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Objectives: Root fracture, from an etiological point of view, constitutes the progression of the incomplete lesion. The treatment of this type of lesion involves the root fragments extraction, as in the case below, in their entirety. Vertical fractures can in fact include the entire thickness of the root, if complete. They may involve the buccal surface, the lingual surface or both surfaces, also extending to the periodontal attachment. In this case there was a fistula at the buccal level, in fact the presence of fistulas in this type of lesions can be detected in 35-42% of cases of root fractures1. The following article presents the clinical case of a patient who had the fractured root residue of element 1.5 with vestibular fistula that required masticatory and element aesthetic restoration.
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1971-1441
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Matteo  Nagni
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Annali di stomatologia
prosthetic crown
Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report
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Case Report
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Matteo  Nagni
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MSc, Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy
1971-1441
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Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report
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                                                                                                        Case Report


Extraction of an upper premolar due to a root
fracture and subsequent implant positioning:
a case report




Lara Ceresoli*                                              then contextual to the insertion of the implant; The pro-
Serena Ferri*                                               cedure took place with the extraction of the premolar,
Vittorio Pensa*                                             which left the presence of a bone defect of the buccal
Marta Todaro*                                               alveolar wall. Subsequently, after prescribing pre-surgi-
Umberto Manica*                                             cal antibiotic therapy, (with Levofloxacin 500 mg once a
Matteo Nagni**                                              day for ten days, Medrol 0.16 mg 1 tablet on the morn-
                                                            ing of surgery, 3\4 the morning following the day of sur-
* Dental School, Vita-Salute San Raffaele University,       gery, 1\2 two days after surgery and 1\4 three days after
  Milan, Italy and Department of Dentistry, IRCCS San       surgery) implant insertion was carried out. A Winsix KT
  Raffaele Hospital, Milan, Italy                           implant was inserted, 3.8 mm in diameter and 11 mm in
** MSc, Dental School, Vita-Salute San Raffaele Univer-     length, which has the characteristic of having a platform
   sity, Milan, Italy and Department of Dentistry, IRCCS    with a diameter greater than the implant body (4.5 mm)
   San Raffaele Hospital, Milan, Italy                      that adapts perfectly to the post-extraction bone spac-
                                                            es going to optimize prosthetic rehabilitation. A healing
                                                            screw was then placed after repairing the bone defect, in
Corresponding author:                                       fact a mixture of autologous bone taken from the implant
Ceresoli Lara 					                                         positioning site and biomaterial, bio bone, was made, all
email: lara.ceresoli@gmail.com                              covered by a resorbable membrane in equine-derived
                                                            collagen to contain the material inside the bone defect.
                                                            After 3 months, a prosthetic crown was placed.
Abstract
Objectives: Root fracture, from an etiological point of     Results and conclusions
view, constitutes the progression of the incomplete
                                                            At the end of the work, a perfect osseointegration of the
lesion. The treatment of this type of lesion involves
                                                            Winsix KT implant is observed 3.8 mm in diameter x 11
the root fragments extraction, as in the case below,
                                                            mm in length with a maintenance of bone thickness,
in their entirety. Vertical fractures can in fact include
                                                            healing of the defect and good healing of soft tissues,
the entire thickness of the root, if complete. They may
                                                            even at 10 years of follow-up.
involve the buccal surface, the lingual surface or both
surfaces, also extending to the periodontal attach-
ment. In this case there was a fistula at the buccal        Introduction
level, in fact the presence of fistulas in this type of     The prognosis of a dental element should be evaluated
lesions can be detected in 35-42% of cases of root          based on various factors; Although some types of frac-
fractures1. The following article presents the clinical     tures are believed to have an uncertain prognosis, such
case of a patient who had the fractured root residue of     as incomplete fractures or fractures of the crown only,
element 1.5 with vestibular fistula that required masti-    there are some types of injuries, such as vertical frac-
catory and element aesthetic restoration.                   tures of the root or fractures of the middle third of the root
                                                            whose prognosis is considered poor. In fact, vertical frac-
Keywords: Dental implant, root fracture, pre-surgi-         tures often have periodontal ligament involvement and
cal antibiotic therapy, buccal bone defect, prosthetic      among the symptoms, in addition to pain and swelling, a
crown.                                                      periodontal abscess can also occur in a third of cases3.
                                                            For what concerns the timing of implant insertion, it is
                                                            based on clinician experience and on the characteristics
Materials and methods
                                                            of the patient and the implant site. The consensus report
A 48-year-old male patient, non-smoker and without any      published in 2014, describes the timing of implant place-
systemic disease, presented fractured root residue of el-   ment after an extraction4.
ement 1.5 requiring functional and aesthetic restoration    Hammerle et al. considered necessary to develop a clas-
of the element. The technique adopted in this surgical      sification to describe advantages and disadvantages of
procedure was “one stage”, in which the extraction was      various positioning timings, based on clinical observa-


10.59987/ads/2023.2.19-23                                                                                                    19
     Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report

     tion. In particular, the decision to insert or not the im-      Winsix KT implant was inserted, 3.8 mm in diameter and
     plant immediately after extraction is determined both by        11 mm in length, which has the characteristic of having
     the characteristics of soft and hard tissues and by the         a platform with a diameter greater than the implant body
     characteristics of the healing of the alveolus. Among the       (4.5 mm) that adapts perfectly to the post-extraction
     various timings, therefore, the positioning immediately         bone spaces going to optimize prosthetic rehabilitation.
     after the extraction of the element is taken into consid-       Buccal bone defect is then managed with the insertion of
     eration; the advantages include both the reduced num-           both autologous bone taken from implant site mixed with
     ber of surgical procedures and the reduction of the time        biomaterial, biobone (Fig. 4).
     of the treatment plan, with the possibility of making the
     most of the residual bone that is just extracted from the
     element5. The disadvantages includes the morphology
     of the site that could complicate the implant placement,
     as well as tissue biotype and lack of keratinized mucosa.
     It has also been argued in literature that implant place-
     ment after extraction could stimulate new bone forma-
     tion and osseointegration, as well as preserve alveolar
     bone tissue. It was recommended in a 2004 review by
     Chen et al.6 that implant insertion immediately after ex-
     traction helps to avoid bone atrophy.

     Case Report
     A 48-year-old male patient, non-smoker, in good sys-
     temic health, comes to our attention for a fistula at the
     level of the first quadrant.
     In the first instance, a careful intra- and extra-oral ob-      Figure 2. Post-extraction site, with buccal bone defect.
     jective examination was performed, which revealed the
     presence of a residual root at the level of 1.5 and a buc-
     cal fistula (Fig. 1).
     Subsequently always in the first visit, first-level radio-
     graphic examinations were performed: Orthopantomog-
     raphy and Endoral Rx near the root residue.
     After careful evaluation of the patient’s clinical and sys-
     temic situation, “one stage” surgery technique was pro-
     posed as the operative technique, in which extraction
     was concurrent with implant placement.
     The patient was prescribed the antibiotic prophylax-
     is (with Levofloxacin 500 mg once a day for ten days,
     Medrol 0.16 mg 1 tablet on the morning of surgery, 3\4
     the morning following the day of surgery, 1\2 two days
     after surgery and 1\4 three days after surgery).
     At the next appointment after signing informed consent
     and local anesthesia with articaine 4% and adrenaline 1:
     100,000 (Ubistesin 40 mg/ml, 3M ESPE, Italy) avulsion
     of the element has been performed, leaving however a           Figure 3. Winsix KT 3,8 mm diameter x 11 mm length in-
                                                                    sertion in post-extraction site.
     bone defect on the buccal side (Fig. 2).
     At the same stage, after extracting the element, revising
     the cavity, and raising a full-thickness flap, a Winsix KT
     implant is placed in the post-extraction site (Fig. 3). A




     Figure 1. Fractured root element with buccal fistula in        Figure 4. Bone defect management using autologous bone
     place 1.5                                                      and biobone biomaterial



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L. Ceresoli et al.




Figure 5. Positioning of a resorbable membrane on the
bone defect by means of the healing screw.
                                                                Figure 7. Post- extraction implant healing with “one stage”
                                                                technique.




Figure 6. Positioning of a resorbable membrane in Paraso-
rb collagen 0.3 mm thick



                                                                Figure 8. Prosthetic abutment.




Next, a resorbable membrane was placed on the bone
defect and the healing screw was also placed at the
same time (Fig. 5).
To conclude the surgery, the placement of a 0.3-mm-
thick Parasorb collagen resorbable membrane to cover
the healing screw was also opted for, in order not to let
the flap slide coronally to cover the placed and regener-
ated implant and to achieve soft tissue healing (Fig. 6).
Finally, flap closure was performed with a detached
stitch suture with 3/0 resorbable thread (Vicryl, Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA). Post-
operative instructions were reported to the patient. The
patient was reexamined 14 days after surgery to remove
the sutures, and good tissue healing could be observed.
After 3 months, prosthetic rehabilitation was performed,
which included removal of the healing screw with subse-
quent insertion of the abutment. Impressions were taken
for fabrication of the prosthetic restoration. One week
later, the patient was able to receive the ceramic gold
crown (Figg. 7-9).
The patient was placed on a follow-up protocol with an-
nual professional hygiene and radiographic checks at            Figure 9. 3 months follow-up after surgery and placement
the implant site. The final follow-up is at 10 years (Fig.10)   of the ceramic gold crown.



10.59987/ads/2023.2.19-23                                                                                                     21
     Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report

                                                                     in this review, concerning implant positioning associated
                                                                     with dehiscence regeneration following the extraction of
                                                                     the fractured tooth. Most of the works considered used
                                                                     non-absorbable membranes, unlike the type of membrane
                                                                     used in the clinical case described above, in association
                                                                     or not with the insertion of biomaterial (whether it was a
                                                                     xenograft of bovine or autologous origin)15-16 and the suc-
                                                                     cess rate at a 5-year follow-up was around 76.8%17 up to
                                                                     100%16-18. In 14 studies, the insertion of absorbable mem-
                                                                     branes for a total of 406 implants was evaluated and the
                                                                     success rate ranged from 95.4% to 100% with a follow-up
                                                                     varying between 5-7 months and 5 years19-20-21.
                                                                     For what concerns the decision to go to perform a “one
                                                                     stage” technique of implant positioning following the el-
                                                                     ement extraction, the patient’s age and systemic health
                                                                     condition can be the so called protective factors. These
                                                                     factors, together with the patient’s medical and dental his-
                                                                     tory, seem to be factors to be evaluated before implant
                                                                     placement. The factors that can negatively affect implant
                                                                     positioning following extraction can in fact be mainly ana-
                                                                     tomical or biological (alveolar conformation, gingival bio-
     Figure 10. 10 years follow-up from the implant functional       type, periapical lesion or periodontal disease)22.
     load
                                                                     Conclusions
                                                                     At the end of the work, a perfect osseointegration of the
                                                                     Winsix KT implant is observed 3.8 mm in diameter x 11
     Discussion                                                      mm in length with a maintenance of bone thickness,
     The vertical fracture of the root itself has a poor prog-       healing of the buccal defect and good healing of soft tis-
     nosis, as reported by various scientific works, including       sues, even at 10 years of follow-up.
     Khansis et al. 20147; vertical fractures in fact tend to in-
     volve the root and periodontium and involved tooth are
     usually extracted, although there are studies that speak        References
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