|Year : 2012 | Volume
| Issue : 3 | Page : 121-125
Calcium hydroxide: A boon in complete healing of horizontal apical one-third root fracture
Pushpendra K Verma1, Ruchi Srivastava2
1 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, I.M.S, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Periodontics, Faculty of Dental Sciences, I.M.S, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||27-Nov-2012|
Pushpendra K Verma
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, I.M.S, Banaras Hindu University, Varanasi- 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: A variety of traumatic conditions can cause root fractures. The root fractures are more likely to occur in fully erupted permanent maxillary central incisors with a completely formed root followed by the maxillary lateral and the mandibular incisors. They involve the dental pulp, supporting tissues, and the mineralized structures of a tooth. Diagnosis of the horizontal root fractures is mainly reached by the information obtained in clinical and radiographic examinations. Case Report: This case report describes the management of the horizontal apical one-third root-fractured tooth without surgical removal of the apical fragment, by long-term calcium hydroxide dressing with good signs of healing of fracture at 3 months followed by conventional root canal treatment with the follow-up examination for 1 year after the completion of treatment. Discussion: Calcium hydroxide has showed a miracle in successful healing of apical one-third root fracture.
Keywords: Calcium hydroxide; horizontal root fracture; nonsurgical endodontic treatment
|How to cite this article:|
Verma PK, Srivastava R. Calcium hydroxide: A boon in complete healing of horizontal apical one-third root fracture. Dent Hypotheses 2012;3:121-5
| Introduction|| |
Root fractures of permanent teeth are fairly uncommon and horizontal root fractures have been reported to occur in less than 3% of all dental injuries. These fractures are more likely to take place in fully erupted permanent maxillary central incisors with a completely formed root. More commonly, root fractures occurs in the middle third of the root (57%), followed by fracture in the apical part (34%) and in the coronal part (9%). , They involve the dental pulp, supporting tissues, and the mineralized structures of a tooth. The classification depends upon the direction in which it occurs (horizontal or vertical), the number of fractures lines (simple or multiple), or according to the position at which the root is affected (cervical, middle, or apical).  Horizontal fractures that occur at the coronal third are rare and their prognosis is poor than root fracture at the middle or apical third.  When root fracture occurs horizontally, the coronal segment may displace to a varying degree, but generally the displacement of apical segment does not occur. Because the apical pulpal circulation is not disrupted, there is an extremely rare occurrence of pulp necrosis in the apical segment. ,
The diagnosis of root fractures may be reached by the clinical and radiographic examinations. Sensitivity to palpation and/or percussion allows the identification of tooth that presents trauma, but not necessarily fracture. When it is located at the cervical third there is remarkable mobility, at the middle third there is increased mobility, and at the apical third it is nearly normal mobility of coronal fragment. 
The present case describes a management of horizontal apical one-third root-fractured tooth without surgical removal of apical fragment, by long-term calcium hydroxide dressing with good signs of healing of fracture followed by conventional root canal treatment with follow-up examination for 1 year after the completion of treatment.
| Case Report|| |
A 45-year-old male patient presented to the Department of Endodontics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India, about 3 months after trauma from a fall. Patient's chief complaint was pus discharge from gums and pain on palpation in the apical region, in relation to upper-right lateral incisor. The patient attended a private dental clinic 3 months after trauma and treatment was started there. An access opening and working length determination was done there and when a fracture was accidentally detected in the working length radiograph, the patient was referred to our department for further management. Intraoral examination revealed well-preserved maxillary teeth, with discharging sinus in relation to tooth 12, without any discoloration or mobility of the traumatized tooth. The tooth 12 showed tenderness to apical palpation and percussion. All the adjacent teeth showed positive pulp vitality to thermal testing except in tooth 12. The radiographic examination showed horizontal fracture on the apical-third of root of tooth 12 with signs of periapical pathology [Figure 1].
Based on the present clinical condition, root canal treatment of both the fragments was started. Informed consent was taken before the beginning of the treatment. Biomechanical preparation was done with frequent irrigation with 5.25% sodium hypochlorite. After thorough cleaning and shaping, the entire canal was filled with Calcium hydroxide paste [Figure 2]. The calcium hydroxide dressing was changed frequently at an interval of every 1 month for 3 months. At 3 months follow-up, the clinical examination of tooth 12 showed reduced tenderness to apical palpation and percussion and healed sinus tract. The radiographic examination showed decrease in periapical pathology and the healed fracture line with calcified tissue [Figure 3]. The calcium hydroxide dressing was removed from entire canal by irrigation with 5.25% sodium hypochlorite and dried with paper points. Finally the canal was obturated with gutta-percha point and zinc-oxide eugenol sealer, with lateral condensation technique [Figure 4]. The patient was followed up clinically and radiographically for 1 year [Figure 5]. At 1 year, there was no tenderness to palpation and percussion of affected tooth and radiograph revealed a healed fracture line with continued healing of the periapical lesion.
| Discussion|| |
A variety of traumatic conditions can cause root fractures, although the literature shows some predominant causes such as falling while playing and running, during sports activities, and blows received on the face. In this case, the patient had horizontal apical one-third root fracture on the right lateral incisor due to fall during running. Maxillary central incisors are most prone to injury, accounting approximately 80% of all dental injuries, followed by the maxillary lateral and the mandibular incisors. 
As in this case, it is reported that 31% of the patients with root fractures were identified coincidentally at subsequent dental radiographic examination. The prognosis for tooth survival following a horizontal root fracture is quite good.  Healing of the horizontal fracture with or without initial treatment is reported to occur up to 70-80% of the cases. 
The treatment of fracture should be initiated immediately. Immediate management involves the care of gingival tissues, which are commonly dilacerated, repositioning and retention. In our case, the time gap between trauma and treatment was about 3 months and the mobility of coronal segment was not there, so it was difficult to reposition the fracture segments. The period of retention pulp tissue status depends on the position of the root fracture.  The repair depends on health of the pulp, dentine, cementum, and alveolar bone, stage of root formation, time period between trauma and treatment, the location of the fracture, reduction in fracture and retention and degree of displacement of the coronal fragment. Root fractures at the apical third are more difficult to immobilize and have a higher probability of pulp contamination. ,,
When the fracture is immediately reduced, there may be reunion of the fragments with formation of mineralized tissue. If the fracture is not immediately repositioned and there is no contamination of the pulp tissue, there may be a repair by interposition of bone or fibrous tissue between the fragments, which can be regarded as healing. The type of repair, either with bone or with fibrous tissue, depends on the pulpal status, especially of coronal portion, as it occurs only in the presence of vital pulp. When the aggression to the pulp is greater, there is an increased possibility for pulpal necrosis that affects the repair and healing.
In the study on fractures in the middle and apical parts of the root, splinting of the luxated coronal fragments and the duration of splinting were found to be less important, whereas factors such as root development, pulpal vitality, and reduction of dislocated fragments were highly predictive of the frequency.  Pulpal necrosis may be determined most accurately initially after the accident by radiographic evidence of an unhealing fracture, continued tooth mobility, spontaneous pain, and persistent or severe percussion sensitivity. In our case, there was no mobility of coronal fragment so splinting was not done. After a root fracture, the apical fragment remains vital in approximately 99% of cases but the pulp tissue on the coronal fragment can develop necrosis with consequent formation of granulation tissue between the fragments. 
In cases of horizontal root fracture the incidence of necrosis is over 20%, so it has been suggested that immediate endodontic intervention should be avoided; only clinical and radiographic follow-up should be the treatment of choice, provided there are no clinical and/or pathological signs. , Decision for endodontic treatment should be taken after 3 months of follow-up, if the tooth still fails to respond to electric or thermal pulp testing and if radiographs show radiolucency next to the fracture line. 
In our case, pulpal necrosis was present in both the coronal and apical fragment and it was confirmed by clinical and/or radiographic examination and thermal pulp testing. Clinically, there was sinus tract discharging pus in relation to tooth 12, denoting the contaminated fracture site. Radiographically, there was radiolucency next to the fracture line and in the periapical area. Thus, decision was made to perform endodontic treatment in coronal fragment and surgical removal of the apical fragment. But patient was not ready to go for surgical treatment due apprehension, so the treatment was modified to perform a nonsurgical endodontic treatment in both the fragments through the fracture line, which was quite difficult and the prognosis was in dilemma because any endodontic manipulation, medicaments, and fillings have detrimental effect on the fracture site.
There are two conditions responsible for fracture repair or healing, that is, damage to the pulp and bacterial invasion. If fracture is not contaminated with bacteria and the fragments are united or close, there may be a possibility of repair, by formation of a dentin callus between the two fragments. Healing is complicated, when fracture site is contaminated because there is accumulation of granulomatous tissue between the root fragments as a reaction against pulp infection. , Granulation tissue is formed when a severe injury to pulp occurs with odontoblastic activity failure. The ideal condition for consolidation is fracture sealing to the oral environment, because the contact with oral secretions generates contamination and subsequent healing failure. 
When there is pulp necrosis in the coronal fragment, it should be detected and treated as soon as possible because the necrotic pulp releases toxins into the fracture area, and thus may impair the pulp present at the apical fragment.  Pulpal necrosis often occurs only in the coronal fragment, whereas the pulpal tissue in the apical fragment may remain vital; hence, root canal treatment is performed only in the coronal fragment. But, it is difficult to seal coronal fragment because an apical stop is often impossible to achieve. ,
Calcium hydroxide has been used to achieve an apical stop to seal the coronal fragment. In our case, it was not aim at forming the apical stop in the coronal segment. Calcium hydroxide is antimicrobial because of its release of hydroxyl ions that can cause damage to the bacterial cellular components. Besides the fact that Ca(OH) 2 functions as a potent disinfectant, early evidence has been suggested that it has osteoinductive properties, although it has been difficult to demonstrate this effect in vitro. The high pH may be a contributing factor for the induction of hard tissue formation.  Calcium hydroxide also has the ability to dissolve necrotic tissue. In this respect, it has been found that when a Ca(OH) 2 dressing is used in addition to irrigation with NaOCl, the canal is cleaned as effectively. In our case, Ca(OH) 2 was packed into the entire canal and was spread into the fracture line, sealing the fracture site. At 3 months, the fracture site was healed showing normal anatomy of root with a good sign of healing of periapical lesion. At 1 year, the patient was symptomless. The main drawbacks of this calcium hydroxide procedure is the need of multiple visits, susceptibility of treated canals to reinfection, and susceptibility of treated roots to fracture, in immature teeth, because root resistance to fracture reduces after a long-term contact between calcium hydroxide and root dentin. 
| Conclusion|| |
Although there are detrimental effects of any endodontic manipulation, medicaments or any fillings through the fracture line, but if the root canal is completely cleaned, thoroughly disinfected and prevented from any reinfection during treatment, the healing of fracture site may be possible as in this case. Here calcium hydroxide has showed a miracle in successful healing of apical one-third root fracture.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]