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Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 95-98
A novel approach in treating horizontally fractured canine using RIBBOND splint and MTA as an obturating material and intra-radicular splint: A case report

1 Department of Conservative and Endodontics, Manubhai Patel Dental College and Hospital, Vadodara, India
2 Department of Conservative and Endodontics, AME's Dental College and Hospital, Raichur, India

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Date of Submission25-Sep-2012
Date of Decision29-Jan-2013
Date of Acceptance23-Mar-2013
Date of Web Publication21-Apr-2014


Radicular fractures in permanent teeth are uncommon injuries among dental traumas, being only 0.5-7% of the cases. Management of horizontal root fractures presents a formidable challenge for clinicians because of the difficulty of achieving a stable reunion of fracture fragments. This case report presents the management of horizontally fractured canine by approximation of fracture fragments, fiber splinting, and use of MTA - both as an obturating material and intra-radicular splint. Short-term follow-up of the case showed promising results both clinically and radiographically.

Keywords: Fiber splint, horizontal root fracture, mineral trioxide aggregate

How to cite this article:
Agrawal V, Patil D. A novel approach in treating horizontally fractured canine using RIBBOND splint and MTA as an obturating material and intra-radicular splint: A case report. Indian J Dent Res 2014;25:95-8

How to cite this URL:
Agrawal V, Patil D. A novel approach in treating horizontally fractured canine using RIBBOND splint and MTA as an obturating material and intra-radicular splint: A case report. Indian J Dent Res [serial online] 2014 [cited 2023 Sep 24];25:95-8. Available from:
Andreasen [1] states that the root fractures in permanent teeth are relatively infrequent occurrences, implicating in 0.5-7% of all dental traumas. Horizontal root fractures occur mainly in the anterior region of the maxilla, usually owing to a frontal impact, more frequently observed in fully erupted teeth with complete root formation. Horizontal fractures occur most frequently in the middle third of the root and rarely in the apical-third. [2],[3],[4] The prognosis is poorer if the fracture level is in the coronal third. [5] Treatment is usually directed at repositioning and stabilizing a tooth (if necessary) in its correct position and monitoring the tooth for an extended period for pulpal vitality. [6] Root fractures represent complex healing patterns due to concomitant injury to the pulp, periodontal ligament, dentine, and cementum. [2]

Healing in teeth with horizontal fracture is with one of these types: healing with hard tissue, interposition of connective tissue, interposition of bone and connective tissue, and interposition of granulation tissue. While the first three types are considered favorable and the 'healing with hard tissue' is the most desired, the last one represents inflammatory state and is unfavorable. [7] If the dental pulp is necrotic, repair does not occur without root canal treatment. A factor with significant influence in the healing process in cases of horizontal fractures is the presence or absence of communication of the fracture line with the oral environment because of contamination from bacteria present in the sulcus. [8]

Various treatment techniques for managing fractured teeth with necrotic pulp have been suggested. The initial treatment consists of the repositioning of displaced coronal segments, followed by the stabilizing of the tooth to allow healing of the periodontal ligament supporting the coronal segment to occur. The amount of dislocation and the degree of mobility of the coronal segment affect the prognosis. [9]

The treatment of choice for fractured, non-vital teeth consists in using calcium hydroxide dressings for certain periods of time followed by gutta-percha filling. [10] Inspite of the good results with calcium hydroxide, the technique is very time consuming and does not always imply success due to inherent complication of long-term calcium hydroxide therapy. [11] Mineral trioxide aggregate (MTA) is a biocompatible material with numerous interesting clinical applications in endodontic. The material appears to be an improvement over other materials for some endodontic procedures that involve root repair and bone healing. Current literature supports its efficacy in promoting the overgrowth of cementum and it may facilitate the regeneration of the periodontal ligament because of its alkaline pH of 12.5 and the presence of several mineral oxides in its composition. [12]

This case report presents the novel approach toward approximation, stabilization, and endodontic management of a horizontally fractured canine using stainless steel file, fiber splinting technique, and MTA.

   Case Report Top

A 26-year-old male visited the Department of Conservative Dentistry and Endodontics with the complaint of loose tooth and pain in the upper right front region. He had suffered a dental injury in the upper anterior teeth during a road accident which had occurred 1 month ago. Medical history was not contributory. Patient gave the history of dental treatment being started by some of the general dentist in upper right front teeth. Clinical examination revealed Ellis Type II fracture in right central incisor, Ellis Type III fracture in right lateral incisor, and lateral luxation of right canine. The right canine was mobile and both right lateral incisor and canine did not respond to electric and thermal pulp testing. Right central incisor responds to both the thermal and electric pulp testing in normal limits. Discomfort was noted during percussion and palpation in right canine.

Radiographic examination revealed crown fracture of the right lateral incisor and also the endodontic treatment has been carried out in right lateral incisor as gutta-percha was present in the apical and middle third of the canal [Figure 1]. Also, horizontal fracture was evident in the middle third of the root on the right canine; separating coronal and apical root fragments from each other [Figure 1]. There was no significant bone loss. Patient's oral hygiene was satisfactory.

Re-endodontic treatment was carried out in the right lateral incisor and fiber post and core was placed for the reinforcement of the fractured crown. Endodontic treatment of right canine was initiated under local anesthesia. A number 15-K file was passed through the fracture in right canine to access the apical root segment [Figure 2]. The necrotic pulp tissue was extirpated. The root canal was cleaned, shaped with a number 60-K file. Then the approximation of the fracture fragments were carried out by inserting the number 80 stainless steel H file in clockwise motion. Care was taken to position the file 2-mm short of the apex [Figure 3]. Keeping the number 80-H file and approximated fragments in its position, all the upper anterior teeth were splinted with Ribbond splint (Ribbond Inc., Seattle, WA, USA) [Figure 4] using flowable light cure composite (Ivoclar Vivadent, Bendererstrasse Liechtenstein) [Figure 5]. After splinting the teeth, number 80-H file was removed from the canal and the canal was filled with calcium hydroxide slurry.
Figure 1: Preoperative IOPA

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Figure 2: Working length

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Figure 3: Approximation of fracture fragments through number 80-H fi le

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Figure 4: Splinting with RIBBOND fi bers

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Figure 5: Light curing of RIBBOND fibers and flowable

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The patient was recalled 2 weeks later, the calcium hydroxide dressing was carefully removed from the canal of right canine. The canal was flushed with sterile water and dried with paper points, and was obturated with vertically compacted MTA (ProRoot MTA, DENTSPLY Tulsa Dental) by using a stainless steel size 80-K file and a 5/7 endodontic plugger. MTA will also act as an intra-radicular splint joining the two fractured fragments [Figure 6]. The access cavity was sealed appropriately.
Figure 6: Postoperative IOPA

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The patient remained asymptomatic for the next 8 weeks, at which time he returned for removal of the splint. He had no complaint and no change in probing depths or in results of clinical tests. The tooth was not tender to percussion. The patient's postoperative course was uneventful. At a 4-month recall visit, the right canine and lateral incisor was asymptomatic and responded normally to percussion, palpation, and pressure [Figure 7].
Figure 7: Fourth month follow-up

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   Discussion Top

After dental trauma, restoration of the oral cavity to a normal functional state and preservation of the natural dentition is a primary goal in dentistry. With the tooth stabilized, the periodontal membrane will regrow if prior damage has not been too extensive. [13]

Horizontal root fracture is one of the consequences of dental trauma. The separation of the fragments is an important variable to fracture healing. The ideal repair process should be the formation of hard tissue between the two fragments, creating a functional unit with normal dental mobility and pulp vitality. [14]

In the above case, horizontal fracture was present at the coronal-middle third of the tooth root. Removal of the apical fragment would lead to poor crown-root ratio. Hence, the non-invasive technique of canal negotiation and root canal procedure was performed in the above case.

Previous studies have shown that fractured roots that radiographically revealed less space between the fragments after repositioning healed more frequently with hard tissue repair than those with more space between the fragments. [15]

Hence, the approximation of the fractured fragment was carried out by inserting the number 80-H file.

Immobilization of the fragments with a rigid splint is arguable. For some authors, the rigid splinting must be maintained for 2-3 months, to provide matrix position in accordance with principles for root healing. However, some studies have found that the matrix deposition occurs to a greater extent in teeth, which are not submitted to immobilization, as root consolidation takes place more efficiently under functional stress. [16],[17] Hence, the splinting was done with fiber splint which is a semi-rigid type of splinting allowing some physiological movements.

MTA is a biomaterial that has been investigated for various endodontic implications such as root-end fillings, pulp capping, apical filling of teeth with open apices, apexification therapy, repair of root, and furcal perforations. MTA has been recognized as a bioactive material that is hard tissue conductive, hard tissue inductive, and biocompatible. MTA has proven to have cementogenic and osteogenic potential. [18] Hence, the fracture line was sealed with the use of MTA and the canals were completely obturated with MTA so that it provides a sort of intra-radicular splint after setting.

Short-term follow-up for the case showed promising results. Patient has to be reviewed after 1 year to confirm success of the treatment.

   Conclusions Top

Horizontal fractures in middle-coronal third of root have long been considered to have hopeless prognosis because of poor understanding of the biological concept of such fracture and lack of availability of biocompatible materials. Availability of materials, like Ribbond fibers and MTA have put forth varied treatment options for clinicians in the management of horizontal fractures.

   References Top

1.Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1298 cases. Scand J Dent Res 1979;78:329-42.  Back to cited text no. 1
2.Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol 2004;20:192-202.   Back to cited text no. 2
3.Versiani MA, Sousa CJ, Cruz-Filho AM, Cruz-Perez DE, Sousa-Neto MA. Clinical management and subsequent healing of teeth with horizontal root fractures. Dent Traumatol 2008;24:136-9.   Back to cited text no. 3
4.Caliskan MK, Pehlivan Y. Prognosis of root-fractured permanent incisors. Endod Dent Traumatol 1996;12:129-36.   Back to cited text no. 4
5.Feiglin B. Clinical management of transverse root fractures. Dent Clin North Am 1995;39:53-78.   Back to cited text no. 5
6.Clark SJ, Eleazer P. Management of a horizontal root fracture after previous root canal therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:220-3.   Back to cited text no. 6
7.Kocak S, Cinar S, Kocak MM, Kayaoglu G. Intraradicular splinting with endodontic instrument of horizontal root fracture-Case report. Dental traumatology 2008;24:578-80.  Back to cited text no. 7
8.Hovland EJ. Horizontal root fractures. Dent Clin North Am 1992;36:509-25.  Back to cited text no. 8
9.Andreasen FM, Andreasen JO. Root fractures. Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3 rd ed. Copenhagen: Munksgaard; 1993. p. 279-311.  Back to cited text no. 9
10.Cvek M, Mejare I, Andreasen JO. Conservative endodontic treatment of the teeth fractured in the middle or apical part o the root. Dent traumatol 2004;20:261-9.  Back to cited text no. 10
11.Bramante CM, Menezes R, Moraes IG, Bernardinelli N, Garcia RB, Letra A. Use of MTA and intracanal post reinforcement in a horizontally fractured tooth: a case report. Dent traumatol 2006;22:275-8.  Back to cited text no. 11
12.Schwartz RS, Mauger M, Clement DJ, Walker WA. Mineral trioxide aggregate. A new material for endodontics. J Am Dent Assoc 1999;130:967-75.  Back to cited text no. 12
13.Geetha IB, Razvi S, Asifulla M. Non invasive and invasive management of horizontal root fracture :a report of two cases. J Health Sci Res 2011;2:1-4.  Back to cited text no. 13
14.Bullar K, Bal R, Malhotra S, Malik S, Bal CS. Management of horizontal root fracture - A case report. Ind J Compr Dent Care 2012;2:267-70.  Back to cited text no. 14
15.Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing 400 intra-alveolar root fractures 2. Effect of treatment factor such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol 2004;20:203-11.  Back to cited text no. 15
16.Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4 th ed. Oxford: Blackwell Munksgaard; 2007.   Back to cited text no. 16
17.Cvek M, Andreasen JO, Borum MK. Healing of 208 intralveolar root fractures in patients aged 7-17 years. Dent traumatol 2001;17:53-8   Back to cited text no. 17
18.Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.  Back to cited text no. 18

Correspondence Address:
Vineet Agrawal
Department of Conservative and Endodontics, Manubhai Patel Dental College and Hospital, Vadodara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.131148

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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