of adjacent incisors: a case report

AIM: To report different patterns of root fracture healing in adjacent maxillary central incisors with distinct post-treatment outcomes. SUMMARY: To describe the case of a 12-year-old girl who presented with an avulsed coronal fragment of tooth 11 and root fractures in the middle thirds of teeth 11 and 21. Four months after initial treatment, she was referred for specialized endodontic care. Tooth 11 presented no clinical or radiographic signs of pulp breakdown. However a sinus tract was found related to the middle root third of tooth 21, indicating pulp necrosis in the coronal fragment. The coronal fragment was root filled and periapical surgery was performed to remove the apical fragment. Twelve months after the clinical procedures and 16 months after trauma, hard tissue healing was evident in tooth 11 region. Bone healing was also satisfactory in the periapical region of tooth 21. *Even adjacent teeth may display different reaction patterns after trauma. *The prognosis of root fractures is variable and different clinical approach may be required to preserve teeth with fractured roots.     

Tooth mobility changes subsequent to root fractures: a longitudinal clinical study of 44 permanent teeth

Abstract – The purpose of this study was to analyze tooth mobility changes in root‐fractured permanent teeth and relate this to type of interfragment healing (hard tissue healing (HT), interfragment healing with periodontal ligament (PDL) and nonhealing with interposition of granulation tissue (GT) because of pulp necrosis in the coronal fragment. Furthermore, the effect of age, location of the fracture on the root, and observation period on mobility values was analyzed. Mobility values were measured for 44 of 95 previous reported root‐fractured permanent incisors. Mobility changes were measured with a Mühlemanns periodontometer and noninjured incisors served as controls. The mobility values represented the labial‐lingual excursion of the root measured in μm when the tooth received a frontal and a palatal impact of 100 g force. In 18 cases of hard tissue healing (HT), a slightly increased mobility was seen after 3 months and 1 year, and a normalization of mobility value was usually found after 5 and 10 years. In 17 cases of PDL healing, generally a higher mobility was found in comparison with root fractures healing with hard tissue, and a consistent decrease in mobility value was found in the course of the 10 year observation period. A tendency for reduced mobility over time was found, a relation that could possibly be explained by the known general decrease in tooth mobility with increasing age. Finally, nine cases of nonhealing with initial interposition of granulation tissue (GT) because of pulp necrosis in the coronal fragment resulted in increasing mobility values possibly related to a lateral breakdown of the PDL in relation to the fracture line. In control teeth, a lowering of mobility was found over the course of a 10‐year observation period. In conclusion, mobility changes appeared to reflect the radiographic healing stages and known age effects upon tooth mobility.     

Long-term splinting of maxillary incisor with intra-alveolar root fracture

Abstract This case report describes the treatment of a maxillary right central incisor with an intra-alveolar horizontal root fracture in the coronal one-third of the root. Repositioning and immobilization of the coronal fragment were carried out. After 2 months the clinical examination revealed the pulp in the coronal fragment to be necrotic. Radiographically, a small periapical radiolucency was seen. Endodontic therapy was initiated and the pulp in the apical fragment proved to be necrotic as well. Instrumentation of the root canal through the fracture line and long-term calcium hydroxide treatment were carried out. One year later the radiograph indicated repair of the fracture with hard tissue. The tooth was then obturated with guttapercha and Grossman's sealer and restored with an acid–etch resin technique. At the 12-month follow-up examination the tooth was functionally and esthetically normal. Radiographically, the fracture line was not discernible and repair of the apical periodontitis had taken place.     

Root fracture in immature anterior teeth followed for 15 years

Abstract –  We report a case of injury to an immature tooth, observed over a period of 15 years. In 1987, a 9-year-old boy fell down in a schoolyard. The right central incisor demonstrated palato-version and radiographic observations revealed that the roots of both central incisors were incomplete. Further, a root fracture in the apical region of the central incisors was observed. During the first treatment visit, the right central incisor was repositioned and both teeth splinted. After confirming that the line of fracture was aligned, the fixation was continued for 2 months. The teeth were examined periodically for the next 15 years. Both teeth had favorable outcomes with continued root development of both the apical and coronal segments with good apposition of the fracture lines.     

Prognosis of root-fractured permanent incisors — prediction of healing modalities

Abstract A population of 85 patients, comprising 95 root-fractured permanent incisors followed up to 11 years, was studied prospectively for the type of fracture healing that occurred (i.e. union of the fragments by interposition of hard tissue (HT) or connective tissue (CT), or nonunion characterized by interposition of granulation tissue between the fragments (GT)). Initial treatment was provided according to established treatment guidelines by the attending oral surgeon at the emergency room. Follow-up examination and treatment were provided by 2 of the authors. It appeared that GT could be diagnosed after approximately 3 weeks, while HT or CT could be diagnosed approximately 6 weeks after trauma. Many factors considered one at a time were found to have a significant or nearly significant effect on the type of fracture healing that occurred. However, a multivariate regression analysis revealed that the following factors were significantly related to fracture healing by HT: a large diameter of the apical foramen and severity of luxation of the coronal fragment (concussion/subluxation > lateral luxation > extrusion); fracture healing by CT: the presence of restorations in the injured teeth at the time of injury and the presence of marginal periodontal disease; and fracture nonhealing by GT: type of fixation (i.e. orthodontic band fixation versus acid etch or no fixation), antibiotic therapy, a constricted apical foramen, increased loosening of the coronal fragment, and stage of root development (GT never occurred in teeth with open apices). It was previously demonstrated following luxation injuries that type of luxation, stage of root development and type of fixation (orthodontic bands versus acid etch or no fixation) determined the prognosis of pulp survival. It therefore appears that the general factors that are able to predict the type of healing seen after root fracture are the same as those after luxation injuries, supporting the hypothesis that root fractures are another form of luxation injury, this time of only the coronal fragment.     

Prognosis of root-fractured permanent incisors--prediction of healing modalities

A population of 85 patients, comprising 95 root-fractured permanent incisors followed up to 11 years, was studied prospectively for the type of fracture healing that occurred (i.e. union of the fragments by interposition of hard tissue (HT) or connective tissue (CT), or nonunion characterized by interposition of granulation tissue between the fragments (GT)). Initial treatment was provided according to established treatment guidelines by the attending oral surgeon at the emergency room. Follow-up examination and treatment were provided by 2 of the authors. It appeared that GT could be diagnosed after approximately 3 weeks, while HT or CT could be diagnosed approximately 6 weeks after trauma. Many factors considered one at a time were found to have a significant or nearly significant effect on the type of fracture healing that occurred. However, a multivariate regression analysis revealed that the following factors were significantly related to fracture healing by HT: a large diameter of the apical foramen and severity of luxation of the coronal fragment (concussion/subluxation greater than lateral luxation greater than extrusion); fracture healing by CT: the presence of restorations in the injured teeth at the time of injury and the presence of marginal periodontal disease; and fracture nonhealing by GT: type of fixation (i.e. orthodontic band fixation versus acid etch or no fixation), antibiotic therapy, a constricted apical foramen, increased loosening of the coronal fragment, and stage of root development (GT never occurred in teeth with open apices). It was previously demonstrated following luxation injuries that type of luxation, stage of root development and type of fixation (orthodontic bands versus acid etch or no fixation) determined the prognosis of pulp survival. It therefore appears that the general factors that are able to predict the type of healing seen after root fracture are the same as those after luxation injuries, supporting the hypothesis that root fractures are another form of luxation injury, this time of only the coronal fragment.     

Unusual healing of apical root fracture

A 23-yr-old woman received a blow to the symphysis region of the mandible. She sustained several injuries including a root fracture of the mandibular left lateral incisor. The pulp in the coronal root portion of that tooth became necrotic. A radiolucent lesion developed at the apex of the coronal root portion, and the apical root fragment was displaced 2 1/2 mm. Following endodontic treatment of the coronal segment, the apical fragment returned to its original position.     

Outcomes for root-fractured permanent incisors: a retrospective study

PURPOSE: The objective of this study was to assess the outcomes for treated root-fractured permanent incisors with respect to pulp vitality, root tissue union, and tooth survival and to examine the effects of clinical and radiographic parameters and rigid splinting on the outcome. METHODS: Eighty-four teeth were identified and data extracted from case notes prior to transfer to an SPSS data base for analysis. The odds ratios for each factor were calculated and the significance of differences was determined. Tooth loss and relevant risk variables were examined using Cox's regression model and Kaplan-Meyer survival curves. RESULTS: Fourteen (17%) had fractures in the apical third, 47 (56%) in the middle third, and 23 (27%) in the coronal (gingival) third. Twenty-four (29%) also had crown fractures involving enamel and dentine. Crown fractures were identified as significant risk factors for pulp vitality. Loss of pulp vitality, horizontal displacement, and extrusive displacement of the coronal fragment were significant risk factors for hard root tissue union. Survival was poorest with gingival third fractures with 14 (61%) of these teeth being lost. Splinting rigidly had no significant effect on pulp vitality and type of root tissue healing. CONCLUSIONS: Loss of pulp vitality was significantly associated with enamel-dentine crown fracture. Hard root tissue union was significantly affected by pulp necrosis and luxation of the coronal fragment. Survival was poorest for root fractures within the gingival third of the root. Splinting with rigid fixation had no significant effect on pulp vitality and type of root tissue union.     

In vitro evaluation of four methods of sealer placement.

Sealer is required during root canal obturation, although no studies have shown which method of sealer placement provides the best coverage. This study evaluated and compared four methods of sealer placement: file, lentulo spiral, ultrasonic files, and master gutta-percha cone. Forty mandibular incisors were prepared by a step-back technique. AH26 (0.04 ml) was applied to the placement device, the sealer was placed in the canal, and the canal was obturated with lateral condensation of gutta-percha. The specimens were cleared and evaluated for the presence of the sealer in the apical, middle, and coronal thirds of the canal. The results showed no statistically significant differences among the four groups. The greatest variation in sealer coverage was found in the apical level. Sealer coverage in the coronal and middle thirds was nearly identical regardless of sealer placement technique.     

Diagnosis and treatment of pulp necrosis in permanent anterior teeth with root fracture

A follow-up study was made of 20 traumatized permanent incisors with pulp necrosis observed as a sequel to root fracture. The material included 19 patients aged 8–17 years (mean 11.6 years) at the time of injury. Negative response to electric stimulation was noted in 16 teeth from the first examination. In four teeth an initial positive response changed to negative within 2–9 months. The negative response was supported by additional signs and symptoms of necrosis in 19 teeth. Radiolucencies adjacent to the fracture line or coronal discolorations were the most important diagnostic factors. Discolorations occurred within 2 months, whereas radiographic changes in the fracture area took from 3 to .5 months. to develop. Four teeth were extracted without attempting endodontic therapy. Endodontic treatment confined to the coronal fragment was performed in 16 teeth. In most cases the canal was filled temporarily with calcium hydroxide until a closure at the fracture site was observed. Two apical fragments showing radiographic changes were surgically removed in conjunction with the permanent filling of the coronal fragments. During the postoperative observation period one tooth was extracted due to communication between the fracture area and the oral cavity. The treatment of the remaining 15 teeth was judged as successful after a mean observation period of 4.2 years, ranging from 2 to 5 years.     

Endodontic Management of a Long-standing Horizontal Mid-root Fracture: Case Report in a Young Patient

The purpose of this case report was to present the successful endodontic management of a long-standing horizontal mid-root fracture in a permanent maxillary central incisor. A 12-year-old boy with a history of traumatic injury sustained 15 months previously to the maxillary central incisor presented for treatment. Clinical examination revealed physiological mobility, pulp chamber exposed to the oral environment, and the buccal mucosa with a sinus tract in the area of the traumatized tooth. A radiolucent lesion at the fracture line and apical fragment with obliteration of the root canal space were observed radiographically. Conservative root canal treatment of the coronal segment was performed using calcium hydroxide as an intracanal dressing. The calcium hydroxide was replaced every 8 weeks for 10 months. A hard tissue barrier was observed after this period, and the coronal fragment of the root canal was filled. After 4 years, the tooth was asymptomatic and functional and no periapical lesion was observed.     

Root Fractures in permanent teeth: a clinical review

A retrospective study of 22 root fractures in 21 patients was performed. Ten patients were less than 11 years of age, and boys were involved more often than girls. Ten patients had more than one injured tooth, but there was no case of alveolar fracture. Twenty-one of the teeth were upper central incisors. Only 11 teeth were seen within the first week, so that not all teeth were splinted and not all displaced teeth were repositioned. Long-term clinical and radiographic review showed that loss of vitality of the coronal pulp could not be reliably detected for at least 1 year. No tooth became abscessed or developed a sinus tract, and resorption of bone at the fracture line was observed in only one out of five non-vital teeth. Lack of displacement and placing of a splint increased the chances of the pulp remaining vital and healing of the fracture occurring with hard tissue. Sclerosis of the coronal pulp occurred mainly when healing was by connective tissue. The apical pulp always remained vital, and there was sclerosis of the apical pulp in almost every case.     

Conservation of root‐fractured primary teeth—report of a case

A 3.5‐year‐old girl presented to our clinic experiencing pain in her maxillary central incisors following traumatic injury during a fall. Radiographic examination revealed both primary maxillary central incisors with mid‐root and apical third horizontal root fractures, respectively. Splinting with orthodontic brackets and stainless steel wire was performed. At 2 weeks, resorption of the apical fragments in both injured teeth was observed, and after 3 months, almost complete resorption was noted on radiographs. Tooth mobility at this point was back to physiologic levels and the splint was removed. After 2.5 years, the primary maxillary incisors were replaced by permanent incisors demonstrating normal tooth color, position, and root development. Although this case illustrated the favorable prognosis of two primary teeth with root fractures and severely mobile coronal fragments by a conservative approach, more scientific evidences are needed and frequent recalls are necessary when primary root fractures are attempted to be managed with splinting.     

Conservative treatment for root fracture located very close to gingiva

Abstract –  When a root fracture is located very close to the gingiva, the chance of healing with calcified tissue is poorest. Therefore, a preferable treatment is usually thought to be the removal of the coronal fragment and subsequent orthodontic or surgical extrusion of remaining apical fragment. This case report describes conservative treatment for root fracture located very close to the gingiva. The treatment of root fracture was by repositioning and fixation. A 7-years follow-up showed healing with calcified tissue and pulp canal obliteration.     

Evaluation of technical quality and periapical health of root-filled teeth by using cone-beam CT

Objective

This study aimed to assess the quality of root fillings, coronal restorations, complications of all root-filled teeth and their association with apical periodontitis (AP) detected by cone-beam computed tomography (CBCT) images from an adult Turkish subpopulation.

Material and Methods

The sample for this study consisted of 242 patients (aging from 15 to 72 years) with 522 endodontically treated teeth that were assessed for technical quality of the root canal filling and periapical status of the teeth. Additionally, the apical status of each root-filled tooth was assessed according to the gender, dental arch, tooth type and age classification, undetected canals, instrument fracture, root fracture, apical resorption, apical lesion, furcation lesion and type and quality of the coronal structure. Statistical analysis was performed using percentages and chi-square test.

Results

The success rate of the root canal treatment was of 54.4%. The success rates of adequate and inadequate root canal treatment were not significantly different (p>0.05). Apical periodontitis was found in 228 (45.6%) teeth treated for root canals. Higher prevalence of AP was found in patients aging from 20 to 29 years [64 (27%) teeth] and in anterior (canines and incisors) teeth [97 (41%) teeth].

Conclusions

The technical quality of root canal filling performed by dental practitioners in a Turkish subpopulation was consistent with a high prevalence of AP. The probable reasons for this failure are multifactorial, and there may be a need for improved undergraduate education and postgraduate courses to improve the clinical skills of dental practitioners in endodontics.     

Complications associated with fractured file removal using an ultrasonic technique

A technique utilizing modified Gates Glidden burs and ultrasonics has recently been advocated to remove fractured instruments from root canals. Varying extents of tooth structure are removed during this procedure, potentially leading to complications. This study evaluated the in vitro and in vivo complications associated with fractured file removal. Fractured instrument fragments were removed from three different levels (coronal, middle, or apical third) of mesiolingual canals of extracted human mandibular molars. The success rate, frequency of perforations, and root strength were recorded for each group. Perforations and unsuccessful file removal occurred only with fragments lodged in the apical third. Fracture resistance declined significantly with more apically located file fragments. A review of 60 clinical cases showed similar rates of successful file removal and rate of perforations. Removal of a fractured file fragment from the apical third of curved canals should not be routinely attempted.     

Management of cervical root fracture using orthodontic extrusion and crown reattachment: a case report

Root fractures involve damage to pulp, cementum, dentin, and periodontal ligaments. These injuries affect 0.5% to 7% of permanent teeth. Cervical root fractures are less frequently seen and have a worse prognosis compared with the fractures in the apical or middle third of the root. This case report describes the treatment of a cervical root fracture in a maxillary central incisor. After removal of the coronal fragment, the root was filled temporarily with calcium hydroxide and orthodontic extrusion was initiated. The remaining root portion was elevated above the epithelial attachment and a successful coronal restoration was made using the natural crown of the traumatized tooth.     

Conservative endodontic treatment of teeth fractured in the middle or apical part of the root

Abstract –  According to treatment type, root-fractured teeth with pulp necrosis or exposed pulps were divided into five groups, group 1: 17 teeth in which the root canal of the coronal fragment only was filled with gutta-percha (GP); group 2: seven teeth in which the root canals of the coronal and apical fragments were both filled with GP; group 3: 19 teeth in which the coronal fragment was filled with GP and the apical fragment was surgically removed; group 4: 68 teeth where the root canal of the coronal fragment was treated with calcium hydroxide and subsequently filled with GP; and group 5: five vital teeth with root and concomitant crown fractures in which the exposed pulps were treated by partial pulpotomy. The frequency of periodontal healing was 76% in group 1, zero in group 2, 68% in group 3 and 86% in group 4. Compared with groups 1 and 2 combined, healing in group 4 was significantly more frequent. In groups 1, 2 and 4, failures occurred significantly more often in teeth showing overfilling, i.e. protrusion of GP into the space between the fragments, compared with teeth without overfilling. All five teeth in group 5 showed healing. It was concluded that root canal filling with GP of the coronal fragment only, with or without surgical removal of the apical fragment, can be successful in selected cases. Treatment of the root canal with calcium hydroxide followed by GP filling appears to be the treatment of choice in root-fractured non-vital teeth. Partial pulpotomy of exposed pulps in five teeth showed results similar to root-unfractured teeth with pulp exposure treated with this technique.