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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 79-82

Reattachment of fractured fragment with pin-point pulp exposure in a mature tooth with partial pulpotomy using white mineral trioxide aggregate


Department of Conservative Dentistry and Endodontics, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India

Date of Web Publication5-Jan-2016

Correspondence Address:
Nikhil M Jambagi
Department of Conservative Dentistry and Endodontics, KLE VK Institute of Dental Sciences, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.173224

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   Abstract 

Complicated crown fractures involving direct pulp exposure are not viewed as a hopeless situation for pulp survival in mature teeth. The vitality of a healthy pulp can be preserved after traumatic exposure with predictable outcomes with the use of appropriate biomimetic materials. Hence, this case report highlights the reattachment of fractured fragment with pin-point pulp exposure in a mature tooth with partial pulpotomy using white mineral trioxide aggregate with 18 months follow-up.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

  • Case reported to trauma, dealt in oral surgery
  • Case restored by an endodontist
  • Case managed by prosthodontists for further evaluation.

Keywords: Mature tooth, partial pulpotomy, white mineral trioxide aggregate


How to cite this article:
Jambagi NM, Joshi SB. Reattachment of fractured fragment with pin-point pulp exposure in a mature tooth with partial pulpotomy using white mineral trioxide aggregate. J Interdiscip Dentistry 2015;5:79-82

How to cite this URL:
Jambagi NM, Joshi SB. Reattachment of fractured fragment with pin-point pulp exposure in a mature tooth with partial pulpotomy using white mineral trioxide aggregate. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Jun 19];5:79-82. Available from: http://www.jidonline.com/text.asp?2015/5/2/79/173224


   Introduction Top


Traumatic dental injuries occur with great frequency in preschool, school-age children, and young adults. Crown fractures in anterior teeth are more commonly reported 33% of adults.[1]

These fractures could be categorized as enamel fractures, uncomplicated fractures involving enamel-dentin or complicated fractures involving enamel, dentin and pulp or crown-root fractures which could be uncomplicated, and not involving pulp or complicated with pulpal involvement.[1]

The choice of treatment for a complicated fracture depends mainly on the patients' age. The extent of fracture and fracture pattern, defining the amount of tooth structure remaining, pulpal and periodontal involvement, and occlusion also influence the treatment plan.

The vitality of a healthy pulp can be preserved after traumatic exposure with predictable outcomes with the use of appropriate biomimetic materials.[2]

This case report describes the reattachment of fractured fragment with pin-point pulp exposure in a mature tooth with partial pulpotomy using white mineral trioxide aggregate (W MTA).


   Case Report Top


A 23-year-old male patient reported to dental college with a crown fracture in the upper front right region of the jaw [Figure 1] after slipping in the bathroom 2 h prior. The patient had brought the tooth fragment wrapped in a tissue to the dental clinic. This was immediately disinfected with chlorhexidine (Periex, DENTAIDS, India) and placed in saline (sodium chloride 0.9% w/v, Marck, India).
Figure 1:(a and b) Preoperative photograph of fractured lateral incisor. (c) Mineral trioxide aggregate placed followed by glass ionomer cement. (d) Radiograph taken after mineral trioxide aggregate. (e) Tooth fragment. (f) Approximation of tooth fragment. (g) Full thickness mucoperiosteal flap raised to expose the fracture line. (h) Fragment attached with flowable composite after etching and applying bonding agent. (i) Flaps approximated and sutures placed. (j) One week follow-up. (k) Finishing and polishing of composite. (l) One year follow-up radiograph

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The patient had some discomfort and sensitivity to both cold and hot with respect to the tooth.

A comprehensive history was taken to rule out any other injury. The patient's medical history was noncontributory.

Extraoral examination revealed no significant findings. Intraoral examination revealed horizontal fracture of an upper lateral incisor with exposed of pulp measuring 1 mm in diameter with slight oozing of blood and the fracture line running labial to palatal direction subgingivally. The tooth was slightly rotated distally and showed no mobility. There were no signs of soft tissue lacerations and evidence of alveolar bone fracture.

Radiographic findings revealed complete root development with no periapical changes or root fractures associated with the tooth.

On examination, the fragment revealed a clean fracture line with fragmentation of edges. On approximation of the fragment with the tooth margins fitted well and no space was present between the tooth and the fragment. The fragment was immediately replaced in saline solution (sodium chloride 0.9% w/v, Marck).

After thorough examination, treatment options were presented to the patient including endodontic treatment with postcore and crown, endodontic treatment with reattachment of the tooth fragment, and reattachment of the tooth fragment with vital pulp therapy. The limitation of each was explained to the patient. After weighing pros and cons, prognosis and cost factor, the patient decided to opt for more conservative line of treatment of fragment reattachment with vital pulp therapy.

The patient was injected with local infiltration of 2% lidocaine (LOX 2%, Neon Lab Ltd., India) without vasoconstrictor. The area was carefully irrigated with chlorhexidine (Periex, Dend Aids, India).

A sterile round diamond bur (Dia burs, Mani, India) at high speed with water as coolant was used to remove 2 mm of the exposed pulp from the pulp chamber. A cotton pellet with 3% sodium hypochlorite was pressed gently against the pulp. After complete hemostasis was confirmed, W MTA (angelus) was mixed as per manufacturer's instructions and placed into the prepared chamber and allowed to set for 15 min, after checking for the initial set, type II glass ionomer cement (GC Gold Label, Glass Ionomer, India) was used as interappointment temporization, as the reattachment could not be done on the same appointment due to time constraint.

The patient was recalled after a week, periodontal surgery was scheduled to raise a mucoperiosteal flap palatally to expose the subgingival margins of the fractured tooth and to provide adequate isolation of the operative field for bonding of the tooth fragment.

Prior to raising the flap, internal dentin grooves prepared on the fragment and the tooth. The tooth and the fragment were acid etched (Eco Etch, Ivocla Vivadent, India) for 15 s, after which it was rinsed and completely dried. Two coats of bonding agent (3M™ ESPE™ Adper™ Single Bond Plus, USA) were applied and excessive was removed by air drying for 5 s.

Flowable composite of A2 (Tetric N Flow, Ivoclar Vivadent, India) shade was applied onto the fragment and the tooth. The fragment is brought in approximation to the tooth and after verification of the fit it was light cured for 30 s on each side. Excess of the composite was removed using a finishing bur (Shofu, USA). The flaps were approximated and sutured. Any occlusal discrepancy and was checked with articulating paper and high points reduced and the patient was recalled after a week.

In the next visit after the removal of sutures, the tooth, and the periodontal tissues were evaluated. External chamfer was prepared along the fracture line and restored with A2 shade nanohybrid composite (Tetric N Ceram, Ivoclar Vivadent, USA). After removing excess, the composite was finished and polished using polishing disks and strips (Super Snap, Shofu, USA).

The patient was recalled after 1 month, pulp vitality tests using electric pulp testing (Electric Pulp Vitality Tester, Parkell, France) and cold tests (Endo Frost Roeko, Coltene, Germany) were performed, and the results showed vitality was maintained similar to the adjacent teeth.

An 18 months follows up, showed no clinical symptoms and the vitalities were well maintained. In addition, radiographic examination showed no pathological changes. The crowns were functionally and esthetically acceptable.


   Discussion Top


Complicated crown fractures involving direct pulp exposure are not viewed as a hopeless situation for pulp survival in developing teeth. If the complicated fractures occur in an adult with fully formed root, the treatment plan includes a practical approach of endodontic treatment followed by prosthetic crown or endodontic treatment followed by reattachment of the fragment.

In a long-term observation, teeth with mature apices with complicated crown fractures treated with Cvek's partial pulpotomy technique by de Blanco demonstrated success.[2] Clinical and histological findings of exposed pulp tissue of the same study confirmed that partial pulpotomy is a permanent treatment in both mature and immature teeth.[2] The advantage of partial pulpotomy is that the vitality of the tooth is maintained, cell rich coronal pulp tissue is preserved, which necessitates better healing and physiologic positioning of dentin in coronal area, natural color and translucency of the tooth is preserved, it is possible to perform pulp sensitivity tests, the pulp is not deprived of continued physiologic dentin production in the crown and at the cervical area of the tooth; and it is a relatively simple procedure.[1]

In the present case, the fracture occurred in an adult with a fully formed root. The availability of the fragment in a single mass, its close approximation to the tooth without any discrepancy, minimal time lapse, and patients willingness indicated reattachment of the fragment with vital pulp therapy similar to the fracture treated in young patients with open apex.

The severity of the accident plays an important role in the capability of pulp healing. In the present case, the tooth was located out of arch, therefore, prone to fracture. There was no mobility associated with the tooth. Thus eliminating the possibility of luxation injury to the tooth which would have compromised the ability of the pulp to defend itself. The direction of impact was in labial direction with fracture line running labial to palatal direction subgingivally. This was a favorable fracture as the fragment was supported by the tooth from forces in palatal direction decreasing chances of debonding.

The time elapsed between the exposed pulp, in this case is 120 min, which had a very good chance of survival; hence, partial pulpotomy procedure was planned out.[3] Cvek demonstrated that pulpotomy procedure can be done even after several days after pulpal exposure.[3] A golden rule is to proceed as soon as possible.[1] However according to Ingle, after 48 h chances of maintaining a healthy pulp decrease due to direct bacterial contamination which could lead to zone of inflammation progressing apically.[3]

1–2 mm of exposed pulp tissue was amputated as the inflammatory changes are superficial and only that part of pulp tissue affected.

In this case, W MTA was used as direct pulp capping material, which is biocompatible, has antibacterial properties, better adaptation to adjacent dentin which prevents bacterial micro leakage, and ability to induce the release of bioactive dentin matrix proteins which initiates the formation of hard tissue bridges.[1] Hard tissue formation in W MTA does not create zone of necrosis unlike calcium hydroxide when it comes in contact with the pulp; hence, further damage to pulp is avoided in W MTA.[1]

The fragment debonding occurs mostly because of repeated trauma, nonphysiological use of the tooth, or horizontal pulling of the tooth, therefore, the patient was instructed to be careful and avoid lateral movements.

Lise et al. have suggested the modification of both tooth and fragment prior to bonding which increases the fracture resistance up to 97%. These modifications such as dentin groove, bevel, chamfer or over contour remove fractured enamel prisms and retain prisms which are in a favorable position for effective etching.[4] As the fit of the segment had no discrepancy, internal dentin groove provided space for resin composites which reinforced the reattachment. An external chamfer was also incorporated in our case to obtain an increase in adhesion area between the tooth and fragment.[5]

The etch and rinse generation bonding agents were used as they provided excellent means of reattaching the fragment to remaining tooth. The raised intrasulcular flap permitted adequate isolation of the operating field most essential for bonding procedures. As the tooth fragment was maintained in dry state for more than 1 h, it would have lowered its bond strength but this was taken care by placing the fragment in the saline.[4]

Dehydration of tooth fragment for prolonged periods can cause undesirable esthetic problems.

However, this problem was avoided since the fragment was hydrated at all times. An external chamfer and composite restoration helped mask the fracture line that was evident at 1 week recall visit.[4]

The vitality of the tooth was checked at 4 weeks, 3 and 6 months, and 1 year interval. The tooth showed similar response as the adjacent tooth. The reattachment case must be followed for 2 years with clinical examination, vitality testing, periodontal probing, and radiographs.

It is important to consider the limitations of the reattachment procedures of possible fragment debonding or refractures.


   Conclusion Top


Even though there are only few documented cases, the outcome of this treatment challenges some widely held concepts. Long-term prognosis of such case is uncertain as a result of a lack of longitudinal studies comparing the same fracture pattern and restorative techniques.[2]

This case report provides a conservative approach of maintaining vitality in a mature tooth after traumatic exposure of the pulp, maintaining the esthetics, function, and health of the periodontal tissues.

 
   References Top

1.
Bakland LK. Revisiting traumatic pulpal exposure: Materials, management principles, and techniques. Dent Clin North Am 2009;53:661-73.  Back to cited text no. 1
    
2.
Lucia P. de Blanco. Treatment of crown fractures with pulp exposure. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiol and Endod 1996;82:564-8.  Back to cited text no. 2
    
3.
Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured teeth: A review of literature regarding techniques and materials. Oper Dent 2004;29:226-33.  Back to cited text no. 3
    
4.
Lise DP, Vieira LC, Araújo É, Lopes GC. Tooth fragment reattachment: The natural restoration. Oper Dent 2012;37:584-90. Epub 2012 Jul 7.  Back to cited text no. 4
    
5.
John I. Ingle, Leif K. Bakland J. Craig Baumgartner. Ingle's endodontics 6th Edition.  Back to cited text no. 5
    


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    Abstract
   Introduction
   Case Report
   Discussion
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