Root fracture of molar. Case report.
A patient came to the clinic complaining of localized pain in tooth 16, which had been bothering him for over a year. On clinical examination, only mild pain on digital palpation in the root region MV. The occlusion of said tooth was observed to be overloaded in relation to the antagonist, tilted. Radiographic examination revealed a fracture line on the MV root.
A preparation and core in these dimensions favor cracking in the root in the long term by concentrating forces that would otherwise be in delicate areas of the root.
Radicular fracture of molar. In: Lima et al. Research, Society and Development, v. 10, n. 12, e59101219988, 2021
Introduction
Horizontal Root Fractures (HRF) usually result from a frontal impact due to hard object trauma or fighting. Comprising 1.2-7% of all traumatic injuries, these occur in permanent teeth (Andreasen, Andreasen & Tsilingaridis, 2018; Andreasen, 1979) and usually affect a single element, as elucidated in the work of Andreasen, Andreasen, and Cvek (2007).
Maxillary central incisors are affected most frequently, followed by maxillary lateral incisors and only in 5% of cases in mandibular incisors (Andreasen, Andreasen & Bayer, 1989).
Traditionally, horizontal root fractures were diagnosed only by radiographic images and classified according to the position of the fracture line, which could be located in the apical, middle or cervical third (Caliskan & Pehlivan, 1996; Wolner-Hansen, 2010). It can also be defined as oblique, when it involves the cervical and middle third, or transverse, when it is restricted to only one third of the tooth (Cvek, Andreasen & Borum, 2001).
Given the need for better diagnostic imaging, radiographic techniques have achieved major developments, and are currently represented by three-dimensional images (Costa et al., 2014).
Cone-Beam Computed Tomography (CBCT) has been successfully used in the diagnosis and
prognostic imaging of root fractures and is shown to be superior to other radiographic methods (Fagundes, Mendonça, Albuquerque & Jacinto, 2014).
Studies have been conducted comparing computed tomography (CT) and radiographs for the diagnosis of root fractures and it was shown that the level of the fracture line on radiographs can vary significantly from
to the three-dimensional image. Therefore, when the exact position of the horizontal fracture cannot be determined, the radiographic
diagnosis should be complemented with the three-dimensional image, which may affect treatment planning (Bornstein, Wolner- Hanssen, Sendi & Arx, 2009; Bernardes et.al, 2009).
With this, there has been a significant improvement in the diagnosis of horizontal root fractures, regarding the presence and absence of these, the exact location, extent and direction of the fracture line (Lenzi & Trope, 2012; Costa et al, 2011).
Root fractures usually present a good prognosis, being characterized by a communication between pulpal and periodontal tissues, thus forming a fracture line. This process promotes the reestablishment of a collateral circulation and drains the edema caused by the trauma, as well as reducing tension in the pulpal vessels
(Mata, Gross & Koren, 1985). Pulp vitality is usually maintained after root fracture, causing spontaneous
healing in 70 to 80% of cases (Andreasen, & Andersson, 2007; Camp, 2000).
The repair of horizontal root fractures involves joining the segments by hard, calcified tissue (occurs rarely), connective tissue interposition (occurs commonly), bone and connective tissue interposition or granulation tissue interposition (Neeraj, Kundabala & Acharaya, 2011).
The separation between the fragments is an important variable in fracture healing (Ozbek, Serper &Semra, 2003).
If the displacement of the coronal fragment is not severe, minimal damage to the pulp and periodontium will occur. In the presence of
a space between the fragments, repositioning the fragments increases the frequency of healing, particularly in
teeth with complete root formation. In teeth with incomplete root formation, tissue regeneration will occur,
even if the fracture space is persistent, because there is an excellent pulpal capacity for revascularization (Andrade, Campos
Sobrinho, Andrade & Matos, 2008).
The occurrence of healing remains the same regardless of the fracture site in relation to the gingival sulcus
(Cvek, Mejare & Andreasen, 2002). However, in the case of a bacterial invasion originating from the gingival sulcus, the
fracture in the cervical region is more prone to contamination due to its proximity to the sulcus. Hard tissue fracture repair is less frequent in the cervical third than in other parts of the root, probably
due to the greater mobility of the coronal fragment (Cvek et al., 2001; Cvek et al., 2002). Moreover, the prognosis is
significantly better in oblique fractures located in the cervical than transverse fractures located in this same
region (Cvek et al., 2002), considering that in oblique fractures, the involvement of the middle third helps to stabilize the
coronary fragment (Fagundes et al., 2014).
Regarding the treatment, it is proposed that there is a reduction of the fracture, which consists of the alignment and juxtaposition
between the fragments, with stabilization of the coronary fragment with the aid of splinting. This procedure aims to allow the
formation of a bridge of calcified tissue between the fragments (Cvek et al., 2001). It is recommended to splint the tooth
using a flexible fixation for 4 weeks if the fracture is located in the middle or apical third. If the fracture is
located cervically, splinting remains for a longer period of time (up to 4 months) (Bourguignon et al., 2020;
Cvek et al., 2001; Diangelis, Andreasen & Ebeleseder, 2012).
It is of great relevance the theoretical foundation in face of the clinical case treated in this work, so that the
addition of knowledge can assist the daily clinical practice, in face of situations of dental urgency of traumatized patients
, in specific of the FRH in permanent teeth. As a result of theory in concomitance with practice,
we will obtain more accurate diagnoses, appropriate treatments and the most positive prognosis possible. Thus, it is of utmost
importance to understand the mechanisms that lead to this type of fracture, the tissue responses, as well as the
management of the different types of fracture and their respective prognoses (Abott, 2019).
Root fracture of a molar.
