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Horizontal root fractures- Courtesy ROOTS
From: Marga Ree
Sent: Wednesday, March 23, 2005 2:33 PM
To: ROOTS
Subject: [roots] 1 year follow-up of two horizontal root fractures
This 21 year old man was involved in a bar fight. His dentist made a splint and did an attempt to perform rct,
but he was not able to instrument the apical parts. (page 1) He referred the patient to me.
Consultation:
11 (#8) and 21(#9) horizontal root fractures
21 (#9) uncomplicated crown fracture
12 (#7) apical periodontitis
First thing I did is remove the splint, C&S 11 and 21, place Ca(OH)2 and make a filling of composite in # 21.
After 1 month I obturated # 11 and 21 completely with MTA, 12 with gp and AH26 (page 2)
After 3 months he returned for a follow-up, and complained about sensitivity upon biting and palpation of # 11.
There was a pocket buccal of # 11 till the fracture level. I decide to raise a flap and clean the fracture gaps.
I applied Emdogain, because I was hoping to prevent apical downgrowth of the epithelium. (page 3 and 4)
Rad on page 4 is immediate follow-up after surgery
1 year follow-up (page 4 and 5): Probing depths of 2 mm, no sensitivity, patient can function without any problems,
radiographs show healing. It is very rewarding treating these trauma patients. - Marga
Marga: incredible as usual. can you clarify for me what you did in the surgical phase in cleaning the fracture gaps.
the healing is just amazing. - Gary
Thanks Gary. I removed the granulation tissue with a lot of embedded root fragments and extruded MTA. - Marga
Marga, Why did you instrument/fill the apical sections? - Robert M. Kaufmann DMD MS(Endo)
Rob, Unfortunately I had to, because the referring dentist already instrumented the apical fragments, as you can
see on the first page (btw: without a rubber dam ). It would have been better if the dentist had left the apical
fragments untouched, and had instrumented till the fracture level. Usually the apical fragments maintain vitality. - Marga
Nice treatment plan, excellent decisions, wonderful documentation! - Liviu
Marga, You are one-of-a-kind. I do not think anyone but you could have done this. - Wes
Fantastic Marga ...............I am sure in most parts of the world the patient would have lost his tooth and would
now be having a prosthesis. You removed the initial splint placed by the refg.dentist and the clinical images don't
show a fresh splint So how did you manage to prevent the mobility during function?? - Sachin
Thanks Sachin! The splint was already 4 weeks in place, and was applied in a way that it didn't serve it's purpose,
to put it mildly. It was more a source of plaque retention and tissue irritation. In addition, according to this paper
of Cvek and Andreasen, there is no benefit of splinting for more than 4 weeks. I adjusted the teeth out of direct
and excursive occlusion. - Marga
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 hrs 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.
Copyright Blackwell Munksgaard, 2004.
Marga...I'm surprised you did the apical sections....did you have a reason why? - Joey D, "Just curious"
Joey, Yes, I had a good reason, see my previous answer to Rob. - Marga
Marga, Joey, Rob: would it matter at what level the fracture occurred as to whether or not you need to enter the
apical segment? - Gary
Gary, Here is a slide of my friend and colleague Michiel de Cleen on the occurence of pulp necrosis in horizontal
root fractures, which is less than 30%. So usually the best approach is to do nothing, and to follow-up very carefully,
because there is a big chance for the tooth to maintain vital. If the coronal segment becomes non-vital, then perform
an endo in the coronal part. The apical segment will show often pulp canal obliteration after a while. - Marga
Hi Marga, without having seen the patient, my first impression is that I would
have left the apical fragments untouched because thy usuallly stay
vital. Did you have any reason to clean and shape that part as well?
OOps, typing this I just read your answer.
I posted a similar case a couple years ago and asked for opinions. Did
nothing but spinting for 3 months. Patient has been fine and there are
non functional deficits. Sensitivity to cold is questionable. There was
a general agreement on that case that, if endo was needed, it should
only involve the coronal part. So far it hasn't been necessary. What do
you think? Sorry about the German text - I just copied it from a power
point presentation. I used the silicon matrix in the patient's habitual
occlusion to make sure I would not push the teeth back (causing occlusal
interferences) when splinting them. BTW, your healing is beautiful.! - Winfried Zeppenfeld
Winfried, This is some info in that regard posted by Doug Rakich some time ago.- Kendel
Old post from Doug Rakich :
My trauma atlas (Andreasen) is at the office, but if memory serves, horizontal fractures are rigidly
splinted (like setting a bone) if mobile, for 6 weeks give or take, up to 3 months. It sounds like
these are not particularly mobile, if that is the case, no splint is required. So by monitoring you are
doing exactly the right thing. You will want to follow these teeth closely with radiographic controls
and pulp testing. I forget the exact recommended sequence of recalls, but 1, 3, 6, 9 and 12 weeks
seems reasonable.
You can expect four possible outcomes:
Successful healing:
1. calcified tissue forms in the fracture
2. connective tissue interposes
3. bone and connective tissue interposes.In 2 & 3 the apical segment may migrate. Non-healing:
4. The coronal segment may undergo necrosis. If this occurs and mobility is not excessive, you may be
able to retain the teeth by performing endodontics on the coronal segments, leaving the apical portion
untouched. Note that the incidence of necrosis in these teeth is only about 25%, so your patient has a
pretty good chance. Hope this helps. DougR
Andreason last weekend was talking about using temp c&b materials as splints, eg pro temp,
so as to alow a little flexibility. Interesting. Lovely case as usual. - Bill