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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 292-296

Conservative approach for managing complicated crown-root fracture in a 4-year-old child: A case with 12-month follow-up


1 Department Pediatric and Preventive Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth, An Institution Deemed to be University, Vadodara, Gujarat, India
2 Public Health Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth, An Institution Deemed to be University, Vadodara, Gujarat, India

Date of Submission17-May-2022
Date of Acceptance09-Jun-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. Pratik B Kariya
Department Pediatric and Preventive Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth, An Institution Deemed to be University, Vadodara - 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_109_22

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  Abstract 


Traumatic dental injuries (TDIs) are of great concern when it comes to a child. Crown-root fracture is the most complicated type as both crown and root are affected by trauma. Complicated crown-root fracture seldom occurs in deciduous dentition. It is a tragic experience and requires immediate attention and quick functional and esthetic repair. Appropriate and early diagnosis leads to successful treatment, for which knowledge on types of TDIs, classification, and management is necessary. Complete restoration of teeth affected with trauma will restore function and esthetics and preserve occlusal harmony. The objective of the present case report is to discuss the appropriate diagnosis and conservative treatment of this unusual and rare case of complicated crown-root fracture in a 4-year-old child using tooth fragment reattachment. This case will focus on the options to restore the uncommon trauma and normalize the function and esthetics of the patient, which will lead to improvement of speech, increase in self-confidence and protection of successors, and describe the treatment and aspects concerning follow-up of the patient.

Keywords: Complicated crown-root fracture, deciduous dentition, fragment reattachment, traumatic dental injuries


How to cite this article:
Kariya PB, Singh S, Deshpande AN, Desai A. Conservative approach for managing complicated crown-root fracture in a 4-year-old child: A case with 12-month follow-up. Arch Med Health Sci 2022;10:292-6

How to cite this URL:
Kariya PB, Singh S, Deshpande AN, Desai A. Conservative approach for managing complicated crown-root fracture in a 4-year-old child: A case with 12-month follow-up. Arch Med Health Sci [serial online] 2022 [cited 2023 Jan 31];10:292-6. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/292/364947




  Introduction Top


Traumatic dental injury (TDI) is commonly seen in young children as they are very playful.[1] TDI is very prevalent in specific age groups such as 1 1/2 to 2 years when children learn to walk and 3 to 4 years when they start playing outdoor games independently. The worldwide prevalence of TDIs accounts for 8%. The prevalence of TDI in the deciduous dentition is 41.1%, where the most commonly affected age group is 3 to 6 years, and the most frequently impacted teeth are deciduous maxillary central incisors.[2] In permanent dentition, the prevalence of TDI is 56.6%, with most commonly seen around 23.0 years of age, and the most frequently affected teeth are permanent maxillary central incisors.[3] In the Indian population, the prevalence of TDI has been reported to be 15% for deciduous dentition and 12% for permanent dentition.[4] Maxillary incisors are the teeth most commonly affected by trauma in deciduous and permanent dentition. The possible reason may be its position in the most prominent part of the face; further, the incidence increases with predisposing factors such as incisor proclination, class II malocclusion, etc. Trauma can be extraoral or intraoral. Many classifications have been proposed for TDI, including Ellis and Davey's in 1960 and Gracia Godoy's in 1956. Among different traumatic injuries, the highest prevalence is of subluxation (33.7%), followed by lateral luxation (27.6%), avulsion (15.6%), and intrusion (15.6%).[3]

Crown-root fractures are defined as fractures involving enamel, dentin, and cementum, which may or may not involve the pulp. Depending on the involvement of pulp, they can be further classified as complicated and noncomplicated. Complicated crown-root fracture seldom occurs in deciduous dentition. Appropriate and early diagnosis leads to successful treatment, for which knowledge on types of TDIs, classification, and management is necessary. Complete restoration of traumatized teeth will not only restore the function and esthetics but also preserve occlusal harmony.[5] The objective of the present case report is to discuss the appropriate diagnosis and conservative treatment of this unusual and rare case of complicated crown-root fracture in a 4-year-old child. This case will focus on the options to restore the unusual trauma and normalize the function and esthetics of the patient, which will lead to improvement of speech, increase in self-confidence and protection of successors, and describe the treatment and aspects concerning follow-up of the patient.


  Case Report Top


A 4-year-old boy reported to a private dental clinic with the chief complaint of pain in maxillary front teeth for 4 days. He was accompanied by his parents, who gave a fall history while playing at home 4 days ago. Parents gave negative history regarding vomiting, drowsiness, and loss of consciousness immediately after the fall. The patient experienced bleeding from the upper lip and upper front region of teeth. Parents controlled bleeding by pressure application using cotton. The patient presented with a complete set of primary dentitions and good oral hygiene on clinical examination. A complicated crown-root fracture with the right maxillary deciduous central incisor (51) was evident on close intraoral examination [Figure 1]. Vertical fracture involving 51 was extending below the cementoenamel junction subgingivally from the incisal edge. Crown of 51 was fractured into labial and palatal halves. The labial fragment had Grade III mobility and was retained in the oral cavity owing to the soft tissue attachment. Pulp tissue could be seen in between the fractured fragments of 51. The patient had pain during mastication since the day of trauma.
Figure 1: Intraoral photographs showing fractured primary maxillary right central incisor (51)

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An intraoral periapical radiographic examination revealed a radiolucent fracture line obliquely dividing the crown and extending beyond the cementoenamel junction. The periapical region revealed a widening of periodontal ligament space [Figure 2]. Considering intraoral periapical radiograph interpretation and clinical history, the final diagnosis was a complicated crown-root fracture to 51, causing acute irreversible pulpitis.
Figure 2: Intraoral periapical radiograph showing fractured primary maxillary right central incisor (51)

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After explaining the treatment plan to parents, written informed consent was obtained to carry out the treatment. The fractured labial fragment was extracted and stored in 0.9% normal saline solution till further use [Figure 3]. Further, the access cavity was prepared, and the pulp was extirpated followed by chemomechanical preparation of the root canal. The root canal was obturated using calcium hydroxide with iodoform paste (Metapex Plus, META Biomed, Colmar, PA). The fractured fragments were reattached using flowable composite [Figure 4]. As the oblique fracture extended below the cementoenamel junction, it had a less occlusal load-bearing strength. Fragment reattachment followed by full-coverage restoration using zirconia crown was performed to restore the occlusal and gingival harmony [Figure 5]. One-year follow-up visit presented healing of periapical lesion and restoration of function with respect to 51 [Figure 6].
Figure 3: Extracted labial fragment

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Figure 4: Intraoral periapical radiograph showing obturated primary maxillary right central incisor (51)

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Figure 5: Photograph showing zirconia crown on primary maxillary right central incisor (51)

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Figure 6: Twelve-month follow-up visit

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  Discussion Top


TDIs are of great concern for a child as trauma affects them more psychologically than esthetically or functionally. In the present case, a complicated crown-root fracture was diagnosed. The treatment of such TDI requires a holistic approach where conservative, endodontic, esthetic, and prosthetic techniques go hand in hand.[6]

TDIs are of various types: crown fracture involving enamel, fracture involving enamel and dentin, fracture involving enamel, dentin, and pulp, crown-root fracture, avulsion, etc., Among all, the crown-root fracture is the most complicated type as both crown and root are affected by trauma. Complicated crown-root fracture involves enamel, dentin, cementum, and pulp exposure. However, complicated crown-root fracture prevalence is only 4.5% in primary dentition and 17.1% in permanent dentition.[3] Direct and indirect impact to the tooth by fall while playing, contact sports, fighting, and bottle cap opening accounts for the primary etiology.

Sequalae of complicated crown root fracture in deciduous teeth are nonvital pulp, displacement of the fragment, and impingement of root to develop a permanent successor. Similarly, when the complicated crown-root fracture occurs in permanent teeth, it may lead to a complete or partial nonvital pulp, displacement of the fractured fragment, and fracture of alveolar bone.[7]

Scanty literature is available on complicated crown-root fracture in the primary dentition[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] [Table 1]. Morisaki et al., Soviero et al., Götze Gda et al., Tejani et al., Abdelnur et al., Tewari et al., and Kanimozhi et al. have discussed treatments such as extraction followed by space management, and Hariharan and Rayen have discussed treatment option pulpectomy followed by stainless steel crown. There is significantly less literature on fractured fragment reattachment procedures in treating a complicated crown-root fracture. The present case is reported to discuss appropriate diagnosis and conservative treatment of this unusual and rare case of complicated crown-root fracture in a 4-year-old child using tooth fragment reattachment.
Table 1: Cases of crown-root fracture in primary dentition reported worldwide

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According to the International Society of Dental Traumatology guidelines, the ideal treatment modality for treating a complicated crown-root fracture in primary teeth is either pulpectomy or extraction.[18] There are various treatment modalities discussed for complicated crown-root fractures such as repositioning followed by splinting, orthodontic tooth movement followed by splinting, fractured fragment reattachment, esthetic composite restoration using a direct or indirect technique, crown placement, post and core, revascularization, extraction, and prosthetic rehabilitation.[18],[19],[20] All these modalities are preferably used in permanent dentition. Application of these treatment modalities in primary dentition may not always be possible. A child patient is different from an adult in behavior management and pain tolerance. In the present case, we chose the conservative approach, which is less invasive and novel method. After a complicated crown-root fracture, pulpectomy is a must to preserve and increase the longevity of teeth in the oral cavity until the permanent successors erupt.[5] Fractured fragment reattachment is the most conservative approach through which traumatized teeth can be restored. It is a minimally invasive, esthetic, cost-effective, and practitioner-friendly technique.[21] Fragment reattachment has advantages such as preserving natural teeth, which gives better strength and esthetics, and minimally invasive treatment. Treatment with pulpectomy and fractured fragment reattachment should always be followed by prosthetic rehabilitation by full-coverage crown placement.[18] There are many options in crowns for the pediatric age group such as stainless steel, polycarbonate, and zirconia. In the case of an esthetic restoration, a zirconia crown is more recommended due to its appearance as a tooth.[22]


  Conclusion Top


While treating a child patient, the operator should have a vision of obtaining appropriate and predictable outcomes in minimally invasive ways. With recent techniques and advanced materials available, desirable results can be achieved. Thus, the fragment reattachment technique should be considered a viable alternative to restore primary dentition's form, function, and esthetics in minimally invasive ways.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Costa VP, Goettems ML, Baldissera EZ, Bertoldi AD, Torriani DD. Clinical and radiographic sequelae to primary teeth affected by dental trauma: A 9-year retrospective study. Braz Oral Res 2016;30:S1806-83242016000100702.  Back to cited text no. 1
    
2.
Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis-one billion living people have had traumatic dental injuries. Dent Traumatol 2018;34:71-86.  Back to cited text no. 2
    
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Mahmoodi B, Rahimi-Nedjat R, Weusmann J, Azaripour A, Walter C, Willershausen B. Traumatic dental injuries in a university hospital: A four-year retrospective study. BMC Oral Health 2015;15:139.  Back to cited text no. 3
    
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Tewari N, Mathur VP, Siddiqui I, Morankar R, Verma AR, Pandey RM. Prevalence of traumatic dental injuries in India: A systematic review and meta-analysis. Indian J Dent Res 2020;31:601-14.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Wang G, Wang C, Qin M. Pulp prognosis following conservative pulp treatment in teeth with complicated crown fractures-A retrospective study. Dent Traumatol 2017;33:255-60.  Back to cited text no. 5
    
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Tewari N, Mathur VP, Singh N, Singh S, Pandey RK. Long-term effects of traumatic dental injuries of primary dentition on permanent successors: A retrospective study of 596 teeth. Dent Traumatol 2018;34:129-34.  Back to cited text no. 7
    
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Morisaki I, Kitamura K, Ooshima T, Sobue S. Vertical crown-root fracture of the mandibular first primary molar in a one-year-old child. Endod Dent Traumatol 1989;5:197-9.  Back to cited text no. 8
    
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Soviero VM, Guimarães L, Miasato JM, Ramos ME, Alto LA. Traumatic fractures of primary molars: A case report. Int J Paediatr Dent 1997;7:255-8.  Back to cited text no. 9
    
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Götze Gda R, Barreira AK, Maia LC. Crown-root fracture of a lower first primary molar: Report of an unusual case. Dent Traumatol 2008;24:e377-80.  Back to cited text no. 10
    
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Tejani Z, Johnson A, Mason C, Goodman J. Multiple crown-root fractures in primary molars and a suspected subcondylar fracture following trauma: A report of a case. Dent Traumatol 2008;24:253-6.  Back to cited text no. 11
    
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Abdelnur JP, da Rosa Götze G, Barreira AK, Maia LC. Parasymphyseal fracture associated with fracture of a maxillary primary molar in a child: Case report. Dent Traumatol 2009;25:e21-4.  Back to cited text no. 12
    
13.
Tewari N, Pandey RK, Jindal G. Management of crown root fracture in primary “double tooth”: A case report. Dent Traumatol 2011;27:71-3.  Back to cited text no. 13
    
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Hariharan VS, Rayen R. Case report: Management of crown-root fracture in lower first primary molar caused by injury to the chin: Report of an unusual case. Eur Arch Paediatr Dent 2012;13:217-20.  Back to cited text no. 14
    
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Lima Mde D, de Moura MS, Leopoldino Vde D, Batista-Netto Ode S, Carvalho CM, Moura Lde F. Crown-root fracture of fused primary teeth – A case report. Gen Dent 2012;60:e101-3.  Back to cited text no. 15
    
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Khatri A, Kumar S, Kalra N, Tyagi R. Fragment reattachment of a complicated crown-root fracture in primary maxillary central Incisor and 1 year follow-up. SRM J Res Dent Sci 2016;7:124-7.  Back to cited text no. 16
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Kanimozhi I, Ramakrishnan M, Ravikumar D, Sharna N. Management of crown-root fracture in primary canine by surgical extrusion: A case report with 1-year follow-Up. Case Rep Dent 2018;2018:3753807.  Back to cited text no. 17
    
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Levin L, Day PF, Hicks L, O'Connell A, Fouad AF, Bourguignon C, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: General introduction. Dent Traumatol 2020;36:309-13.  Back to cited text no. 18
    
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Martins AV, Albuquerque RC, Lanza LD, Vilaça ÊL, Silva N, Moreira AN, et al. Conservative treatment of a complicated crown-root fracture using adhesive fragment reattachment and composite resin restoration: Two year follow-up. Oper Dent 2018;43:E102-9.  Back to cited text no. 19
    
20.
Farmakis ET. Orthodontic extrusion of an incisor with a complicated crown root fracture, utilising a custom-made intra-canal wire loop and endodontic treatment: A case report with 7-years follow-up. Eur Arch Paediatr Dent 2018;19:379-85.  Back to cited text no. 20
    
21.
Sarapultseva M, Sarapultsev A. Long-term results of crown fragment reattachment techniques for fractured anterior teeth: A retrospective case-control study. J Esthet Restor Dent 2019;31:290-4.  Back to cited text no. 21
    
22.
Sonbol HN, Al-Bitar ZB, Shraideh AZ, Al-Omiri MK. Parental-caregiver perception of child oral-health related quality of life following zirconia crown placement and non-restoration of carious primary anterior teeth. Eur J Paediatr Dent 2018;19:21-8.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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