Traumatic Injuries:
Avulsed and Root-Fractured Maxillary Central Incisor
Bill Kahler and Louis M. Lin
Chief Complaint
“The splint had come loose” on a tooth that had been root fractured and the avulsed coronal fragment came off.
Medical History
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.
Dental History
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.
Figure 23.1 A periapical radiograph showing the retained apical fragment of the root of tooth #8 and the space (red arrow) from which the coronal fragment of the root was avulsed. The retained apical fragment has an open apex.
Figure 23.2 The coronal fragment of the root of tooth #8 was repositioned by the emergency dentist of a hospital and splinted with interproximal composite resin to teeth #7 and #9. The root fragments have been placed in close apposition (red arrow).
Clinical Evaluation (Diagnostic Procedures)
Examinations
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.
Figure 23.3 A clinical photograph of the second splint consisting of composite resin and light wire placed after failure of the interproximal composite resin splint. The remains of the first splint placed earlier that same day are seen between teeth #8 and #9 (red arrow). A 4/0 silk suture was placed between teeth #7 and #8 to unite a gingival laceration.
Diagnostic Tests
| Tooth | #7 | #8 | #9 | #10 |
| Percussion | – | + | – | – |
| Palpation | – | + | – | – |
| Cold | + | – | + | + |
| EPT | Vague | – | + | Vague |
EPT: Electric pulp test; +: Response to percussion or palpation, and normal response to cold and EPT; –: No response to percussions, palpation, cold, or EPT
Radiographic Findings
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.
Pretreatment Diagnosis
Pulpal
Pulp Necrosis, tooth #8
Apical
Normal Apical Tissues, tooth #8
Treatment Plan
Recommended
Emergency:Place a flexible splint
Definitive:Close follow-up of tooth #8
Alternative
If symptoms/signs of infection of tooth #8 develop, endodontic treatment of the coronal fragment will be performed.
Restorative
Composite resin
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
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).
Figure 23.4 A clinical photograph of the third splint of composite resin and Ribbond® (red arrow) placed after the patient had been referred for specialist management.
Figure 23.5 A periapical radiograph showing good apposition of the fractured root fragments with the third splint (red arrow).
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).
Figure 23.6 A clinical photograph taken 1 month after the initial injury showing the Ribbond® splint distended (red arrow) and tooth #8 extruded below the occlusal plane. There is a gingival swelling adjacent tooth #8.
Figure 23.7 A periapical radiograph taken 1 month after the initial injury showing separation of the two fractured fragments (red arrow). Loss of alveolar bone on the distal aspect of tooth #8 is evident.
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).
Figure 23.8 A periapical radiograph showing the coronal root fragment of tooth #8 root filled with MTA. The access cavity has been restored with glass ionomer cement and composite resin. The root fragments remain separated (red arrow).
Post-Treatment Evaluation
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).
Figure 23.9 A periapical radiograph taken 1 year after the injury showing healing by deposition of calcific tissue between the fractured root fragments (red arrow). Intra-canal calcification of the apical fragment is evident. An incidental finding was the PA radiolucency associated with #7 consistent with a diagnosis of asymptomatic apical periodontitis (AAP). This tooth was responsive to cold pulp sensibility testing consistent with a false positive test. The management of this tooth is not discussed in this report.
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).
Figure 23.10 A periapical radiograph taken 10 years after the injury. Healing by hard tissue is likely as no periodontal ligament (PDL) space is evident between the previously fractured root fragments (red arrow). Further calcification of the apical fragment has occurred. Teeth #7 and #9 have been root filled. A favorable healing outcome, as evidenced by osseous repair for all root-filled teeth.
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