|Year : 2014 | Volume
| Issue : 1 | Page : 57-60
Multidisciplinary treatment approach for horizontal root fractures
Neslihan Simsek1, Mevlüt Sinan Ocak1, Abubekir Eltas2, Ali Keles1
1 Department of Endodontics, Inonu University, Malatya, Turkey
2 Department of Periodontology, Inonu University, Malatya, Turkey
|Date of Web Publication||20-Mar-2014|
Department of Endodontics, Inonu University, Malatya
Source of Support: None, Conflict of Interest: None
The aim of this case report is to present a multidisciplinary treatment plan for horizontal root fracture of maxillary anterior teeth that resulted from trauma. A 16-year-old male presented a horizontal root fracture in the middle-third of teeth 11 and 21. Dislocated tooth fragments were repositioned using a composite splint technique. Follow-up examinations revealed the teeth lost vitality after trauma. Separated tooth fragments were removed by a surgical operation and then reattached using fiber post and resin cement. Teeth were replanted into the alveolar socket and splinted after root canal treatment. After 1 year of follow-up examinations, this comprehensive treatment was observed to be successful both clinically and radiographically. Horizontal root fractures can be treated successfully by extraoral reattaching of fractured segments and intentional replantation of teeth after root canal treatment.
Keywords: Horizontal root fracture, multidisciplinary treatment, root canal treatment
|How to cite this article:|
Simsek N, Ocak MS, Eltas A, Keles A. Multidisciplinary treatment approach for horizontal root fractures. J Res Dent 2014;2:57-60
| Introduction|| |
One of the more unusual sequelae of traumatic tooth injury is root fracture. It is defined as fractures involving the dentine, the cementum, and the pulp. This injury comprises only 0.5-7% of all dental injuries, and is most likely to affect those between 10 and 20 years of age. , Generally, root fractures affect the central (68%) and lateral (27%) maxillary incisors. 
The presentation of the fractures varies widely in terms of location, angulation, and severity.  Horizontal root fractures are classified according to their location (apical third, middle third, and cervical third of the root) and the degree of dislocation of the coronal fragment.  Diagnosis of horizontal root fracture is based on the information obtained from both clinical and radiographic examinations.  Root fractures often present as a slightly extruded tooth, which is often lingually displaced. The tooth is often mobile and the degree of mobility is determined by the fracture location. 
Treatment options for root fractures depend on the fracture location  and may include observing orthodontic or surgical extrusion, periodontal surgery, and intentional replantation, and extraction.  Intentional replantation involves the deliberate extraction of a tooth and its immediate reinsertion into its socket.  This procedure allows the clinician to perform endodontic treatment or restoration, which may be impossible to complete otherwise. In 2001, Aouate used this procedure successfully to treat a horizontally fractured root. 
This case report will present an intentional replantation of central incisors with horizontal root fracture.
| Case Report|| |
A 16-year-old male patient who experienced dental trauma was referred to the endodontics clinic by a general dentist. Clinical examination revealed erosions in the soft tissues. The patient had constant pain and was unable to close his mouth completely because of the altered positions of his upper anterior teeth. Mobility was observed in teeth 11 and 21. The crowns on both teeth 11 and 21 were dislocated in a palatal direction [Figure 1].
A periapical radiograph was taken of the upper anterior teeth. It revealed the presence of a horizontal root fracture in the middle third of both roots. Teeth 11 and 21 were diagnosed with horizontal root fracture. No signs of alveolar bone fracture were observed [Figure 2].
|Figure 2: Diagnostic radiograph of horizontally fractured and depositioned teeth|
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The initial treatment plan comprised repositioning and rigid splinting of teeth 11 and 21. Under local anesthesia, the teeth were repositioned using gentle digital manipulation. Rigid splinting of teeth 12-22 was performed using dentin-bonded composite resin (Spectrum TPH3, Dentsply DeTrey, Milford, DE, USA) and the splint remained for 2 months [Figure 3]. Electrical pulp test was performed 2 months after the initial treatment, and the teeth showed loss of vitality. Preservation of natural teeth was decided; therefore, surgical and endodontic treatments were chosen. The treatment plan was explained to the patient and his parents for consent.
|Figure 3: The control radiograph of repositioned teeth and composite splint|
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In this case, the surgery was performed under local anesthesia, during which a rectangular ﬂap was elevated to provide visibility and access to the bone and the fractured root surface. After granulation and inflamed periodontal tissues were removed using fine scissors, the fractured segments of the teeth were removed. All fragments were soaked in physiological saline solution and left there except for the operative procedure. Then fragments were re-used in the operation. During the operation on the fractured parts and throughout extraoral procedures, teeth fragments were held with forceps and irrigated with additional saline to avoid the loss of periodontal ligament cells. After the fractured parts were glued using a dual-cure resin-based cement called Panavia F (Kuraray Medical Inc., Osaka, Japan), the root canal treatment was completed using gutta percha points (Diadent Group International Inc., Vancouver, BC, Canada) and AH-plus root canal sealer (Dentsply DeTrey, Konstanz, Germany). A fiberglass Glassix plus post (Chailly/Montreux, Switzerland) at a diameter of ψ1.2-ψ0.6 was used to reinforce the roots. The fiberglass posts were cemented using Panavia F.
Root resection was performed for both teeth after the posts were cemented. Apical preparations were filled using a biocompatible material called ProRoot MTA (Dentsply, Tulsa, USA) to achieve a fluid tight seal. The extraction sockets were gently curetted to remove debris. Then the teeth were replanted into the alveolar socket to their original positions. The teeth were stabilized by rigid splinting using a composite resin and then a postoperative radiograph was taken. The patient was instructed to take three doses of 500 mg amoxicillin and two doses of 550 mg naproxen daily for 1 week and to rinse with a 0.2% chlorhexidine solution for a week. Postoperative instructions were given on a soft diet for a week and careful brushing after every meal [Figure 4].
|Figure 4: The images of surgical procedure and the control radiograph of completed treatment|
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One week after the operation, there was no symptom, and the gingiva healed. The patient was scheduled for routine examinations.
Three months after surgery, the patient had second trauma on tooth 11. As a result of this second trauma, mobility was observed in right maxillary first incisor tooth again. Therefore, a palatal retainer was placed on teeth 12-22.
One year after the treatment, there was no sign of periradicular inflammation both radiographically and clinically, and the teeth functioned normally [Figure 5].
| Discussion|| |
Direct trauma caused by automobile accident, sporting activity, violence, or malocclusion on the jaw or on an individual tooth may result in tooth fractures.  Horizontal root fractures are relatively infrequent injuries, occurring in less than 3% of all dental injuries.  Fractured teeth can heal spontaneously if proper fixation is used and if bacterial contamination does not occur.  Initial treatment of horizontal root fractures involves repositioning the fractured tooth segments and then stabilizing the tooth to allow healing of the periodontal ligament. , In this case, the first treatment option was based on this established knowledge. But surgical root canal treatment was performed later because pulp necrosis and resorption were seen on the fracture line. The resorption of teeth segments may occur due to the close proximity between the fracture line and the level of the alveolar crest and periodontal pocket, which may contaminate the pulp and periradicular tissues through disrupted epithelial attachment and gingival sulcus. 
Replantation of a fractured tooth is performed to maintain natural teeth by removing granulation tissue that has grown between the fragments over time. , This technique provides a clear view of the fractured areas and an environment to attach the fractured segments securely. Numerous studies have reported the successful use of this method. ,,, Aouate used this method to treat a horizontal root fracture and improve prognosis.  Endodontic instruments were used to fix the separated tooth fragments in horizontal root fractures. , In this study a fiberglass post was used to fix teeth fragments while a dual-cure resin-based cement was applied extraorally to reassemble the fragments for the same purpose.
Panavia F was used in this case because it is a self-etching and self-adhesive system that does not require a water rinse, which may affect the root surface and periodontal ligament. 
The patient was examined 1 year after treatment to confirm the success of this treatment option for horizontal root fracture. The short-term follow-up for this case showed the teeth were asymptomatic and functioning normally.
Intentional replantation is a treatment option to consider in the management of horizontal root fractures. The availability of bondable material and fiberglass posts have introduced different treatment options for managing horizontal root fractures to clinicians.
| References|| |
|1.||Berman LH. Intraalveolar root fractures. In: Berman LH, Blanco L, Cohen S, editors. A Clinical Guide to Dental Traumatology. 1st ed. St. Louis: Mosby; 2006. p. 51. |
|2.||Roig M, Espona J, Mercade M, Duran-Sindreu F. Horizontal root fracture treated with MTA, a case report with a 10-year follow-up. Dent Traumatol 2011;27:460-3. |
|3.||Caliskan MK, Pehlivan Y. Prognosis of root-fractured permanent incisors. Endod Dent Traumatol 1996;12:129-36. |
|4.||Wolner-Hanssen AB, von Arx T. Permanent teeth with horizontal root fractures after dental trauma. A retrospective study. Schweiz Monatsschr Zahnmed 2010;120:200-12. |
|5.||Molina JR, Vann WF Jr, McIntyre JD, Trope M, Lee JY. Root fractures in children and adolescents: Diagnostic considerations. Dent Traumatol 2008;24:503-9. |
|6.||Malhotra N, Kundabala M, Acharaya S. A review of root fractures: Diagnosis, treatment and prognosis. Dent Update 2011;38:615-6. |
|7.||Wang Z, Heffernan M, Vann WF Jr. Management of a complicated crown-root fracture in a young permanent incisor using intentional replantation. Dent Traumatol 2008;24:100-3. |
|8.||Martins WD, Westphalen VP, Perin CP, Da Silva Neto UX, Westphalen FH. Treatment of extrusive luxation by intentional replantation. Int J Paediatr Dent 2007;17:134-8. |
|9.||Aouate G. Treatment of an intra-alveolar root fracture by extra-oral bonding with adhesive resin. Information Dentaire 2001;26:2001-8. |
|10.||Versiani MA, de Sousa CJ, Cruz-Filho AM, Perez DE, Sousa-Neto MD. Clinical management and subsequent healing of teeth with horizontal root fractures. Dent Traumatol 2008;24:136-9. |
|11.||Trope M. Endodontic Considerations in Dental Trauma. In: Ingle JI, Bakland LK, Baumgartner JC, editors. Ingle's Endodontics. 6th ed. Shelton: People's Medical Publishing House; 2007. p. 1330. |
|12.||Subay RK, Subay MO, Yilmaz B, Kayatas M. Intraradicular splinting of a horizontally fractured central incisor: A case report. Dent Traumatol 2008;24:680-4. |
|13.||Taºdemir T, Yeºilyurt C. Repair of untreated horizontal root fracture: A case report. Hacettepe Dis Hek Fak Derg 2006;30:47-9. |
|14.||Andreasen FM. Pulpal healing after luxation injuries and root fracture in the permanent dentition. Endod Dent Traumatol 1989;5:111-31. |
|15.||Arikan F, Franko M, Gurkan A. Replantation of a vertically fractured maxillary central incisor after repair with adhesive resin. Int Endod J 2008;41:173-9. |
|16.||Kawai K, Masaka N. Vertical root fracture treated by bonding fragments and rotational replantation. Dent Traumatol 2002;18:42-5. |
|17.||Dogan MC, Akgun EO, Yoldas HO. Adhesive tooth fragment reattachment with intentional replantation: 36-month follow-up. Dent Traumatol 2013;29:238-42. |
|18.||Demir B, Demiralp B, Guncu GN, Uyanik MO, Caglayan F. Intentional replantation of a hopeless tooth with the combination of platelet rich plasma, bioactive glass graft material and non-resorbable membrane: A case report. Dent Traumatol 2007;23:190-4. |
|19.||Kocak S, Cinar S, Kocak MM, Kayaoglu G. Intraradicular splinting with endodontic instrument of horizontal root fracture: Case report. Dent Traumatol 2008;24:578-80. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]