Central Incisor vs. Hardwood Floor

Brought to you by Board-Certified Endodontist, Dr. William Nudera

What happens when a 15-year-old's central incisor slams into a hardwood gym floor during a basketball game? This case walks you through the initial emergency care, unexpected complications and the strategic endodontic decisions that followed.

From pulp caps and CBCT confirmation to necrosis, oblique fractures and biologic width violations, this case highlights the multidisciplinary management of a complex injury, guided by thoughtful planning and collaboration.

The patient, a healthy 15-year-old male, presented to my office two days after a traumatic dental injury sustained during a basketball game. The injury resulted in a complicated crown fracture of the maxillary central incisor with pulpal exposure

Emergency care had been initiated promptly by a local general dentist, who placed a pulp cap and rebonded the fractured fragment. A cone beam CT scan confirmed proper seating of the fragment with no evidence of additional pathology.

Clinically, the tooth demonstrated:

• No mobility
• No spontaneous pain
• Mild tenderness to percussion and bite
• Positive responses to pulp vitality testing

Given the stable condition and normal pulp testing results, a conservative observation protocol was initiated with a planned re-evaluation in three months.

Complications Arise

Two months later, the patient's family contacted my office reporting that the bonded tooth fragment had turned dark and spontaneously detached. I instructed them to return to the clinic immediately for evaluation. Upon examination, it became clear that in addition to the original crown fracture, the patient had sustained a secondary oblique fracture on the palatal side.

The pulp was now necrotic, and the fracture line extended apically, violating the biologic width and likely reaching or exceeding the level of the alveolar crest. This shift significantly changed the long-term prognosis and narrowed the restorative options.

Treatment Approach

Given the patient's age and the importance of preserving natural dentition whenever possible, our primary goal was to retain the tooth while maintaining the potential for future restorative success.

I performed a conservative intrasulcular incision on the palatal to detach and remove the remaining fractured fragment.

While the remaining coronal tooth structure was far from ideal, there appeared to be sufficient root length to consider future orthodontic extrusion and periodontal surgery for potential long-term retention through a multidisciplinary strategy.

Endodontic Treatment

I proceeded with root canal therapy using the following approach:

• Hemostasis was achieved with a cotton pellet
• A split dam technique was used with gingival retention on the facial and rubber dam blockout material.
• Access was gained and the working length determined
• Irrigation was performed with a positive pressure irrigation protocol, without the use of engine-driven instruments due to the large canal diameter
• Obturation was completed using a single cone technique
• The access was closed with a sponge and Cavit

As an endodontist, my office does not stock extensive restorative materials. However, I created a temporary restoration to protect the site and provide some aesthetic coverage. This provisional solution was not extended beyond the palatal gingival tissues to avoid compromising periodontal health and to maintain access for hygiene.

Outcome and Next Steps

The final endodontic result was successful, with no files required—just thorough irrigation and passive agitation.

The patient was referred to both an orthodontist and a periodontist for further evaluation and planning of definitive restorative treatment and possible extrusion procedures.

I will continue to follow this case closely and provide updates as the multidisciplinary treatment plan evolves.

Conclusion

This case highlights the importance of a conservative and strategic approach in managing complex traumatic dental injuries, particularly in young patients. With timely intervention, careful diagnosis, and collaboration across specialties, even severely compromised teeth may be retained long-term.