The opinions within this web page are not ours.
Authors have been credited |
for the individual posts and photographs where they are.
Horizontal root fractures- Courtesy ROOTS
From: Marga Ree
Sent: Wednesday, March 23, 2005 2:33 PM
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.
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
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.(page3 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. email@example.com
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, 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:
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