|Year : 2014 | Volume
| Issue : 2 | Page : 101-105
Endodontic and restorative considerations of traumatically injured teeth
Ugur Aydin1, Nihan Kulacaoglu2, Semih Ozsevik3, Ugur Inan4
1 Department of Endodontics, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey
2 Department of Restorative Dentistry, Faculty of Dentistry, Ondokuz Mayis University, Samsun, Turkey
3 Department of Restorative Dentistry, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey
4 Department of Endodontics, Faculty of Dentistry, 19 Mayis University, Samsun, Turkey
|Date of Web Publication||11-Jul-2014|
Department of Endodontics, Faculty of Dentistry, Gaziantep University, Gaziantep
Source of Support: None, Conflict of Interest: None
Traumatic injuries cause different kinds of damage to dental and periodontal tissues. The treatment approach varies according to the type and degree of injury. Periodontal injuries in which loosening or loss of attachment is present require immediate fixation of the tooth. In this kind of injury, root canal treatment is indicated when the signs of pulp necrosis such as spontaneous pain, pain to percussion, periradicular pathosis, inflammatory root resorptions and discoloration are present. In cases of coronal fractures, the treatment strategy differs according to the status of pulp tissue. If the fracture line is limited in enamel or dentin, restoration of the missing tissues can be achieved with composite resin. However, involvement of pulp may require direct pulp capping, pulpotomy or pulpectomy. The treatment process for three subluxated and four crown fractured teeth requiring a follow up over 8 months is presented in this case report.
Keywords: Crown fracture, dental trauma, glass fiber post, subluxation
|How to cite this article:|
Aydin U, Kulacaoglu N, Ozsevik S, Inan U. Endodontic and restorative considerations of traumatically injured teeth. J Res Dent 2014;2:101-5
|How to cite this URL:|
Aydin U, Kulacaoglu N, Ozsevik S, Inan U. Endodontic and restorative considerations of traumatically injured teeth. J Res Dent [serial online] 2014 [cited 2019 Jul 17];2:101-5. Available from: http://www.jresdent.org/text.asp?2014/2/2/101/136651
| Introduction|| |
Epidemiological studies indicate that dental trauma is a significant problem in young people and that the incidence of trauma exceeds that of dental caries and periodontal disease in this population.  In traumatic cases, clinicians face hard tissue injuries, periodontal injuries or a combination of both. The aim of treatment for traumatically injured teeth is to provide acceptable function and appearance. The treatment strategy is planned according to the type and degree of the injury as well as delay until treatment. 
Luxation of permanent teeth are classified as: Subluxation, lateral luxation, intrusion and extrusion  while crown fractures are divided into 4 main groups: Enamel infraction and enamel fractures, enamel-dentin fracture without pulpal involvement (uncomplicated crown fractures), enamel-dentin fracture with pulpal involvement (complicated crown fractures), and crown-root fractures. ,
Subluxation is a kind of luxation injury in which there is slight horizontal mobility due to laceration of periodontal ligament fibers and bleeding from the gingival sulcus.  In this type of dental injury, displacement of the teeth is not seen.  In cases of luxation, the immediate concern is to stabilize the tooth in its normal position to allow revascularization and re-attachment of periodontal ligaments.  A transient apical breakdown may occur after luxation injuries. For this reason, traumatically injured teeth must be observed for a period of time after splinting to avoid unnecessary endodontic treatment.  If the signs of pulp necrosis like periradicular radiolucency, root resorption and pain to percussion are observed during this period, immediate endodontic treatment should be planned. 
Crown fractures of the permanent dentition comprise the most frequent form of traumatic dental injuries generally resulting from accidents, sport activities or violence. , The treatment strategy for crown fractures involving pulp (complicated crown fractures) includes pulp capping, vital amputation and pulpectomy , while treatment of uncomplicated crown fractures involves disinfection of the dentin and projection with either calcium hydroxide covered with a restoration or a restoration bonded directly to the broken tooth surface.  In teeth with crown fractures, if hard tissue loss is excessive, coronal restoration can be achieved with composite resin materials combined with non-metallic posts such as glass fiber posts to increase mechanical resistance and provide an esthetic appearance. 
This case report presents the treatment process for traumatically injured teeth, including stabilization of subluxated teeth, restoration of complicated crown fractures and their endodontic treatment over an eight month follow up period.
| Case report|| |
A 17-year-old boy presented to the Department of Endodontics, Faculty of Dentistry, University of Ondokuz Mayis with the complaint of trauma to his anterior maxillary region. He reported that he sustained trauma during a fight one week ago. Clinical examination confirmed crown fractures of the maxillary right lateral incisor, maxillary left canine, maxillary left first premolar teeth involving pulp and a crown fracture of mandibular right central incisor not involving pulp. However, the maxillary central incisors and maxillary left lateral incisor teeth were horizontally luxated but displacement of these teeth was not seen. The maxillary right central incisor and maxillary left lateral incisor represented only a slight mobility (grade 1) while maxillary left central incisor represented a higher degree of luxation (grade 2). Intra-oral examination revealed no laceration or any other soft tissue damage. Radiographically, no alveolar bone fracture and root resorption was detected [Figure 1]a. Periodontal membrane of subluxated teeth were apically enlarged [Figure 1]b while that of the maxillary left canine was enlarged in the 1/3 rd middle portion of the root [Figure 1]a. There was no spontaneous pain in his subluxated teeth but pain to percussion was present. Electrical vitality test of these subluxated teeth gave negative results. The maxillary crown fractured teeth were sensitive to thermal and mechanical stimulus due to exposure of pulp to the oral environment.
|Figure 1: (a) Panoromic radiograph one week after trauma. No alveolar bone fracture was detected. Periodontal membrane of maxillary left canine enlarged in the middle of root (b) Occlusal radiograph one week after trauma. Periodontal membrane of subluxated teeth enlarged apically|
Click here to view
Pulp tissues of crown-fractured teeth were removed, root canals were prepared with the step-back technique and temporary calcium hydroxide (Sultan Chemists Inc., Englewood, NJ, USA) dressing was applied. Access cavities were filled temporarily with glass ionomer cement (Voco, Cuxhaven, Germany). Subluxated teeth were splinted with a flexible orthodontic wire bonded to labial surfaces by using composite resin (TPH, Dentsply, USA). In order to preserve the luxated teeth in their normal position and to prevent them from occlusal forces, thermoplastic plaque (Imprelon, Am Burgberg, Iselohn, Germany) was prepared to hinder the contact of anterior teeth [Figure 2]a-c. The patient was advised to avoid biting with his anterior teeth.
|Figure 2: Intraoral view one week after trauma. Subluxated teeth were splinted, crown fractured teeth were extirpated and mandibular occlusal plaque was applied. (a) anterior view (b) right aspect (c) left aspect|
Click here to view
Furthermore, the fracture of mandibular right central incisor was restored with composite resin bonded directly to the dentin. At a recall after two weeks, the crown fractured teeth were asymptomatic. Root canals were obturated with lateral condensation technique using standard gutta-percha cones and AH-plus sealer (Dentsply, Konstanz, Germany). Access cavities were temporarily filled with glass-ionomer cement. The patient reported spontaneous pain in his subluxated teeth on this visit. Pain to percussion was also present. Pulp tissues of subluxated teeth were removed and calcium hydroxide was applied after canal preparation. One week later, the root canals were filled as former ones. Access cavities were restored with composite resin (TPH, Dentsply, USA). So, all root canal procedures were completed two weeks after initiation of treatment [Figure 3].
|Figure 3: Periapical radiographs after root canal treatments were completed|
Click here to view
The splint was also removed after two weeks and no luxation was detected. After that, coronal restorations of crown-fractured teeth were planned. Because of excessive hard tissue loss, coronal restorations were supplied with glass fiber posts (GF glass fiber post, j.morita, USA). For this purpose, coronal 2/3 rd of root canal fillings were removed with gates-glidden, peeso- reamer burs (Pulpdent, USA) and glass fiber posts were cemented with a dual-cure resin cement (Panavia, Kuraray Dental, Japan) [Figure 4]. After cementation of posts, coronal portions were restored with composite resin (TPH, Dentsply, USA) [Figure 5]a-c.
|Figure 4: Cemented glass fiber posts. Maxillary right lateral incisor and maxillary left lateral incisor|
Click here to view
|Figure 5: Intraoral view after coronal restorations were completed. (a) anterior aspect, (b) right aspect (c) left aspect|
Click here to view
Clinical and radiographical evaluation
Eight months later, clinical evaluation confirmed no abnormalities such as pain, luxation or root resorption [Figure 6]a-c. Apical radiolucencies of subluxated teeth were significantly smaller at this visit. Enlargement of periodontal membrane of maxillary left canine was also absent [Figure 7]. Furthermore any complication associated with gingival and other soft tissues, discoloration and fracture of restorations was not detected clinically. Any disturbance of margins and cavosurfaces of restorations was also absent. A review was scheduled after another six months to evaluate the progress.
|Figure 6: Intraoral view eight months later. (a) anterior view, (b) right aspect, (c) left aspect. No fracture of composite restorations was detected|
Click here to view
|Figure 7: Periapical radiographs eight months later. Periapical radiolucencies were signifi cantly smaller|
Click here to view
| Discussion|| |
In subluxation injuries, the tooth is tender to touch and mobile but not displaced.  Barnett reviewed that pulp necrosis is rare in these cases but the signs of pulp necrosis such as development of periradicular radiolucency, external inflammatory root resorption, sinus tract formation, pain to percussion, or development of tooth mobility after the initial healing period requires immediate endodontic intervention to prevent progressive inflammatory root resorption.  In this case, spontaneous pain and pain to percussion was observed two weeks after trauma and root canal treatment was initiated.
Flores et al., reported that no radiographic abnormalities will be found in subluxated teeth.  However, Çalışkan observed that enlargement of periodontal membrane may be seen. In this case, the subluxated teeth represented radiographically enlarged apical periodontal membrane.
In their study comparing four different splinting techniques, von Arx et al., suggested that a physiologic splint should be firm enough to stabilize a traumatized teeth but should be flexible enough to functionally stimulate periodontal healing.  Çalışkan stated that subluxation injuries does not require splinting but may be considered if necessary  while Flores et al., stated a flexible splint option can be used for the comfort of the patient for seven to 10 days.  Bakland and Andreasen stated that in cases of luxation, the splint should be removed three to four weeks after trauma.  In our case, a flexible orthodontic wire bonded to the labial surfaces of subluxated teeth was used as a splint for three weeks. Another tooth for support was not needed. Instead, maxillary left central incisor was splinted to two other subluxated teeth representing a lower degree of luxation. To avoid biting forces, a thermoplastic plaque was applied to the lower teeth and the patient was advised not to bite with his anterior teeth during the healing period.
In the present case, beside subluxation injury, three teeth represented complicated crown fractures with no concomitant luxation injury while a lower anterior tooth represented an uncomplicated crown fracture. In fact, the clinical view of maxillary crown fractured teeth resembles the clinical view of crown root fractures but because the fracture lines were not subgingival and cement tissue was not involved, these fractures were considered as crown fractures.
Prognosis of the pulp is very good in uncomplicated crown fractures and composite restorations can be used for restorative treatment.  In the present case, the coronal fracture of lower incisor tooth was limited to superficial dentin and restoration was achieved with composite resin bonded directly to the tooth.
Complicated crown fractures involve both the enamel and dentin with the pulp being exposed in these cases. Treatment options include direct pulp capping, pulpotomy (partial or cervical) or pulpectomy, depending on factors such as the interval between the accident and examination, the degree of root development and size of exposure.  Fuks et al., did not find a significant relationship between treatment delay and pulp healing with respect to pulp capping.  But Cvek was of the opinion that when the exposure site is large or time elapsed between the accident and examination is long, vital pulpotomy should be considered as the treatment of choice.  It has also been suggested by Bakland and Andreasen that if the final restoration is a prosthetic crown in complicated crown fractures, the patient may wisely choose to have root canal treatment prior to restoration.  Çalışkan reported that root canal treatment is a treatment of choice if the final restoration is a prosthetic crown. He also stated that in cases of horizontal or vertical complicated crown fractures, because a post application is necessary, root canal treatment should be performed as the first treatment of choice.  On the contrary, Jackson et al., reported that with the recent development of composite materials, root canal treatment is no more necessary in many cases.  In the present case, the remaining coronal portion of crown-fractured teeth was incapable of supporting the coronal restorations and reinforcing the coronal restorations with a post-core was necessary. For this reason, root canal treatment was applied to the crown fractured teeth.
Glass fiber posts are more flexible than metal posts and have approximately the same modulus of elasticity as dentin. They also have superior esthetic results.  Pest et al., concluded that adhesive luting of fiber posts is an alternative technique that is comparable and in some ways superior to traditional techniques.  In their case report, Fidel et al., restored a vertically fractured tooth with light cured composite reinforced with a glass fiber post and confirmed the integrity of glass fiber post and composite resin both clinically and radiographically 13 months later.  In the present case, coronal restoration of maxillary crown fractured teeth was accomplished with composite resin reinforced by glass-fiber posts and the patient was told that prosthetic crowns can be applied if any complication associated with composite restorations was observed. At a recall eight months later, clinically there was no pain, luxation, sensitivity to percussion-palpation and soft tissue problem or root resorption. Radiographically, no periradiculer radiolucency and resorption was observed.
| Conclusion|| |
This case presented the treatment strategy of traumatically injured teeth including fixation of luxated teeth, restoration of crown fractured teeth and their endodontic treatment. This study also supported the view of treating crown fractures by using composite resin reinforced with glass fiber posts instead of prosthetic crown application which is more expensive and requires more time. Additional evaluation still needs to be carried out to reveal the long-term clinical performance of these restorations.
| References|| |
|1.||Caldas AF Jr, Burgos ME. A retrospective study of traumatic dental injuries in a Brazilian dental trauma clinic. Dent Traumatol 2001;17:250-3. |
|2.||Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries- a review article. Dent Traumatol 2002;18:116-28. |
|3.||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. |
|4.||Olsburgh S, Jacoby T, Krejci I. Crown Fractures in permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15. |
|5.||Caliskan MK. Endodontide Taný ve Tedaviler. 1st ed. Istanbul: Nobel Medical Publishing; 2006. p. 601-31. |
|6.||Barnett F. The role of endodontics in the treatment of luxated permanent teeth. Dent Traumatol 2002;18:47-56. |
|7.||Bakland LK, Andreasen JO. Dental traumatology: Essential diagnosis and treatment planning. Endodontic Topics 2004;7:14-34. |
|8.||Cohenca N, Karni S, Rotstein I. Transient apical breakdown following tooth luxation. Dent Traumatol 2003;19:289-91. |
|9.||Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann JL, Oikarinen K, et al., International Association of Dental Traumatology. Guidelines for the evaluation and Management of traumatic dental injuries. Dent Traumatol 2001;17:145-8. |
|10.||Robertson A, Andreasen FM, Andreasen JO, Noren JG. Long-term prognosis of crown-fractured permanent incisors. The effect of stage of root development and associated luxation injury. Int J Paediatr Dent 2000;10:191-9. |
|11.||Sonmez IS, Sonmez H. Long-term follow-up of a complicated crown fracture treated by partial pulpotomy. Int Endod J 2007;40:398-403. |
|12.||Fidel SR, Sassone L, Alvares GR, Guimaraes RP, Fidel RA. Use of glass fiber post and composite resin in restoration of a vertical fractured tooth. Dent Traumatol 2006;22:337-9. |
|13.||Caliskan MK. Endodontide Tani ve Tedaviler. 1 st ed. Istanbul: Nobel Medical Publishing; 2006. p. 657-89. |
|14.||von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device [TTS] with three commonly used splinting techniques. Dent Traumatol 2001;17:266-74. |
|15.||Fuks AB, Bielak S, Chosak A. Clinical and radiographic assessment of direct pulp capping and pulpotomy in young permanent teeth. Pediatr Dent 1982;4:240-4. |
|16.||Cvek M. Endodontic treatment of traumatized teeth In: Andreasen JO, editor. Traumatic Injuries to the Teeth. 2 nd ed. Copenhagen: Blackwell Munksgaard; 1981. p. 321-83. |
|17.||Caliskan MK. Endodontide Taný ve Tedaviler. 1st ed. Istanbul: Nobel Medical Publishing; 20 06. p. 601-31. |
|18.||Jackson NG, Waterhouse PJ, Maguire A. Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care. Dent Traumatol 2006;22:179-85. |
|19.||Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: A literature review. J Endod 2004;30:289-301. |
|20.||Boschian Pest LB, Cavalli G, Bertani P, Gagliani M. Adhesive post-endodontic restorations with fiber posts: Push-out tests and SEM observations. Dent Mater 2002;18:596-602. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]