Multidisciplinary treatment approach for crown fracture and crown-root fracture - a case report

The increased incidence of traumatic injuries to anterior teeth is a consequence of leisure activities, where the most common injuries are crown fractures. Treatment of the dental trauma is complex and requires a comprehensive and accurate diagnostic and treatment plan. It is also important to consider the biological, functional, esthetic and economic aspects, as well as the patient's desire. The purpose of this article is to report a case that shows the multidisciplinary approach required to successfully manage the rehabilitation of a maxillary central incisor with a complex crown fracture and a maxillary lateral incisor, that at first presented an oblique crown-root fracture, and after the orthodontic extrusion, suffered a more apical new crown-root fracture.

Influence of Microgap Location and Configuration on Radiographic Bone Loss Around Submerged Implants: An Experimental Study in Dogs

Purpose: The vertical location of the implant-abutment connection influences the subsequent reaction of the peri-implant bone. It is not known, however, whether any additional influence is exerted by different microgap configurations. Therefore, the radiographic bone reactions of two different implant systems were monitored for 6 months. Materials and Methods: In eight mongrel dogs, two implants with an internal Morse-taper connection (INT group) were placed on one side of the mandible; the contralateral side received two implants with an external-hex connection (EXT group). on each side, one implant was aligned at the bone level (equicrestal) and the second implant was placed 1.5 mm subcrestal. Healing abutments were placed 3 months after submerged healing, and the implants were maintained for another 3 months without prosthetic loading. At implant placement and after 1, 2, 3, 4, 5, and 6 months, standardized radiographs were obtained, and peri-implant bone levels were measured with regard to microgap location and evaluated statistically. Results: All implants osseointegrated clinically and radiographically. The overall mean bone loss was 0.68 +/- 0.59 mm in the equicrestal INT group, 1.32 +/- 0.49 mm in the equicrestal EXT group, 0.76 +/- 0.49 mm in the subcrestal INT group, and 1.88 +/- 0.81 mm in the subcrestal EXT group. The differences between the INT and EXT groups were statistically significant (paired t tests). The first significant differences between the internal and external groups were seen at month 1 in the subcrestal groups and at 3 months in the equicrestal groups. Bone loss was most pronounced in the subcrestal EXT group. Conclusions: Within the limits of this study, different microgap configurations can cause different amounts of bone loss, even before prosthetic loading. Subcrestal placement of a butt-joint microgap design may lead to more pronounced radiographic bone loss. INT J ORAL MAXILLOFAC IMPLANTS 2011;26:941-946

Use of Titanium Mesh for Reconstruction of Extensive Defects in Fronto-orbito-ethmoidal Fracture

Traumatic injuries treatment of the fronto-naso-orbito-ethmoidal region has been one of the most challenging treatments within maxillofacial surgery, particularly of extensive orbital defects, very common in this type of pathologic condition. A 48-year-old man involved in a car collision presented an extensive bilateral fracture of the orbit medial wall, nasal bones, the nasal septum, and the frontal anterior table. The clinical and tomographic findings concluded the diagnosis of a maxilla and fronto-naso-orbito-ethmoidal fracture. Among the variety of biomaterials, the titanium mesh was elected because of the extension and magnitude of the bone defect, obtaining this way esthetic and functional results with better prognosis.

Digital Radiographic Evaluation of the Level of Alveolar Bone Crest in External Hexagon Implants Submitted to 2 Types of Implant Abutments Under Immediate Loading

Purpose: The aim of this study was to evaluate by means of digital radiography the behavior of the alveolar bone crest in external hexagon implants following the use of 2 different types of abutments, one for conventional cemented prosthesis and one for modified cemented prosthesis.Methods: Ten external hexagon implants (platform 4.1) were placed in 5 patients. Initial instrumentation was carried out to obtain primary stability of the temporary prostheses under immediate loading. Each patient received both abutments for conventional and modified cemented prosthesis. Standardized digital periapical radiographies were performed at times T0 (immediately after implant placement) and T1 (4 months after implant placement). A straight line was initially established from the implant platform to the distal and mesial periimplantar marginal bone tissue (immediately in contact with the implant) and measured by digital radiography, using Sidexis version 2.3 (Sirona Dental Systems GmbH, Bensheim, Germany) software. The data were submitted to paired-samples t-test analysis.Results: There was no significant difference between the conventional and modified cemented prosthesis. In both cases, t-test results were within the null hypothesis level.Conclusion: The abutment for the modified cemented prosthesis resulted in no significant radiographic difference of alveolar bone crest height, when compared with the conventional cemented prostheses.

Resolution of a titanium implant fracture after a recurrent trauma

Post-traumatic complications occasionally lead to tooth loss as well as the need for future implants. However, rehabilitation with endosseous osseointegrated implants does not protect the patient from the risk of suffering a new trauma. Implant fracture and the damage of the hexagon are post-traumatic complications that guide the clinician to preparing a more intricate treatment plan. The authors present a clinical case of a recurrent trauma of maxillary implant fracture. The treatment plan was to remove the implants followed by autogenous bone grafting to correct the defect. Two titanium implants were replaced, followed by connective tissue graft after allowing complete the healing process of the bone graft to occur. In the postoperative period of 6 months, satisfactory results have been shown as regards soft and hard tissues wound healing.

Influence of Microgap Location and Configuration on Radiographic Bone Loss in Nonsubmerged Implants: An Experimental Study in Dogs

Purpose: The implant-abutment connection (microgap) influences the pen-implant bone morphology. However, it is unclear if different microgap configurations additionally modify bone reactions. This preliminary study aimed to radiographically monitor pen-implant bone levels in two different microgap configurations during 3 months of nonsubmerged healing. Materials and Methods: Six dogs received two implants with internal Morse taper connection (INT group) on one side of the mandible and two implants with external-hex connection (EXT group) on the other side. One implant on each side was positioned at bone level (equicrestal); the second implant was inserted 1.5 mm below the bone crest (subcrestal). Healing abutments were attached directly after implant insertion, and the implants were maintained for 3 months without prosthetic loading. At implant placement and 1, 2, and 3 months, standardized radiographs were taken to monitor pen-implant bone levels. Results: All implants osseointegrated. A total bone loss of 0.48 +/- 0.66 mm was measured in the equicrestal INT group, 0.69 +/- 0.43 mm in the equicrestal EXT group, 0.79 +/- 0.93 mm in the subcrestal INT group, and 1.56 +/- 0.53 mm in the subcrestal EXT group (P>.05, paired t tests). Within the four groups, bone loss over time became significantly greater in the EXT groups than in the INT groups. The greatest bone loss was noted in the subcrestal EXT group. Conclusion: Within the limits of this animal study, it seems that even without prosthetic loading, different microgap configurations exhibit different patterns of bone loss during nonsubmerged healing. Subcrestal positioning of an external butt joint microgap may lead to faster radiographic bone loss. Int J Prosthodont 2011;24:445-452.

Radiographic assessment of photodynamic therapy as an adjunctive treatment on induced periodontitis in immunosuppressed rats

Objective: The aim of this study was to assess radiographically the effect of photodynamic therapy (PDT) as an adjunctive treatment to scaling and root planing (SRP) on induced periodontitis in dexamethasone-induced immunosuppressed rats. Material and Methods: The animals were divided into 2 groups: ND group (n=60): saline treatment; D group (n=60): dexamethasone treatment. In both ND and D groups, periodontal disease was induced by the placement of a ligature in the left first mandibular molar. After 7 days, ligature was removed and all animals received SRP, being divided according to the following treatments: SRP: saline and PDT: phenothiazinium dye (TBO) plus laser irradiation. Ten animals per treatment were killed at 7, 15 and 30 days. The distance between the cementoenamel junction and the height of the alveolar bone crest in the mesial surface of the mandibular left first molars was determined in millimeters in each radiograph. The radiographic values were analyzed statistically by ANOVA and Tukey's test at a p value <0.05. Results: Intragroup radiographic assessment (ND and D groups) showed that there was statistically significant less bone loss in the animals treated with PDT in all experimental periods compared to those submitted to SRP. Intergroup radiographic analysis (ND and D groups) demonstrated that there was greater bone loss in the ND group treated with SRP compared to the D group treated with PDT at 7 and 30 days. Conclusion: PDT was an effective adjunctive treatment to SRP on induced periodontitis in dexamethasone-induced immunosuppressed rats.

THE EFFECT of E-GLASS FIBERS and ACRYLIC RESIN THICKNESS on FRACTURE LOAD IN A SIMULATED IMPLANT-SUPPORTED OVERDENTURE PROSTHESIS

Statement of problem. Implant overdenture prostheses are prone to acrylic resin fracture because of space limitations around the implant overdenture components.Purpose. The purpose of this study was to evaluate the influence of E-glass fibers and acrylic resin thickness in resisting acrylic resin fracture around a simulated overdenture abutment.Material and methods. A model was developed to simulate the clinical situation of an implant overdenture abutment with varying acrylic resin thickness (1.5 or 3.0 mm) with or without E-glass fiber reinforcement. Forty-eight specimens with an underlying simulated abutment were divided into 4 groups (n=12): 1.5 mm acrylic resin without E-glass fibers identified as thin with no E-glass fiber mesh (TN-N); 1.5 mm acrylic resin with E-glass fibers identified as thin with E-glass fiber mesh (TN-F); 3.0 mm acrylic resin without E-glass fibers identified as thick without E-glass fiber mesh (TK-N); and 3.0 mm acrylic resin with E-glass fibers identified as thick with E-glass fiber mesh (TK-F). All specimens were submitted to a 3-point bending test and fracture loads (N) were analyzed with a 2-way ANOVA and Tukey's post hoc test (alpha=.05).Results. The results revealed significant differences in fracture load among the 4 groups, with significant effects from both thickness (P<.001) and inclusion of the mesh (P<.001). Results demonstrated no interaction between mesh and thickness (P=.690). The TN-N: 39 +/- 5 N; TN-F: 50 +/- 6.9 N; TK-N: 162 +/- 13 N; and TK-F: 193 +/- 21 N groups were all statistically different (P<.001).Conclusions. The fracture load of a processed, acrylic resin implant-supported overdenture can be significantly increased by the addition of E-glass fibers even when using thin acrylic resin sections. on a relative basis, the increase in fracture load was similar when adding E-glass fibers or increasing acrylic resin thickness. (J Prosthet Dent 2011;106:373-377)

Severe lateral luxation and root fracture: report of a case with 5-year follow-up

A case of severe lateral luxation and root fracture in upper incisors is reported. Treatment involved the repositioning and fixation of the injured teeth and endodontic treatment with calcium hydroxide. The importance of long-term follow-up is emphasized.

Influence of the type of dental trauma on the pulp vitality and the time elapsed until treatment: a study in patients aged 0-3 years

The purpose of the present study was to determine the influence of the type of trauma on the pulp vitality and the time elapsed until seeking dental care in children aged 0-3 years seen at the Baby Clinic of the Aracatuba Dental School, UNESP. A total of 1813 records were analyzed. Two hundred and three patients, corresponding to 302 traumatized teeth, were assessed clinically and radiographically. Hard-tissue injuries were the most frequent (52%), with a predominance of enamel crown fractures (41.4%), followed by concussions (12.6%) and intrusions (11.6%). Clinical and radiographic examination revealed that 72% of the traumatized teeth maintained pulp vitality. In the case of supporting-tissue lesions, 51.1% of the patients sought care within 1-15 days after injury, while in the case of hard-tissue injuries, 52.7% sought care only after 16 days. The results showed that supporting-tissue injuries had a significant influence on the faster seeking of dental care.

Comparison of visual inspection, radiographic examination, laser fluorescence and their combinations on treatment decisions for occlusal surfaces

Purpose: To compare visual inspection (VI), radiographic examination (RX) and the laser fluorescence device DIAGNOdent (L), as well as their combinations in vitro regarding treatment decisions for occlusal surfaces. Methods: 72 extracted human permanent teeth (molars and premolars) were used. Treatment decisions were recorded by three calibrated examiners, and the options available were fissure sealant and conservative restoration. For validation of treatment decisions, the teeth were sectioned and examined in a stereomicroscope. Thereafter, dental slices were scanned and the images were edited to facilitate classification of existing carious lesions. Intra and inter-examiner reproducibility for the determination of treatment plans were calculated using Cohen's kappa test (95%-CI). Sensitivity, specificity, positive and negative predictive values, and the area under the ROC curve were also calculated. Results: VI and L provided on average the greatest intra- and inter-examiner reproducibility, respectively. Although the combination of diagnostic methods may decrease both intra- and inter examiners reproducibility, combination of VI, L and RX resulted in the greatest sensitivity, being statistically superior to RX and L. There was more inter-examiner agreement for the option of restorative treatment, while the use of sealants as a treatment option yielded the lowest values. Negative predictive values were numerically inferior to positive predictive values, indicating that the examiners preferred not to restore a carious tooth than to proceed operatively in an intact tooth. The combination of the three methods studied showed the best results in determining treatment plans for occlusal surfaces, when compared to the other types of exams. on the other hand, radiographic examination and laser fluorescence were less efficient when used alone.

Alternative Treatment Modalities for Immature Intruded Permanent Incisors: Report of 2 Cases

Intrusion of permanent teeth is one of the most severe types of traumatic injuries. Different treatment strategies have been proposed, and the best approach for each case depends on the stage of root development, severity of the intrusive luxation, presence of alveolar fracture and number of intruded teeth. The purpose of this paper is to describe the treatment management of 2 cases of severely intruded immature permanent maxillary central incisors in 71/2- and 8-year-old children. In case 1, the traumatized tooth was treated by surgical repositioning, while in case 2 watchful waiting for spontaneous re-eruption was the treatment of choice. Treatment strategies were successful in both cases, as demonstrated by the continuation of root development, maintenance of pulp vitality, and absence of signs of per/apical pathosis during the follow-up period. Regardless of the treatment strategy, traumatically intruded teeth should undergo periodical clinical and radiographic surveillance on a long-term basis to allow early detection of possible complications. (Pediotr Dent 2009;31:340-5) Received March 11, 2008 vertical bar Last Revision June 25, 2008 vertical bar Revision Accepted July 16, 2008

Influence of examiner's clinical experience on the reproducibility and accuracy of radiographic examination in detecting occlusal caries

The aim of this in vitro study was to assess the influence of varying examiner's clinical experience on the reproducibility and accuracy of radiographic examination for occlusal caries detection. Standardized bitewing radiographs were obtained from 166 permanent molars. Radiographic examination was performed by final-year dental students from two universities (A, n=5; B, n=5) and by dentists with 5 to 7 years of experience who work in two different countries (C, n=5; D, n=5). All examinations were repeated after 1-week interval. The teeth were histologically prepared and assessed for caries extension. For intraexaminer reproducibility, the unweighted kappa values were: A (0.11-0.40), B (0.12-0.33), C (0.47-0.58), and D (0.42-0.71). Interexaminer reproducibility statistics were computed based on means +/- SD of unweighted kappa values: A (0.07 +/- 0.05), B (0.12 +/- 0.09), C (0.24 +/- 0.08), and D (0.33 +/- 0.10). Sensitivity, specificity, and accuracy were calculated at D(1) and D(3) thresholds and compared by performing McNemar test (p=0.05). D(1) sensitivity ranged between 0.29 and 0.75 and specificity between 0.24 and 0.85. D(3) specificity was moderate to high (between 0.62 and 0.95) for all groups, with statistically significant difference between the dentists groups (C and D). Sensitivity was low to moderate (between 0.21 and 0.57) with statistically significant difference for groups B and D. Accuracy was similar for all groups (0.55). Spearman's correlations were: A (0.12), B (0.24), C (0.30), and D (0.38). In conclusion, the reproducibility of radiographic examination was influenced by the examiner's clinical experience, training, and dental education as well as the accuracy in detecting occlusal caries.

Longitudinal clinical and radiographic evaluation of severely intruded permanent incisors in a pediatric population

Intrusion is defined as the axial dislodgment of the tooth into its socket and is considered one of the most severe types of dental trauma. This longitudinal outcome study was undertaken to evaluate clinically and radiographically severely intruded permanent incisors in a population of children and adolescents. All cases were treated between September 2003 and February 2008 in a dental trauma service. Clinical and radiographic data were collected from 12 patients (eight males and four females) that represented 15 permanent maxillary incisors. Mean age at the time of injury was 8 years and 9 months (range 7-14 years and 8 months). Mean time elapsed to follow-up was 26.6 months (range 10-51 months). The analysis of data showed that tooth intrusion was twice as frequent in males. The maxillary central incisors were the most commonly intruded teeth (93.3%), and falling at home was the main etiologic factor (60%). More than half of the cases (53.3%) were multiple intrusions, 73.3% of the intruded teeth had incomplete root formation and 66.6% of the teeth suffered other injuries concomitant to intrusion. Immediate surgical repositioning was the treatment of choice in 66.7% of the cases, while watchful waiting for the tooth to return to its pre-injury position was adopted in 33.3% of the cases. The teeth that suffered additional injuries to the intrusive luxation presented a fivefold increased relative risk of developing pulp necrosis. The immature teeth had six times more chances of presenting pulp canal obliteration that the mature teeth and a lower risk of developing root resorption. The most frequent post-injury complications were pulp necrosis (73.3%), marginal bone loss (60%), inflammatory root resorption (40%), pulp canal obliteration (26.7%) and replacement root resorption (20%). From the results of this study, it was not possible to determine whether the type immediate treatment had any influence on the appearance of sequelae like pulp necrosis and root resorption after intrusive luxation, but the existence of additional injuries and the stage of root development influenced the clinical case outcome in a negative and positive manner, respectively.