Avulsed and Root-Fractured Maxillary Central Incisor
Bill Kahler and Louis M. Lin
“The splint had come loose” on a tooth that had been root fractured and the avulsed coronal fragment came off.
The patient (Pt) was a 10-year-old healthy male. Pt was taking no medication. Medical history was non-contributory.
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
The boy had fallen running down the stairs at home, which caused a horizontal mid-root fracture of tooth #8. The coronal fragment was avulsed and immediately placed in milk and re-implanted into the socket 1 hour later in the Emergency Department of a hospital. Tooth #8 was stabilized by interproximal composite resin. The periapical (PA) radiograph showed the socket of avulsed coronal fragment (Figure 23.1) and repositioned coronal fragment in the socket (Figure 23.2). A silk suture was placed for a gingival laceration. The splint de-bonded later that day and a composite resin and light wire splint was placed. The second splint de-bonded again and the Pt was referred to a specialist for management and seen the next day.
Extra-oral Examination (EOE)
There was no asymmetry, swelling, or discoloration of the face. No palpable lymph nodes in neck area were present. Some swelling of the upper lip was noted.
Intra-oral Examination (IOE)
Oral hygiene was good. At the emergency clinic, a 4-0 silk suture had been placed for a gingival laceration. There was no swelling or draining sinus tract. A composite and wire splint had de-bonded from tooth #7. Interproximal composite resin between teeth #8 and #9 from the first splint was still present (Figure 23.3). Tooth #8 had grade 2 mobility. Tooth #9 had an uncomplicated crown fracture.
EPT: Electric pulp test; +: Response to percussion or palpation, and normal response to cold and EPT; –: No response to percussions, palpation, cold, or EPT
Figure 23.1 shows a mid-root horizontal root fracture of tooth #8 where the coronal fragment of the root was avulsed. The retained apical fragment has an open apex. Figure 23.2 shows the repositioned coronal fragment.
Pulp Necrosis, tooth #8
Normal Apical Tissues, tooth #8
Emergency:Place a flexible splint
Definitive:Close follow-up of tooth #8
If symptoms/signs of infection of tooth #8 develop, endodontic treatment of the coronal fragment will be performed.
First visit (Day 1): The prior splints of composite resin and wire were removed. The silk suture was also removed. A composite and Ribbond® fiber splint (Ribbond, Seattle, WA, USA) was placed (Figure 23.4). A PA radiograph was taken to check the correct repositioning of the coronal fragment (Figure 23.5).
Second visit (1 week): One week review showed healing of the gingival tissue. Tooth #8 was asymptomatic (ASX).
Third visit (2 weeks): Again the tooth was ASX after another one week review.
Fourth visit (1 month): A gingival swelling was noted in the buccal (B) gingiva of tooth #8. Tooth #8 was extruded (Figure 23.6). A PA radiograph of tooth #8 revealed a space between the fractured fragments as well as loss of PA bone (Figure 23.7). The tooth did not respond to electric pulp test. A diagnosis of pulp necrosis and gingival abscess was made. The procedure and prognosis for root canal treatment of the coronal fragment was discussed with the Pt’s parents, and informed consent was obtained. Tooth #8 was anesthetized with 1.8 cc, 2% lidocaine (lido) containing 1:100,000 epinephrine (epi) administered by local infiltration. A rubber dam (RD) was placed on tooth using a cuff technique with Wedjets® (Coltene, Altstätten, Switzerland). The length of the coronal fragment from the incisal edge to the level of fracture was determined radiographically with a size #40 Hedstrom file. The working length was 12 mm. The pulp chamber was accessed and necrotic tissue was removed with minimal mechanical debridement. The canal of the coronal fragment was irrigated with 1% sodium hypochlorite (NaOCl) solution, dried and dressed with (Ca(OH)2) to a level of 12 mm below the incisal edge. The access cavity was closed with Cavit™ (3M, Two Harbors, MN, USA) and glass ionomer cement, Fuji IX GP® (GC Corporation, Tokyo, Japan).
Fifth visit (3 months): The Pt was symptom free and the gingival tissue appeared healthy. A RD was placed on tooth #8 without local anesthesia. The tooth was accessed and irrigated with 1% NaOCl, and rinsed with 17% Ethylenediaminetetraacetic acid (EDTA). The canal was dried, and mineral trioxide aggregate (ProRoot® MTA; Dentsply Sirona, Johnson City, TN, USA) was placed in the canal using Buchanan pluggers to the level of fracture site. A wet cotton pellet was placed on the MTA to facilitate the setting of the material. The access cavity was restored with Cavit™ and glass ionomer cement. The fiber and composite resin splint was removed. The tooth had grade 1 mobility.
Sixth visit (3 months and 1 week): The tooth was isolated with a RD without local anesthesia. The access cavity was reopened and the cotton pellet removed. The setting of MTA was checked with an endodontic explorer. The access cavity was restored with composite resin. The coronal fragment was slightly displaced from the apical fragment (Figure 23.8).
Seventh visit (1-year follow-up): Tooth #8 was ASX and had grade 1 mobility. A PA radiograph revealed blunting of the fractured fragments on the lateral borders of the root. Deposition of calcified material adjacent to the MTA and intracanal calcification of the apical fragment was evident. The coronal fragment was slightly displaced from the apical fragment. There was evidence of healing of fractured fragments by interposition of calcific tissue. No inflammatory or replacement root resorption was noted. A large periapical radiolucency was associated with tooth #7 (Figure 23.9).
Eighth visit (10-year follow-up): Tooth #8 was ASX and had grade 1 mobility. A PA radiograph of tooth #8 showed similar presentation as observed ten years before. Teeth #7 and #9 were subsequently treated with non-surgical root canal therapy (NSRCT) because of development of pulpal–periapical disease (Figure 23.10).