Longitudinal tooth fracture indicating a questionable prognosis for an endodontist

INTRODUCTION

Longitudinal fracture is also known as vertical fracture of a tooth. It means a fracture of the tooth, which initiates at any level in the root and extends along the root in a vertical direction.^[1-3] This type of fracture changes with time or, in other words, extends with time as compared to fracture due to trauma. It mostly occurs in premolars with a higher incidence followed by first molars. It commonly involves a buccolingual surface and may include a proximal surface. Longitudinal fractures are of several types depending on the severity of fracture,^[1] as shown in Figure 1.

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Figure 1:

Types of longitudinal fracture from least to severe.

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ETIOLOGY OF LONGITUDINAL FRACTURE

There are several reasons for longitudinal (vertical) fractures to occur^[4] mentioned in Table 1.

CHALLENGES IN THE DIAGNOSIS OF LONGITUDINAL FRACTURE

1. These types of tooth fractures are not rare and are most challenging for a dental surgeon. On the one hand, some cases are manageable; on the other hand, some are near to extraction. It may be complete or incomplete. In endodontics, it is the most common reason for failure and reason for extraction.^[1]

2. Longitudinal fractures of tooth are difficult to diagnose and manage without any expert opinion. Why this incorrect diagnosis or difficulty in diagnosis arises is a critical factor to be considered in dental practice. Inappropriate knowledge regarding the type of fracture and characterization of severity of fracture are among these factors.^[1]

3. Longitudinal fracture develops slowly in a timely manner, mostly unnoticed by the patient until clinical signs and symptoms like pain during biting, are visible. Longitudinal fracture of endodontically treated teeth are irritating for the patient as well as for the dental health care professional and are most difficult to diagnose.^[2]

4. F-speed conventional and digital radiographic methods (two-dimensional [2D] radiographic images) are insufficient in diagnosing longitudinal fracture. Hence, the diagnosis of vertical root fractures (VRFs) remains a challenge using 2D radiographic images.^[5]

5. When the diagnosis is incorrect, how can the right management be expected? When talking about the right diagnosis, then, future consideration is the prognosis of the root with longitudinal fracture, which is not always good, especially when it extends below the gingival attachment, indicating the extraction of the offending tooth or amputation of the root.^[1]

CHALLENGES IN THE TREATMENT OF LONGITUDINAL FRACTURE

1. Early identification and management an important factors for a good prognosis since restorative intervention can limit the extension of the fracture prevent any microleakage and encroachment of pulpal or periodontal tissues.^[1]

2. Management of different types of longitudinal fractures depends on factors such as the extent of the fracture line and the vitality status of the tooth.^[1,6]

3. The most challenging is the treatment of split tooth involving the pulp chamber. In case of fracture extending to the root, surgical crown lengthening and orthodontic extrusion of the stable fragment can be done, followed by removal of the mobile fragment. Risk factors in such case stay with the site for bacterial infection, leading to bony imperfection.^[1]

4. A long, regular follow-up is required to assess the success of treatment so that any necessary alternation can be done.^[1]

BONDING MATERIALS FOR LONGITUDINAL FRACTURE AND FACTORS AFFECTING THE PROGNOSIS OF LONGITUDINAL FRACTURE

Bonding material used for the treatment of longitudinal fracture must possess some desirable properties^[7] which are. Factors affecting the prognosis of longitudinal fracture are listed in Table 2.

There are different materials used for bonding longitudinal tooth fracture, which are Biodentine, iRoot BP plus, mineral trioxide aggregates, and 4-methacryloxyethyl trimellitate anhydride/methyl methacrylate-tri-n-butylborane (4-META/MMA-TBB), a combination of iRoot BP plus adhesive composite resin, as shown in Table 3.^[8-16]

RECENT ADVANCES IN THE DIAGNOSIS AND MANAGEMENT OF LONGITUDINAL FRACTURE

1. Three-dimensional (3D) images like cone-beam computed tomography (CBCT) scan aids in the assessment of anatomical structures that CBCT has been proved accurate in the detection of VRFs as compared to 2D radiographic images, that is, digital and periapical radiographs.^[17-19]

2. With recent advancements in adhesives, fractures once considered irreparable and recommended for extraction can now be successfully restored and reinforced both internally and externally, for example, an intentional replantation method involving the combination of resin and bioceramic material to repair longitudinal fracture through a retention form on both sides of the fracture.^[20]

3. Full coverage restoration can be performed if the fractured segment of the split tooth is stable. For reinforcement of fragments, composite resin, full coverage crown, adhesives, and ligature wires have been done in the literature. Lasers such as carbon dioxide and neodymium-doped yttrium aluminum garnet (NdYAG) used to fuse the fracture segments, and intentional reimplantation has been successfully tried.^[20-26]

4. Apposition of new cement at the fracture site involving the pulpal floor can be done using novel biomaterials.^[20]

5. Vital teeth not involving the pulp can be conservatively managed by a cast gold inlay or full cast crown.^[20]

6. Fractured cusp can be treated by a novel technique known as the matricing and holding technique, which involves the temporary retention of the fractured cusp segment using a matrix band so that there occurs proliferation of granulation tissue and re-attachment of periodontium to the root dentin surface. It prevents pocket formation in the involved root surface area. This temporary retention of the fractured cusp segment is followed by permanent bonded restoration and then removal of tooth fragment during crown preparation.^[27]

CONCLUSION

Functional and esthetic outcomes following longitudinal fracture treatment are important considerations in the case of anterior teeth. When talking about the practical utility of the above-mentioned treatment modalities it is still in controversy, and further research is still required. The success of longitudinal fracture depends on its location, direction, extent, prognosis, and treatment modalities available so we cannot rely on one of them; in fact, we have to consider them all.