A review of root fractures: diagnosis, treatment and prognosis

Healing After Horizontal Root Fracture of Maxillary Central Incisor: A Case Report With 24-Month Follow-Up

Facial traumatic injuries are quite common, resulting in the fracture and displacement of tooth and/or bone fragments. Loss of tooth structure may have lifetime consequences for the patient. Horizontal root fractures (HRFs) may occur in the maxillary anterior teeth at different locations, showing varied patterns of healing. The treatment options range from simple observation and follow-ups to conservative management or even complex surgical procedures. Correct and timely intervention can help preserve the tooth structure, leading to the long-term survival of the tooth. The present case report showcases endodontic treatment and favourable healing of a horizontal root fracture at the apical third of a permanent maxillary central incisor. At the 24-month follow-up, the tooth is clinically healthy, and radiographic images show a successful outcome.

Management of Periapical Lesion Associated With Root Fracture in the Elderly: A Case Report

The early detection and management of root fractures pose a challenge to dentists. There are two treatment options in such cases: conservative and endodontic or surgical. Follow-up of such cases involves the continual evaluation of the tissue repair process and the possible occurrence of undesirable events, such as periapical lesions, pulp calcification, and internal or external resorption. This case report describes the finding of a periapex with relatively extensive bone rarefaction resulting from a root fracture in a 64-year-old male who presented with gingival hyperplasia in the right maxillary lateral incisor region sensitivity at the touch of the exploratory probe and mild bleeding with exudate. In this case, the early diagnosis of root fracture enabled the choice of the best therapeutic option with a satisfactory outcome.

Diagnosis of Vertical Root Fractures in Endodontically Treated Teeth by Cone-Beam Computed Tomography

The purpose of this study was to investigate the characteristics and the detection ability of vertical root fractures in endodontically treated teeth by intraoral radiography and cone-beam computed tomography (CBCT). CBCT images of 50 patients with root fractures in endodontically treated teeth were reviewed, and 36 vertical root fractures were taken in this study. The cause of fracture, core construction, kind of teeth, and fracture direction (bucco-lingual and mesio-distal fractures) were investigated. Detection ability of vertical root fractures by intraoral radiography and CBCT was also examined. Statistical analyses concerning the characteristics were performed by χ2 test, and the detection ability was analyzed by cross-tabulation. All of the fractured teeth were nontraumatized teeth. The vertical root fracture occurrence was not differed by core construction. The vertical root fracture number was largest at the premolar teeth (p = 0.005), and the number of the bucco-lingual fracture was larger than the mesio-distal fracture (p = 0.046). Vertical root fractures were detectable using CBCT, while undetectable by intraoral radiography (p < 0.001). Vertical root fractures occurred easily in premolar teeth with bucco-lingual direction, and CBCT is an adequate radiographic method to diagnose vertical root fracture.

Appropriate fabrication method for pressure-formed mouthguards using polyolefin sheets

BACKGROUND/AIM

Polyolefin sheet mouthguards are usually formed in the same manner as ethylene-vinyl acetate sheet mouthguards. However, the heating condition of the polyolefin sheet for the pressure-forming process has not been determined. The aim of this study was to examine the appropriate heating condition for polyolefin sheet mouthguards when fabricated with the pressure-formed technique.

MATERIALS AND METHODS

Mouthguard sheets of 3.0 mm polyolefin were pressure formed on working models at three heating temperatures: 90°C, 105°C, and 120°C. The thickness of the mouthguard was measured at the labial surface of the central incisor, and the buccal and occlusal surfaces of the first molar. The fit of the mouthguard was examined at the central incisor and the first molar by measuring the distance between the mouthguard and the cervical margin of the working model. Differences in the thickness and fit of the mouthguards according to the heating conditions and the measured regions were analyzed using two-way analysis of variance.

RESULTS

Mouthguard thickness varied among the measured regions of the central incisors and first molars (p < .01). The greatest thickness was found at the labial surface of the central incisor in mouthguards fabricated with the heating temperature of 90°C (p < .01). The greatest thickness was found in mouthguards fabricated with the heating temperature of 105°C at the buccal surface of the first molar (p < .01), and 105°C or 120°C at the occlusal surface of the first molar (p < .01). The fit was not significantly different among the three heating conditions both at the central incisor and the first molar.

CONCLUSIONS

The appropriate heating condition for pressure-formed mouthguards using polyolefin sheets was 90°C to maintain the mouthguard thickness at the anterior teeth area with proper fit.

Secreted Frizzled-Related Protein 1 Promotes Odontoblastic Differentiation and Reparative Dentin Formation in Dental Pulp Cells

Direct pulp capping is an effective treatment for preserving dental pulp against carious or traumatic pulp exposure via the formation of protective reparative dentin by odontoblast-like cells. Reparative dentin formation can be stimulated by several signaling molecules; therefore, we investigated the effects of secreted frizzled-related protein (SFRP) 1 that was reported to be strongly expressed in odontoblasts of newborn molar tooth germs on odontoblastic differentiation and reparative dentin formation. In developing rat incisors, cells in the dental pulp, cervical loop, and inner enamel epithelium, as well as ameloblasts and preodontoblasts, weakly expressed Sfrp1; however, Sfrp1 was strongly expressed in mature odontoblasts. Human dental pulp cells (hDPCs) showed stronger expression of SFRP1 compared with periodontal ligament cells and gingival cells. SFRP1 knockdown in hDPCs abolished calcium chloride-induced mineralized nodule formation and odontoblast-related gene expression and decreased BMP-2 gene expression. Conversely, SFRP1 stimulation enhanced nodule formation and expression of BMP-2. Direct pulp capping treatment with SFRP1 induced the formation of a considerable amount of reparative dentin that has a structure similar to primary dentin. Our results indicate that SFRP1 is crucial for dentinogenesis and is important in promoting reparative dentin formation in response to injury.

Conservative endodontic management using a calcium silicate bioceramic sealer for delayed root fracture: A case report and review of the literature

BACKGROUND

The success rate of conservative endodontic management for root fracture varies greatly based on different methods used. It has been rarely reported that calcium silicate-based materials are applied in root fracture treatment.

CASE SUMMARY

A 38-year-old male patient presented with spontaneous pain from the upper left anterior teeth for 1 wk. The spontaneous pain was subsequently relieved, but pain on mastication persisted for 3 d. The patient had a dental trauma from a boxing match 15 years ago. Cone beam computed tomography showed that the maxillary left central incisor had oblique fracture lines and a radiolucent lesion around the fracture line. The tooth was diagnosed with an oblique root fracture with no healing and symptomatic apical periodontitis. In the following conservative endodontic management, the coronal and apical fragments of the canal both were chemo-mechanically prepared and obturated using a single cone gutta-percha with iRoot SP (Innovative BioCreamix Inc, Vancouver, Canada), a new calcium silicate-based bioceramic root canal sealer. At follow-ups at 1, 6, 12, and 24 mo, the patient was asymptomatic and the radiolucency around the fracture line was healing radiographically.

CONCLUSION

Conservative root canal treatment is an alternative treatment in some cases of oblique root fracture with no healing. The application of bioceramic sealers and single core obturation techniques may also be essential to obtain an excellent outcome.

Difference in laminated mouthguard thickness according to the laminate order

BACKGROUND/AIM

Mouthguard thickness should be maintained to prevent oral trauma by protecting the teeth and the surrounding soft tissue. The aim of this study was to examine the difference in laminated mouthguard thickness according to the laminate order.

MATERIALS AND METHODS

The mouthguard sheets used in this study were 2.0 mm and 3.0 mm ethylene-vinyl acetate. The sheets were pressure-formed using a pressure former, and the laminated mouthguard was fabricated. Two laminate conditions were examined. One condition used the 2.0-mm sheet for the first layer and the 3.0-mm sheet for the second layer (condition 2F3S) and the other condition used the 3.0-mm sheet for the first layer and 2.0-mm sheet for the second layer (condition 3F2S). The first layer was trimmed to cover the labial surface and incisal edge of the anterior teeth and the buccal and occlusal surfaces of the posterior teeth. The second layer was formed over the first layer. The mouthguard thickness was measured at the labial surface of the central incisor and the buccal and occlusal surfaces of the first molar. Differences in thickness by measurement region of mouthguards formed under different laminate conditions were analyzed by two-way analysis of variance.

RESULTS

The mouthguard thickness was significantly different at the measured regions of the central incisors and the first molars (p < .01). The thickness at the labial surface of the central incisor and at the buccal and occlusal surfaces of the first molar became statistically significantly larger with the 3F2S condition than that for the 2F3S condition (p < .05 or p < .01).

CONCLUSIONS

The thickness of the laminated mouthguard became larger when the sheet thickness of the first layer was greater. It is recommended to use the thicker mouthguard sheet as the first layer when fabricating a laminated mouthguard.

Diagnosis of root fractures using cone-beam computed tomography: difference of vertical and horizontal root fracture

OBJECTIVES

The aim of this study was to investigate the occurrence of vertical and horizontal root fractures using cone-beam computed tomography (CBCT).

METHODS

We reviewed the CBCT images of 51 patients who were examined by CBCT for the diagnosis of root fracture. The occurrences of vertical and horizontal root fractures were investigated concerning the pulpal vitality and the kind of tooth, and analyzed by cross-tabulation. The fracture direction of vertical root fracture and the fracture angle were also investigated, and analyzed by cross-tabulation and Kruskal-Wallis test, respectively.

RESULTS

The occurrence of vertical and horizontal root fractures was statistically significantly different between vital tooth and non-vital tooth (p = 0.044). The occurrence of vertical and horizontal root fractures was also different among anterior, premolar, and molar teeth (p = 0.004). The kind of tooth on traumatized tooth was only anterior teeth and the number was larger on horizontal root fracture. The occurrence of vertical and horizontal root fractures on non-traumatized tooth was different among the kind of tooth (p = 0.007), and the number of vertical root fracture was larger than that of horizontal root fracture on premolar teeth. Fracture direction was not different, but the fracture angle was different among the kind of tooth on vertical root fracture (p = 0.027).

CONCLUSIONS

The results suggested that the number of vertical root fracture was larger on non-vital tooth and that of horizontal root fracture was larger on vital tooth. The number of vertical root fracture was larger on premolar teeth.

Surgical extrusion of a maxillary premolar after orthodontic extrusion: a retrospective study

Objectives

Crown-root fracture and cervical caries in maxillary premolars constitute a challenge in cases of subgingival placement of restoration margins. Surgical extrusion has been practiced successfully in permanent anterior teeth. The aim of the present retrospective study was to assess the clinical outcome of surgical extrusion after orthodontic extrusion in maxillary premolars.

Materials and Methods

Twenty-one single, tapered root maxillary premolars with subgingival crown-root fracture or caries were included. Presurgical orthodontic extrusion was performed on all teeth to prevent root resorption. Extent of extrusion and rotation was determined based on crown/root ratio. The postoperative splinting period was 7 to 14 days. Clinical and radiographic examination was performed at an interval of 1, 2, and 3 months.

Results

After the mean follow-up of 41.9±15.2 months, failure was observed as increased mobility in 3 of 21 cases. No significant difference was observed in the outcome of surgical extrusion based on tooth type, age, sex, 180° rotation, or time for extraction. Furthermore, marginal bone loss was not observed.

Conclusion

Surgical extrusion of maxillary premolars can be a possible therapeutic option in cases of subgingival crown-root fracture.

Combined orthodontic, surgical, and restorative approach to treat a complicated crown-root fracture in a maxillary central incisor

This case report shows the treatment of a severe traumatic tooth injury. For the maxillary right central incisor, the trauma was considered a complicated crown-root fracture. The level of the fracture line, the length of the remaining root segment, and the presence and condition of the tooth fragment determined the type of therapy. Traumatized teeth with fractures below the alveolar crest are often considered hopeless. As this report shows, the treatment of a complicated crown-root fracture in the esthetic region can be challenging. Orthodontic extrusion and crown-length surgery were performed to bring the fracture line above the alveolar bone crest. A multidisciplinary approach was required for complete rehabilitation of the traumatized maxillary incisor. Suggestions are made to improve treatment planning of complicated crown-root fractures.

Management of Multiple Dental Trauma: Case Report with Eight-Year Follow-up

This case report documents the clinical approach adopted for two maxillary incisors with intrusion and horizontal root fracture in the middle third after trauma. The proposed procedures involved maintaining pulp vitality and periodontal stability of the fractured teeth with 8 years of follow-up.

The Evaluation of Root Fracture with Cone Beam Computed Tomography (CBCT): An Epidemiological Study

Background

The aim of this study was evaluation of the cone-beam computed tomography (CBCT) image of 50 patients at the ages of 8-15 suspecting root fracture and root fracture occurred, exposed to dental traumatic. In additionally, this study was showed effect of crown fracture on root fracture healing.

Material and Methods

All of the individuals included in the study were obtained images with the cone-beam computed tomography range of 0,3 voxel and 8.9 seconds.(i-CAT®, Model 17-19, Imaging SciencesInternational, Hatfield, Pa USA).The information obtained from the history and CBCT images of patients were evaluated using chi-square test statistical method the mean and the distribution of the independent variables.

Results

50 children, have been exposed to trauma, was detected root fracture injury in 97 teeth. Horizontal root fracture 63.9% of the 97 tooth, the oblique in 31.9%, both the horizontal and oblique in 1.03%, partial fracture in 2.06% ,and both horizontally and vertical in 1.03% was observed.The most affected teeth, respectively of, are the maxillary central incisor (41.23% left, right, 37.11%), maxillary left lateral incisor (9.27%), maxillary right lateral incisor (11.34%), and mandibular central incisor (1.03%).

Conclusions

Crown fractures have negative effects on spontaneous healing of root fractures. CBCT are used selected as an alternative to with conventional radiography for diagnosis of root fractures. In particular, ıt's cross-sectional image is quite useful and has been provided more conveniences seeing the results of diagnosis and treatment for clinician. Key words:Root fracture, CBCT, Epidemiolog.

A 42-Month Follow-Up of Double Root Fracture of a Lateral Mandibular Incisor

This case report describes the treatment of a double root fracture of a lateral mandibular incisor and its follow- up over 3.5 years.

The reason for the consultation was a tooth mobility following a fall that had occurred 2 days earlier. A test of pulp vitality for tooth 42 was positive. Periodontal probing at the level of the gingival sulcus confirmed the intactness of the epithelial attachment. Retro-alveolar radiographic examination revealed a double root fracture of tooth 42.

A semi-rigid extra-coronal splinting was performed and a light grinding of the incisal edge of tooth 42 was then carried out in light of the dislocation of the coronal fragment, and the occlusion was checked with a strip of articulating paper. The outcomes at 6 months revealed that pulp vitality was still preserved, consolidation of the apical fracture had occurred, and the coronal root fracture was starting to heal. The 1-year, 2-year and 3-year follow ups revealed preserved pulp vitality, an absence of a fracture line in apical images, and no root resorption.

This case report provides evidence for the preservation of vitality in the setting of a double root fracture.

Intentional replantation of adhesively reattached vertically fractured maxillary single-rooted teeth

AIM

To evaluate the clinical outcomes of intentionally replanted maxillary single-rooted teeth with vertical root fractures (VRFs) after being repaired extraorally using 4-methacryloxyethyl trimellitate anhydride/methacrylate-tri-n-butyl borane (4-META/MMA-TBB) resin cement.

METHODOLOGY

Twenty-one root filled maxillary single-rooted teeth with VRFs were evaluated. After atraumatic extraction, fractured fragments were adhesively cemented. The teeth were then replanted and splinted to the neighbouring teeth for 2 weeks. Plaque index (PI), gingival index (GI), probing depth (PD) and clinical attachment level (CAL) were assessed at baseline, 6 and 12 months, and radiographic evaluations were made using PAI scores at baseline and 12 months. Mobility was evaluated using periotest values (PTV) at baseline, 1, 3, 6 and 12 months. Replanted teeth, contralateral teeth (control teeth) and adjacent teeth were analysed statistically using repeated measures one-way anova, unpaired t-tests and Wilcoxon matched-pairs signed-rank tests.

RESULTS

Two teeth were extracted in the first month after surgery. PI, GI, CAL and PD scores of the replanted teeth were significantly lower at 6 month (P < 0.0001 for all) and 12 month (P < 0.0001 for all) postoperatively when compared to baseline, but the values were not significantly different from those of the control and adjacent teeth. PTV of the test teeth increased significantly (P < 0.0001) after the intervention and decreased to baseline levels by month 12. PTVs were significantly higher (P < 0.05) at baseline, 1, 3 and 6 months in the test teeth when compared with the control teeth, but were not significantly different at month 12. PAI scores of teeth with VRF were significantly lower (P < 0.05) at 12 months compared with baseline.

CONCLUSIONS

Adhesive cementation and intentional replantation were an effective treatment modality for this group of vertically fractured maxillary single-rooted teeth. The clinical periodontal parameters decrease by month 6, and the mobility returned to the physiological limits of natural teeth 12 months after replantation.

Multidisciplinary approach for the treatment of horizontal root-fractured maxillary anterior teeth

Dental trauma can lead to a wide range of injuries of which crown and root fractures are examples. Crown-root fractures often need complex treatment planning. This case report describes the use of MTA in the multidisciplinary management of a patient with a horizontally fractured central incisor and luxation in a different central incisor. A 42-year-old female patient presented within 1 h of receiving direct trauma to her maxillary area. Clinical examination revealed that the right and left maxillary central incisors presented mobility and sensitivity to percussion and palpation but no sensitivity to thermal stimulations. Occlusal displacement with extrusion in the left maxillary central incisor and luxation in the right maxillary central incisor was observed. Radiographic examination revealed horizontal root fracture at the apical third of the left maxillary central incisor. Root fracture in the right maxillary incisor was not observed. Endodontic and aesthetic restorative treatments were completed. MTA showed a good long-term outcome when used in root-fractured and luxated teeth. In addition, composite resin restoration provided satisfactory aesthetic results even after 15 months.

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.

Management of complete impacted maxillary second deciduous molar with the aid of cone-beam computed tomography: Case report and a review of the literature

Complete impaction of primary teeth is a very rare condition and less seen at the dental office compared with permanent dentition. To report the use of cone-beam computed tomography in the management of a 7-year-old boy with completely impacted maxillary second deciduous molar due to the presence of odontoma and a cystic lesion.

Dental pulp stem cells from traumatically exposed pulps exhibited an enhanced osteogenic potential and weakened odontogenic capacity

OBJECTIVES

Traumatic pulp exposure can bring about some permanent damages to tooth tissues including dental pulps. This study was designed to evaluate the effects of traumatic pulp exposure on the osteo/odontogenic capacity of dental pulp stem cells (DPSCs).

METHODS

Rat incisors were artificially fractured and dental pulps were exposed to the oral environment for 48 h. Then, multi-colony-derived DPSCs from the injured pulps (iDPSCs) were isolated. Their osteo/odontogenic differentiation and the involvement of NF-κB pathway were subsequently investigated.

RESULTS

iDPSCs presented a lower proliferative capacity than normal DPSCs (nDPSCs), as indicated by MTT and FCM assay. ALP levels in iDPSCs were significantly higher (P<0.01) than those in nDPSCs. Alizarin red staining revealed that iDPSCs exhibited an increased capacity of calcium deposition. Moreover, iDPSCs expressed stronger osteogenic markers (Runx2/RUNX2 and Ocn/OCN) and less odontogenic gene/protein (Dspp/DSP) than nDPSCs in vitro. In vivo transplantation showed that nDPSCs implants generated the typical dentine-pulp complex while all iDPSCs pellets formed the osteodentin-like tissues which were immunopositive for OCN. Mechanistically, iDPSCs expressed the higher levels of cytoplasmic phosphorylated IκBα/P65 and nuclear P65 than nDPSCs, indicating an active cellular NF-κB pathway in iDPSCs. After the inhibition of NF-κB pathway, the osteogenic potential in iDPSCs was significantly down-regulated while odontogenic differentiation was up-regulated, as indicated by the decreased Alp/Runx2/Ocn and uprised Dspp expression.

CONCLUSIONS

Pulp exposure for 48 h decreased the odontogenic capacity and enhanced the osteogenic potential of DPSCs via the NF-κB signalling pathway.

Diagnosis demystified: CT as diagnostic tool in endodontics

Diagnosis in endodontics is usually based on clinical and radiographical presentations, which are only empirical methods. The role of healing profession is to apply knowledge and skills towards maintaining and restoring the patient's health. Recent advances in imaging technologies have added to correct interpretation and diagnosis. CT is proving to be an effective tool in solving endodontic mysteries through its three-dimensional visualisation. CT imaging offers many diagnostic advantages to produce reconstructed images in selected projection and low-contrast resolution far superior to that of all other X-ray imaging modalities. This case report is an endeavour towards effective treatment planning of cases with root fracture, root resorption using spiral CT as an adjuvant diagnostic tool.

The evolutionary paradox of tooth wear: simply destruction or inevitable adaptation?

Over the last century, humans from industrialized societies have witnessed a radical increase in some dental diseases. A severe problem concerns the loss of dental materials (enamel and dentine) at the buccal cervical region of the tooth. This “modern-day” pathology, called non-carious cervical lesions (NCCLs), is ubiquitous and worldwide spread, but is very sporadic in modern humans from pre-industrialized societies. Scholars believe that several factors are involved, but the real dynamics behind this pathology are far from being understood. Here we use an engineering approach, finite element analysis (FEA), to suggest that the lack of dental wear, characteristic of industrialized societies, might be a major factor leading to NCCLs. Occlusal loads were applied to high resolution finite element models of lower second premolars (P₂) to demonstrate that slightly worn P₂s envisage high tensile stresses in the buccal cervical region, but when worn down artificially in the laboratory the pattern of stress distribution changes and the tensile stresses decrease, matching the results obtained in naturally worn P₂s. In the modern industrialized world, individuals at advanced ages show very moderate dental wear when compared to past societies, and teeth are exposed to high tensile stresses at the buccal cervical region for decades longer. This is the most likely mechanism explaining enamel loss in the cervical region, and may favor the activity of other disruptive processes such as biocorrosion. Because of the lack of dental abrasion, our masticatory apparatus faces new challenges that can only be understood in an evolutionary perspective.

Treatment of a vertical root fracture using dual-curing resin cement: a case report

Introduction. Vertical root fracture (VRF) is one of the most frustrating complications of root canal treatment. The prognosis of the root with VRF is poor therefore tooth extraction and root amputation are usually the only treatment options. However, bonding of the fracture line with adhesive resin cement during the intentional replantation procedure was recently suggested as an alternative to tooth extraction. Methods. A vertically fractured left maxillary incisor was carefully extracted, fracture line was treated with adhesive resin cement, a retrograde cavity was produced and filled with calcium-enriched mixture (CEM) cement, and tooth was replanted. Results. After 12 months the tooth was asymptomatic. The size of periapical radiolucency was noticeably reduced and there was no clinical sign of ankylosis. Conclusion. Using adhesive resin cement to bond the fracture lines extraorally in roots with VRF and intentional replantation of the reconstructed teeth could be considered as an alternative to tooth extraction, especially for anterior teeth.