Biological approach for management of anterior tooth trauma: triple case report

Anterior crown fractures are a common form of injury that mainly affect children and adolescents. The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. In the pre-adhesive era, fractured teeth needed to be restored either with pin-retained inlays or cast restorations that sacrificed healthy tooth structure and were a challenge for clinicians to match with adjacent teeth. The development of adhesive dentistry has allowed dentists to use the patient's own fragment to restore the fractured tooth. Three cases are presented here with complicated crown fracture of maxillary central incisors; the reattachment of the fractured tooth segment in this case has been performed using different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.     

Biological approach for management of anterior tooth trauma: triple case report

Anterior crown fractures are a common form of injury that mainly affect children and adolescents. The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. In the pre-adhesive era, fractured teeth needed to be restored either with pin-retained inlays or cast restorations that sacrificed healthy tooth structure, and were a challenge for clinicians to match with adjacent teeth. The development of adhesive dentistry has allowed dentists to use the patient's own fragment to restore the fractured tooth. Three cases are presented here with complicated crown fracture of maxillary central incisors; the reattachment of the fractured tooth segment in these cases has been performed using different combinations of techniques, viz. simple reattachment, circumferential bevel and internal dentinal groove.     

Treatment of intruded permanent incisors: a multidisciplinary approach

Abstract The case presented is a report of a healthy 11- year-old boy, who fell down and traumatized his four maxillary incisors. Both central incisors were deeply intruded with concomitant uncomplicated crown fractures, and both lateral incisors suffered concussion. The intruded teeth were repositioned using a removable orthodontic appliance and were endodontically treated 3 weeks after trauma. Tooth 11 became ankylosed 3 months post trauma, and tooth 21 was extruded to its original position after 5 months. Five months post-trauma, teeth 12 and 22 underwent necrosis and were endodontically treated. In addition, tooth 22 presented an external inflammatory root re-sorption that was arrested by calcium hydroxide paste after 3 months. A crown-lengthening procedure was performed on tooth 11 10 months post-trauma, exposing the clinical crown to a better condition for restoration. All 4 incisors were restored with a composite material, and the incisal edges of the central incisors were shaped at the same level. Two months after the crown lengthening procedure, spontaneous eruption occurred on tooth 11, that had been ankylosed. The restored incisal edge of tooth 11 was reduced to the same level of tooth 21. The patient is under periodical examination till a definitive orthodontic treatment can be performed.     

Management of an uncomplicated crown fracture by reattaching the fractured fragment—Case report

Coronal fractures of the anterior teeth are common sequelae of traumatic dental injuries. Reattachment of fractured tooth fragments using dental adhesive techniques offers some advantages, including restoration of the function, esthetics, shape, texture, and brightness of the surface. The present report describes a clinical case of reattachment with a 4‐year clinical and radiographic follow up in a permanent maxillary central incisor with an uncomplicated crown fracture. Fragment reattachment is a conservative procedure, preserving esthetics and functionality, and it can provide an immediate positive emotional response from the patient.     

Alternative treatment procedure in the case of fractured abutment of adhesive bridge: a clinical report

In this case report, an alternative approach was presented for treatment of coronal fracture including pulp of maxillary central incisor, one of the abutments of an adhesive bridge, by using fiber post and tooth's own fractured component. The patient was referred to our clinic with the complaint of pain from the upper right central incisor and mobility of the adhesive bridge in maxillary anterior segment. It was realized that, the upper right central incisor, one of the abutments of the adhesive bridge, had been fractured at middle thirds of the crown including the pulp chamber. After dismounting the adhesive bridge and completion of the root canal treatment, a fiber post was placed into the fractured tooth. The fractured component, adherent to adhesive bridge retainer, was concorded to the fiber post. The whole structure was cemented with adhesive resin. A 1-mm-wide groove was made along the fracture line and restored with composite resin. The patient was evaluated clinically and radiographically at 12 and 30 months after the treatment. CLINICAL SIGNIFICANCE: Adhesive cementation of fractured component by supporting the remaining tooth structure with a fiber post is an inexpensive and conservative treatment alternative when the fractured component is compatible with the remaining tooth structure in cases of tooth fractures including the pulp chamber at anterior segment.     

Reattachment of fractured teeth: a review of literature regarding techniques and materials

Anterior crown fractures are a common form of injury that mainly affects children and adolescents. The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. In the pre-adhesive era, fractured teeth needed to be restored either with pin-retained inlays or cast restorations that sacrificed healthy tooth structure and were a challenge for clinicians to match with adjacent teeth. The development of adhesive dentistry has allowed dentists to use the patient's own fragment to restore the fractured tooth. Since then, several successful case reports that use a variety of techniques and materials to reattach fractured teeth have been published. This article presents a comprehensive literature review on techniques and materials used to restore uncomplicated dental trauma.     

Multidisciplinary approach to the rehabilitation of a tooth with two trauma episodes: systematic review and report of a case

Abstract – Studies have shown that some children and adolescents are affected only once with dental trauma, while others seem to be accident‐prone and suffer from multiple dental trauma episodes. Less is known about treatment consequences related to repeated traumatic dental injuries to the same tooth and treatment guidelines are not well established. Complicated crown fractures and crown‐root fractures pose difficulties for dentists to establish adequate treatment plans because these fractures require multidisciplinary knowledge and approach for a correct case planning and prognosis. The objective of this paper was to present and discuss a case of a child who sustained a second trauma to the same tooth following treatment of an earlier sustained crown fracture. The research‐based background for establishment of the treatment plan is discussed. Reattachment of tooth fragment is a minimal invasive and esthetic method. Essential advantage of the reattached teeth is the fact that all the alternative methods as direct adhesive resin reconstruction, veneers and crowns can be performed in case of failure or a refracture. As a consequence of initial trauma, the tooth suffered a complicated crown fracture which was resolved by endodontic therapy and fragment reattachment. During follow‐up, the child suffered a second trauma resulting in dislodgement and fracture of the reattached fragment and a crown‐root fracture extending subgingivally with involvement of the biologic width. A conservative restorative option is described. After 1 year of follow‐up, the clinical and radiographic findings demonstrated that the adopted clinical protocol was successful and yielded healthy periodontal tissues with no signs of periradicular pathosis. The occurrence of repeated traumatic dental injuries to teeth involving conservative management of both crown‐root fracture and complicated crown fracture on the same tooth is extremely rare and a challenge for dental professionals to treat.     

Replantation of three avulsed permanent incisors with complicated crown fractures

AIM: To report a rare case of multiple avulsions of permanent teeth associated with complicated crown fractures. SUMMARY: The case describes a 3-year follow-up of the treatment of three avulsed maxillary incisors with complicated crown fractures. The teeth were replanted after an extra-oral time of 90 min (extra-oral dry time 6 min). After root canal treatment, the fractured maxillary incisors were restored with a layered hybrid composite material to re-establish aesthetics and function. Follow-up visits showed signs of replacement resorption affecting the maxillary central incisors but only minor signs of root resorption on the maxillary right lateral incisor. These findings were supported by digital volume tomography, which was performed 18 and 36 months post-trauma in order to assess extent, severity and progression of root resorption more accurately. *Healing of avulsed teeth depends on the degree of periodontal ligament (PDL) damage. *Digital volume tomography might improve diagnostics of root resorption.     

Anatomic crown width/length ratios of unworn and worn maxillary teeth in white subjects

STATEMENT OF PROBLEM: Dimensions of teeth have been available for a century. Some significant and clinically relevant aspects of dental esthetics, however, such as the crown width/length ratios, have not been presented in tooth morphology sources until recently. PURPOSE: The purpose of this study was to analyze the anatomic crowns of 4 tooth groups (central incisors, lateral incisors, canines, and first premolars) of the maxillary dentition with respect to width, length and width/length ratios and determine how these parameters are influenced by the incisal edge wear. MATERIAL AND METHODS: Standardized digital images of 146 extracted human maxillary anterior teeth from white subjects (44 central incisors, 41 lateral incisors, 38 canines, 23 first premolars) were used to measure the widest mesiodistal portion "W" (in millimeters) and the longest inciso-cervical/occluso-cervical distance "L" (in millimeters). The width/length ratio "R" (%) was calculated for each tooth. A 1-way analysis of variance was used to compare the mean values of W, L, and R for the different groups ("unworn" and "worn" subgroups, except for premolars). Multiple least significant difference range tests (confidence level 95%) were then applied to determine which means differed statistically from others. RESULTS: There was no influence of the incisal wear on the average value of W (width) within the same tooth group. The widest crowns were those of central incisors (9.10 to 9.24 mm) > canines (7.90 to 8.06 mm) > lateral incisors (7.07 to 7.38 mm). Premolars (7.84 mm) had similar width as canines and worn lateral incisors. The L-value was logically influenced by incisal wear (worn teeth were shorter than unworn teeth) except for lateral incisors. The longest crowns were those of unworn central incisors (11.69 mm) > unworn canines (10.83 mm) and worn central incisors (10.67 mm) > worn canines (9.90), worn and unworn lateral incisors (9.34 to 9.55 mm), and premolars (9.33 mm). Width/length ratios also showed significant differences. The highest values were found for worn central incisors (87%) and premolars (84%). The latter were also similar to worn canines (81%), which constituted a homogeneous group with worn lateral incisors (79%) and unworn central incisors (78%). The lowest ratios were found for unworn canines and unworn lateral incisors (both showing 73%). CONCLUSIONS: Along with other specific and objective parameters related to dental esthetics, average values for W (mesiodistal crown dimension), L (inciso-cervical crown dimension), and R (width/length ratio) given in this study for white subjects may serve as guidelines for treatment planning in restorative dentistry and periodontal surgery.     

Bilateral buccal radicular groove in maxillary incisors: case report

AIM: To present the rare localization of a radicular groove on the buccal aspect of a tooth and to discuss the pathology and management of the concomitant endo-periodontal defect. SUMMARY: Bilateral buccal radicular grooves were found on the maxillary central incisors of a 60-year-old female Caucasian. One groove was associated with deep local pocketing resulting in pulp necrosis and the formation of a periodontal-endodontic lesion. After endodontic treatment of the affected tooth, periodontal surgery was performed during which an apicoectomy was carried out on the root-filled tooth. Both the buccal grooves were removed by grinding, the roots were planed with curettes and a guided-tissue regeneration technique applied using amelogenin (Emdogain, Biora, Sweden). Following a period of 2 years, re-examination showed excellent healing with the complete elimination of the periodontal pocket on both incisors and significant radiographic evidence of bone regeneration. KEY LEARNING POINTS: Deep radicular grooves can predispose to pulp necrosis and the establishment of combined periodontal-endodontic lesions. Evaluation of clinical signs and appropriate diagnostic tests are of paramount importance in order to prevent incorrect diagnosis and treatment. Endodontists must be capable of performing advanced periodontal regeneration techniques during endodontic surgery.     

Achieving gingival esthetics

INTRODUCTION: Dentists traditionally have thought of periodontal treatment as a means of saving the teeth while leaving the patient with an esthetic problem. This no longer is true. The goal of this article is to show how esthetic crown-lengthening procedures, papillary regeneration and root coverage may enhance the overall esthetic results of periodontal treatment. METHODS AND RESULTS: Esthetic crown lengthening aims not only to provide biological width for the healthy restoration of teeth, but also to permit esthetic gingival and prosthetic contours. Papillary regeneration aims to fill the dark spaces that may occur interproximally with the progression of periodontitis or as a result of tooth alignment. Finally, root coverage procedures now can provide predictable results with the application of connective-tissue periodontal grafts and plastic surgery techniques. This article presents a case report for each type of procedure, each of which resulted in improved esthetics and cosmetic appearance. CLINICAL IMPLICATIONS: Periodontal treatment now is part of the solution for certain esthetic problems. While technically demanding, these procedures, in the hands of an appropriately trained and experienced clinician, can improve the overall results of patient treatment.     

Treatment of oblique crown fractures in maxillary premolars using adhesive tooth fragment reattachment: 19 years of follow up

Abstract – This report presents an oblique crown fracture in the maxillary right premolars of an adolescent because of fall, which was treated using adhesive tooth fragment reattachment. The impact of the mandible base to the floor caused minor fractures in multiple teeth, severe fracture of teeth 14 and 15, and condylar fractures. The fragments of teeth 43, 45, 46, and 16 were lost at the site of accident. The condylar fractures were managed with a non‐surgical conservative approach combining mandibular immobilization and stabilization of temporomandibular joints with maxillomandibular fixation using acrylic splints. After 3 months, the interocclusal splints were removed, and the patient was referred for dental care. Teeth 14 and 15 presented complicated oblique crown fractures causing separation of the buccal and palatal fragments, which were in place, attached to the gingival tissue. Tooth 15 presented chronic hyperplastic pulpits. The fragments were banded for stabilization during the endodontic treatment, and the bands served as matrix for adhesive tooth fragment reattachment. The other fractured teeth received direct composite resin restorations. After 8 years, tooth 16 developed pulp necrosis and was treated endodontically and restored with composite resin. Clinical and radiographic examination 19 years after trauma showed a good adaptation of the tooth fragment/composite resin restoration, good periodontal health, no signs of root resorption, and intact lamina dura.     

Intentional Replantation with an Atraumatic Extraction System in Teeth with Extensive Cervical Resorption

External cervical resorption (ECR) often renders a tooth nonrestorable, especially if it extends deeply within the dental hard tissue. Intentional replantation is sometimes performed as the last resort to save the tooth but may limit conventional forceps extraction because of the high risk of periodontal ligament cell damage or crown fracture.This case report describes the intentional replantation of an upper central incisor with extensive ECR using an axial, atraumatic extraction system to save the otherwise hopeless tooth. The patient was an asymptomatic 37-year-old man with no contributing medical history. The treatment protocol included atraumatic extraction followed by granulation tissue removal, extraoral root canal treatment, and adhesive restoration of the extensive resorption defect. During extraoral manipulation, the utmost care was taken to prevent root surface drying, contamination with dental adhesive, or heat-induced periodontal ligament damage during curing. Two and a half years after replantation, clinical and radiographic examinations revealed normal healing and no symptoms but a slight reduction of bone level compared with the preoperative level and no signs of root resorption or ankylosis. The successful outcome in this case supports the idea of performing intentional replantation with an atraumatic extraction system to save teeth with extensive cervical root resorption and a high risk of fracture during extraction.     

Complicated crown fractures – management and treatment options

Aim  Complicated crown fractures involve enamel, dentine and the pulp. The incidence of complicated crown fractures ranges from 2% to 13% of all dental injuries and the most commonly involved tooth is the maxillary central incisor. Various treatment modalities are available depending upon the clinical, physiological and radiographic status of the involved tooth. The aim of this article was to discuss techniques for the management of complicated crown fractures.
Summary  Management of complicated crown fractures depends upon several factors with the result that various clinical modalities have been suggested. Seven case reports of complicated crown fractures are presented and risks/benefits of the treatment plans are discussed.   Key learning points: 

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  Proper diagnosis, treatment planning and follow-up care are important factors in the prognosis of complicated crown fractures.
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  Thorough understanding of the available treatment modalities and their specific indications is critical.
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  The risks and benefits of each treatment option should be carefully evaluated during the treatment planning process.

     

Closed-eruption surgical technique for impacted maxillary incisors: a postorthodontic periodontal evaluation.

The aim of this study was to evaluate the clinical appearance and pulpal and periodontal status of impacted maxillary central incisors that had been exposed and aligned after a closed-eruption surgical technique. Twenty-one patients were examined 4.5 years (median) postretention. The treated central incisors showed no significant differences in plaque and gingival indexes, widths of attached gingiva, and crown lengths, whereas a small, but statistically significant, increase was found in the mean pocket depth compared with the contralateral incisors. The bone support was reduced by 5% to 6% in the treated teeth, and, in one third of the cases, an abnormal gingival contour was recorded. The lateral incisors revealed similar plaque and gingival indexes and pocket depths on each side, but the lateral incisors immediately adjacent to the treated tooth showed decreased widths of keratinized gingiva and increased crown lengths. Even though statistically significant differences were found in some of the periodontal parameters measured, the overall clinical consequences of a conservative exposure and orthodontic alignment of impacted incisors by the closed-eruption technique are minimal.     

Adhesive fragment reattachment after orthodontic extrusion: a case report

Abstract –  In the treatment of crown fractures, adhesive fragment reattachment provides a good alternative to other restorative techniques, offering several advantages. The present paper reports a case in which the treatment of a cervical crown fracture was accomplished by reattaching the tooth fragment with a flowable resin composite. Orthodontic root extrusion was performed with a modified Hawley appliance prior to fragment reattachment. The clinical and radiographic results after 2.5 years were successful.     

Reattachment of an autogenous tooth fragment in a fracture with biologic width violation: a case report.

An 11-year-old patient that fractured her maxillary left central incisor is presented. The fracture involved two thirds of the crown, compromising the pulp, and extended subgingivally on the palatal aspect, invading the biologic width. The procedure used to repair the fracture included flap surgery with a slight ostectomy and endodontic treatment. The reattachment of the tooth fragment and the restoration were performed with a bonding system and a resin composite. Examination 6 months after treatment revealed periodontal health, good esthetics, and normal function.     

Reattachment of endodontically treated lateral incisor with supragingivally complicated crown fracture using fiber‐reinforced post

Abstract – Re‐restoring endodontically treated teeth with complicated crown or crown root fractures is a major challenge for dental practitioners, because they can present difficulties for successful treatment. This report describes the management of supragingivally complicated crown fracture of an endodontically treated maxillary lateral incisor. The involved tooth was restored with the reattachment procedure using light transmitting fiber post. After 11 months, the reattached tooth had a satisfying function, favorable physiological and esthetic outcomes and healthy surrounding periodontal structures.     

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.     

Bone loss following periodontal therapy in subjects without frequent periodontal maintenance

The longitudinal effects of periodontal therapy in patients without a frequent periodontal maintenance program have been minimally documented. In this study we used Duckworth's modification of the Schei Ruler Technique to assess the difference in bone level around individual teeth treated for periodontal disease in subjects receiving infrequent posttherapy maintenance (less than or equal to 1 time/year). Crestal bone height differences were evaluated using the initial presenting series of long cone parallel radiographs of 23 subjects with their subsequent posttherapy analogous radiographic series taken 5.4 +/- 2.9 years later. Bone loss was defined as a reduction in the alveolar crest of greater than 50% of the radiographic crown height which corresponds to approximately 4 mm in posterior and 5 mm in anterior teeth. The loss for each tooth was expressed as a per cent of the measured height of the crown after conversion from millimeters using the mean crown-root ratio for each tooth. We found increased alveolar bone loss and tooth loss in subjects examined posttherapy when compared with conditions present when each subject initially presented for periodontal treatment. Our data suggest that molar teeth are more at risk than incisors and cuspids and that a lack of periodontal maintenance care and inadequate plaque control contribute to progressive bone loss following treatment.