Alternatives to management of horizontal root fracture
Treatment of a horizontal root fracture I
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From: Marga Ree
Sent: Saturday, November 19, 2005 07:55 PM
Subject: [roots] Treatment of a horizontal root fx
This 13 year old boy has sustained a trauma on tooth 11.
The horizontal root fracture has unfortunately been
treated by his dentist by performing an endo in the 2
segments. After a while the coronal segment has been
retreated by a resident of the endo program at the
university, with gutta-percha and sealer.
His symptoms never went away, tooth was sensitive to
percussion and showed a greyish discoloration. He has
been adviced to have the tooth extracted,
because everything possible had been done.
I did a conventional retreatment till the fracture
level, and filled the coronal segment with MTA. Then,
in the same session, I raised a flap and removed
the apical fragment in 2 parts. The fracture line is
usually not horizontal, but oblique, and left a reverse
bevel to the palatal aspect of the root. You can
see the apical fractured segment in two parts on the
clinical pic. After removing the sutures, I placed
sodium perborate for a few days, and finally filled the
access opening with composite. The boy is doing well,
and in my opinion there is a reasonable chance for
tooth to be retained, at least till he is old enough
to have an implant. I will keep you informed on the
follow-ups - Marga
1: Dent Traumatol. 2004 Aug;20(4):192-202.
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.
Andreasen JO, Andreasen FM, Mejare I, Cvek M.
Department of Oral and Maxillofacial Surgery, University
Hospital (Rigshospitalet), Copenhagen, Denmark. email@example.com
This retrospective study consisted of 400 root-fractured,
splinted or non-splinted incisors in young individuals aged
7-17 years (mean = 11.5 +/- 2.7 SD) who were treated in the
period 1959-1995 at the Department of Pediatric Dentistry,
Eastman Dental Institute, Stockholm. Four hundred of these
root fractures were diagnosed at the time of injury; and
344 teeth were splinted with either cap-splints, orthodontic
appliances, bonded metal wires, proximal bonding with composite
resin or bonding with a Kevlar or glass fiber splint. In 56
teeth, no splinting was carried out for various reasons.
In the present study, only pre-injury and injury factors were
analyzed. In a second study, treatment variables will be analyzed.
The average observation period was 3.1 years +/- 2.6 SD. The
clinical and radiographic findings showed that 120 teeth out
of 400 teeth (30%) had healed by hard tissue fusion of the
fragments. Interposition of periodontal ligament (PDL) and bone
between fragments was found in 22 teeth (5%), whereas
interposition of PDL alone was found in 170 teeth (43%).
Finally, non-healing, with pulp necrosis and inflammatory
changes between fragments, was seen in 88 teeth (22%). In a
univariate and multivariate stratified analysis, a series of
clinical factors were analyzed for their relation to the healing
outcome with respect to pulp healing vs. pulp necrosis and type
of healing (hard tissue vs. interposition of bone and/or PDL or
pulp necrosis). Young age, immature root formation and positive
pulp sensibility at the time of injury were found to be
significantly and positively related to both pulpal healing and
hard tissue repair of the fracture. The same applied to
concussion or subluxation (i.e. no displacement) of the coronal
fragment compared to extrusion or lateral luxation
(i.e. displacement). Furthermore, no mobility vs. mobility of
the coronal fragment. Healing was progressively worsened with
increased millimeter diastasis between fragments. Sex was a
significant factor, as girls showed more frequent hard tissue
healing than boys. This relationship could possibly be explained
by the fact that girls experienced trauma at an earlier age
(i.e. with more immature root formation) and their traumas were
of a less severe nature. Thus, the pre-injury or injury factors
which had the greatest influence upon healing (i.e. whether hard
tissue fusion or pulp necrosis) were: age, stage of root development
(i.e. the size of the pulpal lumen at the fracture site) and
mobility of the coronal fragment, dislocation of the coronal
fragment and diastasis between fragments (i.e. rupture or
stretching of the pulp at the fracture site)
2: Dent Traumatol. 2004 Aug;20(4):203-11.
Healing of 400 intra-alveolar root fractures.
2. Effect of treatment factors such as treatment delay,
repositioning, splinting type and period and antibiotics.
Andreasen JO, Andreasen FM, Mejare I, Cvek M.
Department of Oral and Maxillofacial Surgery, University Hospital
(Rigshospitalet), Copenhagen, Denmark. firstname.lastname@example.org
This is the second part of a retrospective study of 400
root-fractured permanent incisors. In this article, the effect
of various treatment procedures is analyzed. Treatment delay,
i.e. treatment later than 24 h after injury, did not change the
root fracture healing pattern, healing with hard tissue between
fragments (HH1), interposition of bone and/or periodontal ligament
(PDL) or pulp necrosis (NEC). When initial displacement did not
exceed 1 mm, optimal repositioning appeared to significantly
enhance both the likelihood of pulpal healing and hard tissue
repair (HH1). Significant differences in healing were found among
the different splinting techniques. The lowest frequency of healing
was found with cap splints and the highest with fiberglass or
Kevlar splints. The latter splinting procedure showed almost the
same healing result as non-splinting. Comparison between
non-splinting and splinting for non-displaced teeth was found to
reveal no benefit from splinting. With respect to root
fractures with displacement, too few cases were available for
analysis. No beneficial effect of splinting periods greater than
4 weeks could be demonstrated. The administration of antibiotics
had the paradoxical effect of promoting both HH1 and NEC. No
explanation could be found. It was concluded that, optimal
repositioning seems to favor healing. Furthermore, the chosen
splinting method appears to be related to healing of root
fractures, with a preference to pulp healing and healing fusion
of fragments to a certain flexibility of the splint and possibly
also non-traumatogenic splint application. Splinting for more
than 4 weeks was not found to influence the healing pattern.
A certain treatment delay (a few days) appears not to result in
inferior healing. The role of antibiotics upon fracture healing
Hi Marga, You do get some cool trauma cases! Well done!
Any Mobility? Did you splint? DougR Mobility was not of any
significance. Therefore I didn't splint. I did recommend to have
a mouth guard fabricated by his dentist - Marga
You never cease to amaze me. I would never have thought to do that.
Give this one to kendo to document - Gary
very nice case Marga. are you planning on splinting the tooth the
the adjacent teeth to minimize the chance of further trauma
(face hes a 13 yr old boy and they can be active) from exfoliating
the remaining tooth? - Gregori Kurtzman
P S.I am more concerned with him playing around with other kids and
getting it bumped accidentally boys will be boys
Greg, I did recommend a mouth guard. Mobility is WNL - Marga
I did a conventional retreatment till the fracture level, and filled
the coronal segment with MTA. Then, in the same session, I raised a
flap and removed the apical fragment in 2 parts. The fracture line
is usually not horizontal, but oblique, and left a reverse bevel to
the palatal aspect of the root. You can see the apical fractured
segment in two parts on the clinical pic.
After removing the sutures, I placed sodium perborate for a few days,
and finally filled the access opening with composite. The boy is
doing well, and in my opinion there is a reasonable chance for tooth
to be retained, at least till he is old enough to have an implant.
I will keep you informed on the follow-ups - Marga
Marga, I feel if the tooth doesn't sustain more trauma it will stay
there for a long time. Is it asymptomatic now ? Why did you remove
the apical segment ? Couldn't you just remove the GP and leave it
alone ? - Thomas
Thomas, The tooth is currently asymptomatic.
What do you mean with just removing the gp? From the apical segment?
I don't think this would have made any difference. The apical segment
should never have been treated and was highly probably causing the
symptoms. I found removal to be the most predictable treatment option.
This was the first time that I had to remove the apical segment,
in the majority of cases I can leave it alone, without any treatment.
When left alone, you often see that the apical segment shows pulp
canal obliteration after some time - Marga
Yes, I ment just removing the Gutta percha from the apical segment
to allow blood enter the root canal system. Why would
the apical segment cause the pain ? If you removed the GP I think
there would be no more cause for contamination - Thomas
I don't agree. The apical part has been contaminated, and the same
goes for the fracture site. It is not likely that this
problem can be solved with just removing the gp (assumed that the
apical part is accessible). Moreover, by trying to clean
the apical fragment, you will inevitably push its contaminated
content in the fracture site.
I have treated a hor fx case in which I treated both segments
with MTA, because both segments were treated in the first
place by the dentist. MTA was pushed out in the fracture site.
The patient kept symptoms, which only resolved after doing surgery,
and the MTA and a lot of tiny root segments were
removed from the fracture site - Marga
Great case Marga - I can't see why he shouldn't keep the tooth - Simon
Fantastic Marga ..................your Endo is great but the surgical
aspect and the presentations is out of this world.