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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 45-49

Healing of delayed management of double traumatized incisors with complicated crown: Root fracture and apical pathosis


1 VIP Clinic, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
2 Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication10-Jan-2017

Correspondence Address:
Abdullah M Alsaedan
College of Dentistry, King Saud University, P. O. Box 60169, Riyadh 11545
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.197985

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  Abstract 

The present case report shows a 23-year-old male who was subjected to trauma in his maxillary right central and lateral incisors with crown and transverse apical third root fractures. Root canal therapy was started, but the patient did not complete it. After 6 years, the patient was subjected to another trauma on the same teeth and showed up after 3 weeks of the second trauma to continue his treatment. Clinical examination revealed that both incisors were sensitive to percussion and palpation with labial sinus tract and pus discharge through the open access cavity of the central incisor. Radiographic evaluation demonstrated root fracture of the central incisor with large radiolucency. Root canal treatment for both incisors and periradicular surgery was done. Histopathologic examination of the periapical lesion demonstrated tissue necrosis and fungal hyphae. Follow-up showed no symptoms with good healing. The treatment modality appears to be effective in dealing with delayed management of traumatized anterior teeth.

Keywords: Crown-root fracture, delayed treatment, double trauma, fungal infection, healing, mineral trioxide aggregate


How to cite this article:
Alsaedan AM, Saad AY. Healing of delayed management of double traumatized incisors with complicated crown: Root fracture and apical pathosis. Saudi Endod J 2017;7:45-9

How to cite this URL:
Alsaedan AM, Saad AY. Healing of delayed management of double traumatized incisors with complicated crown: Root fracture and apical pathosis. Saudi Endod J [serial online] 2017 [cited 2019 Sep 19];7:45-9. Available from: http://www.saudiendodj.com/text.asp?2017/7/1/45/197985


  Introduction Top


Root fracture (oblique or horizontal) may occur in the coronal, middle, or apical third. Radiographic examination is extremely important to detect it. Emergency treatment involves repositioning of the fractured segments into close proximity as much as possible and splinting them to adjacent teeth for 2–4 weeks with a functional splint.[1],[2] Several investigators have revealed four types of response to root fractures including healing with calcified tissue, interproximal dense connective tissue, interproximal bone, and connective tissue, or interproximal inflammatory tissue without healing. The first three types of healing patterns are considered successful.[1]

Failure in healing may require extraction or endodontic treatment with some modifications such as root canal treatment of both segments if not separated, root canal treatment of the coronal segment and surgical removal of apical segment if it is considerably separated and involved with a lesion, root canal therapy of the coronal segment only if the apical third is vital, use of Ca (OH)2 to induce calcific barrier between the coronal (necrotic) and apical (vital) fragment followed by obturation of the coronal segment, construction of post and crown in case of the fracture occurred near the alveolar process, and removal of the apical segment and placement of an endodontic endosseous implant.[1],[2],[3],[4],[5],[6],[7],[8],[9]

Furthermore, in complicated crown fractures, bacterial contamination of pulp exposure usually precludes healing and repair unless direct pulp capping is performed quickly. Pulpotomy or pulpectomy and root canal obturation are alternatives, depending on the maturity of the tooth, size of the exposure, and duration.[1],[3]

The ultimate goal of endodontic therapy is to remove the diseased pulp and bacterial infection by chemomechanical debridement. As reported by several investigators, bacterial levels and the number of taxa were substantially reduced after chemomechanical preparation and intracanal medication. However, failure may occur if residual microorganisms of sufficient pathogenicity and number gain access to the periradicular tissues and pathosis develops. In this situation, failure needs retreatment followed by proper obturation. This restores and maintains the health of the periradicular tissues.[10],[11],[12],[13] Furthermore, endodontic surgery is the treatment of choice when teeth cannot be treated appropriately by nonsurgical means. The goal is to remove infection, disease, prevent it from recurring, and facilitate healing.[14],[15]

Bacteria and fungi present in the oral cavity can contaminate the root canal left open without temporary filling causing periapical inflammation. Apical periodontitis is essentially an inflammatory disease of microbial etiology primarily caused by infection of the root canal system.[16],[17] Moreover, several investigations have reported that endodontic infections and diseases are associated with fungi, archaea, and virus. These fungi have been shown to be associated with failed root canal and can be found as constituents of the oral microbiota.[17],[18],[19],[20],[21] In addition, some morphologic studies have demonstrated that the root canal microbiota in primary infections was dominant by bacterial morphotypes such as cocci, rods, filament, and spirochetes as well as fungal cells.[22],[23],[24],[25]

The purpose of this case report was to demonstrate the endodontic treatment modalities to deal with double traumatized maxillary incisors with complicated crown-root fracture and periapical lesion left without treatment for a long time.


  Case Report Top


A 23-year-old male was seen in the Endodontic Clinic, College of Dentistry, King Saudi University, Riyadh, Saudi Arabia complaining of severe pain, swelling, and pus discharge from the access opening of his maxillary right central incisor. The patient informed that he had a history of trauma 6 years ago that affected his maxillary right central (#11) and lateral (#12) incisors [Figure 1]a. Clinical examination revealed that the patient started the endodontic treatment, but he did not finish it. The patient informed that incomplete root canal therapy was performed at that time only for the central incisor in a private clinic [Figure 1]b.
Figure 1: (a) Clinical photograph of the maxillary right central showing fractured crown. (b) Diagnostic periapical radiograph showing apical root fracture, crown fracture with open access cavity left without filling. (c) Periapical radiograph after the second trauma showing large apical radiolucency and fractured apical third of the root (arrow). Sinus tract traced with gutta-percha

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Three weeks ago, before he showed up to our clinic, the patient was subjected to another trauma affecting the same teeth. The medical history was noncontributory. Clinical examination revealed a crown fracture of #11 and labial sinus tract. Both teeth were sensitive to percussion and palpation and no response to cold or electric pulp tester. The remaining anterior teeth responded to pulp test within normal limits. The access cavity of #11 has no filling.

Radiographic examination demonstrated a root fracture in the apical third of tooth #11 with the large radiolucent area and incomplete root canal treatment. Tracing the sinus tract with size 30 Gutta-percha pointed at tooth #12 [Figure 1]c. Pulp necrosis of both teeth with apical pathosis was diagnosed. Complete chemomechanical debridement was achieved for both teeth under rubber dam isolation. The apical third of the canal of #11 was plugged with mineral trioxide aggregate (MTA) (ProRoot MTA, Dentsply, USA) [Figure 2]a and the remaining part with gutta-percha and AH26 cement (Dentsply Maillefer, Switzerland) as well as tooth #12.
Figure 2: (a) Mineral trioxide aggregate plug filling the apical part of tooth #11. (b) Post and core construction. Note the obturation of tooth #12

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Post and core were constructed for tooth #11 [Figure 2]b. The patient returned in 1 month with symptoms. Under local anesthesia, a flap was raised, and the apical root segment of tooth #11 was removed with the apical lesion [Figure 3]a and [Figure 3]b. The surgical site was copiously irrigated with saline and the apical portion of the root was beveled and a subsequent radiograph indicated the periapical area was clean. The flap was repositioned and sutured. Analgesic and systemic antibiotic were prescribed, and the sutures were removed after 5-days.
Figure 3: (a) Clinical and (b) radiographic images during periapical surgery. Radiograph was taken before suturing

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The patient was referred to finish the crown [Figure 4]a. The patient did not return for follow-up examination. One and a half years after surgery, the patient came for endodontic treatment of the mandibular left first molar. Radiographic examination of teeth #11 and 12 showed a normal periapical pattern [Figure 4]b. Histopathologic examination of the periapical lesion demonstrated tissue necrosis and fungal hyphae [Figure 5].
Figure 4: (a) Clinical photograph after crown construction. (b) One and half year follow-up radiograph showing normal periapical healing

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Figure 5: Photomicrograph showing necrosis with fungal hyphae

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  Discussion Top


Crown and intra-alveolar root fractures can occur as a result of dental trauma. In general, many factors play an important role in influencing the outcome and pattern of healing. The most important are the length of time between trauma and treatment, degree of mobility, site of crown and root fracture, stage of root development, and quality of endodontic therapy.[1],[2],[3],[4],[5],[6],[7],[8],[9] In the current case, the patient was subjected to trauma 6 years ago without proper management that resulted in pulpal necrosis with apical pathosis. This is usually the result of delayed management.[26]

It has been reported that the longer the time between injury and endodontic treatment, the worse the effects on healing.[1],[3],[7],[9] In fact, root fracture of the apical third was reported to have favorable prognosis compared to fracture of the coronal and middle third fractures due to difficulty in immobilization and exposure of the pulp to bacterial contamination in the oral environment.[7],[27] Healing of the fractured apical third was not observed in the current case due to delayed treatment and coronal microbial contamination.

The histological report of the present case revealed tissue necrosis and fungal hyphae. This may indicate that fungi may play a role in the development of periapical lesion.[24],[25],[28] Early endodontic therapy is very important.

Numerous bacterial species and fungi have been demonstrated to be associated with unfilled or failed root canal treatment. The penetration of bacteria into the dentinal tubules was shown to ranged from 10 to 150 µm.[24] Furthermore, fungi are members of the oral microbiota that have been found only occasionally in primary root canal infections.[17],[18],[19],[20],[21],[22],[23],[24]

Surgical intervention was performed due to persistent symptoms and the contaminated root fragment. It was done to accelerate periradicular healing. This treatment supported previous studies.[14],[15] Bacteria remaining in the root canal after chemomechanical procedures and obturation had the potential to escape or resist these procedures, survive, and rapidly adapt to this drastic situation that resulted in altered environment.[17] Mineral trioxide aggregate was used to plug the apical third due to the large canal. This helped in getting good prognosis with the surgical intervention due to the superior sealing ability of MTA as well as tissue biocompatibility.[29],[30]


  Conclusion Top


It was suggested that failure of the current case report was due to several factors:

  1. The patient did not continue the endodontic treatment after trauma which occurred earlier, 6 years ago
  2. Bacterial and fungal contamination present in the root canal and periradicular area are due to open access cavity for a long time
  3. The inability of performing good chemomechanical cleaning of the root canal system because of the inaccessible location of the microorganisms in the accessory canals, dentinal tubules, and apical region. These findings are supported by the previous numerous investigators.[13],[17],[19],[24],[25],[31]


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Slots J, Sabeti M, Simon JH. Herpesviruses in periapical pathosis: An etiopathogenic relationship? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:327-31.  Back to cited text no. 20
    
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Vianna ME, Conrads G, Gomes BP, Horz HP. Identification and quantification of archaea involved in primary endodontic infections. J Clin Microbiol 2006;44:1274-82.  Back to cited text no. 21
    
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Fredricks DN, Relman DA. Application of polymerase chain reaction to the diagnosis of infectious diseases. Clin Infect Dis 1999;29:475-86.  Back to cited text no. 22
    
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Baumgartner JC, Watts CM, Xia T. Occurrence of Candida albicans in infections of endodontic origin. J Endod 2000;26:695-8.  Back to cited text no. 25
    
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al-Nazhan S, Andreasen JO, al-Bawardi S, al-Rouq S. Evaluation of the effect of delayed management of traumatized permanent teeth. J Endod 1995;21:391-3.  Back to cited text no. 26
    
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Cvek M, Mejàre I, Andreasen JO. Healing and prognosis of teeth with intra-alveolar fractures involving the cervical part of the root. Dent Traumatol 2002;18:57-65.  Back to cited text no. 27
    
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Nair PN, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:231-52.  Back to cited text no. 28
    
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