Ex vivo investigation on the effect of minimally invasive endodontic treatment on vertical root fracture resistance and crack formation.

The evidence base on minimally invasive endodontic (MIE) treatment is limited. This study investigated the influence of MIE shaping on vertical root fracture (VRF) resistance and crack formation of root canal filled teeth. Human maxillary central incisors were randomized into six groups (n = 18, power = 0.9) and embedded in acrylic blocks with artificial periodontal ligaments. The root canals were either instrumented to size #40 and 0.04 taper (+MIE) or enlarged to ISO size #80 (-MIE). The canals were filled with cement-based (C) or adhesive resin-based (A) sealers in single-cone technique. The controls received no treatment or were left unfilled. After chewing simulation (staircase method, 25-150 N, 120,000×), the crack formation on the root surface was analyzed using stereomicroscope/digital imaging and classified (no defect, craze line, vertical crack, horizontal crack). Subsequently, the samples were loaded until fracture. The incidence of defects (56% vertical cracks) was not significantly different between the groups (p ≥ 0.077). VRF resistance was significantly higher in untreated teeth than in +MIE/C (p = 0.020) but did not significantly differ between the other groups (p ≥ 0.068). Minimal canal shaping did not reduce the risk of vertical root fracture and defects of root canal filled teeth.

Fracture resistance and failure mode of three esthetic CAD-CAM post and core restorations.

BACKGROUND: The rising demand for improved aesthetics has driven the utilization of recently introduced aesthetic materials for creating custom post and core restorations. However, information regarding the fracture resistance of these materials remains unclear, which limits their practical use as custom post and core restorations in clinical applications. AIM OF THE STUDY: This study aimed to evaluate the fracture resistance of three non-metallic esthetic post and core restorations and their modes of failure. MATERIALS AND METHODS: Thirty-nine single-rooted human maxillary central incisors were endodontically treated. A standardized post space preparation of 9mm length was performed to all teeth to receive custom-made post and core restorations. The prepared teeth were randomly allocated to receive a post and core restoration made of one of the following materials (n=13): glass fiber-reinforced composite (FRC), polyetheretherketone (PEEK) and polymer-infiltrated ceramic-network (PICN). An intraoral scanner was used to scan all teeth including the post spaces. Computer-aided design and computer-aided manufacturing (CAD-CAM) was used to fabricate post and core restorations. Post and core restorations were cemented using self-adhesive resin cement. All specimens were subjected to fracture resistance testing using a universal testing machine. Failure mode analysis was assessed using a stereomicroscope and SEM. The data was statistically analyzed using One-Way ANOVA test followed by multiple pairwise comparisons using Bonferroni adjusted significance level. RESULTS: Custom PEEK post and core restorations displayed the least fracture load values at 286.16 ± 67.09 N. In contrast, FRC exhibited the highest average fracture load at 452.60 ± 105.90 N, closely followed by PICN at 426.76 ± 77.99 N. In terms of failure modes, 46.2% of specimens with PICN were deemed non-restorable, while for PEEK and FRC, these percentages were 58.8% and 61.5%, respectively. CONCLUSIONS: Within the limitation of this study, both FRC and PICN demonstrated good performance regarding fracture resistance, surpassing that of PEEK.

Restoration of Complicated Crown-Root Fracture in a Primary Incisor with Fragment Reattachment.

In traumatic dental injuries in children, due to a lack of maturity to cope with the situation, pain intolerance, amount of treatment procedure, and parental anxiety, simplified and non-invasive treatment procedures, such as biologic restorations, are useful. Using advanced adhesive material for fragment reattachment provides excellent esthetic results and a positive attitude from the patient and family. The purpose of this case report is to describe the biological restoration of a complicated crown-root fracture of a primary maxillary central incisor with the fragment reattachment technique.

Unconventional Dental Implant Placement Through an Impacted Maxillary Central Incisor in Stable Contact With Enamel and Dentin: A Case Report.

When edentulism is accompanied by an impacted tooth, conventional treatment usually involves traumatic tooth extraction, which would inevitably destroy the surrounding alveolar bone and cause unfavorable esthetics, especially for anterior teeth. Recently, implant placement through the impacted tooth or residual root has been proposed as an alternative to invasive extraction. A particular type of integration has been observed between dentin/cementum and titanium implant, while enamel-implant contact has not been reported. In this article, an implant was placed through the impacted maxillary central incisor, thereby avoiding an invasive extraction surgery. The buccal section of the tooth, including crown enamel, was retained in situ for buccal alveolar ridge preservation. The follow-up results were satisfactory, and a stable enamel-implant contact was observed. Combining with previous similar studies, this technique opens intriguing possibilities and brings fresh insight for the concept of dentointegration. More histological and clinical studies with long-term follow-up are warranted before endorsing this technique in routine application.

One case of complicated crown root fracture of upper anterior teeth managed by multidisciplinary joint approaches.

Complicated crown root fracture is a serious combined fracture of the enamel, dentin, and cementum in dental trauma. The treatment method is complicated. During the procedure, the condition of pulp, periodontal, and tooth body should be thoroughly evaluated, and a multidisciplinary approach combined with sequential treatment is recommended. This case reported the different treatment and repair processes of one case of two affected teeth after complicated crown root fracture of upper anterior teeth, including regrafting of broken crown after flap surgery at the first visit, direct resin repair to remove broken fragments, and pulp treatment and post-crown repair at the second visit. After 18 months of follow-up, the preservation treatment of the affected teeth with complicated crown root fracture was achieved. Therefore, fragment reattachment and post-crown restoration are feasible treatment options for children with complicated crown root fracture.

Polychromatic Restoration of Anterior Fractured Teeth Using a Custom-made Silicone Matrix.

When restoring anterior teeth using resin composites, the use of silicone guide matrices obtained from diagnostic wax-ups is recommended, as this technique facilitates layering and optimizes working time. This is particularly important in polychromatic layering and when more than one anterior tooth is to be restored with resin composites. However, in cases of fractured anterior teeth, it is often not feasible to perform a previous impression and waxing. In these cases, due to trauma and related psychological aspects, patients usually seek immediate esthetic solutions. Therefore, an interesting restorative approach that can simplify the restorative technique is the creation of a silicone guide matrix obtained from the patient's fractured tooth, without the need for prior waxing. This type of personalized matrix was initially proposed by Bertholdo, Ricci, and Barrote. Thus, the purpose of the present work is to demonstrate a modification of the technique for making this type of custom-made matrix for the restoration of two upper central incisors of a 14-year-old patient who fractured his teeth in a bicycle accident.

Effect of wire diameter and extent of wire composite splint on the mobility of luxated and anchor primary teeth: A typodont study.

BACKGROUND/AIMS: The recommendations for splinting are well established for the injuries of permanent dentition; however, ambiguity still exists for the injuries in primary dentition. Hence, this study aimed to determine the most appropriate dimensions of stainless steel wire and its extent, for achieving the physiologic mobility in primary dentition. MATERIAL AND METHODS: This study was designed as an in vitro experiment by using a typodont model of primary dentition. The baseline mobility of primary maxillary incisors was calibrated to the physiologic mobility of natural primary incisors by using a Teflon tape wrapped around the roots of resin teeth. Splinting was done using a stainless steel wire of 0.2 mm (Group I), 0.3 mm (Group II), and 0.4 mm (Group III). These groups were subdivided (a, b, and c) on the basis of the extent of the splint, and pre splint mobility (Pre-PV) and post-splint mobility (Post-PV) were tested by Periotest M. The splint effect was calculated by subtracting Post-PVs and Pre-PVs. RESULTS: The normal values of mobility in healthy human volunteers ranged from 10.5 to 13. The overall splint effect was higher in Group III irrespective of the extent of the splint, whereas it was found to be the lowest in Group I (b and c). The splint effect increased with the extent of the splint in all the groups. Among all the groups, the splint effect on the anchor teeth was observed to increase with the extent of the splint and the diameter of the wire. CONCLUSION: The mobility of the injured and anchor teeth splinted with 0.2-mm stainless steel wire was similar to the pre-splint and physiologic mobility. The most favorable extension was one tooth adjacent to the injured tooth on each side for both 0.2- and 0.3-mm wires.

Long-term prognosis after decoronation of avulsed teeth with replacement resorption: a report of three cases.

The complications of replacement resorption following tooth injury in growing children include infrapositioning of the tooth, tilting of the adjacent teeth, and alveolar ridge deformity. Decoronation is a conservative treatment method that facilitates bone preservation. The current case report focuses on the long-term preservation of alveolar ridge dimension following decoronation in three patients. Decoronation was performed prior to occurrence of the pubertal growth spurt, and the patients' ridge width and vertical apposition were monitored for at least 4 years. Timely intervention and regular monitoring are essential for maximization of the benefits of decoronation, a simple procedure that preserves esthetics and minimizes the need for further treatments. The importance of space management for prosthetic treatment has also been highlighted. The findings of this study show that infrapositioned teeth in growing children can be treated successfully using decoronation.

The consequences of orthodontic extrusion on previously intruded permanent incisors-A retrospective study.

AIM: The aim of this study is to compare the adverse effects that occur after orthodontic extrusion of teeth that have been traumatically intruded with those of similar teeth that have not experienced any trauma. BACKGROUND: The outcome of incisors intrusion can be affected by the patient's age, extent of injury, root development, and malocclusion. Orthodontic extrusion is a potential solution, but it may also cause complications. MATERIALS AND METHODS: A retrospective study of the effects of extrusion of traumatically intruded teeth was carried out. The study group included 21 teeth in 14 patients. The control group included 32 teeth in 10 patients that underwent orthodontic extrusion with no history of trauma. Patients' age, gender, and stage of root development were recorded. The severity of the intrusion was classified as mild (<3 mm), moderate (3-6 mm), and severe (≥7 mm). A comparison of signs of pulp necrosis and root resorptions between the groups was made. RESULTS: The central incisor is the tooth that is most injured in 80.9% of cases. A majority of these incidents involve severe intrusion, which was found in 42.9% of cases. 90% of the traumatized teeth had already lost their vitality prior to orthodontic treatment. Various forms of root resorption were observed in the study group. In the control group, 31.2% of teeth showed signs of external root resorption, but no endodontic intervention was carried out during the follow-up period, as these teeth remained vital. CONCLUSIONS: Following intrusion, there is a high risk for root resorption and pulp necrosis. Orthodontic repositioning should be carried out with caution and mild force to prevent complications. Long-term follow-ups are required to ensure the best possible outcome.

Guided Autotransplantation of an Immature Premolar to the Maxillary Incisor Region with Immediate Restoration of Esthetics: A Case Report.

This case report describes the treatment of two maxillary central incisors following a traumatic injury with tooth #8 developing replacement resorption and #9 developing inflammatory root resorption. A 10-year-old girl presented complaining of pain in her maxillary central incisors. Upon clinical examination, teeth #8 and #9 were tender to percussion and palpation of the buccal soft tissues. Thermal and electrical pulpal sensitivity tests for teeth #8 and #9 were negative. An intraoral periapical radiograph revealed resorptive defects in tooth #8, which were filled with bone-like tissue, while tooth #9 had radiolucent resorptive defects along the root surface and a periapical radiolucency. A diagnosis of replacement resorption was made for tooth #8 and external inflammatory root resorption for tooth #9. Tooth #8 was treated with a multidisciplinary approach utilizing a guided template for premolar autotransplantation with an immediate veneer restoration, while tooth #9 was managed with root canal treatment using a tricalcium silicate cement to fill the canal. At the 1, 4, 8, 12, and 24-month follow-ups, the patient remained asymptomatic, and there was no radiographic evidence of root or periapical pathosis on either tooth. The root-end of the donor tooth transplanted to the #8 site continued to develop. This case report highlights successful interdisciplinary management of two forms of root resorption using modern treatment strategies that provided immediate function and esthetics to the maxillary central incisors in a young patient following trauma.

Clinical Guidelines for the Surgical/Orthodontic Management of Impacted Maxillary Central Incisors Based on a Decision Tree.

Maxillary central incisors are critical to occlusal function, smile esthetics, and even one's self-image. Furthermore, their impaction at an early age could have harmful psychological consequences on the individual. Maxillary central incisors can be impacted due to early dentoalveolar trauma to the upper anterior region that displaces the incisor in formation and, in rare instances, tooth germs are deformed. The aftermath of trauma during primary dentition is seen later during mixed dentition. Other causes are either an impediment in the eruption pathway of the maxillary central incisor due to the presence of odontomas or supernumerary teeth, an insufficient eruption space, or, very rarely, syndromic and/or other general medical conditions. Diagnosis is completed through a detailed medical/dental history, clinical evaluation, and appropriate imaging. Arch width increase, space opening, removal of obstructions if present, suitable soft-tissue management, well-designed orthodontic traction mechanics, and long-term periodontal follow-up are all essential elements in resolving cases of impacted maxillary central incisors.

[Surgical extrusion, an alternative to a dental implant?] / Chirurgische extrusie, een alternatief voor een tandheelkundig implantaat?

Unfortunately, accidents do happen. Dentoalveolar injury to the front teeth resulting from trauma can sometimes be so problematic that an (adhesive) restoration seems almost impossible to make, let alone saving the tooth. In this contribution the case of a 17-year-old patient whose upper incisor suffered severe dentoalveolar trauma in a traffic accident is presented. His upper incisor was fractured deeply subgingivally, at bone level, and at first glance, appeared to be lost. Surgical extrusion, however, in this patient represents a full alternative to a prosthetic solution, such as a dental implant.

Multidisciplinary management of a tooth with severe root dilaceration and enamel hypoplasia: a case report.

Dental trauma in primary teeth can cause irreversible changes in the development of permanent tooth germs, including enamel hypoplasia, crown dilaceration, and root dilaceration. This article discusses multidisciplinary treatment of enamel hypoplasia and root dilaceration in the maxillary left central incisor of an 11-year-old girl. A 10-year follow-up is reported to demonstrate the long-term clinical outcomes. At the initial presentation, the patient's mother reported that the child had an accident at the age of 2 years, resulting in intrusive luxation of the primary maxillary left central incisor. After the accident, the patient was monitored for eruption of the permanent successor tooth, and different approaches were proposed during each period of the patient's development on the basis of the clinical diagnosis of root dilaceration and enamel hypoplasia. The crown was restored with composite resin, and the root defect was restored with resin-modified glass ionomer cement. After 10 years, the clinical outcomes highlight that the multidisciplinary approach was successful in preserving the natural tooth with good periodontal health conditions.

Abordagem de incisivos centrais superiores traumatizados: relato de caso / Approach to traumati zed maxillary central incisors: case report

Introdução: O traumatismo dentário é uma ocorrência frequente durante a infância e adolescência. Geralmente, o diagnóstico acontece de forma tardia, devido à falta de conhecimento da população. Cada tipo de trauma necessita de uma conduta única e especializada. Nos casos de comprometimento pulpar, é necessário cuidado quanto à escolha da técnica a ser empregada, bem como a seleção da medicação intracanal que, por sua vez, apresenta grande interferência no sucesso do tratamento. Não obstante o avanço das técnicas de instrumentação, a troca da medicação entre as sessões nesses casos é mandatória. Relato de caso: Um paciente, sexo masculino, em idade escolar (15 anos) apresentou-se ao serviço de saúde bucal com relato de escurecimento e dores na mastigação após trauma dentário durante a infância. Os testes de vitalidade pulpar revelaram necrose pulpar, com resultado negativo no teste térmico e positivo na percussão. O exame radiológico evidenciou uma lesão apical, juntamente com reabsorção externa no elemento 21, confirmado em tomografia. O paciente foi submetido a um tratamento endodôntico. Resultado: Após o tratamento, foi solicitado novo exame tomográfico, em que se evidenciou um processo de cicatrização óssea no periápice e reabsorção por substituição na lesão cervical. Conclusão: A partir deste caso clínico, pôde-se evidenciar a importância do diagnóstico adequado, do manejo e da técnica endodôntica eficaz na resolução de problemas decorrentes de traumas dentários em pacientes jovens.

Introduction: Dental trauma is a frequent occurrence during childhood and adolescence. Generally, diagnosis happens late, due to lack of knowledge among the population. Each type of trauma requires a unique and specialized approach. In cases of pulp involvement, care must be taken when choosing the technique to be used, as well as the selection of intracanal medication, which, in turn, has a major impact on the success of the treatment. Despite advances in instrumentation techniques, changing medication between sessions in these cases is mandatory. Case report: A male patient of school age (15 years old) presented to the oral health service with reports of darkening and pain when chewing following dental trauma during childhood. Pulp vitality tests revealed pulp necrosis, with a negative result in the thermal test and positive in percussion. The radiological examination showed an apical lesion, together with external resorption in element 21, confirmed on tomography. The patient underwent endodontic treatment. Result: After treatment, a new tomographic examination was requested, which showed a process of bone healing in the periapex and resorption by replacement in the cervical lesion. Conclusion: From this clinical case, it was possible to highlight the importance of adequate diagnosis, management, and effective endodontic technique in solving problems arising from dental trauma in young patients.

Should we splint traumatised primary teeth?

DESIGN: Systematic review. REVIEW QUESTION: Does splinting of traumatised primary teeth improve clinical outcomes? CASE SELECTION: Clinical studies published after 2003 reporting trauma (luxation, root fracture or alveolar fracture) to primary teeth, with a minimum follow-up of 6 months, were eligible for inclusion. Case reports were excluded, but case series were included. Studies reporting the outcome of splinting following avulsion injuries were excluded, as current guidance does not recommend re-implantation of teeth for these injuries. DATA ANALYSIS: Two researchers independently assessed the risk of bias in the included studies, with a third researcher resolving any disagreements. The same two independent researchers conducted a quality assessment of the included studies. RESULTS: Three retrospective studies met the inclusion criteria. Only one of these studies had a control group. High success rates were reported for the management of teeth with root fractures. A benefit for splinting teeth with lateral luxation was not identified. No alveolar fractures were included. CONCLUSIONS: This review suggests that the outcome of the management of root fractures in primary teeth may benefit from flexible splinting. However, the evidence base is low.

Long-term Outcome of Endodontically Treated Traumatized Immature Upper Incisors.

INTRODUCTION: In a growing child, preservation of traumatized immature permanent upper incisors is challenging. This study aimed to evaluate the long-term outcome of endodontically treated traumatized immature upper incisors and associated variables. METHODS: A total of 183 traumatized immature upper incisors treated with pulpotomy, apexification, or regenerative endodontic procedure (REP), with follow-up between 4 and 15 years, were assessed for presence of pulpal responses or periodontal/bone responses using standardized clinical and radiologic criteria. Logistic regression, including stage of root development, type and complexity of traumatic event, type of endodontic intervention, and history of orthodontic management, were used to estimate impact on tooth survival and occurrence of tissue responses. Study approved by Ethics Committee Research UZ/KU Leuven (S60597). RESULTS: After a median follow-up of 7.3 years (interquartile range, 6.1-9.2), 159 teeth (86.9%) were still functional. From these teeth, 58 (36.5%) developed tissue responses. This was significantly associated with stage of root development at moment of trauma (root length <¾) and type of endodontic intervention (REP presenting worst outcome). Tooth loss (24 teeth, 13.1%) occurred after a mean time span of 3.2 years (±1.5) and was significantly associated with type and complexity of the traumatic event and type of endodontic intervention, with apexification showing better results than REP (odds ratio, 0.30; 95% confidence interval, 0.11-0.79). CONCLUSIONS: A large number of endodontically treated traumatized immature teeth could be kept functional. Very immature teeth, teeth with periodontal tissue damage, and teeth treated with REP were at highest risk for an unfavorable outcome.

Combined orthodontic and prosthodontic treatment in an adolescent patient with traumatically ankylosed incisors: A case report.

Symmetric extraction of premolars is a frequently used orthodontic treatment for dental crowding and protrusion. However, when a patient has incisors with ankylosis, the establishment of a treatment protocol often plagues orthodontists. An adolescent patient with a history of incisor trauma sought treatment for dental protrusion and crowding. Upon percussion of his infrapositioned maxillary central incisors, characteristic dull metallic sounds were noted, and a lack of normal mobility of these teeth under the application of external forces was detected. Follow-up radiographs after the trauma showed replacement root resorption of the maxillary central incisors. Based on clinical and radiological findings, ankylosis of the maxillary central incisors was tentatively diagnosed. A combination of orthodontic and prosthodontic treatment options involving extraction of the maxillary central incisors and mandibular first premolars was chosen to resolve the functional and esthetic problems. After treatment, well-aligned dentition, improved smile esthetics, and a more harmonious facial profile were achieved, and these outcomes remained stable during the follow-up period. This case report illustrates a viable treatment strategy for tackling predicaments caused by ankylosed incisors, which is unusual in the literature.

Laser doppler flowmetry to detect pulp vitality, clinical reference range and coincidence rate for pulpal blood flow in permanent maxillary incisors in Chinese children: a clinical study.

BACKGROUND: A laser doppler flowmetry (LDF) test can reflect the pulp vitality caused by the change in pulp blood flow (PBF). This study aimed to investigate the PBF of the permanent maxillary incisors using LDF and to calculate the clinical reference range and coincidence rate for pulp vitality using PBF as an indicator. METHODS: School-age children (7-12 years) were recruited randomly. A total of 455 children (216 female and 239 male) were included in this study. An additional 395 children (7-12 years) who attended the department due to anterior tooth trauma from October 2015 to February 2018 were included to assess the clinical occurrence rate. The PBF was measured using LDF equipment and an LDF probe. RESULTS: The clinical reference range of PBF values for the permanent maxillary incisors (teeth 11, 12, 21, and 22) in children were from 7 to 14 perfusion units (PU), 11 (6.016; 11.900 PU), 12 (6.677; 14.129 PU), 21 (6.043;11.899 PU), and 22 (6.668; 14.174 PU). There was a statistically significant correlation between PBF and children's age (p < 0.000) without any significant gender discrimination (p = 0.395). For all incisors, for any age group, the PBF detection value of the lateral incisors was significantly higher than that of the central incisors (p < 0.05). The clinical coincidence rate of detecting PBF in the traumatic teeth was 90.42% and the sensitivity and specificity were 36.99% and 99.88%, respectively. CONCLUSIONS: The determination of the PBF clinical reference range and clinical coincidence rate for the permanent maxillary incisors in children using LDF provided a promising theoretical basis for clinical applications.

Implications of Post-Traumatic Treatment of Immature Maxillary Incisors.

The aim of this review was to discuss traumatic dental injuries in view of their treatment implications to provide an evidence-based resource for clinicians when planning treatment for traumatised immature maxillary incisors. Dental trauma to immature maxillary incisors can result in various complications, such as critical fractures, resorptions, or ankylosis, and might lead to tooth loss. Traumatised teeth may exhibit various unaesthetic discolourations as a result of different dental trauma sequelae or materials used for treatment. All of the above can influence patients' social experience, including self-esteem, confidence, eating and speaking abilities, as well as proper development and growth of the jaw bones. Treatment of traumatised immature incisors should focus not only on the acute phase but on the long-term consequences. Any time gained with the tooth in the jaw bone, free of infection, is an achievement, as it allows normal growth and development. All these aspects are discussed in this narrative review, and an evidence-based summary resource is suggested for clinicians to use when planning treatment for traumatised immature maxillary incisors.

Multidisciplinary Approach for Autotransplantation and Restoration of a Maxillary Premolar into an Area of an Avulsed Anterior Tooth: A Case Report with a 6-Year Follow-up.

The loss of an anterior tooth because of avulsion has been reported in up to 3% of dental injuries. Management alternatives, such as implant-supported restorations and a fixed partial denture, are contraindicated in growing patients because of the continuous growth of the alveolar process. At the same time, orthodontic treatment for gap closure will result in asymmetry and will require adjustment of the adjacent healthy teeth. Therefore, restoring a missing tooth imposes a treatment challenge, especially in children and young adults. Tooth autotransplantation is a treatment modality with high reported survival and success rates that overcome these mentioned limitations. It might also help to preserve the alveolar bone and the soft tissues. This case report describes a multidisciplinary approach for managing a 13-year-old boy who lost his right maxillary central incisor because of a fall. Management included autotransplantation of the left maxillary second premolar to the site of the lost right maxillary central incisor, management of external inflammatory resorption with an endodontic treatment, orthodontic treatment, and aesthetic restoration of the area with composite resin crowns that can be adapted to the expected changes of the jaws during the craniofacial growing period. At the 6-year follow-up, the teeth demonstrated a positive outcome.