Treatment of a horizontal root fracture I
================================================================================== 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. rh11323@rh.dk 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. rh11323@rh.dk 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 is questionable.
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. - Sachin
