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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 8  |  Issue : 3  |  Page : 150-153

Nonsurgical management of horizontal root fracture associated external root resorption and internal root resorption


Department of Conservative Dentistry and Endodontics, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bengaluru, Karnataka, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Md Zaighum Raza
“34 Gomathinalaya, 1st Block, 2nd Cross, Cholanayakahalli, RT Nagar post, Bengaluru - 560 032, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-4003.191722

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  Abstract 

Horizontal root fractures, which frequently affect the upper incisors, usually result from a frontal impact. As a result, combined injuries occur in dental tissues such as the pulp, dentin, cementum, periodontal ligament, and alveolar bone. Internal root canal inflammatory resorption involves a progressive loss of intraradicular dentin without adjunctive deposition of hard tissues adjacent to the resorptive sites. It is frequently associated with chronic pulpal inflammation, and bacteria might be identified from the granulation tissues when the lesion is progressive to the extent that it is identifiable with routine radiographs. With the advancement in technology, it is imperative to use modern diagnostic tools such as cone beam computed tomography and radiovisuography to diagnose and confirm the presence and extent of resorptions and fractures and their exact location. This case report presents a rare case having internal root resorption and horizontal root fracture with external inflammatory root resorption both which were treated successfully following guidelines by International Association of Dental Traumatology by nonsurgical treatment with 1 year follow-up.

Keywords: Cone-beam computed tomography, fracture, resorption


How to cite this article:
Pasha S, Valli S K, Raza MZ. Nonsurgical management of horizontal root fracture associated external root resorption and internal root resorption. Indian J Dent Sci 2016;8:150-3

How to cite this URL:
Pasha S, Valli S K, Raza MZ. Nonsurgical management of horizontal root fracture associated external root resorption and internal root resorption. Indian J Dent Sci [serial online] 2016 [cited 2019 Sep 17];8:150-3. Available from: http://www.ijds.in/text.asp?2016/8/3/150/191722


  Introduction Top


Dental traumas affect the anterior teeth most commonly leading to fractures and resoptions. Among dental traumas, horizontal root fractures are relatively uncommon injuries and comprises only 0.5%–7.0% of injured permanent teeth. These injuries involve various dental tissues such as the dental pulp, dentin, cementum, and supportive tissues (e.g., the periodontal ligament and alveolar bone).[1] This leads to permanent pulpal necrosis in the coronal fragments in approximately 25% of patients and requires endodontic treatment.[2]

Internal root resorption (IRR) is defined as the loss of dental hard tissue due to osteoclastic activity inside the root canal space. Chronic pulpal inflammation and loss of predentin after trauma are thought to be potential predisposing factors for IRR.[3] It manifests by means of a slow or rapid progression. They are usually asymptomatic and detected incidentally during routine radiographic examinations.[4]

In general, there are three choices for treating extensive inflammatory root resorption; (a) no treatment with eventual extraction when the teeth become asymptomatic, (b) immediate extraction (c) access debridement and restoration of the resorptive lesion.[4]


  Case Report Top


A 27-year-old female patient with nonsignificant medical history reported to our department with a chief complaint of discolored upper front teeth. On history taking patient revealed trauma in the same region 5 years back. No history of pain or swelling reported. On clinical examination, discolored tooth was found irt 21.

No response was observed during sensibility testing with heat test (Heated GP), cold test (ROEKO Endo-Frost, Coltène/Whaledent GmbH + Co., KG Raiffeisenstr), and electric pulp test (electric pulp tester) compared to adjacent and contralateral teeth. Intraoral periapical radiograph (IOPAR) [Figure 1] irt 11 revealed radiolucency in the cervical third of the root with obliterated root canal space without any periapical changes. Irt 21 crown was found intact, and root was present only till the middle third with obliterated root canal space and diffuse radiolucency in the periapical region. Irt 22 crown and root was found to be normal, and a diffuse radiolucency was seen in the periapical region. To confirm the extent of cervical radiolucency irt 11 and to find out the exact reason for the missing root structure irt 21, it was decided to do three-dimensional cone-beam computed tomography (CBCT) examination for the patient. On CBCT examination, sagittal view irt 11 [Figure 2] revealed oval-shaped radiolucency in the cervical third of the root which was found to be nonperforating when different sections were examined axially [Figure 3] and sagittally. Irt 21 [Figure 4] crown and root till middle third was found and an apical fractured fragment was seen in the sagittal view [Figure 5]. In between the coronal and the apical fragment radiopacity and a small radiolucency was seen. Irt 22 [Figure 6] well-defined radiolucency measuring approximately <5 mm was seen in the periapical region and also loss of labial cortical bone was seen.
Figure 1: Preoperative.

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Figure 2: Cone beam computed tomography saggital view irt 11.

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Figure 3: Cone beam computed tomography axial view.

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Figure 4: Cone beam computed tomography saggital view irt 21.

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Figure 5: Apical fractured fragment.

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Figure 6: Cone beam computed tomography saggital view irt 22.

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After evaluation of subjective signs and symptoms, clinical examination, results of sensibility tests, and radiographic interpretation, the patient was diagnosed as internal inflammatory root resoprtion irt 11, horizontal root fracture with external inflammatory root resorption irt 21 and chronic periapical periodontitis irt 22.

A definite treatment plan was decided, and it was decided to do the nonsurgical root canal treatment for the entire three teeth with periodic radiographic follow-up. Following isolation with rubber dam, access opening was done and working length was determined using Ingles radiographic method. For tooth 21 wein's modification was used for W/L determination due to loss of root and bone. Thorough biomechanical preparation was down using crown down technique with copious irrigation with 3% sodium hypochlorite and chlorhexidine and intracanal medicament of calcium hydroxide was placed for 1 week. After 1 week when the patient reported back to the department, canal was found dry and asymptomatic. Mastercone gutta-percha point was selected, and obturation was done using cold lateral condensation technique using AH plus sealer irt 21 and 22. To fill the resorptive defect irt 11 flowable thermoplastisized obturation technique was used (COXO ® Endo Cordless C-Fill Obturation System). [Figure 7] shows IOPAR taken immediately after obturation. One year postoperative IOPAR shows periapical status within normal limit [Figure 8].
Figure 7: Immediate postoperative.

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Figure 8: 1 year follow up.

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  Discussion Top


Root fractures leads injury to combined dental tissues such as the pulp, dentin, cementum, periodontal ligament, and alveolar bone.[2] The prognosis of root fractures depends on the extent of the fracture line, the pulp tissue situation, occlusion, dislocation of fragments, and the general health of the patient.[1]

Andreasen and Hjorting-Hansen classified the healing of root-fractured teeth into four groups [5] (a) healing with hard tissue, (b) healing with the interposition of hard and soft tissue, (c) healing with interposition of soft tissue, (d) no healing.

According to Andreasen et al., root resorption has been found to occur in approximately 60% cases of root fractures and five types of resorptions are reported, (1) external surface resorption, (2) external inflammatory resorption, (3) external replacemental resorption, (4) internal surface resorption, (5) internal tunneling resorption. Partial or complete obliteration of the pulp canal with slight yellowing discoloration of the crown is a common finding after root fracture.[1] It is seen in 69%–73% of the teeth.[6],[7]

In the above case, second type of healing (Andreasen et al.) was seen as identified by CBCT examination and the fracture line was seen below the alveolar crest. Furthermore, the tooth was not mobile and found non vital by the sensibility testing. Considering all the factors, above case irt 21 was diagnosed as horizontal root fracture with external inflammatory root resorption.

After evaluation of preinjury and injury factors and considering the apical fragment to be vital and because of the interposition of bone and connective tissue in between the fragments which indicate good prognosis (Andearsen), it was decided to leave the apical fragment in place and do the nonsurgical endodontic treatment for the coronal fragment.

Internal root canal inflammatory resorption involves a progressive loss of intraradicular dentin without adjunctive deposition of hard tissues adjacent to the resorptive sites and is frequently associated with chronic pulpal inflammation, and bacteria might be identified from the granulation tissues when the lesion is progressive to the extent that it is identifiable with routine radiographs.[8]

The early diagnosis and therapy are very important to stop the resorption process. The success or failure of therapy should be followed clinically and by radiographic control. In the above case irt 11, considering the patient's age, periodontal status, resorption location, absence of perforations, and resistance of remaining root hard tissue, a nonsurgical endodontic treatment along with thermoplasticized gutta-percha obturation was done. The difficulty in cleaning the concavity resorption area required cleaning with chemical substances that have an appropriate organic solvent capacity. Complementing the action of the sodium hypochlorite, the intracanal medication with calcium hydroxide for a prolonged period was placed. The flowable gutta-percha was condensed using vertical condensation using the plugger and the resorptive defect was filled using lateral condensation with the use of the spreader following AH plus sealer application.

The success or failure of therapy should be followed up clinically and by radiographic control.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen FM, Andreasen JO, editors. Root fractures. In: Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen: Munksgaard; 1994. p. 279-314.  Back to cited text no. 1
    
2.
Cvek M, Mejàre I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol 2004;20:261-9.  Back to cited text no. 2
    
3.
Patel S, Ricucci D, Durak C, Tay F. Internal root resorption: A review. J Endod 2010;36:1107-21.  Back to cited text no. 3
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4.
Goultschin J, Nitzan D, Azaz B. Root resorption. Review and discussion. Oral Surg Oral Med Oral Pathol 1982;54:586-90.  Back to cited text no. 4
[PUBMED]    
5.
Andreasen JO, Hjorting-Hansen E. Intraalveolar root fractures: Radiographic and histologic study of 50 cases. J Oral Surg 1967;25:414-26.  Back to cited text no. 5
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6.
Welbury R, Kinirons MJ, Day P, Humphreys K, Gregg TA. Outcomes for root-fractured permanent incisors: A retrospective study. Pediatr Dent 2002;24:98-102.  Back to cited text no. 6
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7.
Zachrisson BU, Jacobsen I. Long-term prognosis of 66 permanent anterior teeth with root fracture. Scand J Dent Res 1975;83:345-54.  Back to cited text no. 7
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8.
Wedenberg C, Zetterqvist L. Internal resorption in human teeth – A histological, scanning electron microscopic, and enzyme histochemical study. J Endod 1987;13:255-9.  Back to cited text no. 8
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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