Cumhuriyet Dentl Journl Volume 19 Issue 1 doi: 10.7126/cdj.58140.5000012076 ville t http://dergiprk.ulkim.gov.tr/cumudj/ CASE REPORT Multi-disciplinry pproch for the tretment of mxillry nterior teeth with luxtion injuries nd complicted crown frctures: A cse report İsmil Özkoçk, DDS, PhD, 1 Bde Sont, DDS, PhD, 2 Fehmi Gönüldş, DDS, 3 Ftm Aytç, DDS, PhD, 4 Mehmet Keml Tümer, DDS, PhD 5 1 Deprtment of Endodontics, Fculty of Dentistry, University of Gziosmnps, Tokt 2 Deprtment of Endodontics, Fculty of Dentistry, University of Ankr, Ankr, Turkey 3 Deprtment of Prosthodontics, Fculty of Dentistry, University of Ankr, Ankr, Turkey 4 Deprtment of Restortive Dentistry, Fculty of Dentistry, University of Gziosmnps, Tokt, Turkey 5 Deprtment of Orl nd Mxillofcil Surgery, Fculty of Dentistry, University of Gziosmnps,Tokt, Turkey ARTICLE INFO Article history: Received 02-Ferury-2014 Accepted 08-My-2014 Keywords: Complicted crown frctures, Dentl injuries, Endodontics, Luxtion ABSTRACT Anterior tooth frctures re commonly seen types of dentl injury. In the tretment of complicted crown frctures, two tretment options s extrction nd root cnl tretment could e considered due to the remining tooth structure. Endodontic tretment is vitl in order to mintin function nd provides etter esthetics nd reliefs the ptient s pin. The im of this cse report is to present 17-yers-old femle ptient s tretment nd five-yers follow-up rdiogrphs nd photogrphs. Ptient hd the multiple trumtized (luxtion nd complicted crown frctures) mxillry incisor teeth with peripicl lesions. After creful exmintion nd multidisciplinry tretment, peripicl lesions were heled, teeth nd djcent tissues were helthy nd functionl. Endodontic tretment must e considered y clinicns insted of extrction of tooth s priority. Corresponding uthor t: İsmil Özkoçk, Deprtment of Endodontics, Fculty of Dentistry, University of Gziosmnps, Ali Şevki Erek Yerleşkesi 60150, Tokt/Turkey. Tel: +90 538 327 72 05, Fx: +90 356 212 4225. E-mil: dr_ozkock@yhoo.com 50
INTRODUCTION Trumtic dentl injuries my occur in ccidents (utomoile, icycle etc.), during sport-relted ctivities, flls nd fights. 1 The mxillry nteriors re the most frequently trumticlly injured teeth due to their exposed position in the dentl rch. 2 The incidence of complicted crown frctures rnges from 2% to 13% of ll dentl injuries nd the most commonly involved tooth is the mxillry centrl incisor. 3 The nterior tooth loss or frcture occurring s result of trum, cn cuse esthetic nd psychologicl prolems especilly in young ptients. Anterior esthetic nd functionl dentl rehilittion plys n importnt role in the development of qulity of life, one s self-confidence nd to engge in n ctive socil life of next term. Dentl trum cn cuse mny different types of injuries on dentl nd surrounding tissues. Crown frctures involving enmel, dentin, nd pulp, re clled s complicted crown frctures. Teeth with crown frctures nd exposed pulps cn e treted either y pulpotomy or root cnl therpy efore restortion of lost tooth structure. If vitl pulp therpy is plnned, it is importnt to perform tretment s soon s possile fter the injury. 4,5 Lterl luxtion is defined s trum, displced the tooth lingully, ucclly, mesilly, or distlly, which is, out of norml position. 5 Complicted injuries such s luxtion comined with frctures could pose risk fctor for pulp helth. 6,7 In trum cses, right dignosis, tretment plnning nd follow-up re crucil in order to chieve successful tretment results 8 nd function nd esthetics should quickly regined. In the tretment of complicted crown frctures, two different tretment options emerge ccording to the remining tooth structure; these re tooth extrction nd root cnl tretment. 9 Injuries hve een restored with posts nd crown techniques fter endodontic tretment in this clinicl cse. The ojective of this cse report is to present multi-disciplinry pproch of trumtized mxillry nterior teeth treted in endodontic, restortive dentistry nd prosthodontic deprtments. CASE REPORT A 17-yers-old femle ptient referred to Ankr University Fculty of Dentistry Deprtment of Endodontics with trum history which cused frcture of her nterior teeth. Clinicl exmintion reveled crown frcture of mxillry left centrl, lterl, nd mxillry right lterl, comined with lterl luxtion injury in mxillry right centrl incisor. Rdiolucent lesions were determined in the peripicl re of mxillry right centrl, lterl nd mxillry left centrl incisors rdiogrphiclly. It ws lerned from the ptient tht she hd gone under orthodontic tretment due to her protrusive incisors for out 3 yers nd the tretment ws ended 1 yer efore the injury. Severe pin, moility, percussion nd plption sensitivity ws oserved cliniclly. Clinicl sitution reflect the comintion of complicted crown frctures nd luxtion injuries on teeth. After the tretment of soft tissues, dislocted tooth repositioned with finger pressure under locl nesthesi. The dmged teeth were splinted with composite resin nd pulp extirptions were mde immeditely (Figure 1). Clcium hydroxide dressing ws pplied to the root cnls monthly for 4 months. And then root cnl fillings were mde y gutt-perch nd Sel-Apex root cnl seler (Figure 2). The splint ws removed fter three weeks. The teeth were restored with composite resin (Filtek Z 250, 3M Espe, St. Pul, MN, USA) temporrily (due to esthetic concerns nd the ptient s ge) fter plcing the fier 51
Figure 1. Introrl view fter splint ppliction (), Introrl view from pltinl fter splint ppliction (), fter removing splint (c) c Figure 2. Rdiogrphs tken from right () nd left incisors () fter endodontic tretment posts (Glssix, Hrld Nordin SA, Chilly- Montreux, Switzerlnd) (Figure 3). The ptient ws clled for routine controls for out 1 yer fter the endodontic tretment (then ws clled in 1-yer intervls) nd no prolem ws oserved (Figure 4). Mxillry nterior teeth hve een permnently restored with zirconi-sed ll-cermic restortions (Figure 5). After endodontic tretment, peripicl lesions were heled, the ptient s gums were helthy, nd there were no symptoms of sensitivity to percussion, plption tenderness, fistul or swelling. Five yers records nd clinicl exmintion showed tht the teeth were helthy, moreover, no signs of root resorption nd peripicl lesions ws oserved (Figures 4,5). DISCUSSION Trumtic dentl injuries (TDIs) of permnent teeth occur frequently Figure 3. Fier post ppliction () nd composite restortions () fter root cnl tretment Figure 4. Rdiogrphs of 1 yer follow up (), 3 yers follow up () nd 5 yers follow up (c) Figure 5. Zirconium oxide sed cermic restortions fter 1 yer () nd 5 yers of tretment () in children nd young dults. Crown frctures nd luxtions re the most commonly occurring ones mong ll dentl injuries. The susceptiility of teeth to trum is closely relted to position of the teeth in the mouth. The mxillry incisors were found to hve much higher prevlence nd incidence of trum thn c 52
the mndiulr incisors, nd the mxillry centrl incisors hd higher prevlence nd incidence of trum thn did the mxillry lterl incisors. Especilly, if mxillry incisors re ssocited with Clss II division 1 mlocclusion, risk fctors increses due to trum. 10,11 The ptient in the present cse hd een treted orthodonticlly ecuse of her Clss II division 1 mlocclusion pproximtely 5 yers efore the trum. However, the ptient still hs n excessive overjet. When the ptient referred to the clinic just fter the ccident, not only frctures ut lso peripicl lesions were oserved in the peripicl re of mxillry incisors rdiogrphiclly. These lesions my hve occurred s result of orthodontic forces during mxillry incisor retrction which were pplied in order to correct clss II reltionship nd excessive overjet. Neurogenic inflmmtion y inducing orthodontic forces ssocited with the relese of neuropeptides cn led to chnges in the pulp. This itrogenic injury my vry from simple pulp necrosis to the internl resorption. 12 We considered tht the peripicl lesions were relted to orthodontic forces five yers prior therpy, ecuse there ws no history of trum to teeth, filling or deep decy. Orofcil trum my led to different results strting from simple enmel frcture to more complex injury nd require long-term follow-up. One of the most chllenging prolem in dentistry is to decide which tretment option is the est for the restortion of one or more of the mxillry incisors tht hve een frctured s result of trumtic injuries. Different tretment pproches hve een indicted for trumtized teeth, depending on the loction of the frcture, remining tooth structure, helth of djcent tissue, type of injuries, ptient s coopertion nd esthetic expecttions, socioeconomic sttus. 9 Primrily, in the present cse we decided endodontic therpy nd follow up ecuse of femle ptient s ge, type of trum nd peripicl lesions. Clcium hydroxide hs wide ppliction re in endodontic prctice s dressing mteril ecuse of its iologicl properties nd ntimicroil effects. Clcium hydroxide shows these fetures y inducing one formtion nd y inctivting lipopolyscchride. Clcium hydroxide my e the est choice for different clinicl situtions. A high degree of success hs een reported in severl studies y using clcium hydroxide in the tretment of peripicl lesions. 13-15 In the present cse esides trum injuries, there were peripicl lesions in the teeth, so clcium hydroxide dressing ws pplied for period of 4 months nd the results were successful in non-surgicl tretment of lesions. Mitin et l. primrily performed root cnl tretment nd extrused the tooth orthodonticlly for 12 weeks, then tooth ws restored with metl cst core nd porcelin fused crown. 16 Bigi et l. performed root cnl tretment, uild up the tooth y glss fier nd composite resin nd restorted tooth with limun cermic crown tht in their cse of crown frcture. 17 Altun et l. hve pplied primrily intrcnl medicment for 4 months in the tretment of crown frcture, uthors pplied endodontic tretment nd restorted the tooth with glss fier post nd composite resin sme s in the present study. 18 In the present study, in order to provide etter esthetic teeth were restorted with zirconi-sed llcermic restortions finlly fter peripicl heling. Asgry nd Fzly treted to complicted crown frcture with miniml pulpotomy out 1 mm nd restored with 53
composite resin. In the present study, teeth were nonvitl nd exposed res were very lrge, therefore root cnl tretment ws preferred. 19 Frgment rettchment hs een pplied in mny cses in the literture s nother tretment option 20-23 ut in the present cse, the ptient hd serious ccident nd fructured components could not e reched. The purpose of the endodontic nd restortive tretment is to gin dentl function, form nd esthetics gin. Anterior teeth esthetics my significntly ffect the ptient s psychology. Trditionlly cst posts hve een used for long time to restorte complicted crown frcture. Depending on developments in dhesive dentistry resin-sed fier-reinforced posts hve een used in the restortion of mxillry nterior teeth. 9 Fier resin posts shows similr hrdness to dentin nd exhiits greter durility thn the metl posts. Hving elstic modulus similr to dentin, strengthens the remining tooth structure nd increses resistnce to tooth frcture. 24-26 Becuse of this dvntges, fier post ws used in this cse to restorte the frctured teeth with composite resins. The present cse demonstrted tht the teeth cn e kept in the mouth in helthy wy even in severe dentl trum s result of creful nd multidisciplinry study. CONCLUSION Physicins must pproch rther conservtive for physiclly nd psychologiclly worn ptient. In such cses, during ssessing tretment options, the occurring loss of dentl hrd tissues, tooth eruption, esthetics, function nd the ptient s expecttions should e considered crefully. In such cses experienced reserchers nd clinicins from relted deprtments should e included in the steps of tretment. Endodontic tretment is vitl for the protection of tooth in the mouth s functionl, to ringing ck the esthetics of the ptient nd to relief the ptient s pin. REFERENCES 1. Grg N, Grg A. Mngement of trumtic injuries, in: Textook of Endodontics, 1 st ed., Jypee Pulishers, New Delhi; 2007; p. 339 62. 2. Atek D, Alçm A, Aydintug I, Konkoglu G. A retrospective study of trumtic dentl injuries, Dent Trumtol 2014;30:154-61. 3. Andresen JO, Andresen FM, Crown frctures. In: Andresen JO, Andresen FM, eds. Text Book nd Color Atls of Trumtic Injuries to the Teeth, 3 th ed., Copenhgen: Munksgrd, 1993; p. 219-56 4. Ingle J, Bklnd L, eds. Endodontics. 5 th ed., Hmilton Ontrio, Cnd: B C Decker Inc. Ltd.; 2002; p. 795 845. 5. Wlton R, Torinejd M., Principles nd Prctice of Endodontics, 4 th ed., Elsevier Inc.:Sunders, 2009; p. 389 424 6. Luridsen E, Hermnn NV, Gerds TA, Kreiorg S, Andresen JO. Pttern of trumtic dentl injuries in the permnent dentition mong children, dolescents, nd dults, Dent Trumtol 2012;28:358-63. 7. Luridsen E, Hermnn NV, Gerds TA, Ahrensurg SS, Kreiorg S, Andresen JO. Comintion injuries 3.The risk of pulp necrosis in permnent teeth with extrusion or lterl luxtion nd concomitnt crown frctures without pulp exposure, Dent Trumtol 2012;28:379-85. 8. Dingelis AJ, Andresen JO, 54
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25. Hyshi M, Suget A, Tkhshi Y, Imzto S, Eisu S. Sttic nd ftigue frcture resistnces of pulpless teeth restored with postcores. Dent Mter 2008;24:1178-86. 26. Coelho CS, Biffi JC, Silv GR, Arhão A, Cmpos RE, Sores CJ. Finite element nlysis of wekened roots restored with composite resin nd posts. Dent Mter J 2009;28:671 8. How to cite this rticle: İsmil Özkoçk, Bde Sont, Fehmi Gönüldş, Ftm Aytç, Mehmet Keml Tümer. Multi-disciplinry pproch for the tretment of mxillry nterior teeth with luxtion injuries nd complicted crown frctures: A cse report. Cumhuriyet Dent J 2016;19(1):50-56. 56