h b y u i n n current aspects of restoring tese n c e ...treatment of tooth fractures. since...

$: h b y u i N n Current Aspects of Restoring tese n c e ...treatment of tooth fractures. Since ex-posed dentinal tubules permit invasion of bacteria into the endodontic system, a protective$
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124THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 6 • NUMBER 2 • SUMMER 2011

Current Aspects of Restoring

Traumatically Fractured Teeth

Gabriel KrastlAssistant Professor, Department of Periodontology, Endodontology and Cariology and

Head of the Center of Dental Traumatology, University of Basel, Switzerland

Andreas FilippiProfessor, Department of Oral Surgery, Oral Radiology and Oral Medicine, and

Head of the Center of Dental Traumatology, University of Basel, Switzerland

Nicola U. ZitzmannProfessor, Department of Periodontology, Endodontology and Cariology,

Center of Dental Traumatology, University of Basel, Switzerland

Clemens WalterAssistant Professor and Director of Postgraduate Programme in Periodontology,

Department of Periodontology, Endodontology and Cariology,

University of Basel, Switzerland

Roland WeigerProfessor and Chair, Department of Periodontology, Endodontology and Cariology,

Center of Dental Traumatology, University of Basel, Switzerland

Correspondence to: Dr Gabriel Krastl

Center of Dental Traumatology, University of Basel, Hebelstr. 3, CH-4056 Basel, Switzerland;

tel: +41 61 267 26 22; fax: +41 61 267 26 59; e-mail: [email protected]

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Abstract

Endodontic and restorative considera-

tions are of primary significance in the

treatment of tooth fractures. Since ex-

posed dentinal tubules permit invasion

of bacteria into the endodontic system,

a protective dressing must be applied

as part of the emergency treatment.

Pro vided the dentin wound has been

sealed, restorative treatment can also

be carried out at a later stage. The frac-

tured tooth fragment can be reattached

using adhesive protocols in order to re-

store function and esthetic appearance.

If reattachment is difficult or impossible,

eg, in cases of multiple or missing frag-

ments, current composite materials ena-

ble excellent esthetic results. Minimally-

invasive direct composite restorations

are preferred over the more invasive

indirect restorations, at least in imma-

ture teeth with an extensive coronal

pulp dimension. Restorative treatment

of crown-root fractures is frequently de-

manding due to inaccessible subgingi-

val fracture margins. Extrusion of the re-

maining root is an alternative method to

surgical crown lengthening for re-estab-

lishing the biological width. This can be

carried out either orthodontically (forced

eruption), or surgically (intra-alveolar

transplantation). Although the treatment

of crown-root fractures is one of the most

technically sensitive procedures in den-

tal traumatology and is frequently con-

sidered as a long-term temporary resto-

ration, tooth conservation up to the age

at which implants can be placed may be

regarded as a success.

(Eur J Esthet Dent 2011;6:124-141)



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Introduction

A dental trauma can be a traumatic ex-

perience for the patient, most often a

child. While the patient’s primary con-

cern is to have the visible effects of the

accident rectified, the practitioner must

take into account the consequences of

individual treatment options, which fre-

quently have serious implications. Aside

from minor luxation injuries such as con-

cussion or loosening of the teeth, crown

fractures are the most common conse-

quences of dental trauma. Fractures of

the roots, on the other hand, occur very

rarely.1,2

Tooth fractures are most frequently

observed in the permanent dentition,

while luxation injuries are more likely in

the deciduous dentition because of its

more elastic bone structure.3

Restorative and endodontic consid-

erations are of primary importance in

treating tooth fractures.4 Injuries to peri-

odontal structures must be taken into

account, especially in cases of root frac-

ture and crown-root fracture, because of

the luxation of the coronal fragment.

This article provides an overview of

the current state of knowledge regard-

ing the treatment of tooth fractures in the

permanent dentition.

Diagnosis and classifica-

tion of tooth fractures

Tooth fractures (Table 1) primarily af-

fect the enamel and/or the dentin. How-

ever, in many cases the pulp tissue is

also involved, either directly through the

fracture line, or indirectly when exposed

dentinal tubules allow the entry of micro-

organisms.5 Furthermore, the energy of

impact resulting in a tooth fracture can

also cause damage to the periodontium.

Accordingly, a detailed diagnosis

must be carried out to identify all con-

comitant injuries, including both the

obviously injured teeth and adjacent

dentition, which may be affected. As

with all tooth trauma, the standard clini-

cal examination comprises evaluation

of tooth mobility, dislocations, circular

probing pocket depths, injuries to the

soft tissues, as well as sensitivity and

percussion tests. Most tooth fractures

are localized in the crown region and

therefore easy to diagnose. Any type of

trauma, particularly intra -alveolar frac-

ture, requires radiographic examination

as well. In relevant cases, cone-beam

computed tomography (CBCT) avail-

able at specialized centers provide

valuable three-dimensional information

about the fracture morphology and/or

potential pulp involvement.

The direction and position of fracture

lines caused by frontal impacts fall into

four categories: horizontal crown frac-

tures, horizontal tooth fractures at the

neck of the tooth, oblique crown-root

fractures, and oblique root fractures.6

Enamel infractions

Traumatically-induced enamel cracks

demonstrate variously patterned infrac-

tion lines, which are hard to visualize

and frequently overlooked.7 Illuminat-

ing the tooth with different light sources

from various directions, or illuminating

the tooth through the dental hard tis-

sue, makes the fine discontinuities in

the enamel visible and helps to assess

the extent of the fracture. An exact esti-

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mation of the depth and possible crack

propagation in the dentin is, however,

not feasible.

Crown fractures

Crown fractures may be restricted to

the enamel or may also involve the

dentin. In the latter case, the pulp may

be exposed, depending on the fracture

line.

Enamel fractures are frequently local-

ized in the incisal region, leaving behind

a rough, sharp-edged surface. Clinical

symptoms are rather unlikely, provided

that there is no concomitant luxation

injury to the respective tooth. As soon

as crown fractures additionally affect the

dentin or the pulp, increased tempera-

ture sensitivity has been observed.7

Crown-root fractures

In maxillary anterior teeth, crown-root

fractures have a typical fracture line: on

the facial side, the fracture is localized

paragingivally or supragingivally, while

palatally the defect often extends far

into the root region. Although the coronal

fragment reveals increased mobility, it is

still retained palatally by the intact peri-

odontal fiber attachment. Usually, only

one fracture line is diagnosed in the peri-

apical radiographs and corresponds to

the buccal fracture line. The palatally

situated fracture is, however, usually not

visible because of an overlap with the al-

veolar bone and the absence of diasta-

sis between the fragments in this region.

In order to assess the extent of the frac-

ture, it is necessary to remove the coro-

nal fragment. The pulp is frequently, but

not always, involved.8

Root fractures

Radiographic imaging is, in most in-

stances, the only way to diagnose root

fractures. Eccentric radiographs (usu-

ally increasing the projection angle in

the maxillary anterior teeth) facilitate vis-

ibility of the oblique fractures, especially

when the findings from the ortho radial

radiographs are inconclusive. CBCTs, if

Table 1 Classification of tooth fractures

Enamel infractions

Visible cracks in the enamel without loss of tooth substance.

Crown fracture (with and without pulp involvement)

Enamel or enamel-dentin fracture with possible exposure of the pulp.

Crown-root fracture (with and without pulp involvement)

Crown fracture extending to the root. Mobile crown fragment is often still attached to the gingiva.

An exposure of the pulp occurs frequently but is not inevitable.

Root fracture

Horizontal or diagonal fracture of the root. There is often increased mobility of the coronal fragment,

possibly with luxation. Contact with the oral cavity via the sulcus is possible, and depends on the

localization of the fracture line.

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available, provide valuable information

about the location of the fracture line in

relation to the gingival sulcus and the al-

veolar bone level. In problematic cases,

the fracture spreads to the oral cavity,

most often palatally. Since transverse

root fractures are always accompanied

by a luxation injury of the coronal frag-

ment, this fragment may be loosened

or luxated. Depending on the resultant

damage to the pulp, sensitivity testing

may be negative.9

Treatment of tooth

fractures

Endodontic and restorative considera-

tions are of primary importance in the

treatment of tooth fractures. Within the

context of the emergency treatment, a

definitive restoration is not necessarily

required. Simple measures serving to

promote the vitality of the tooth are essen-

tial as part of the initial treatment. These

treatment modalities comprise covering

the existing dentin wounds, or splinting

in case of root fractures. Maintaining

pulp vitality ensures the physiological

completion of root development, espe-

cially in immature teeth.10 Any required

restorative and/or additional endodontic

treatments can be carried out at a later

stage.

Enamel cracks

Enamel cracks do not generally require

any special treatment measures. Al-

though in vitro studies have identified

enamel cracks as potential entries for

microorganisms,11 an infection of the

endodontic system is unlikely if the pulp

is healthy. In individual cases, seal-

ing with acid-etching techniques may

be worthwhile if there are pronounced

enamel cracks and/or in cases of a luxa-

tion injury with concomitant pulp dam-

age.

Crown fracture without pulp

exposure

Restorative treatment of crown fractures

confined to the enamel is not essential

in every case. The sharp edges are

smoothed and polished. Another possi-

bility is treatment with composite, which

necessitates removal of broken enamel

rods by chamfering the edges of the

fracture lines.

Most crown fractures cause a dentin

wound. In regions near the pulp, 80% of

the total cross-sectional area consists of

the lumina of the dentinal tubules. This

presents a high risk of infection of the

pulp tissue.10 The sealing of the exposed

dentin surface that has been applied in

the course of the emergency treatment

has to be removed (possibly keeping the

dressing near the pulp). Before place-

ment of the final adhesive restoration,

the surface of the fracture is cleaned,

using a small brush and pumice flour.

This cleaning step must be carried out

with the utmost care, in order to pre-

vent impairment of composite adhesion.

When removing an adhesive dressing,

refreshing the area to be bonded with a

fine diamond bur is recommended.

Reattachment restoration

The adhesive reattachment of the coro-

nal fragment12 easily facilitates the re-

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establishment of function and esthetics

(Fig 1). Reattachment is, however, not

recommended if multiple fragments are

involved because of the difficulties in

handling and a possibly compromised

esthetic outcome. As long as the frag-

ments have been stored under moist

conditions after the accident, reattach-

ment is ideally performed immediately in

the course of the emergency treatment,

so that removal of an initial dressing at

a later stage is avoided. However, if the

fragment is kept in dry conditions for an

extended time period, both the esthetic

result and the bond strength are com-

promised.13 The above problems can

be avoided by storing the fragment in

water for several hours.

Rehydration time can be shortened by

storing the fragment in a pressure vessel

filled with water. Storing the crown frag-

ments in a special tissue culture medium

(tooth rescue box) is not necessary,

since no vital cells need to be kept alive.

If rehydration of the fragment is required,

reattachment should be performed the

following day; in the meantime, dentin

should be covered with a temporary ma-

terial that is easy to remove (eg, light-

curing calcium hydroxide cement, Ultra-

blend Plus, Ultradent Products, South

Jordan, UT, USA).

Fig 1 Reattachment restoration: (a) crown fracture in the maxillary left central incisor, (b) exposed pulp,

(c) direct pulp capping with calcium hydroxide, (d) after reattachment of the fragment with composite

resin.

a

c

b

d

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The tooth surface and the fragment

are pretreated with an adhesive system

before reattachment. Multi-step sys-

tems using phosphoric acid etching are

preferable to the simplified self-etching

products. Precuring the bonding agent

would impair the fit and should there-

fore be avoided. Composites of medium

consistency (flowables) are suitable as

attachment media, and facilitate com-

pensation for the partial loss of hard tis-

sue.

Additional preparation such as cham-

fering the enamel margins or place-

ment of an internal groove can lead to

improved bond strength, but impede

re positioning of the fragment.14 In in-

dividual cases where there is a small

adhesion surface, the fragment can be

adhesively reattached first; the fracture

lines are then chamfered with a round

diamond bur, followed by composite

restoration. Clinical studies demonstrate

that reattachment of the coronal frag-

ment is a realistic alternative to place-

ment of conventional resin-composite

restorations.12

Direct composite

restoration

If repositioning of a coronal fragment is

difficult or even impossible in cases of

multiple or missing fragments, current

composites enable excellent esthetic

results (Fig 2).15,16 While smaller defects

can be easily built up in a “freehand”

manner, the restoration of larger coronal

parts requires a waxup, or a direct in-

traoral composite mock-up to evaluate

the treatment outcome. Creating the oral

and incisal contours of the crown is of

crucial importance for the success of this

procedure. The proper spatial referenc-

es are then preserved using a silicone

index. After removal of the mock-up, the

edges of the enamel are chamfered. The

composite restoration is built up, prefer-

ably using a rubber dam. Alternatively,

retraction cords can be placed in the

gingival sulcus to establish dry condi-

tions, along with cotton rolls, so that any

contamination of the adhesion surfaces

by sulcus fluid is prevented. The use of

special esthetic composites is advisable

to achieve optimal results. These materi-

als offer a great variety of different colors

and opacities, thus enabling layering

techniques to be carried out based on

the structure of natural teeth.

Due to the great improvements in

filler technology over the last decades,

modern small-particle hybrid compos-

ites and particularly nanocomposites

facilitate stable optical surface charac-

teristics, similar to those of the enamel.

Placement of various composite layers

are required in order to replicate normal

tooth structure. First, the palatal parts of

the tooth are built up with a thin layer of

transparent enamel material placed in

the silicon index, which is then applied

to the teeth before light-curing. Different

matrix techniques can be used to facili-

tate proximal contouring. The individual

matrix technique suggested by Klaiber

et al is efficient for more difficult cases.

With this technique, transparent matri-

ces are attached to the adjacent tooth

with a temporary filling material (eg, Sys-

temp Onlay, Ivoclar Vivadent, Schaan,

Liechtenstein) and molded before cur-

ing to produce well-proportioned ap-

proximal contours.17 Further layering is

carried out with opaque dentin mass to

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Fig 2 Composite restoration: (a) crown fracture with chamfered enamel margins, (b) buildup of the

palatal and proximal walls by means of a silicone index, (c) dentin core with opaque material, (d) polished

restoration before simulation of an adequate micromorphology, (e) surface texture created with a coarse

diamond bur, (f) situation after polishing with a brush and polishing paste.

a

c

e

b

d

f

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build up the dentin core. The extension

of the artificial dentin core exceeds that

of the natural tooth and partly covers the

chamfered enamel, nonetheless leaving

adequate space for a thin (0.3–0.5 mm)

enamel layer in the labial region. Accord-

ing to the previous tooth analysis and

shade selection, the incisal edge can

be characterized by highly transparent

material, which accentuates the existing

mamelon structures of the dentin core.

Craze lines or hypo-calcifications within

the dentin or enamel can be simulated

by applying intensive (usually white or

brown) colors to specific regions of the

restoration to match the appearance of

the remaining dentition. Finally, the arti-

ficial enamel layer is placed without over

contouring the restoration.

Finishing is performed with polishing

strips, fine aluminum oxide disks (Sof-

Lex, 3M ESPE), and abrasive impreg-

nated silicon rubber points (Jiffy Polish-

ers medium, Ultradent) at low speed. If

required, the enamel surface texture is

reproduced using a 40 μm diamond bur

for a short time. A final polishing proce-

dure with a silicon carbide particle brush

(Occlubrush, Kerr Hawe; Bioggio, Swit-

zerland) and a felt wheel with polishing

paste (Enamel plus Shiny C, Micerium;

Avegno, Italy) add luster and shine. A

recently published book by Hugo18 con-

tains superbly illustrated step-by-step

instructions about the clinical procedure

for carrying out esthetic direct anterior

restorations.

While the initial esthetic properties of

composites are widely accepted, there

are only limited data on the long-term

clinical outcomes of anterior composite

restorations.16,19 Due to the high failure

rates in children, composite restorations

are often considered as a semi-perma-

nent solution at that age.20,21 However,

bearing in mind that one of the main

reasons for restoration loss is a new

trauma,21 the available studies may not

reflect the real potential of direct anterior

restorations.

Indirect ceramic

restorations

The use of all-ceramic restorations

(veneers or crowns) is always a feasi-

ble alternative to the direct composite

technique in view of the excellent es-

thetic results22 and the high survival

rates.23 Tooth preparation can, however,

entail additional damage to the pulp,

especially in vital immature teeth with

extended coronal pulps. In the authors’

opinion, the indication of indirect resto-

rations should be restricted to extensive

defects in adult patients.

Crown fractures with pulp

exposure

In cases of crown fracture with pulp ex-

posure, endodontic treatment must be

carried out either during the initial treat-

ment or before performing the restorative

treatment. In general, vital pulp therapy

should be preferred over root canal treat-

ment. The indication depends on the pre-

sumed condition and the regenerative

capabilities of the pulp.24 Decisive fac-

tors comprise the size of the exposure,

the stage of root development, the age

of the tooth, the pulpal health before trau-

ma, and the time elapsed between the

injury and the emergency treatment.25

The latter is considered to be the most

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important parameter, since the longer

the pulp is exposed to the oral environ-

ment, the greater the likelihood of partial

or entire pulp infection. In addition, the

resistance of the pulp to infections may

be substantially impaired when a con-

comitant luxation injury compromises

the nutritional supply to the endodontic

system.26

Direct pulp capping

Although it has been shown that direct

capping is still possible after an exposure

time of up to 24 hours, it appears advis-

able to restrict this period to a maximum

of 2 hours.27 Small pulp exposures are

capped with calcium hydroxide or MTA

(mineral trioxide aggregate). Avoiding

bacterial penetration by efficient seal-

ing with a final restoration is crucial for

a good long-term prognosis. The suc-

cess rate after direct pulp capping is

high (81–88%)28,29 but does not reach

that of partial pulpotomy (94–96%).30,31

This may be attributed to a superficial in-

flammation of the pulp tissue developing

soon after exposure. The risk of infection

led to a more restrained indication for

direct pulp capping (Trope 2008, lecture

at the Annual Meeting of the Academy of

Dental Materials).

Partial pulpotomy

In cases of pulp exposure for more than 2

hours, partial pulpotomy is indicated (Fig

3).30 The potentially infected exposed

pulp tissue is removed under continu-

ous irrigation with physiological saline

solution. The healthy pulp tissue is clini-

cally identified by the symptom of bleed-

ing that stops within 5 minutes. Hence

the exposure time itself is a less limiting

factor than the pulp status; irreversible

pulpitis prevents covering the ampu-

tated pulp due to continuous bleeding.

The formation of a blood clot may com-

promise the outcome and should be

avoided. Therefore, pulpal hemorrhage

is best controlled with sodium hypochlo-

rite.32,33 Calcium hydroxide or MTA is

applied to the artificially exposed pulp

surface and coated with a layer of set-

ting calcium hydroxide base material.

From a biological point of view, MTA is

preferable in cases of vital pulp therapy

since it has superior long-term sealing

ability and stimulates a higher quality

and greater amount of reparative den-

tin.33,34 Although scarcely mentioned in

the recent literature,35 tooth discolora-

tion following MTA application may im-

pair the esthetic result. Partial pulpotomy

has a high success rate,31 irrespective

of the amount of pulp exposed and the

stage of root development. Additional

root formation can be expected in im-

mature teeth when the procedure is suc-

cessfully performed. This avoids, on the

one hand, a costly and time-consuming

apexification and, on the other, provides

additional strength, considering that im-

mature teeth have an increased fracture

incidence.36

Pulpectomy

The removal of the entire pulp with sub-

sequent root canal treatment (Fig 4) is in-

dicated if there are no realistic chances

for regeneration of the pulpal structures,

for example, in cases of concomitant se-

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Fig 3 Partial pulpotomy: (a) complicated crown

fracture with sealed dentin during emergency treat-

ment just after the accident, (b) exposed pulp after

removal of the sealing material, (c) bleeding after

removal of the potentially infected tissue, (d) after

cessation of bleeding (e) after placement of calci-

um hydroxide on the pulp surface, (f) reattachment

of the coronal fragment, (g) final radiograph.

a

c

e

g

b

d

f

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vere luxation injury. In immature teeth, an

apical plug with MTA before further root

canal filling has proven its worth as an

alternative to conventional apexification,

using calcium hydroxide.

Restorative treatment

The same options that are available for

crown fractures without pulp exposure

are available for restorative treatment.

Crown-root fractures with and

without pulp exposure

The treatment of crown-root fractures

is difficult, requiring consideration of

periodontal, endodontic and, in par-

ticular, restorative aspects. Although

maintaining vitality is desirable (using

the measures mentioned above), this is

often precluded due to the necessity of

an endodontic post for the retention of

coronal build-up. Restorative treatment

of crown-root fractures is even more

demanding when fracture margins are

located deeply subgingival. Additional

smaller dentin fractures can occur on

the palatal side of the root. All fragments

must be removed in order to assess the

situation and to initiate treatment prop-

erly (Table 2).

It is not essential to restore the origi-

nal defect completely in every case. A

supragingival restoration margin that

covers only a part of a steep fracture

line may be preferable over subgingival

margins. In many cases, however, ad-

equate treatment depends on good

access to the defect site. This can be

achieved by performing a surgical

Table 2 Treatment options for crown-root fractures

Clinical situation Options for restorative treatment

Defect accessible (possibly after using

simple measures such as electrotomy)OPTION 1: Restorative treatment of the whole defect

Defect not accessible

OPTION 2: Restorative treatment of the accessible

regions (mostly supragingival)

OPTION 3: Denudation of the fracture site / surgical

crown lengthening + restoration

OPTION 4: Orthodontic extrusion of the apical fragment

(forced eruption) + restoration

OPTION 5: Surgical extrusion (intra-alveolar transplanta-

tion) + restoration

Tooth cannot be restored OPTION 6: Extraction

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crown lengthening, provided that es-

thetics are not compromised. Selective

reduction of the alveolar bone makes the

defect accessible for restorative treat-

ment and re-establishes the biological

width. The distance between the base of

the gingival sulcus and the alveolar bone

crest is relatively stable in the context of

periodontal health. The term “biologic

width” refers to the histological dimen-

sions of epithelial and connective tissue

attachment. The biologic width is 2 mm

on average.37 Placement of subgingival

crown margins or insufficiently adapted

margins may lead to accumulation of a

pathogenic biofilm and subsequently to

gingival inflammation and loss of peri-

odontal attachment.38,39

From a clinical point of view, a distance

of at least 3 mm between the margin of

a restoration and the limbus alveolaris

is suggested.40 Several pre-prosthetic

possibilities are discussed in order to

establish the biologic width. Surgical

crown lengthening, using apically re-

positioned flaps and (selective) reduc-

tion of the alveolar bone are options in

cases for which esthetics are not com-

promised. A healing period of at least 6

months after surgical crown lengthening

is indicated when prosthetic reconstruc-

tions are planned on such teeth.41

Extrusion of the remaining root is an-

other alternative, which can be carried

out either orthodontically (forced erup-

tion)42,43 or surgically (intra-alveolar

Fig 4 Root canal treat-

ment due to pulp necro-

sis after crown fracture

with concomitant luxation

injury: (a) pulp necrosis

after crown fracture (with-

out any dentin sealing

during emergency treat-

ment), (b) initial radio-

graphic view, (c) situation

after root canal treatment,

internal bleaching and di-

rect restoration with com-

posite (Filtek Supreme

XT, 3M Espe), (d) radio-

graphic view of the root

canal-treated tooth.

a

c

b

d

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Fig 5 Surgical extrusion: (a and b) crown-root

fracture of the right lateral incisor, clinical view, (c) intra-alveolar transplantation after 180° rotation of the

extracted root, (d) splinting, (e) radiographic view

of the surgical extrusion, (f-i) restoration with com-

posite, (j) radiographic view after 3 months with root

canal filling and functional healing on tooth 12, and

root-fractured tooth 11 with root canal filling in the

coronal fragment (apical fragment shows circumfer-

ential periodontal ligament space), (k) 2 years after

therapy following final restoration with composite.

a

c

b

d

transplantation).44 For the surgical ex-

trusion, the root is extracted, re-implant-

ed after 180° rotation, and splinted in a

position located more coronally (Fig 5).

Provided that an atraumatic extraction

technique is employed, there is little

mechanical damage to the root cement

layer. Periodontal healing (without anky-

losis) can therefore be expected (simi-

lar to the situation after avulsion and im-

mediate replantation). Clinical studies

confirm the favorable prognosis of this

method with periodontal healing in up to

90% of all cases.44,45

Esthetic rehabilitation includes all

methods of restorative treatment, rang-

ing from composite buildups to the

placement of crowns, depending on the

residual tooth substance.

Although the treatment of crown-root

fractures is one of the most technically

demanding procedures in dental trau-

matology, and is considered in many

cases rather as a long-term temporary

restoration, even tooth conservation

up to the age at which implants can be

placed is accepted as success.

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Root fractures

The treatment of intra-alveolar root frac-

tures does not generally require any

restorative treatment other than radio-

graphic observation. In most cases, the

pulp in both coronal and apical frag-

ments survives or recovers with no need

for any endodontic therapy.46

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a

e

cb d

Fig 6 Orthodontic extrusion after cervical root

fracture: (a) after extraction of the coronal fragment,

(b) amount of the orthodontic extrusion, (c) radio-

graphic view 2 years after therapy, (d) radiographic

view 4 years after therapy, (e) clinical view 4 years

after therapy (extrusion, root canal treatment, endo-

dontic post, composite buildup, composite crown).

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If pulp necrosis occurs, it is restricted in

the majority of cases to the coronal frag-

ment. Hence, only this fragment should

be root canal treated if necessary.10

In cases of intra-extra-alveolar root

fracture, the coronal fragment at least

has to be extracted. If the residual at-

tachment of the apical part is sufficient,

the root can be extruded according

to the procedures recommended for

crown-root fractures in order to enable

restorative treatment (Fig 6).

Conclusion

When treating traumatically fractured

teeth, endodontic and in some cases

periodontal aspects have to be consid-

ered in order to promote healing of the

injured tissues.

The recent developments in adhesive

dentistry during the last decades have

simplified the restorative care of patients

with crown fractures. If re attachment of

fragments is not possible, current com-

posite materials enable excellent es-

thetic results and should be preferred

over indirect restorations, particularly in

young patients. Tooth preparation is non-

invasive, usually restricted to chamfering

the enamel margins, thus minimizing the

risk of additional pulp damage.

Prognoses for crown-root fractures are

more difficult to estimate.4 In many cas-

es, the pulp has to be sacrificed because

of the necessity of an endodontic post

for retention of the coronal fragment or

a core buildup. However, the prognosis

of restored root canal treated teeth may

also be compromised due to caries, and

restorative and/or periodontal reasons.

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