Saving an immature tooth with a deep vertical fracture

Dive into a highly complex case involving an immature fractured tooth.

A 6.5-month-old standard poodle was presented to VDS for a fracture of the maxillary left canine (204). (Figures 1a-1c)

Figure 1a: Intraoral dental pictures revealing the severe subgingival fracture of the maxillary canine tooth. The tooth is still vital, as evidenced by the bleeding pulp.
Figure 1b
Figure 1c

Normally, fractured teeth can have a very good prognosis; however, two issues complicated the procedure in this case. First, there was a deep subgingival fracture on the tooth. This extended below the bone, which will create periodontal issues. In addition, because the patient was so young, the root was not complete (Figure 2), and thus standard root canal therapy was not an option.

Figure 2: Pre-operative intraoral dental picture confirming a very immature tooth without a complete apex.

To save this tooth, multiple procedures would be required, and each would have a questionable prognosis. The combination of these issues made the overall prognosis for a successful, long-term, infection-free maintenance of this tooth poor. All of this was discussed with the owner, and extraction was recommended; however, due to his age, they elected to proceed with the process of salvaging the tooth.

The patient was placed under general anaesthesia, and an exam and dental radiographs were performed (Figure 3). This confirmed the absence of a complete apex and the vertical root fracture.

Figure 3: Post-operative dental radiograph of the vital pulp therapy performed on the tooth. Due to the fracture’s uniqueness and the large defect, the filling appears mottled.

The first step was to create a periodontal flap to restore the vertical root fracture and prevent leakage. Next, vital pulp therapy was performed (Figure 3) to protect the tooth and (hopefully) allow it to mature to the point of receiving root canal therapy in the future. The subgingival defect was restored with glass ionomer to allow for superior periodontal attachment. Finally, the flap was sutured (Figure 4).

Figure 4: Post-operative picture of the tooth following restoration and flap closure

The patient was re-presented 9 months later for follow-up (6 months was recommended). Per the owner, the tooth had broken 2 weeks previously. Upon presentation, the tooth was found to be further broken, with about ½ of the tooth missing and the subgingival restoration lost (Figures 5a and 5b). The tooth was necrotic.

Figure 5a: Intraoral dental picture at recheck, revealing a significant fracture and necrotic pulp
Figure 5b

The patient was placed under general anaesthesia and an exam and dental radiographs exposed. The images revealed that the tooth had lived long enough to complete apexogenisis; however, there was slight periapical lucency, indicating endodontic infection (Figure 6a and 6b).

Figure 6a: Pre-operative dental radiograph confirming complete apexogensis. In addition, there is mild periapical lucency and minimal alveolar bone loss.
Figure 6b

The tooth was treated with standard endodontic therapy (Figure 7) and prepared for a titanium crown (Figure 8). The client was instructed on home care and to recheck in 6 months.

Figure 7: Post-operative dental radiograph of the endodontic treatment confirming a complete fill and good apical seal.
Figure 8: Post-operative dental picture of the installed crown.

One year later, the pet was presented for follow-up. The client had not been very compliant with home care. On presentation, the crown was intact with mild to moderate gingival recession, but minimal inflammation (Figure 9). Dental radiographs were exposed, which revealed that the root canal was successful and there was minimal to no progression of periodontal loss. (Figure 10). The tooth was cleaned, and the client was instructed on home care.

Figure 9: 1-year recheck demonstrating that the tooth is intact. There is some gingival recession with calculus covering the exposed root, but minimal periodontal inflammation
Figure 10: Recheck dental radiograph confirming the success of the endodontic treatment, as well as no progression of the periodontal loss.

This case represents a successful result of a highly complex case requiring two endodontic treatments, periodontal surgery, and multiple advanced restorative procedures. Despite the poor prognosis (and client compliance), the tooth was saved and has a decent long-term prognosis.

Figure 11: The tooth following scaling and polishing.

 

Learn more about broken or fractured teeth.