Vertical root fracture treated by bonding fragments and rotational replantation

Tooth intentional replantation from 1964 to 2023: A bibliometric analysis

BACKGROUND/AIM

There is no thorough overview of intentional tooth replantation techniques. We performed a bibliometric analysis of the development of intentional tooth replantation.

MATERIALS AND METHODS

A comprehensive search of the Web of Science and SCOPUS databases was conducted in February 2023. Original articles and reviews of human studies with "intentional replantation" or synonyms in the titles, abstracts, or keywords were included. A descriptive analysis of bibliographic data, co-occurrence analysis, and coupling of publications was performed. Multivariate analysis was used to explore the bibliometric parameters associated with the citation counts.

RESULTS

The study included 171 papers, which were co-authored by 500 individuals affiliated with 217 institutions from 28 countries/regions. The USA contributed the greatest number of publications, followed by China, and Japan. The USA had 694 citations, followed by Japan (210), and Turkey (210). The Journal of Endodontics and Dental Traumatology contributed the most citations. Five directions for future research were identified based on the coupling relationships of publications, including "managing vertical root fractures with adhesive resin using the intentional replantation technique," "intentional replantation for periodontally hopeless or endodontically compromised teeth," "intentional replantation for treating abnormalities of morphological development," "outcomes and prognosis factors of intentional replantation," and "treating root replacement resorption by intentional replantation." Multivariate analysis showed that the publication year, Journal Citation Reports ranking of journals, study design, and disease type were predictors of citation counts.

CONCLUSIONS

This bibliometric analysis provides a comprehensive description of the intentional replantation technique. The USA published the greatest volume of papers and generated the most citations. The Journal of Endodontics and Dental Traumatology are considered the most influential. The Journal Citation Reports journal ranking (Q1, Q2), study design (case reports, cohort studies), and disease type (crown root fractures) were associated with the citation counts.

New approach for the treatment of vertical root fracture of teeth: A case report and review of literature

BACKGROUND

Vertical root fracture (VRF) is one of the most common reasons for tooth extraction, although various methods have been applied for saving teeth with VRF.

CASE SUMMARY

This case report describes a woman who had a sinus tract on the labial gingiva of the left maxillary central incisor for past two months. Periodontal probing revealed an 8–10 mm deep, narrow, isolated pocket on the palatal side of the tooth. Clinical and radiographic examination confirmed a longitudinal root fracture. A new approach using a combination of resin and iRoot BP Plus through intentional replantation was used for the treatment of the tooth. At one-year follow-up, the tooth remained asymptomatic with normal periodontal probing depth, and radiographic images showed almost normal bone and periodontal structures around the root.

CONCLUSION

This new approach may be developed as an effective method for saving teeth with VRF.

Vertical root fractures in root treated teeth-current status and future trends

Vertical root fracture (VRF) is a common reason for the extraction of root filled teeth. The accurate diagnosis of VRF may be challenging due to the absence of clinical signs, whilst conventional radiographic assessment is often inconclusive. However, an understanding of the aetiology of VRFs, and more importantly, the key predisposing factors, is crucial in identifying teeth that may be susceptible. Thorough clinical examination with magnification and co-axial lighting is essential in identifying VRFs, and although CBCT is unable to reliably detect VRFs per se, the pattern of bone loss typically associated with VRF can be fully appreciated, and therefore, increases the probability of correct diagnosis and management. The prevalence of VRFs in root filled teeth is significantly greater than in teeth with vital pulps, demonstrating that the combination of loss of structural integrity, presence of pre-existing fractures and biochemical effects of loss of vitality, are highly relevant. Careful assessment of the occlusal scheme, presence of deflective contacts and identification of parafunctional habits is imperative in both preventing and managing VRFs. Furthermore, anatomical factors such as root canal morphology, may predispose certain teeth to VRF. The influence of access cavity design and root canal instrumentation protocols should be considered although the impact of these on the fracture resistance of root filled teeth is not clearly validated. The post-endodontic restoration of root filled teeth should be expedient and considerate to the residual tooth structure. Posts should be placed 'passively' and excessive 'post-space' preparation should be avoided. This narrative review aims to present the aetiology, potential predisposing factors, histopathology, diagnosis and management of VRF and present perspectives for future research. Currently, there are limited options other than extraction for the management of VRF, although root resection may be considered in multi-rooted teeth. Innovative techniques to 'repair' VRFs using both orthograde and surgical approaches require further research and validation. The prevention of VRFs is critical; identifying susceptible teeth, utilizing conservative endodontic procedures, together with expedient and appropriate post-endodontic restorative procedures is paramount to reducing the incidence of terminal VRFs.

Vertical Root Fracture in Non-Endodontically and Endodontically Treated Teeth: Current Understanding and Future Challenge

A vertical root fracture (VRF) is a complex complication that usually leads to tooth extraction. The aim of this article is to review the prevalence, demography, distribution, diagnostic methods, etiology and predisposing factors, clinical features, radiographic characteristics and treatment strategies of VRFs in non-endodontically treated teeth (VRFNETT) and endodontically treated teeth (VRFETT). Search terms for each subject related to VRFNETT and VRFETT were entered into MEDLINE, PubMed and Google Scholar. Systematic reviews, retrospective cohort studies, demographic research, clinical studies, case reports and case series were reviewed. Most of the VRFs were found in patients older than 40 years old. Older populations were discovered in the non-endodontically treated VRF group when compared to the endodontically treated VRF group. Male patients were found at a greater prevalence than females in the non-endodontically treated VRF group. The initial occurrence of a VRF may accompany radiolucent lines within the root canal, unusual space between the canal wall and intracanal material, a widening of the PDL space along the periradicular surfaces, angular bony destruction, step-like bone defects, V-shaped diffuse bone defects, or root resorptions corresponding to the fracture line before the clear separation of the fractured fragment. The indicative clinical and radiographic signs of VRF included a coronally positioned sinus tract, deep-narrow periodontal defects, the displacement of a fractured fragment, periradicular radiolucent halos and the widening of the root canal space. Interestingly, VRFNETT are more often observed in the Chinese population. Some patients with multiple VRFs were observed, suggesting possible predisposing factors in genetics and tooth development. The management of a VRF usually involves a multidisciplinary approach. The common distribution and features of VRFNETT and VRFETT were elucidated to facilitate recognition and diagnosis. Besides extraction, variable therapeutic schemes, such as the repair of the VRF, root amputation and others reported in earlier literature, are available. A long-term prognosis study of the various therapeutic strategies is needed.

Evaluation of Restorative Techniques for Vertically Fractured Roots

The purpose of this study was to examine the effects of combining specific adhesive materials and various surface treatments on bonding durability and microleakage of vertically fractured roots. Adhesive models were prepared using bovine lower incisors. The experiment included the following five groups: SB-G group (control) (10% citric acid with 3% ferric chloride solution (10-3 solution) + an adhesive resin cement (4-META/MMA-TBB; Super-Bond^®)), EC group (self-cure bonding agent (UB) + core composite resin (EC)), EC-G group (10-3 solution + UB + EC), EC-P group (40% phosphate solution + UB + EC), and EC-E group (18% ethylenediaminetetraacetic acid (EDTA) solution + UB + EC). After applying a load of 50,000 cycles, microleakage, microtensile bond strength (μTBS), and failure modes were examined. Microleakage of the EC, EC-G, and EC-E groups was significantly lower than that of the EC-P group. The μTBS of the EC-G group was significantly higher than that of the other groups. All EC groups showed that mixed (cohesive and adhesive) and adhesive failures were the most prevalent types of failure modes. The EC-G group showed the highest bonding durability and the lowest microleakage results, which indicates a possible alternative to current adhesive and tooth surface treatments.

N-acetylcysteine attenuates PGE2 and ROS production stimulated by 4-META/MMA-based resin in murine osteoblastic cells

This study examined the effects of N-acetylcysteine (NAC) on the inflammatory reactions of murine osteoblastic cells cultured on the 4-methacryloxyethyl trimellitate anhydride/methyl methacrylate (4-META/MMA)-based resin. Superbond C&B (SB) was used as the 4-META/MMA-based resin and placed in a 48-well cell culture plate. The cells were cultured in αMEM (control) as well as on SB and SB in αMEM with NAC (SB+NAC). They were examined using the WST-1 proliferation assay, real-time PCR, enzyme-linked immunosorbent assay (ELISA), intracellular reactive oxygen species (ROS) measurements, and cellular glutathione (GSH) detection. COX-2 and IL-6 gene expressions were upregulated in SB; however, they were suppressed by NAC. Furthermore, PGE₂ production in the culture medium was increased in SB, whereas NAC decreased the PGE₂ production. NAC lowered the ROS level in the culture medium and significantly increased the intracellular GSH level. The present in vitro study demonstrated that NAC might be effective for dental material detoxification.

Periodontal tissue repair after sealing of the gap in vertical root fracture

The aim of this study was to determine whether sealing of fracture gap using adhesive resin through the root canal can prevent inflammation of periodontal tissue, and resealing the incompletely sealed fracture gap from outside can resolve such inflammation in experimentally created vertical root fractures. Vertical root fractures were created in incisor of beagles. In the experimental group, the fracture gap was sealed through the root canal with adhesive resin. After 5 weeks, sites with the clinical attachment level ≥4 mm were further divided randomly into the poor-replanting group and the poor-untreated group. In the poor-replanting group, the tooth was extracted and replanted after resealing the fracture gap with adhesive resin from the outer surface. Sites with clinical attachment level ≤3 mm after 5 weeks were considered as the satisfactory group. The poor-untreated group and the satisfactory group were subjected to no further treatment. The clinical attachment level was evaluated at baseline and after 2, 5, and 9 weeks. After 9 weeks, histological measurements were made to determine the length of the epithelial downgrowth and the area of alveolar bone resorption. The clinical attachment level and the area of bone resorption were significantly smaller in the poor-replanting group and the satisfactory group than in the poor-untreated group (p < 0.05). The results indicate the possibility that periodontal inflammation along the fracture line can be prevented and improved if the fracture gap is sealed.

Microsurgical re-treatment of an endodontically treated tooth with an apically located incomplete vertical root fracture: a clinical case report

Although it is challenging, the early diagnosis of a vertical root fracture (VRF) is crucial in order to ensure tooth preservation. The purpose of this clinical case report was to describe reparative surgery performed to treat a tooth affected by an incomplete VRF. A 26 year old male patient was suspected to have a VRF in a maxillary left central incisor, and an exploratory flap was performed in order to confirm the diagnosis. After detecting the fracture, the lesion was surgically treated, the fracture and the infected root-end were removed, and a platelet-rich plasma membrane was used to cover the defect in order to prevent bacterial migration. A 24 month clinical and radiological follow-up examination showed that the tooth was asymptomatic and that the healing process was in progress. The surgical approach described here may be considered an effective treatment for a combined endodontic-periodontal lesion originating from an incomplete VRF and a recurrent periapical lesion.

Influence of enamel matrix derivative on healing of root surfaces after bonding treatment and intentional replantation of vertically fractured roots

BACKGROUND/AIM

The objectives of this study were to histopathologically evaluate cementum regeneration on root surfaces when an enamel matrix derivative (EMD) was used to bond a vertically fractured root and to evaluate the effectiveness of EMD in inhibiting root resorption.

MATERIAL AND METHODS

A total of 40 roots from 24 maxillary premolars in beagles were used. The root was vertically fractured using a chisel and mallet. Super-Bond was then used to bond the fractured root. In the experimental group, the root surface was treated with ethylenediaminetetraacetic acid and an EMD. The control group received no treatment. The root was then replanted in its original location. Histopathological observation and measurement using image-analyzing software were carried out after 8 weeks.

RESULTS

In the experimental group, shallow resorption cavities developed on the root planed surfaces with new acellular cementum appearing over them. In the control group, no new cementum was seen on the planed surfaces, and there was connective tissue joining the roots. In some of the samples, resorption and multinucleated giant cells were seen. The experimental group showed a significantly larger volume of cementum formation (P < 0.001), and the volume of root resorption was significantly smaller (P = 0.004).

CONCLUSION

When bonding and replanting tooth roots after a vertical fracture, the application of EMD was effective in regenerating cementum on root surfaces from which periodontal ligament had been lost in the area around the fracture line and in reducing the incidence of root resorption.

The biomechanical role of periodontal ligament in bonded and replanted vertically fractured teeth under cyclic biting forces

After teeth are replanted, there are two possible healing responses: periodontal ligament healing or ankylosis with subsequent replacement resorption. The purpose of this study was to compare the fatigue resistance of vertically fractured teeth after bonding the fragments under conditions simulating both healing modes. Thirty-two human premolars were vertically fractured and the fragments were bonded together with Super-Bond C&B. They were then randomly distributed into four groups (BP, CP, CA, BA). The BP and CP groups were used to investigate the periodontal ligament healing mode whilst the BA and CA groups simulated ankylosis. All teeth had root canal treatment performed. Metal crowns were constructed for the CP and CA groups. The BP and BA groups only had composite resin restorations in the access cavities. All specimens were subjected to a 260 N load at 4 Hz until failure of the bond or until 2×10⁶ cycles had been reached if no fracture occurred. Cracks were detected by stereomicroscope imaging and also assessed via dye penetration tests. Finally, interfaces of the resin luting agent were examined by scanning electron microscope. The results confirmed that the fatigue resistance was higher in the groups with simulated periodontal ligament healing. Periodontal reattachment showed important biomechanical role in bonded and replanted vertically fractured teeth.

A comparative study of the effects of 4-META/MMA-TBB resin and cyanoacrylate on wound healing of skin defects

The purpose of this study was to investigate the healing process of wounded skin following the application of cyanoacrylate or a 4-(2-methacryloxyethyl) trimellitic anhydride/methyl methacrylate-tributylborane resin (4-META resin). Those materials were applied to skin wound areas in rats, and the regenerating tissues were biopsied and examined at days 1, 3, 5, 7, and 14. Paraffin-embedded specimens were sectioned and stained with hematoxylin and eosin or with Azan-Mallory stain. Sections were also immunohistochemically stained with Pan-cytokeratin and CD68 antibodies. In cyanoacrylate-treated wounds, CD68-positive cells were observed in the connective tissue and their number increased up to day 5. The wound surface was completely covered by epithelial tissue at day 14. In 4-META resin-treated wounds, CD68-positive cells appeared in the soft-tissue hybrid layer (STHL) and epithelial tissue had migrated under the STHL by day 5. The wound surface was completely covered by epithelial tissue at day 7. CD68-positive cells were distributed over the entire area of the cyanoacrylate-treated wounds, but accumulated under the STHL in the 4-META resin-treated wounds. In conclusion, the results suggest that covering skin defects with a 4-META resin is an effective strategy to promote wound healing compared to cyanoacrylate.

Surgical management with intentional replantation on a tooth with palato-radicular groove

A palato-radicular groove (PRG) is a developmental anomaly primarily found in the maxillary lateral incisors. It is a potential communication path between the root canal and the periodontium that decreases the survival prognosis of the affected tooth, therefore compromising the stability of the dental structure in the oral cavity. The aim of this case report is to present an original technique where a PRG was treated by means of intracanal disinfection, PRG sealing with glass ionomer, replantation with intentional horizontal 180 degree rotation of the tooth, and an aesthetic veneer placed to provide adequate tooth morphology. The clinical and biological benefits of this novel technique are presented and discussed.

Vertical root fractures and their management

Vertical root fractures associated with endodontically treated teeth and less commonly in vital teeth represent one of the most difficult clinical problems to diagnose and treat. In as much as there are no specific symptoms, diagnosis can be difficult. Clinical detection of this condition by endodontists is becoming more frequent, where as it is rather underestimated by the general practitioners. Since, vertical root fractures almost exclusively involve endodontically treated teeth; it often becomes difficult to differentiate a tooth with this condition from an endodontically failed one or one with concomitant periodontal involvement. Also, a tooth diagnosed for vertical root fracture is usually extracted, though attempts to reunite fractured root have been done in various studies with varying success rates. Early detection of a fractured root and extraction of the tooth maintain the integrity of alveolar bone for placement of an implant. Cone beam computed tomography has been shown to be very accurate in this regard. This article focuses on the diagnostic and treatment strategies, and discusses about predisposing factors which can be useful in the prevention of vertical root fractures.

New treatment option for an incomplete vertical root fracture--a preliminary case report

Instead of extraction this case report presents an alternative treatment option for a maxillary incisor with a vertical root fracture (VRF) causing pain in a 78-year-old patient. After retreatment of the existing root canal filling the tooth was stabilized with a dentine adhesive and a composite restoration. Then the tooth was extracted, the VRF gap enlarged with a small diamond bur and the existing retrograde root canal filling removed. The enlarged fracture line and the retrograde preparation were filled with a calcium-silicate-cement (Biodentine). Afterwards the tooth was replanted and a titanium trauma splint was applied for 12d. A 24 months clinical and radiological follow-up showed an asymptomatic tooth, reduction of the periodontal probing depths from 7 mm prior to treatment to 3 mm and gingival reattachment in the area of the fracture with no sign of ankylosis. Hence, the treatment of VRF with Biodentine seems to be a possible and promising option.

Implant treatment choice after extraction of a vertically fractured tooth. A proposal for a clinical classification of bony defects based on a systematic review of literature

OBJECTIVES

The objectives of this study were to propose a classification for the bone defects resulting after extraction of a vertically fractured tooth and to review the existing literature about the treatment of such kind of defects by means of dental implants in combination with regenerative procedures.

MATERIALS AND METHODS

An electronic search was performed on biomedical databases using a combination of appropriated search terms combined through the use of Boolean operators. All articles concerning the treatment of peri-implant bone dehiscences and fenestrations through guided bone regeneration (GBR) with at least 6 months follow-up were eligible. Outcomes data extracted from the selected articles were summarized using descriptive tables. A classification of the bone defects associated with vertical root fracture (VRF) was also proposed.

RESULTS

A total of 33 articles were included in the review. Twenty-three articles (814 implants) were about bone dehiscence treatment, ten articles presented the treatment of fenestrations, and ten (429 implants) adopted vertical bone augmentation. The percentage of bone filling was variable among different procedures and defect classification. The use of resorbable membrane was associated with better outcomes than the use of non-resorbable ones.

CONCLUSIONS

Guided bone regeneration for the management of bone defects in the presence of a VRF of the extracted tooth is a viable treatment option. The assessment of bone defect geometry prior to a tooth extraction could be clinically relevant for evaluating the feasibility and the success of immediate implant placement as well as the need of GBR.

Intentional replantation: a procedure as a last resort

AIM

To address the indications, contraindications, surgical procedure, complications following treatment, factors influencing the results and success rate of intentional replantation procedure.

BACKGROUND

Intentional replantation is extraction of a tooth to do extraoral root canal therapy, curettage of apical lesion when present, and its replacement in its socket. It has been proposed as an alternative to routine extraction; however, it should be considered a last resort because the root may be fractured during extraction.

RESULTS

The success rate of intentional replantation is far below than routine endodontic treatment or apical surgery. Difficultness of tooth extraction, the possibility of fracture during extraction and the risk of external resorption are some limitations of this treatment. The most common causes of failure in intentionally replanted teeth are external inflammatory resorption or replacement resorption and ankylosis caused by periodontal ligament damage.

CONCLUSION

The success rate up to 95% with an average retention of 3 to 5 years, has been reported.

CLINICAL SIGNIFICANCE

In some cases, endodontic retreatment or apical surgery is impossible or impractical. In these situations, intentional replantation may be considered as a last resort for preserving the tooth, so all clinicians should know about its indications/contraindications, surgical procedure and complications following treatment.

Intentional re-plantation of a vertically fractured tooth repaired with an adhesive resin

AIM

To present the successful treatment of a vertically fractured tooth by intentional re-plantation after root canal treatment and repair with an adhesive resin.

SUMMARY

Vertical root fracture is a challenging problem in respect of diagnosis and management options. In this case, a vertically fractured maxillary premolar was treated by intentional re-plantation after repairing it with 4-Methacryloxyethyl trimellitate anhyride/methacrylate-tri-n-butyl borane (4-META/MMA-TBB) resin cement. At the 36-month follow-up, the tooth was asymptomatic, radiographically sound with reduced deep periodontal pockets and vertical bone loss.

KEY LEARNING POINTS

• Intentional replantation after repairing fractured fragments with an adhesive resin extraorally is a treatment option. • Long-term follow-up is necessary to evaluate the outcome of this technique.

A proposal for classification of tooth fractures based on treatment need

Accuracy in defining a disease makes it easier to study and understand. Similarly, with injuries to the teeth, a comprehensive classification is an aid to correct diagnosis and treatment planning. A thorough review of various classifications of tooth fractures shows that, despite an emphasis on traumatic dental injuries, a consensus needs to be arrived at, especially among clinicians and general/family dentists. The ideal classification would be applicable to both primary and permanent dentition, based on tooth fractures in both the horizontal and vertical planes, encompassing all possible sites, easy to comprehend, communicable amongst health professionals and clinically relevant. With recent improvements in conservative techniques, it is now clinically possible to preserve natural teeth even if they have been horizontally or vertically fractured, and thus an in-depth understanding and knowledge of tooth fractures, together with a simplified classification, is now more than ever essential.

The effect of different posts on fracture strength of roots with vertical fracture and re-attached fragments

The aim of this in vitro study was to test the effect of different post systems on fracture strength of roots with re-attached fragments. Root canals of eighty extracted single-rooted human teeth were instrumented (ProFile) and randomly divided into two groups. The roots in the first group were vertically cracked, and the fragments were re-attached using Super Bond C&B (Sun Medical, Tokya, Japan). The roots in the second group were kept sound. Obturation of the roots was performed with MetaSEAL (Sun Medical) and gutta-percha. Post spaces were prepared, and the roots were restored with one of the followings: UniCore (Ultradent), Everstick (Stick Tech), Ribbond (Ribbond), ParaPost (Coltene/Whaledent) (n = 10). Four mm high build-ups were created (Clearfil DC Bond Core; Kuraray, Tokyo, Japan). Compressive loading of the samples was performed after 24 h (1 mm min(-1)). Mean load necessary to fracture each sample was recorded (Newton) and statistically analysed (One-way anova, t-tests). ParaPost showed the highest fracture strength among the roots with re-attached fragments (P < 0.05). UniCore and ParaPost systems showed similar fracture strength in the sound roots (P > 0.05). Re-attached fragments significantly reduced the fracture strength of roots in UniCore group (P = 0.000). Ribbond post showed mostly repairable fractures. Metal post (ParaPost) showed the highest fracture strength in the roots with re-attached fragments; however, fracture pattern was 41% non-repairable. Re-attached fragments significantly reduced the fracture strength of the roots in UniCore group. Prefabricated posts showed similar fracture strength in the sound roots. Customized post systems EverStick and Ribbond showed mostly repairable failure after loading in sound roots or roots with re-attached fragments.

Effect of the dental adhesive, 4-META/MMA-TBB resin, on adhesion and keratinization of regenerating oral epithelium

BACKGROUND AND OBJECTIVE

The 4-META/MMA-TBB [4-(2-methacryloxyethyl)trimellitic anhydride/methyl methacrylate-tributylborane] resin is widely used as a dental adhesive. It has also been applied in the dressing of gingival wound surfaces following periodontal surgery. However, its effect on the regeneration and/or cell attachment of the oral epithelium remains to be clarified. To evaluate the effect of the resin applied as a wound dressing, we investigated expression of laminin 5, integrin beta(4) and cytokeratin 14 in regenerating oral epithelium treated with this resin following gingivectomy from the viewpoint of cell attachment and differentiation.

MATERIAL AND METHODS

The resin was applied to the entire wound surface in rats after gingival surgery, and regenerating epithelium was examined immediately and at 1, 3, 5, 7 and 14 days later. The resin was removed 2 weeks after application in some animals and tissue further examined at 1, 3, 5 and 7 days later.

RESULTS

Regenerating epithelium under the resin was not keratinized, but became keratinized immediately after removal of the resin. Laminin 5 and integrin beta(4) were immunolocalized in the basal lamina, the internal basal lamina, in marginal cells of the regenerating epithelium and at the resin-regenerating epithelium interface. Cytokeratin 14 localized in the regenerating epithelium underneath the resin, as well as in healthy and regenerated junctional epithelial cells.

CONCLUSION

These results suggest that this resin covers the wound surface and that the regenerating epithelium biologically adheres to the resin during the initial process of its regeneration.

A successful treatment of vertical root fracture: a case report and 4-year follow-up

This case report describes a successful treatment of vertically fractured tooth which was reconstructed with a self-etching dual-cured adhesive resin cement and intentionally replanted without using rotation in conjunction with a bio-absorbable barrier membrane. At a follow-up consultation 4 years later, the tooth was asymptomatic, and attachment gain and bone regeneration were observed. In addition, no ankylosis was detected clinically or radiographically.

Replantation of a vertically fractured maxillary central incisor after repair with adhesive resin

AIM

To describe the replantation of a vertically fractured root-filled maxillary central incisor after repair with adhesive resin.

SUMMARY

Root-filled teeth with vertical root fractures are usually extracted as they generally have a poor prognosis. In this case, an 18-month follow-up of a replanted incisor with vertical root fracture is presented with clinical and radiographic documentation.

KEY LEARNING POINTS

* Replantation of root-filled incisors with complete vertical root fracture after resin bonding might be a realistic alternative to extraction. * Practitioners should be aware of the possible disadvantages as well as advantages associated with failure of a replanted incisor with complete vertical root fracture.

How does canal taper affect root stresses?

AIM

To examine the effect of specific tapers on root stresses and thus vertical root fracture.

METHODOLOGY

The effect of taper on root stresses was calculated during simulated warm vertical compaction of gutta-percha in a straight rooted premolar for three tapers (0.04, 0.06 and 0.12 mm mm(-1)) using finite element analysis. Stresses in the dentine were observed whilst the root was filled with three subsequent gutta-percha increments. Each increment was compacted at 10 or 15 N and the gutta-percha cooled down to 37 degrees C. After filling, composite was polymerized in the access space. A functional occlusal load of 50 N was then applied on the buccal cusp incline. The stress distribution in the root during the occlusal loading was compared with the stresses during filling.

RESULTS

During filling, the highest stresses were found: (a) at the canal surface; (b) using the smallest taper; (c) in the apical third; and (d) during the first gutta-percha increment. The root stress distribution changed when the functional post-filling load was applied. It generated the highest stresses at the external root surface, with a tensile stress concentration at the lingual surface of the cervical third. Since the stresses during simulated masticatory loading concentrated on the external surface, an increased taper size caused only slightly higher root stress levels.

CONCLUSIONS

With increasing taper, root stresses decreased during root filling but tended to increase for masticatory loading. Root fracture originating at the apical third is likely initiated during filling, whilst fracture originating in the cervical portion is likely caused by occlusal loads.

Analysis of Chemical Interaction of 4-MET with Hydroxyapatite Using XPS

Each dental adhesive contains a specific functional monomer that determines its actual adhesive performance to tooth tissue. 4-methacryloxyethyl trimellitic acid (4-MET) is well-known as one of the functional monomers mostly available and consequently widely used in commercial adhesives. We therefore characterized the chemical interaction of 4-MET with hydroxyapatite (HAp) using X-ray Photoelectron Spectroscopy (XPS). XPS revealed that the peak representing -COO- of 4-MET shifted to a lower binding energy, when 4-MET was adsorbed onto HAp. Deconvolution of this shifted peak disclosed two components with a peak representing unreacted carboxyl groups and ester groups, and a peak suggesting chemical bonding of other carboxyl groups to Ca of HAp. XPS spectra of HAp treated with 4-MET also disclosed the surface to be enriched in calcium and decreased in phosphorus, indicating that phosphorus was extracted at a relatively higher rate than calcium. It can thus be concluded that true chemical bonding of 4-MET with calcium present in HAp occurred, as it was proven using XPS.

Hybrid layer seals the cementum/4-META/MMA-TBB resin interface

Although 4-META/MMA-TBB resin has adhesive properties to dentin, and has been clinically used for the bonding treatment of vertically fractured roots and apicoectomy, there has not been any investigation on the adhesion of 4-META/MMA-TBB resin to cementum. The purpose of this in vitro study was to evaluate the bonding and the sealing ability of 4-META/MMA-TBB resin to cementum. Bovine root cementum and dentin surfaces were treated with a citric acid and ferric chloride solution, and the 4-META/MMA-TBB resin was applied on the treated surfaces before testing. The microtensile bond strength and the leakage levels obtained for the cementum were almost equal to those for the dentin. In SEM and TEM observations, a hybrid layer approximately 2-3 microm in thickness was observed at the interface between the resin and the cementum. It is concluded that 4-META/MMA-TBB resin adhered to cementum via a hybrid layer on cementum, as previously reported for dentin.

Restoration of the root-filled tooth: pre-operative assessment

This is the first in a series of four papers related to the management of root canal treated teeth. When teeth compromised by extensive restorations become non-vital, suggestions have been given as to how root canal treatment can be carried out with the greatest chance of success. Once root canal treated, either by a previous dentist or by the current dentist, a review of the assessment process that should be carried out prior to placing costly indirect definitive restorations is given. It will be clear that post-retained restorations are mainly reserved for anterior or single-rooted teeth, posterior teeth rarely requiring a post for core retention. The second paper in this series describes the basic tooth preparation that should be carried out prior to placing a post. Depending on the type of post system used, further modifications to tooth preparation may be required and the cementation techniques may also have to be modified. The third paper therefore discusses the various post types, when and how they should be used for optimum results. The final paper addresses reinforcement and restoration of compromised root canals, such as those with immature, open apices, or those that have been over-prepared for previous post-retained restorations.

Effects of surface treatment and joint shape on microtensile bond strength of reattached root dentin segments

STATEMENT OF PROBLEM

An effective bonding technique for reattaching vertical root fracture segments has not yet been established.

PURPOSE

The purpose of this study was to investigate the effects of surface treatment and joint shape on bond strength of reattached root dentin segments.

MATERIAL AND METHODS

Microtensile dentin specimens (n=120, cross-sectional area=1.5 mm2) were obtained from 12 bovine teeth roots, and fractured under a tensile force. The segments of each group (n=6) were reattached by a 4-META/MMA-TBB adhesive resin after different treatments (etching or polishing, a 50-microm or 500-microm gap space, butt or wedge joint). The group with a 50-microm gap space and butt joint, which was not etched or polished, served as the control. After 24 hours of storage in 0.9% normal saline solution or thermal cycling (3000 cycles, 4 degrees C and 60 degrees C), the specimens were fractured in a universal testing machine at a crosshead speed of 1.0 mm/min. The microtensile bond strengths (MPa) were recorded. The bonded interface and fractured surface were observed by SEM (original magnification x 1000). The results were analyzed by a 2-way analysis of variance and the Fisher protected least significant difference post-hoc test (alpha=.05).

RESULTS

Significantly higher bond strengths (P=.0001) were shown for the nonpolished group (9.78 +/- 4.44 MPa) and the etched group (9.31 +/- 1.23 MPa) than for the polished group (fractured before test). The wedge-shaped joint exhibited the highest bond strength (18.57 +/- 3.40 MPa, P=.0017). SEM observations showed that the penetration of resin tags along the oblique dentinal tubules was within the wedge joint.

CONCLUSION

Etching and oblique tubule orientation contributed to significantly high bond strength of reattached segments to dentin after vertical root fracture.

Intentional replantation with 180o rotation of a crown-root fracture: a case report

Crown root fractures are frequently difficult to treat and have a bad prognosis. To restore the biological space, intentional replantation can be chosen when osteotomy/osteoplasty and dental traction are not viable. Intentional replantation with tooth rotation consists of extraction, 180 degrees rotation and replantation, thus restoring the biological space. After treatment of inflammatory resorption with calcium hydroxide, endodontic treatment was completed. The patient was followed up with clinical examination (mobility test, gingival sulcus depth) and radiographic analysis (to analyze root resorption: inflammatory and/or substitution, and the integrity of the alveolar cortex and the periodontal space) for 3 years and there were no signs of resorption.

Vertical root fractures: clinical and radiographic diagnosis

BACKGROUND

Early detection and management of vertical root fractures, or VRFs, remain a vexing issue that has caused needless suffering for patients as well as for dentists. The authors present techniques to aid the dentist in recognizing VRFs.

METHODS

During a five-year period, the authors examined 36 patients who had VRFs. Absent control subjects and a larger number of patients, the authors did not design this investigation for statistical analysis. They diagnosed VRFs through dental histories and clinical and radiographic examinations.

RESULTS

The study revealed VRFs in 36 teeth, two of which were vital and 34 of which were nonvital (that is, endodontically treated). The 34 VRFs resulted from excessive operative procedures performed in the root canal after endodontic therapy. Thirty-one of these 34 VRFs were caused by poorly designed dowels (too long, too wide or both) or inappropriate selection of the tooth as a bridge abutment; two VRFs were caused by a restoration that exerted lateral pressure on the axial walls of the preparation; and one VRF was caused by overzealous endodontic forces. The VRFs in the two vital teeth were in men who had a history of bruxism or clenching.

CONCLUSIONS AND CLINICAL IMPLICATIONS

VRFs can be detected early by listening to the patient's chief complaints, carefully examining periapical and bitewing radiographs and performing a thorough clinical examination.