Treatment of a Horizontally Fractured Central Incisor
By Dr. Kaufmann



A 23 year old female patient presented with a history of motor vehicle accident several years previously. During the accident her maxillary teeth were chipped. The maxillary right central and lateral incisors lost a thin portion of their incisal edge and became devitalized. Endodontic treatment was initiated at that time by her dentist. However, the left central incisor sustained a horizontal fracture and was not endodontically treated. This tooth was restored with a aporcelina bonded to metal crown. The apical portion of the root had been left in and showed no evidence of pathology.(Fig. 1)



Figure 2 shows the tooth as it presented. The coronal aspect had negative response to pulp tests and I assumed the pulp had become necrotic. Periodontalnand palpation findings were within normal range. Surprisingly, the mobility of the tooth was lower than expected and only slightly greater than normal. Percussion was mildly positive.
Part of the reason for the increased mobility was the premature contact caused by the apparent extrusion. This may have constributed to the percussive sensitivity.

Needless to say, she was not happy with the aesthetics and wanted something done about the appearance. The real question was:; What if (if anything) should be done with the fractured apical portion of the tooth?



Since the remaining coronal fragment was not mobile, we elected to treat that segment endodontically and then remake the crown. The working length was quite short (approx 14 mm to the incisal edge) and the foramen size was approximately size 45. The canal required minimal preparation and was debrided with the aid of ultrasonics.. A custom, chloroform dipped Non-standardized gutta percha cone was fit after preparing the canal with hand instruments.




The canal was filled with standard warm vertical technique and Kerr sealer. Fig. 3 shows the final result. Since the apical portion of the tooth showed no pathology, it likely has retained its blood supply after the trauma and the pulp inside it is probably normal. It would be a mistake to try to treat it at this time or to consider removal of this fragment.



A 1yr. recall was performed at that time with Fig. 4 showing the results. The ultimate insurance details had yet to be arranged (because some time had elapsed since the original accident and the tooth had already been crowned.) We were unsure of the ultimate disposition of the case so the patient chose to leave the tooth for one year while details were arranged.
It is difficult to tell how long the tooth will last. As the patient ages, there likely will be some gingival recession. If the gingival crevice communicates with the area of the horizontal fracture, the case will likely fail due to periodontal reasons, not endodontic pathology.
No effort should be made to try to remove the fracture apical portion. It should be left untreated, in situ. In fact, attempts to remove this fragment would likely result in damage to the periapical bone. Should the coronal portion eventually become mobile and need to be extracted, healthy periapical bone would be very important to allow proper implant placement.
So, the patient was told that the tooth has a limited lifespan but that it is worth restoring. In this case, I would recommend placing porcelain veneers on the right central and lateral incisors at the same time as the crown on the left central incisor is remade. In that way, we get a better shade match and proper contours. It is also important to explain to the patient that any insurance settlement must take into account that this tooth will probably have to be replaced with an implant at some time in the future and the settlement should reflect this fact.