Archives of Dental Sciences 2010, Vol.

1, Issue 1, 69-72

Clinical Case Report Anuradha Agarwal

Case Report
Use of MTA and Intraradicular Splinting in Horizontal Root Fracture. A case report
Anuradha Agrawal1, Anand Shigli2 1. 2. M.D.S., Lecturer, Department of Pedodontics & Preventive dentistry, Government College of Dentistry , Indore (M.P.) India 452001 M.D.S., Professor & Head, Department of Pedodontics & Preventive Dentistry, Modern Dental College & Research Centre, Indore (M.P.) India 452112

Correspondence Author: Anuradha Agrawal M.D.S. Lecturer, Department of Pedodontics & Preventive Dentistry, Government College of Dentistry, Indore (M.P.) e-mail- anupiyush@hotmail.com Abstract Background: Root fractures in permanent teeth are uncommon injuries and represent complex healing patterns and seen more commonly in children. Mineral trioxide aggregate, or MTA, is a new material developed for endodontics that appears to be a significant improvement over other materials for fracture repair. It is the first restorative material that consistently allows for the overgrowth of cementum, and it may facilitate the regeneration of the periodontal ligament. Case Description: This case report presents the endodontic management of a horizontally fractured lower left lateral incisor using MTA and intraradicular splinting technique. Repositioning of fractured fragments was followed by intraradicular splinting of the tooth using a NiTi file and MTA as sealer. This case demonstrates that MTA and intraradicular splinting can be used to manage horizontally fractured teeth. Follow up: At 24 months follow up teeth is asymptomatic and clinical and radiographic investigation of the teeth revealed excellent healing patterns. Conclusion: MTA can be considered as a good choice for a definitive root filling material in horizontal tooth root fractures with excellent biological and physical properties. Key words: Horizontal root fracture, MTA, Intraradicular splinting.

Introduction Root fractures in permanent teeth are less frequent injuries comprising 0.5 to 7 % of all dental trauma cases1. Horizontal root fractures occur mainly in the anterior region of the maxilla, usually owing to a frontal impact, more frequently observed in fully erupted teeth with complete root formation1, 2. Horizontal fractures occur most frequently in the middlethird of the root and rarely in the apical-third1,3,4. The prognosis is poorer if the fracture level is in the coronal third 5.Treatment is usually directed at repositioning and stabilizing a tooth (if necessary) in its correct position and monitoring the tooth for an extended period for pulpal vitality6. Root fractures represent complex healing patterns due to concomitant injury to the pulp, periodontal ligament, dentine and cementum1. Mineral Trioxide Aggregate (MTA)

is a biocompatible material with numerous interesting clinical applications in endodontic. The material appears to be an improvement over other materials for some endodontic procedures that involve root repair and bone healing 7. This report records the use of MTA to achieve a barrier on the coronal aspects of the fracture lines and intraradicular splinting in mandibular lateral incisor with horizontal root fractures. The treatment and long term 2-year follow-up of treated mandibular lateral incisor is presented. Case Report A 13 year old male child visited the department of Pedodontics with the complaint of loose tooth in the lower front region. He had suffered a dental injury in the lower anterior teeth due to fall while playing. Trauma had happened five

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Archives of Dental Sciences 2010, Vol.1, Issue 1, 69-72

Use of MTA and Intraradicular Splinting Anuradha Agarwal

months ago. The patient had visited a general dentist, but did not receive any treatment. The clinical examination revealed grade II mobility with 32 and slight discoloration (Figure 1A).

shaped with a no. 40 K file and the canal was filled with Gutta percha points. Splinting of four lower anterior teeth done by composite wire splint. (Figure 1D).

Figure 1A: Pre treatment clinical view

Figure 1D: Splinting of anterior teeth

The tooth did not respond to electric and thermal pulp tests. Discomfort was noted during percussion and palpation. Radiographic examination revealed horizontal fracture in the cervical third of the root on the lower left lateral incisor, separating the coronal and apical root fragments from each other (Figure 1B).

The patient was recalled one week later, the gutta percha of the coronal fragment was carefully removed from the canal. Then the canal was filled with MTA (ProRoot MTA, DENTSPLY Tulsa Dental) and a NiTi file (Protaper) [which was selected earlier and cut to fit the canal was coated with MTA and inserted into the canal to act as intracanal splint. Sufficient amount of MTA was maintained around the file in the canal (Figure 1E). The access cavity was sealed appropriately.

Figure 1B: Pre-treatment fracture

Figure 1C: Alignment of fragments.

The fractured segments were displaced with space between them. There was no significant bone loss. Patients oral hygiene was satisfactory. Endodontic treatment of the incisor was initiated under local anesthesia. The two displaced fragments were realigned using straight probe. (Figure 1C). A number 15K file was passed through the fracture in lower left lateral incisor to access the apical root segment. The necrotic pulp tissue was extirpated. The root canal was cleaned,

Figure 1E: Mineral Trioxide Aggregate placement in canal

Figure 2: At 6 months follow up

The patient remained asymptomatic for the next four weeks , at which time he returned for removal of the splint . He had no complaint and no change in probing depths or in results of clinical tests. The tooth was not tender to percussion. The patients postoperative course was uneventful. Follow-up was done at three and every 6 month interval. At first 6 month

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Archives of Dental Sciences 2010, Vol.1, Issue 1, 69-72

Use of MTA and Intraradicular Splinting Anuradha Agarwal

recall visit, the left central incisor was asymptomatic and responded normally to percussion, palpation and pressure, with no mobility (Figure 2). The last follow up was at 24 months patient is still asymptomatic and his IOPA x-ray shows excellent healing. (Figure 3)

probability of pulpal necrosis. This was justified when the access was achieved; necrotic pulp tissue was noticed in the canal. Radically, both fragments were treated endodontically because of the risk of apical fragment to have been infected due to the necrosis. By the insertion of NiTi file into the canal a proper approximation of the fracture fragments was aimed. Previous studies have shown that proper repositioning of the coronal fragment is essential for successful healing of the horizontal root fractures. Fractured roots that radiographically revealed less space between the fragments after repositioning healed more frequently with hard tissue repair than those with more space between the fragments 11,12. Hence intraradicular splint was attempted to approximate the fragments for a better healing of the fracture. Materials such as zinc oxide-eugenol cement and resin composite have been used in the past to repair root defects, but their use resulted in the formation of fibrous connective tissue adjacent to the bone. Earlier studies have used AH26 and polycarboxylate cement as the sealer. The disintegration of AH26 and polycarboxylate cement by tissue fluids may cause a foreign body reaction at the fracture site8. Because it allows the overgrowth of cementum and periodontal ligament, MTA may be an ideal material for certain endodontic procedures 13,14. In this case MTA was used as sealer due to the established advantages of MTA in endodontics. Conclusion In this case treatment of horizontal root fractured tooth was carried out with intraradicular splinting using endodontic file and MTA as fracture line sealer. This case demonstrates that intraradicular splinting and MTA is an alternative technique for managing horizontally fractured teeth with necrotic and mobile coronal segment.

Figure 3: Radiograph at 24 months follow up

Discussion Root fracture is one of the consequences of dental trauma. The treatment principles for horizontally fractured teeth involve maintaining pulp vitality by immobilizing the coronal segment. Four types of healing can be observed following the root fractures: healing with calcified tissue, interposition of connective tissue, the interposition of connective tissue and bone and interposition of granulation tissue8. However, in case of nonvital pulp endodontic treatment is required to render the tooth aseptic. The separation of the fragments is an important variable to fracture healing9. Immobilization of the fragments with a rigid splint is arguable. For some authors, the rigid splinting must be maintained for two to three months, to provide matrix position in accordance with principles for root healing 4,10. However, some studies have found that the matrix deposition occurs to a greater extent in teeth, which are not submitted to immobilization, as root consolidation takes place more efficiently under functional stress 4, 11. In the presented case, endodontic treatment was carried out. Although a negative response to the electric pulp test at early examination is not indicative for endodontic treatment, slight discoloration of the crown increased the

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Archives of Dental Sciences 2010, Vol.1, Issue 1, 69-72

Use of MTA and Intraradicular Splinting Anuradha Agarwal

Refrences: 1. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol. 2004 Aug;20(4):192-202. 2. Versiani MA, Sousa CJ, Cruz-Filho AM, Cruz-Perez DE, Sousa-Neto MA. Clinical management and subsequent healing of teeth with horizontal root fractures. Dental Traumatology 2008;24:136-139. 3. Caliskan MK, Pehlivan Y. Prognosis of root-fractured permanent incisors. Endod Dent Traumatol 1996;12:129-36. 4. Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to theTeeth. 4th Edition. Oxford: Blackwell Munksgaard; 2007. 5. Feiglin B. Clinical management of transverse root fractures. Dent Clin North Am 1995;39:53-78. 6. Clark SJ, Eleazer P. Management of a horizontal root fracture after previous root canal therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:220-3. 7. Bramente CM, Menezes R, Moraes IG, et al. Use of MTA and intracanal post reinforcement in a horizontally fractured tooth: a case report. Dent Traumatol 2006;22:275-8. 8. Rustem K S, Melike O S, Bulent Yilmaz, Muzeyyen Kayatas. Intraradicular splinting of a horizontally fractured central incisor: a case report. Dental traumatology. 2008; 24: 680-684. 9. Ozbek M, Serper A, Semra C. Repair of untreated horizontal root fracture: a case report. Dental traumatology. 2003; 19: 2967. 10. Artvinli LB, Dural S. Spontaneously healed root fracture: a case report. Dental traumatology. 2003; 19: 64-5. 11. Cvek M, Andreasen JO, Borum MK. Healing of 208 intralveolar root fractures in patients aged 7-17 years. Dental traumatology. 2001; 17:53-8 12. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dental traumatology. 2004; 20:203-11. 13. Schmitt D, Jacob L, Bogen G.. Multifaceted use of Proroot MTA root canal repair material. Pediatr Dent 2001;23:326-30. 14. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endodon 1999;25:197-205.

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