Management of mid-root fractures presents a formidable challenge for clinicians because of the difficulty of achieving a stable reunion of fracture fragments. This article presents two varied treatment options for mid-root fractures. A 15-year-old female reported an impact injury to the maxillary anterior teeth 2 days after its occurrence. Clinically, the maxillary left central incisor was palatally-extruded with a negative vitality response and radiographic evidence of an oblique fracture at the middle third of the root. An endodontic implant was employed which utilized an open technique and has been on follow-up for ten months. A 32-year-old male reported an injury, which resulted in a mobile maxillary right central incisor, three months after its occurrence. Through clinical and radiographic means, a discolored, extruded, and non-vital maxillary right central incisor with an oblique root fracture at the alveolar-crest level was observed. Exploratory surgery was performed; an apical barrier was created with a mineral trioxide aggregate and obturated with gutta percha. The fragments were stabilized with a fiber post and patient has been on follow-up for five months. Short-term follow-up for both of the cases showed promising results both clinically and radiographically.
endodontic implant; fiber post; maxillary central incisor; root fracture; titanium min screw
Loss of bone and soft tissue attachment are common sequelae of periodontitis that may jeopardize the aesthetic outcome and compromise the functional and aesthetic outcomes of treatment. The following case report describes one of the most predictable techniques of vertical ridge augmentation, which is orthodontic extrusion or forced eruption of hopeless teeth.
A 34-year-old woman who presented with severe attachment loss and deep pockets was diagnosed with generalized aggressive periodontitis. The mobile maxillary incisors were consequently extracted and were replaced with dental implants. However, prior to extraction, orthodontic extrusion of the hopeless incisors was performed to correct vertical ridge defects. Following extrusion and extraction of the maxillary incisors, to prevent soft tissue collapse and to preserve the papillae during socket healing, the crowns of the extracted teeth were used as pontics on a removable partial provisional denture. After 8 weeks, the implants were placed, and an immediate functional restoration was delivered. After 4 months of healing, a fixed definitive partial prosthesis was fabricated and delivered.
After periodontal treatment, over a 2-year period, the progression of aggressive periodontitis was controlled. The mean vertical movement of marginal bone was 3.6 mm. The use of the crowns of extracted teeth appears to be an effective method to maintain papillae.
Orthodontic extrusion is a predictable method for the correction of vertical ridge defects. Orthodontic treatment does not aggravate or hasten the progression of aggressive periodontitis.
Bone augmentation; dental implants; dental papilla; forced eruption; orthodontic extrusion; vertical ridge augmentation.
Traumatic injuries of the face often involve root fractures especially in anterior teeth. The prognosis and the treatment of the root fracture depend on the extent of the fracture line, general health and patient compliance. This case report outlines a new conservative trial treatment modality to stabilize the maxillary central incisors with horizontal root fracture on the cervical to middle third by fabricating canine guidance to remove loading on the traumatized maxillary central incisors during eccentric movements and thus inducing spontaneous healing of the fractured line between the fragments. Radiographs after thirty months showed adequate healing with no signs of pathological changes including root resorption, ankylosis or displacement. Long term follow-up revealed that vitality, stability and aesthetics were maintained and the patient was satisfied with the outcome.
Canine guided occlusion; Root fracture; Spontaneous healing
This case report describes the multidisciplinary management of subgingival horizontal crown-root fracture of an immature permanent maxillary central incisor in a 10-year-old boy. After removal of the fractured fragment, pulpotomy was performed within 48 h from the injury to promote apexogenesis. The tooth was orthodontically extruded until the fracture line was located above the alveolar bone level. Frenectomy, supracrestal fiberotomy, and crown lengthening were performed after adequate stabilization of the extruded tooth for 5 months. Finally, the tooth was restored with composite resin by using the acid etch technique. This report highlights that a multidisciplinary treatment approach with strict cooperation among specialists to manage a complicated crown-root fracture can save and restore a traumatized immature permanent tooth.
Complicated crown–root fracture; immature incisor; traumatized tooth
Resorption of alveolar bone - a common sequel of tooth loss jeopardizes the functional and esthetic outcome of treatment, especially in the maxillary anterior areas. Therefore, augmentation of deficient alveolar ridges is an important aspect of dental implant therapy. A case of severe maxillary ridge deficiency successfully treated with horizontal ridge augmentation to facilitate implant placement is described. Ridge augmentation was achieved using a combination of autogenous block graft, particulate grafting, and guided bone regeneration (GBR). Follow-up was done next day, after ten days, three months, and six months. Various approaches can be followed in order to achieve an increase in the ridge width. In our case, we used a combination of different techniques for ridge augmentation. A significant improvement in ridge width was noticed at six months thus facilitating the placement of implants.
Autogenous block graft; GBR; ridge augmentation
Aim. To describe the subsequent treatment of airway trauma sustained during laryngoscopy and endotracheal intubation.
Methods. A rare injury occurring during laryngoscopy and endotracheal intubation that resulted in perforation of the tongue by an endotracheal tube and the subsequent management of this unusual complication are discussed. A 65-year-old female with intraparenchymal brain hemorrhage with rapidly progressive neurologic deterioration had the airway secured prior to arrival at the referral institution. The endotracheal tube (ETT) was noted to have pierced through the base of the tongue and entered the trachea, and the patient underwent operative laryngoscopy to inspect the injury and the ETT was replaced by tracheostomy. Results. Laryngoscopy demonstrated the ETT to perforate the base of the tongue. The airway was secured with tracheostomy and the ETT was removed. Conclusions. A wide variety of complications resulting from direct and video-assisted laryngoscopy and tracheal intubation have been reported. Direct perforation of the tongue with an ETT and ability to ventilate and oxygenate subsequently is a rare injury.
Complicated crown-root fracture of maxillary central and lateral incisors is common in case of severe trauma or sports-related injury. It happens because of their anterior positioning in oral cavity and protrusive eruptive pattern. On their first dental visit, these patients are in pain and need emergency care. Because of impaired function, esthetics, and phonetics, such patients are quite apprehensive during their emergency visit. Successful pain management with immediate restoration of function, esthetics and phonetics should be the prime objective while handling such cases. This paper describes immediate treatment of oblique crown root fracture of maxillary right lateral incisor with reattachment procedure using light transmitting fiber post. After two and half years, the reattached fragment still has satisfying esthetics and excellent function.
Impaction of maxillary permanent central incisor is not a frequently reported case in dental practice, but its treatment is challenging because of its importance to facial esthetics. Early detection of such teeth is most important if complications are to be avoided. We report a case of a 14-year-old female with an impacted central incisor tooth in the maxillary anterior region. The impacted supernumerary tooth which was preventing the eruption of permanent incisor was surgically removed. Combined approach with surgical exposure and the application of an orthodontic force brought the impacted left maxillary central incisor down to its proper position in the dental arch.
Impacted incisor; orthodontics; surgical exposure
Avulsion is a serious injury which causes damage to dental and supportive tissues, ranging from 1-16 % among dental injuries and it mostly occurs in maxillary incisors. This report presents a case of replantation of a traumatically avulsed central incisor. The left central incisor of an 8 year-old boy with open apex was avulsed and was left in unclean and dry conditions. Tooth was replaced after 270 min and splinted. After 24 hours, tooth was treated endodontically. The calcium hydroxide paste was applied as intracanal medicament. After one year the calcium hydroxide was not replaced and was maintained in the canal, permanently. The tooth followed for 5 years. During follow up, the tooth kept stable. However, the resulted dent alveolar ankylosis prevented growth of the alveolar process. Spite of the fact that in children, replacement resorption leads to the loss of ankylosed teeth within 1-5 years; this tooth has remained in a stable, infra-position for 5 year and in functional position after coronal restoration. However, in such cases other treatments such as decoronation should be considered.
Calcium Hydroxide; Replantation; Resorption; Tooth Avulsion; Traumatic Injury
Deficiencies in the alveolar ridges cause multiple problems in achieving aesthetic and functional outcome of implant therapy and are commonly restored by using onlay graft from intraoral source. Careful assessment of the recipient as well as the donor site using cone beam computed tomography (CBCT) is a prerequisite to ideal treatment planning. This paper highlights the critical role of CBCT in planning a successful rehabilitation of traumatised deficient anterior maxillary alveolar ridge using autogenous block graft from mandibular symphysis, followed by implant placement. A 21-year-old male reported with missing right maxillary lateral incisor due to traumatic avulsion 6 months back. A concavity was found on the labial aspect of edentulous area. Serial transplanar images on CBCT revealed gross irregular radiolucency in place of labial cortical plate. Using CBCT, size of the required block was estimated, and mandibular symphyseal area was evaluated for the feasibility of harvesting a graft of suitable dimension. Onlay block graft was harvested from mandibular symphysis and placed at the edentulous site to augment the alveolar ridge. Implants were placed 5 months later and loaded successfully after osseointegration. After 1 year of followup, implant-based prosthesis is working well, without any complications.
To describe vascular anatomy of the maxillary sinus in dentate specimens dissected from human cadavers.
Twenty dentate maxillary specimens were dissected, anatomically prepared, and injected with liquid latex for a better visualization of the maxillary sinus artery.
We found an intraosseous anastomosis in 100% and an extraosseous anastomosis in 90% of the cases. The anterior lateral wall of the maxillary sinus was transversed by two anastomoses between the posterior superior alveolar artery (PSAA) and the infraorbital artery (IOA). The PSAA was divided into a gingival and dental branch. The gingival branch anastomosed with the terminal extraosseous branch of the extraosseous anastomosis (EOA) and the dental branch with the intraosseous branch of the intraosseous anastomosis (IOA). The mean distances from the alveolar ridge to the extraosseus anastomosis were 16 mm for the second maxillary molar, 12.3 mm for the first maxillary molar, and 13.1 mm for the second maxillary premolar. The mean distances from the intraosseous anastomosis to the alveolar ridge were 17.7 mm for the second maxillary molar, 14.5 mm for the first maxillary molar, and 14.66 mm for the second maxillary premolar.
These findings provide relevant data for clinical dentistry in order to avoid bleeding complications and minimize the risk of injury to the arterial network of the maxillary sinus during surgical procedures in the dentate maxilla region.
Number, type and severity of dental injuries per patient differ according to the patient’s age and the cause of accident. The trauma group resulting from pedestrian-, bicycle-, and car-related injuries is usually dominated by multiple dental injuries, injuries to the supporting bone and soft-tissue injuries.
This report describes a case of a 16.2-year-old female who suffered traumatic injuries to her permanent maxillary incisors after a car accident. Concussion of tooth 12, extrusive luxation of tooth 11, avulsion of tooth 21 and subluxation with complicated crown fracture of tooth 22 were observed at the emergency visit 75 minutes after the trauma. Tooth 21 was dry stored for 15 minutes, then in milk for 60 minutes. The treatment plan according to IADT guidelines was performed with the satisfaction of the dentists and the patient. After 1 year follow- up a replacement root resorption of tooth 21 was diagnosed; it was then considered severe at the time of the 2 year control visit.
Educational programs are essential to optimize the treatment outcome both at the accident site and also at the dental office.
permanent incisor; extrusive luxation; avulsion; crown fracture; replantation; root resorption
A prone position is not a standard position for anesthesia induction and associated with problems like difficult mask fit, impairment of orotracheal intubation by direct laryngoscopy, and reduction of pulmonary compliance. However anesthetic management of trauma victims presenting with penetrating posterior lumbar spine injury requires airway securement and induction of anesthesia in the prone position to avoid further neurological impairment. We herein present the first reported case of an adult trauma patient presented with an impaled knife protruding out of lower back, who underwent endotracheal intubation with an intubating laryngeal mask airway under general anesthesia in the prone position. Our experience indicates that this technique would be easier and less risky compared to direct laryngoscopy or awake fiber optic intubation and might be considered in an emergency situation.
Airway management; endotracheal intubation; intubating laryngeal mask airway; prone position
Trauma to the anterior teeth is relatively a common occurrence. There are several treatment modalities for such condition, one of which is reattachment of fractured fragment itself. Reattachment of fractured fragment provides immediate treatment with better esthetics, restoration of function, and is a faster and less complicated procedure. Reattachment of tooth fragment should be the first choice and is a viable alternative to conventional approaches because of simplicity, natural esthetics, and conservation of tooth structure. Patient cooperation and understanding of the limitations of the treatment is of utmost importance for good prognosis. The present case report describes management of a complicated fracture of maxillary right central incisor treated endodontically, followed by reattachment of the same fragment. Reattachment of fractured tooth fragments offers a viable restorative alternative, immediately restores tooth function for the clinician because it restores tooth function and esthetics with the use of a very conservative and cost-effective approach.
Complicated crown fracture; endodontic treatment; reattachment; resin composite; trauma
Endotracheal intubation involving conventional laryngoscopy elicits a haemodynamic response associated with increased heart and blood pressure. The study was aimed to see if video laryngoscopy and endotracheal intubation has any advantages over conventional laryngoscopy and endotracheal intubation in patients with coronary artery disease. Thirty patients suffering from coronary artery disease scheduled for elective coronary artery bypass grafting (CABG) were studied. The patients were randomly allocated to undergo either conventional laryngoscopy (group A) or video laryngoscopy (group B). The time taken to perform endotracheal intubation and haemodynamic changes associated with intubation were noted in both the groups at different time points. The duration of laryngoscopy and intubation was significantly longer in group B (video laryngoscopy) when compared to group A patients. However, haemodynamic changes were no different between the groups. There were no events of myocardial ischaemia as monitored by surface electrocardiography during the study period in either of the groups. In conclusion, video laryngoscopy did not provide any benefit in terms of haemodynamic response to laryngoscopy and intubation in patients undergoing primary CABG with a Mallampatti grade of <2.
Coronary artery disease; haemodynamic response; video laryngoscopy
Traumatic injuries to an immature permanent tooth may result in cessation of dentin deposition and root maturation. Endodontic treatment is often complicated in premature tooth with an uncertain prognosis. This article describes successful treatment of two traumatized maxillary central incisors with complicated crown fracture three months after trauma. The radiographic examination showed immature roots in maxillary central incisors of a 9-year-old boy with a radiolucent lesion adjacent to the right central incisor. Apexogenesis was performed for the left central incisor and revascularization treatment was considered for the right one. In 18-month clinical and radiographic follow-up both teeth were asymptomatic, roots continued to develop, and periapical radiolucency of the right central incisor healed. Considering the root development of these contralateral teeth it can be concluded that revascularization is an appropriate treatment method in immature necrotic teeth.
Apexogenesis; Open apex; Pulpotomy; Pulp revascularization; Trauma
Ectodermal dysplasia (ED) is a rare, congenital disease that involves the sweat glands, scalp hair, nails, skin pigmentation, and craniofacial structure. Oral symptoms of ED include multiple tooth abnormalities (such as hypodontia, anadontia, impacted teeth, and peg-shaped or conical anterior teeth) and lack of normal alveolar ridge development. A 12-year-old male patient, in the absence of any other systemic abnormalities, exhibited typical characteristics of ED, visited our department of pedodontics and preventive dentistry at Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre. In the clinical and radiographic evaluation, it was occurred that he had only maxillary and mandibular first molars in his mouth. A maxillary and mandibular denture with clasps for retention was fabricated for prosthodontic rehabilitation after considering his growth and the number and condition of his present teeth. At the 18-month follow-up no major complications occurred and further future treatment included implants retained fixed partial dentures.
Ectodermal dysplasia; fixed partial dentures; hypodontia; implants; overdentures; prosthodontic treatment
Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq® and Truview® laryngoscopes may reduce this risk.
We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq® and Truview® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan® manikin.
The Airtraq® reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview® increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq® devices.
The Airtraq® laryngoscope performed more favourably than the Macintosh and Truview® devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting.
Solitary median maxillary central incisor (SMMCI) is a unique developmental anomaly in primary dentition. It involves central incisor tooth germs and may or may not be associated with other anomalies. Its presence, concomitant with fusion of right mandibular incisors has not previously been reported. A 5-year-old girl was presented with a single symmetrical primary maxillary incisor at the midline, with the absence of labial frenulum, an indistinct philtrum and a prominent midpalatal ridge. There was an associated fused tooth in the right incisor region and radiographic examination confirmed only one maxillary central incisor in both the dentitions. Family history revealed that the father of the girl also had a similar anomaly providing probable evidence of etiological role for heredity in SMMCI.
Central incisor; double tooth; maxillary; median; solitary median maxillary central incisor
Prediction of difficult laryngoscopy in obese patients is challenging. In 50 morbidly obese patients, we quantified the neck soft tissue from skin to anterior aspect of trachea at the vocal cords using ultrasound. Thyromental distance <6 cm, mouth opening <4 cm, limited neck mobility, Mallampati score >2, abnormal upper teeth, neck circumference >45 cm, and sleep apnoea were considered predictors of difficult laryngoscopy. Of the nine (18%) difficult laryngoscopy cases, seven had obstructive sleep apnoea history; whereas, only 2 of the 41 easy laryngoscopy patients did (P<0.001). Difficult laryngoscopy patients had larger neck circumference [50 (3.8) vs. 43.5 (2.2) cm; P<0.001] and more pre-tracheal soft tissue [28 (2.7) mm vs. 17.5 (1.8) mm; P<0.001] [mean (SD)]. Soft tissue values completely separated difficult and easy laryngoscopies. None of the other predictors correlated with difficult laryngoscopy. Thus, an abundance of pretracheal soft tissue at the level of vocal cords is a good predictor of difficult laryngoscopy in obese patients.
Anaesthesia; Neck; Obesity; Ultrasound
Bisphosphonates (BPs) are medications used commonly to treat primary and metastatic bone cancer, as well as osteoporosis. Although BPs improve bone mineral density, reduce fracture risk, and reduce hypercalcemia of malignancy, some patients develop BP-related osteonecrosis of the jaws (BRONJ). This devastating complication is defined as clinically exposed bone in the maxillofacial region for more than 8 weeks. Despite an increasing number of BRONJ cases since first reported, the disease pathophysiology remains largely unknown. Since published studies suggest a significant role for dental disease in the pathophysiology of BRONJ, we developed a BRONJ animal model where aggressive periodontal disease is induced by ligature placement around the crown of the right maxillary first molar in the presence of vehicle (veh) or zoledronic acid (ZA), a potent BP. Ligature placement induced significant alveolar bone loss, which was attenuated by ZA treatment. Osteonecrosis was observed associated with ligature-induced periodontitis in the ZA-treated group. This was seen as sequestration and extensive periosteal alveolar bone formation on micro–computed tomography (μCT) in the ligated site of BP-treated animals. Histologic examination confirmed these findings, seen as necrotic bone with diffuse loss of osteocytes and empty lacunae, rimming of the necrotic bone by squamous epithelium and inflammation, and exposure to the oral cavity. Importantly, the rat lesions were strikingly similar to those of BRONJ patients. Our data suggest that dental disease and potent BP therapy are sufficient for BRONJ development in the rat.
OSTEONECROSIS OF THE JAWS; BISPHOSPHONATE; PERIODONTITIS; RAT MODEL; BRONJ; ONJ
A talon cusp is a dental anomaly commonly occurring in the permanent dentition compared to the primary dentition. It commonly affects the maxillary anterior teeth. In primary dentition, the most commonly affected tooth is the maxillary central incisors. This is a rare case report of a 5-year-old male patient with a talon cusp affecting the mandibular primary lateral incisor. Recognition and treatment of this anomaly at early stages is important to avoid complications.
Osseointegrated endosseous implants are widely used for the rehabilitation of completely and partially edentulous patients, being the final prosthodontic treatment more predictable and the failures extremely infrequent. A case of fracture of an endosseous dental implant, replacing the maxillary first molar, occurring in a middle-age woman, 5 years after placement is reported.
Materials and methods
The difficult management of this rare complication of implant dentistry together with the following rehabilitation is described. Additionally, the authors performed an accurate analysis of the removed fractured implant both by the stereomicroscope and by the confocal laser scanning microscope.
Results and discussion
The fractured impant showed the typical signs of a fatigue-induced fracture in the coronal portion of the implant together with numerous micro-fractures in the apical one. Three dimensional imaging performed by confocal laser scanning microscope led easily to a diagnosis of "fatigue fracture" of the implant. The biomechanical mechanism of implant fractures when overstress of the implant components due to bending overload is discussed.
When a fatigue-induced fracture of an dental implant occurs in presence of bending overload, the whole implant suffers a deformation that is confirmed by the alterations (micro-fractures) of the implant observable also in the osseointegrated portion that is easily appraisable by the use of stereomicroscope and confocal laser scanning microscope without preparation of the sample.
Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC® video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy.
In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC®).
A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC® were assessed. In patients with at least one predictor for difficult intubation, the C-MAC® resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC® (7%, C&L grade 3 and 4) (P < 0.0001).
Use of the C-MAC® video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur.
Failure to maintain a patent airway is one of the commonest causes of anesthesia-related morbidity and mortality. Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The objective of this study was to compare Mallampati test (MT) with lower jaw protrusion (LJP) maneuver in predicting difficult laryngoscopy and intubation.
Materials and Methods:
Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated for both these tests with 95% confidence interval (CI) using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP maneuver. A P < 0.05 was taken as significant.
LJP maneuver had higher sensitivity (95.9% vs. 27.1%), NPV (98.7% vs. 82.0%), and accuracy (90.1% vs. 80.3%) when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV. There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the curve favored LJP maneuver over MT.
The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway.
Airway; difficult intubation; lower jaw protrusion maneuver; Mallampati test