QUINTESSENCE INTERNATIONAL

Sandra Tobiska Gabriel Krastl 12 years’ preservation of maxillary permanent incisors with cervical root fractures adjacent to aggressive periodontitis: Report of a case

Sandra Tobiska, Dr med dent1/Gabriel Krastl, Prof Dr med dent2

This case report presents long-term results following hori- consisting of splinting and nonsurgical periodontal therapy zontal root fracture of both maxillary central incisors in a was initiated. Follow-up at 12 years after the start of treat- 19-year-old woman with aggressive periodontitis. Due to ment revealed a stable situation from clinical and radiologic extensive marginal bone loss and the close proximity of the perspectives. Permanent fixation to the adjacent teeth and fracture lines to the bottoms of the periodontal pockets, the regular supportive periodontal care were the basis for a prognosis of both teeth was uncertain at the time of the favorable long-term prognosis. (Quintessence Int 2018;49: accident. Nevertheless, a conservative treatment strategy 543–548; doi: 10.3290/j.qi.a40469)

Key words: aggressive periodontitis, cervical root fracture, dental trauma, splinting

The prognosis of teeth with horizontal root fractures is The treatment of choice for root fractures is reposi- influenced by various factors, including the age of the tioning and splinting of the displaced coronal frag- patient, the stage of root development, localization of ment. The recommended splinting period is 4 weeks in the fracture relative to the alveolar crest, mobility of the most cases. However, fractures located in the cervical coronal fragment, and dislocation and diastasis.1 Many region may require a longer splinting period of up to 3 studies have confirmed a good prognosis for horizontal months, particularly if the coronal fragment is highly root fractures if adequate therapy is administered.2-4 mobile.5 Root fractures, which are relatively rare (accounting for 0.5% to 7% of traumatic dental injuries),6 heal via bridging of the fracture gap by connective tissue (48% to 66%) or bony callus formation (18% to 30%). Heal-

1 Assistant Professor, Department of Conservative , Periodontology and ing does not occur in 16% to 22% of affected teeth, Endodontology, University Hospital Tübingen, Germany. and in 20% to 44% of affected teeth, pulp necrosis 2 Professor and Head, Department of Conservative Dentistry and Periodontology, Center of Dental Traumatology, University Hospital of Würzburg, Germany. develops, necessitating of the 7 Correspondence: Dr Sandra Tobiska, Department of Conservative Dentistry, coronal segment. Periodontology and Endodontology, University Hospital Tübingen, This case report presents long-term results follow- Osianderstr. 2–8, 72076 Tübingen, Germany. Email: [email protected] ing conservative treatment of two maxillary central

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Fig 1 Anterior region 1 day after trauma. Fig 2 Panoramic radiograph taken on the day of the accident.

Fig 3 Radiograph taken on highly mobile. Possible communication of the fracture the day of the accident. gap with the oral cavity could not be safely eliminated. In addition, periodontal pockets and associated hori- zontal bone loss were detected. In this case, treatment decisions were determined based on several pre-injury and injury factors, including the unfavorable positions of the fracture lines, bone loss due to untreated periodontitis, high tooth mobil- ity, and the young age of the patient. Tooth preservation was considered despite the questionable prognosis since alternative, more invasive treatment options, such as extrusion of the apical frag- incisors with root fractures near the bottoms of the ments or implant placement, were associated with periodontal pockets in a patient with aggressive peri- other risk factors. odontitis. Initial findings, therapy, and control at 3½ Accordingly, the patient was thoroughly informed years were the subject of a case report published in about treatment options and the existing periodontitis. 2007.8 Preservation of the teeth was selected because other treatment options could still be performed later if the root fractures failed to heal. Additionally, periodontal CASE PRESENTATION treatment was planned to avoid further loss of attach- Initial treatment ment, minimize mobility, and prevent subsequent In 2002, a 19-year-old woman with an uneventful med- infection of the fracture gap through communication ical history was referred to the Department of Conser- with the oral cavity. vative Dentistry, Periodontology and Endodontology at The teeth were splinted for 3½ months using a com- University Hospital Tübingen, Germany, which she first mercially available titanium ring splint (Mondeal Medi- visited one day after falling on her maxillary central cal Systems) to promote root fracture healing. incisors (Fig 1). Clinical and radiologic examination A diagnosis of aggressive periodontitis was sug- showed cervical root fractures of both maxillary central gested by not only the advanced attachment loss of incisors (Figs 2 and 3). Both coronal fragments were the molars and incisors (Fig 4a) in this clinically healthy

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Figs 4a to 4e Development of probing depths at the sulcus and degrees of tooth demobility. patient at a young age but also the patient’s paternal ganisms (Porphyromonas gingivalis, Treponema denti- family history. Subsequently, prior to periodontal treat- cola, and Tannerella forsythia), the administration of ment, molecular microbiologic analysis was performed antibiotics as an adjunctive periodontal treatment was using a commercially available assay (PadoTest 4.5, deemed unnecessary. Deep Institut für Angewandte Immunologie IAI). The test were performed. results indicated type III, which was stated to indicate At a periodontal reevaluation 8 weeks later, the moderate periodontal disease. Since there was no evi- pocket depths showed only minor improvement dence of Aggregatibacter actinomycetemcomitans and a (Fig 4b). Subsequently, all periodontal pockets were lack of high counts of periodontopathogenic microor- retreated with an ultrasonic scaler (Piezon Master 400,

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a

Figs 5a and 5b Anterior area 12 years after trauma. b

EMS), with povidone-iodine (Betaisodona, Mundip- cification was evident in both the apical and coronal harma; diluted 1:4) used for subgingival irrigation. At fragments. The bone support of the coronal fragments the recall appointment 4 months later, clear reduction appeared unchanged or even slightly improved com- in the probing depths was detected (Fig 4c). pared with that detected in the initial radiographs. The Within the framework of the initial check-up exam- well-corticalized bone crest in the maxillary anterior inations of the two maxillary central incisors, patho- region was regarded as a result of successful periodon- logic changes such as loss of sensitivity, infection of the tal therapy. No radiologic evidence of an endodonti- fracture gap, and worsening of periodontal conditions cally induced bony lesion was detected. The results of remained absent. During the first 2 years after her the microbiologic investigation using PadoTest 4.5 trauma, the patient was recalled every 4 to 6 months corresponded to type I periodontal disease, which was (Fig 4d). Because the patient lived somewhat distant an improvement compared with the initial results of from the institution, intermediary clinical and radio- type III periodontal disease. logic control examinations were performed by her The four maxillary incisors were splinted with a family dentist, who administered a supportive peri- multi-stranded flexible orthodontic wire (0.45 mm) odontal care program that she attended. bonded to the palatal surface using flowable compos- The patient returned to the clinic for a follow-up ite. The patient’s family dentist had applied the splint 1 visit 12 years after her trauma. year before due to apparent mobility of the teeth. Despite residual mobility of the affected teeth, which Control examination 12 years after trauma may be attributed to the rather flexible retainer, the Diagnostic findings in the anterior region (Fig 5), such patient stated that she had become accustomed to and as sensitivity to carbon dioxide snow, sensitivity to per- felt comfortable with her situation and did not see a cussion, and tooth color were unchanged compared need for action with respect to esthetics or function. with the initial findings. She remained highly motivated over time. Two preg- All probing depths were within normal limits with nancies (in 2008 and 2011) and the associated hor- no bleeding, and only one site had a probing depth of monal changes may have negatively affected the 4 mm (Fig 4e). A radiograph at 12 years showed healing patient’s periodontal situation. In 2011, the family den- of the transverse fractures with interposition of connec- tist conducted another nonsurgical periodontal treat- tive tissue in both affected teeth (Fig 6). The fracture ment, using manual instrumentation for subgingival line showed blunted edges, and partial pulp canal cal- scaling and root planing. This treatment in 2011, earlier

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Fig 7 Panoramic radiograph 12 years after trauma.

Fig 6 Control radiograph 12 years after trauma.

periodontal therapy, and associated supporting peri- the oral cavity, and provides good bone-level mainte- odontal therapy minimized further attachment loss and nance and stabilization for later implantation.11 In the thereby favorably affected the preservation of both present case, the short apical fragments were not central incisors. regarded as suitable abutments for fixed restorations. According to information provided by the patient, Resin-bonded all-ceramic fixed dental prostheses pro- she had received two implants for missing mandibular vide a minimally invasive treatment option for manag- second premolars in 2011 (Fig 7). Furthermore, she ing anterior tooth loss12 and show excellent clinical continues to participate in the supportive periodontal longevity, especially if a cantilevered design is used.13 In care program provided by her dentist. the present case, a two-retainer design with the lateral incisors as abutment teeth would have been required for replacement of the two adjacent incisors. This ap- DISCUSSION proach has been shown to produce less favorable The therapy of root-fractured teeth is well investigated results than approaches that utilize a cantilevered in the literature1-5,7,9 and supported by international design.14 Moreover, the use of the lateral incisors with treatment guidelines.10 reduced periodontal tissues as abutment teeth may In the present case, the initial situation, which have increased the risk of failure. Implant placement involved highly unfavorable fracture locations close to was not considered because of the potential for com- the bottoms of the periodontal pockets, substantial plications related to implant infraposition, which has mobility, and dislocation of the coronal fragments with been observed particularly in the maxillary anterior diastasis and the presence of existing periodontal region in young women.15 Furthermore, the placement disease, suggested an uncertain prognosis for both of two adjacent implants in the periodontally compro- affected incisors. Thus, different treatment options had mised esthetic zone would have been a significant to be considered. Orthodontic extrusion of the apical challenge, and this approach has been associated with fragment is a viable treatment approach for root-frac- a significantly higher risk of failure in patients with tured teeth when the fracture gaps communicate with aggressive periodontitis than in healthy patients.16

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Taking into account all these considerations, keep- CONCLUSION ing the affected teeth appeared justifiable. The applied splint at that time was rather rigid, which is in contra- The successful long-term preservation of root fractured diction to recent guidelines favoring more flexible teeth in the described case despite unfavorable basic splints for root fractured teeth.10 However, due to the conditions should serve as encouragement for tooth reduced periodontal support of the entire maxillary an- preservation in similar cases. terior region, absolute immobilization in the trauma- tized region was unlikely despite the splint applied. REFERENCES Thus, the splint might not have interfered with the 1. Andreasen JO, Andreasen FM, Mejàre I, Cvek M. Healing of 400 intra-alveolar natural healing events. root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage Root canal treatment of the affected teeth was not of root development, fracture type, location of fracture and severity of dislo- cation. Dent Traumatol 2004;20:192–202. performed because they reacted to thermal sensitivity 2. Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534 incisors after intra-alveo- test throughout the observation period. However, it is lar root fracture in patients aged 7-17 years. Dent Traumatol 2008;24:379–387. 3. Zachrisson BU, Jacobsen I. Long-term prognosis of 66 permanent anterior well known that testing the neural supply of the pulp teeth with root fracture. Scand J Dent Res 1975;83:345–354. does not necessarily reflect the pulpal blood flow. A 4. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Root fractures: the influence of type of healing and location of fracture on tooth survival rates – an analysis of false-negative result may be possible if the pulpal 492 cases. 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Dent Traumatol regarded as an indirect sign of pulp vitality. Further- 2002;18: 57–65. 8. Tobiska S. Wurzelquerfrakturen der Zähne 11 und 21 in Kombination mit more, it was shown that pulp canal obliteration in aggressiver Parodontitis bei einer 19-jährigen Patientin. Endodontie 2007;16: both fragments was a good predictor of union with 65–70. 9. Cvek M, Andreasen JO, Borum MK. Healing of 208 intra-alveolar root fractures connective tissue.18 in patients aged 7-17 years. Dent Traumatol 2001;17:53–62. Undoubtedly, the preservation of two severely com- 10. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental promised central incisors for 12 years can be regarded injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol as a success even though the most favorable type of 2012;28: 2–12. 11. Malmgren O, Malmgren B, Frykholm A. 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