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Case of the Month

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July 2004Horizontally Fractured Maxillary Incisors: 2 Cases - Treat or Not?


July's Case of the Month deals with two patients. The first one was a female aged 34 that had traumatized her central incisors when she approximately 18 years ago. Both centrals had been endodontically treated and restored with post and core and ceramic crowns. The patient was very happy with the present aesthetics and overall situation. Unfortunately, because of the age of the treatment and that fact that it had been done in a different part of the country, no films of the original condition were available.

Fig. 2

The patient also presented with evidence of buccal sinus that was draining just to the right of the patient's incisive frenum. (Fig.2 ) She was completely asymptomatic but had been told by her dentist that there was an infection that needed treatment. Tracing the fistula caused some discomfort and I tried to be as gentle as possible during the procedure. What impressed me most was the lack of definitive periapical pathology that is usually associated with lesions of endodontic origin that cause drainage. I made sure to check the Perio probings for signs of possible vertical fracture, but there were none. Periodontal probing was within normal range.

Closer examination of the radiograph showed what appeared to be an area of resorption on the Distal aspect of the root at the most apical extent of the post in tooth #21. ( The distal crown margin was also showed some discrepancy.)

Fig. 3

I surmised that a horizontal root fracture had occurred at the most apical extent of the post. This may have been the result of function, or a complication of the original injury. In any case, a decision had to be made as to how to treat this case or whether treatment was warranted at all.

Disassembly and endodontic retreatment meant loss of the crown, risked further root fracture and possible catastrophic loss of the tooth. Surgical treatment was also ruled out because surgical resection would reduce the crown root ratio to an unfavorable level.

After discussing the options with the patient, we decided to leave the tooth as is. I gave instructions to the referral to monitor the area for further signs of pathology. The patient was told that resorption had occurred as a result of the original injury but that it was impossible to tell whether it would cease or continue with time. It was possible that these teeth would have to be extracted and replaced by implants at some time in the future.

July's second Case of the Month deals with another 26 year old female patient that also had history of 10 year old traumatic incident. In this case, #11 and 12 had been treated endodontically but #21 had been crowned without treatment. #21 sustained a complete horizontal root fracture at the midroot that was clearly visible in the X ray image.

Fig. 4 - Referral's Film

The crown appeared to be supra-erupted and the tooth was tender to percussion and touch. Pulp tests (cold) were negative. There was no obvious periapical pathology associated with the apical fragment. Probing depths were normal. A diagnosis of necrosis of the coronal fragment of the root was made and I elected to open the tooth without anesthesia to confirm my diagnosis.

Fig. 5 - My film

The crown was accessed without incident and necrosis was found. The canal was cleaned,shaped and medicated with CaOH for 1 week. The patient's symptoms subsided and the tooth was comfortable.

Fig. 6

A chloroform dip technique (see Custom Fitting Gutta Percha for details) was used to assist the apical fit of a large gutta percha point that had been "rolled down"with a cold roll technique.

Fig. 7

The case was packed just slightly short of the radiographic terminus to ensure that no sealer became trapped between the root fragments. We have no plans to remove the apical section since it is asymptomatic and is very likely still vital.

I explained to the patient that the crown root ratio was poor and that the tooth would likely be exfoliated when she got older and the gingiva receded. I suggested that she prepare herself for eventual replacement with an implant.

Two trauma cases are presented for discussion. Case management of each is quite different. In the first case, the patients concern about aesthetics, the lack of symptoms, the potential costs and risk of loss of the teeth all contributed to the decision not to treat.

In the second case, treatment was performed on the coronal fragment only. The patient was prepared for eventual loss of this tooth.

It is important to know when to treat (and which portions !) and when to not treat.