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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 113-116

Management of complicated crown-root fracture in central incisors using intentional replantation with 180° rotation: A case report


1 Department of Pediatric Dentistry, School of Dentistry, Torabinejad Dental Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Pediatric Dentistry, Torabinejad Dental Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication29-Nov-2017

Correspondence Address:
Alireza Eshghi
Torabinejad Dental Research Center, Department of Pediatric Dentistry, School of Dentistry, Hezar Jerib St, Isfahan University of Medical Sciences, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/denthyp.denthyp_34_17

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  Abstract 

Introduction: Complicated crown-root fractures are rare and their treatment is complex. Numerous methods such as crown lengthening and orthodontic or surgical extrusion have been described for the treatment of crown-root fracture. The aim of this study was to report managing complicated crown-root fracture using intentional replantation with 180° rotation. Case report: This case report demonstrates successful management of complicated crown-root fracture in central incisor of a 10-year-old boy using intentional replantation with 180° rotation. Discussion: At 18-month follow-up, the replanted tooth revealed normal function with no obvious resorption.

Keywords: Tooth Crown, Tooth Fractures, Tooth Replantation


How to cite this article:
Faghihian R, Eshghi A, Mosleh H, Akhlaghi N. Management of complicated crown-root fracture in central incisors using intentional replantation with 180° rotation: A case report. Dent Hypotheses 2017;8:113-6

How to cite this URL:
Faghihian R, Eshghi A, Mosleh H, Akhlaghi N. Management of complicated crown-root fracture in central incisors using intentional replantation with 180° rotation: A case report. Dent Hypotheses [serial online] 2017 [cited 2019 Oct 15];8:113-6. Available from: http://www.dentalhypotheses.com/text.asp?2017/8/4/113/219448


  Introduction Top


Complicated crown-root fracture is a rare injury in which the fracture line originates in the crown portion and extends apically into the root in an oblique direction.[1] Most common etiologic factors are injuries caused by falls, bicycle and automobile accidents, and foreign bodies striking the teeth.[2]

Four treatment options can be considered for the management of a tooth with this kind of fracture:[2],[3]
  1. Surgical exposure of the fracture surface
  2. Orthodontic extrusion of the apical fragment
  3. Extraction of the tooth
  4. Surgical extrusion of the root


There are special challenges regarding coronal restoration of teeth with this kind of injury, especially when the fracture line extends below the marginal bone.[3],[4]

Forceps eruption or intentional replantation has several advantages. It takes less time and enables more precise identification of the fracture line.[1] In this procedure, after tooth extraction, tooth replants in a more coronal position to facilitate its restoration.[4]

However, teeth with severe vertical crown-root fracture generally are extracted: when the coronal fragment comprises more than one-third of the clinical root and in cases that fracture follows the long axis of the tooth extraction is inevitable.[2],[3]

In case of palatally inclined fracture, 180° rotation can often imply that only slight extrusion is necessary to accommodate crown restoration due to difference in position of the cementoenamel junction labially and palatally.[2]

This article presents a case of successful management of complicated crown-root fracture by intentional replantation with 180° rotation.


  Case Report Top


A 10-year-old boy was referred to Isfahan Dental School, Department of Pediatric Dentistry because of crown-root fracture of maxillary left central incisor. Informed consent was obtained before any procedure.

The injury was caused by a bicycle accident 1 month earlier. The patient had no medical history and periodontal status was normal. Clinical and radiographic examination revealed complicated crown-root fracture [Figure 1]. Thermal and Electrical Pulp Tester (EPT) (Analytic Technology Pulp Tester®, Redmond, WA, USA) tests indicated that the tooth was vital.
Figure 1: Radiographic examination revealed complicated crown-root fracture

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After administration of local anesthesia (2% lidocaine with 1:80,000 epinephrine; Lignospan; Septodont, Saint Maur des Fosses, France) with infiltration technique, coronal fragment was gently removed and pulp tissue was extripated. It was found that the fracture line has been extended apically to alveolar crest on the distolingual side. The root end was mature, and apex was closed. Tooth was restored with intermediate restoration material (IRM) (Dentsply De Trey, Konstanz, Germany) dressing.

It was decided to treat the patient with intentional replantation with rotation and slight extrusion to establish good access to the fracture line in all sides of the tooth. The PDL was incised using a surgical blade and the root luxated with a narrow periotum. The tooth was extracted gently with an anterior tooth forceps and was inspected for additional fractures. Then, it was rotated 180° to achieve optimal position and replanted in its socket subsequently. Average extraoral time was 4 minutes.

Then, it was splinted with a orthodontic semi-rigid with 1 mm thick wire (Haekwang, Bucheon, Korea) and flowable composite resin (MetafilFlo; Sun Medical, Shiga, Japan).

Incisal edge was trimmed to remove biting force on the affected tooth. IRM was applied to close the access cavity.

Oral hygiene was explained to the patient, and he was advised to eat a soft diet and avoid biting on the injured tooth. Amoxicillin (500 mg) and 0.2% chlorhexidine mouthwash were prescribed.

After 2 weeks, the tooth was reevaluated. IRM dressing was removed. The root canal was instrumented with the RaCe file (BR0; FKG Dentaire, La Chaux-de-Fonds, Switzerland) up to size 40, 06 taper, 1 mm shorter than the root length. After filling, root canal was filled with calcium hydroxide paste prepared in the proportion of 1:1 of calcium hydroxide and normal saline to prevent subsequent resorption and the tooth was restored with IRM. Then the splint was removed. One month later, root canal was obturated with gutta-percha and AH Plus (Dentsply International) sealer by lateral compaction technique after canal irrigation with 2 mL 2/5% NaOCl [[Figure 2]A].[2],[3]
Figure 2: (A) Root canal was obturated with gutta-percha and AH Plus (B) Tooth was restored with composite resin

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After 1 month tooth was prepared for composite resin restoration. First the tooth was trimmed to shape new buccal and lingual surfaces, then 2 mm of gutta-percha was extracted with a heated plugger to achieve intracanal retention and then it was restored with composite resin (3M ESPE, St. Paul, MN, USA) [[Figure 2]B]. Follow-up sessions were scheduled for 1 month, 6 months, and 18 months after treatment. Clinical and radiographic evaluation showed acceptable results in mobility test, probing depth, and clinical attachment level in all follow-up sessions. No evidence of root resorptions or ankyloses was found. [Figure 3] shows follow-up radiographic evaluation.
Figure 3: Shows follow-up radiographic evaluation. (A) 1 months. (B) 6 months. (C) 18 months later

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  Discussion Top


Four treatment options for managing complicated crown-root fracture are surgical exposure of the fracture surface, orthodontic extrusion, extraction of the tooth, and surgical extrusion of the root.[1],[2]

When the fracture line is subgingival, tooth restoration encroaches biological width, and treatment options such as orthodontic extrusion of the apical fragment, surgical crown lengthening, or intentional replantation should be considered.[4],[5]

In this case, intentional replantation was found to be the best treatment option. Orthodontic extrusion of apical fragment is very expensive and time consuming and was not a suitable treatment for this patient with low economic status who was from a city 240 kilometers away from the referred dental office. Orthodontic extrusion can also lead to undesirable gingival overgrowth.[6] It should be mentioned that this treatment is not the first choice, but because of our limitation, this treatment was selected.

Late complications that compromise healing include external root resorption and enlargement of periapical radiolucencies and ankyloses.[6]

The factors affecting the prognosis are carful case selection, atraumatic surgery procedure, and a structured follow-up to evaluate periodontal and pulpal complications.[2],[4]

In fractures that extended apically to alveolar crest, surgical extrusion combined with rotation of the root 180°, less extrusion is needed favoring the bone support of the root and with this rotation, operator can assess fracture meticulously.[2]

Surgical crown lengthening was not considered in this case because it does not meet the esthetic needs in anterior teeth and could cause resorption of the labial cortical plate which interfere with placing dental implants in conditions where tooth extraction is required.

Data on survival rate of intentionally replanted teeth are limited. Success rate of this procedure was reported to be between 72.0% and 88%.[6],[7],[8]

In cases with high mobility and gingival inflammation this treatment is contraindicated.[9] However, none of these conditions was found in our patient. The major disadvantage of intentional replantation is the potential for postoperative root resorption including surface resorption. However, if no further inflammatory stimulus exists, periodontal healing occurs.[8],[9],[10]

To avoid root resorption, damage to the cementum and periodontal ligament should be minimized. In addition, intracanal medication with calcium hydroxide and systemic antibiotic prescription are recommended to prevent infection-related root resorption.[11] In the case described in this article, root resorption was not found after 18 months of follow-up. Atraumatic extraction, systemic antibiotic prescription, root canal filling with calcium hydroxide between treatment sessions, good coronal restoration with high quality sealing, and patient cooperation for maintaining good oral hygiene are important factors for success of this treatment procedure.[1],[10]

This treatment method was reported to be successful by Kahnberg[12] after 5 years of follow-up. Chung et al.[3] reported a case of crown-root fracture treated with intra-alveolar transplantation with 180° rotation and suture fixation, which was a successful treatment after 1 year follow-up. Bender[6] recommended this procedure for teeth with anatomical limitations and difficult accessibility.

Different analysis of this tooth, as described above, revealed that intentional replantation is the best treatment option. Clinical and radiographic assessments were normal after 18 months of follow-up.


  Conclusion Top


Intentional replantation technique is a promising method to treat fractured teeth with poor prognosis. Careful planning is important for the success of replanted tooth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kim DS, Shin DR, Choi GW, Park SH, Lee JW, Kim SY. Management of complicated crown-root fractures using intentional replantation: Two case reports. Dent Traumatol 2013;29:334-7.  Back to cited text no. 1
    
2.
Andreason JO, Andreason FM, Andreason L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2013.  Back to cited text no. 2
    
3.
Chung MP, Wang SS, Chen CP, Shieh YS. Management of crown-root fracture tooth by intra-alveolar transplantation with 180-degree rotation and suture fixation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:126-30.  Back to cited text no. 3
    
4.
Sahebi S, Dolatkhah V, Shojaee NS. Management of a crown-root fracture in central incisors with 180° rotation: A case report. Iranian Endod J 2011;6:183-7.  Back to cited text no. 4
    
5.
Shanmugam J, Mahendran K, Mandhiradoss R. Management of complicated Crown root fractured teeth by intra alveolar transplantation with 180° rotation: Case series. SRM J Dent Sci 2014;5:203-6.  Back to cited text no. 5
    
6.
Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol 1993;76:623-30.  Back to cited text no. 6
    
7.
Raghoebar GM, Vissink A. Results of intentional replantation of molars. J Oral Maxillofac Surg 1999;57:240-4.  Back to cited text no. 7
    
8.
Torabinejad M, Dinsbach NA, Turman M, Handysides R, Bahjri K, White SN. Survival of intentionally replanted teeth and implant-supported single crowns: A systematic review. J Endod 2015;41:992-8.  Back to cited text no. 8
    
9.
Khayat A, Fatehi S. Clinical evaluation of forceps eruption: Reestablishing biologic width and restoring no restorable teeth. Iran Endod J 2006;1:1-5.  Back to cited text no. 9
    
10.
Cho SY, Lee Y, Shin SJ, Kim E, Jung IY, Friedman S et al. Retention and healing outcomes after intentional replantation. J Endod 2016;42:909-15.  Back to cited text no. 10
    
11.
Fariniuk LF, Ferreira EL, Soresini GC, Cavali AE, Baratto Filho F. Intentional replantation with 180 degrees rotation of a crown-root fracture: A case report. Dent Traumatol 2003;19:321-5.  Back to cited text no. 11
    
12.
Kahnberg KE. Intraalveolar transplantation of teeth with crown-root fractures. J Oral Maxillofac Surg 1985;43:38-42.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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