Management of horizontal root fractures by fabrication of canine protected occlusion using composite resin
A 49 year-old male patient presented to the urgent care clinic, Korea University dental hospital, with the complaint of slightly mobile maxillary central incisors due to a fall while exercising on the treadmill that happened one day prior to his visit. The patient's medical history was unremarkable.\nThe extraoral examination revealed abrasion of the chin and contusion of the upper lip. The intraoral clinical examination showed uncomplicated enamel-dentine fracture of the maxillary right canine and lateral incisor. The maxillary central incisors exhibited enamel chipping as well as many superficial enamel craze lines, and grade 1 to 2 mobility. The surrounding periodontal tissue was slightly erythematous in the cervical area of both maxillary central incisors. He had bruises and superficial lacerations on the inner surface of the upper lip. Horizontal fracture lines were radiographically evident between the middle third and the cervical third of the maxillary central incisors ().\nOtherwise, the status of the traumatized teeth was within normal limits in terms of periodontal pocket, vitality on thermal and electrical test. For the management of soft tissue injuries, analgesic (Ibuprofen 400 mg) and antibiotic (amoxicillin 500 mg) were prescribed to take 3 times a day for the period of 3 adjustment of the opposing mandibular incisors was carried out to eliminate interference on the traumatized incisors in maximum intercuspation. The patient was advised to have a soft diet and avoid loading on the anterior teeth until the teeth become clinically stable. The patient was then referred to the Department of Conservative Dentistry, Korea University Dental Hospital for the management of the maxillary central incisors with horizontal root fractures and the maxillary right lateral incisor and canine with crown fracture. Ten days later, on his first visit to the Department of Conservative Dentistry, slightly increased patient's discomfort and visibly increased mobility of the maxillary central incisors were observed on protrusion and lateral excursion. Composite resin Filtek Z-250 (3M ESPE, St. Paul, MN, USA) was used to repair enamel chipping of the maxillary central incisors, the mesial tip of the maxillary right canine. The fractured incisal third of the maxillary right lateral incisor was restored with composite resin over resin-modified glass ionomer (RMGI) material FUJI II LC (GC, Tokyo, Japan) (). In an attempt to eliminate loading on the traumatized maxillary central incisors upon unavoidable eccentric movements during function, the same composite resin material was added on the maxillary canines establishing canine protected occlusion (). Contact points were marked with the articulating paper in centric occlusion. Composite resin was added incisal to the contact points marked on the occlusal surfaces of the maxillary canines. Selective adjustment of the composite resin build ups was carried out until uniform lines were marked on the resin during lateral excursion and until any interference on the damaged teeth in centric occlusion and during eccentric movement was not marked on the articulating paper. Calculus removal was carefully performed on the same visit to help maintain periodontal health. The patient returned for periodic monthly follow up for 4 month and 3 month follow up for next 2 years. At every recall, the teeth were clinically evaluated for vitality using an electric pulp tester (Digitest, Parkell, Farmingdale, NY, USA), thermal response to cold, pocket depth, percussion, mobility and occlusion, and periapical status with radiographs. After the construction of canine protected occlusion using composite resin, there was a gradual increase in comfort experienced by the patient owing to declining tooth mobility. At 4 month recall, the mobility of both maxillary central incisors exhibited in the range of physiological allowance and the patient did not report any discomfort associated with the injured teeth. At follow up 30 months later, the vitality, stability and esthetics of the maxillary central incisors were maintained (). Despite the presence of noticeable discontinuation of the outlines of the maxillary central incisors between the middle and cervical third root, an increase in the density of the alveolar bone between the root fragments was observed. Radiographically, there were no signs of pathological changes including root resorption or ankylosis ( and ).