Management of a complex traumatic dental injury: Crown, crow
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A 22 year old male patient, with the chief complaint of fractured teeth caused by trauma with a wrench, 3 days before. The medical history was normal and classified as ASA I, According to the pulp sensibility test, teeth #23 and #24 showed a severe response but tooth #8 exhibited a mild response. Interestingly, tooth #9 did not show any response to cold/heat test, exhibited tenderness to periapical tests and showed grade I mobility. The crown fractures of traumatized teeth were revealed on the panoramic radiograph. Intraoral periapical radiograph demonstrated a horizontal root fracture in the apical third of tooth #9; crown and oblique crown fracture line extending subgingivally in tooth #8. The radiographic examination also revealed crown fractures of teeth #23 and #24 and no damage to the adjacent teeth. Based on the clinical and radiographic findings, the patient was diagnosed with complex traumatic dental injuries involving crown root fracture and root fracture in teeth #8 and #9, respectively. Teeth #23 and #24 were also diagnosed with complicated crown fracture.

All the traumatized teeth were subjected to emergency treatment on the first visit. To immobilize tooth #9, semirigid splinting (33) was performed using 0.5 mm diameter round stainless steel wire and composite resin. Also, emergency pulpectomy was initiated for teeth #8, #23, and #24. After local anesthesia and rubber dam isolation. The patient was recalled 1 month later. In the next visit, after splint removal, obturation was performed with guttapercha and AH26 sealer by the lateral compaction technique. In the 8week follow up visit, the existing gutta percha was removed to within 5 mm of the root apex with a selection of Gates Glidden drills in teeth #8, #23, and #24. A temporary hook was cemented inside the canals using zinc phosphate cement to aid in extrusion. A customized orthodontic appliance was made for the patient and orthodontic elastic was applied from the hook to the specially designed loop for rapid extrusion. One month later, circumferential supracrestal fiberotomy was performed to avoid any relapse. After the active period of extrusion, the teeth were stabilized for 8 weeks, using a splint. Following the retentive phase, the retainer was removed and the prosthodontic treatment planning and a primary impression were undertaken.

A custom made post and core was prepared using a direct technique followed by permanent cementation. In the 6 month follow up, the teeth were asymptomatic with no sign of root resorption or lesion. In the 1 year follow up, tooth #9 was responsive to pulp sensibility tests. The previously treated teeth did not show any pain, sign, symptoms, and tenderness to percussion. Interestingly, the healing pattern of the horizontal root fracture was demonstrated to be with calcified tissue.