Diagnosis and management of transverse root fractures

Cone-beam computed tomography-based descriptive classification for transverse root fracture

Transverse root fracture (TRF) is classified as a cervical, middle or apical third root fracture on a periapical radiograph. The International Association of Dental Traumatology (IADT) suggests that cone-beam computed tomography (CBCT) should be considered, when conventional radiographs provide 'insufficient' information for diagnosis and treatment planning. Considering that CBCT can divulge additional information, it would be beneficial to have a clinically pertinent three-dimensional classification for TRF. The proposed alphanumeric classification includes the traumatised tooth number, describes the number of TRF, the facial and lingual location of each fracture line on the anatomic root, and its position relative to the crest of the alveolar bone. Further, diastasis, displacement of the coronal fragment and status of the alveolar bone at the site of TRF are also documented. This comprehensive classification system would provide a standard format for reporting, aid in referral communication and can be applied for future outcome studies on TRF.

Dental and Dentoalveolar Injuries in the Pediatric Patient

Dental and dentoalveolar injuries are common in the pediatric population. Management is predicated on the type of tooth injured (primary or permanent), extent of injury, the dental and behavioral age of the patient, and ability of the patient to tolerate treatment. Although many dental injuries occur in isolation, a systematic evaluation of the patient is mandatory to confirm the absence of basal bone fractures of the maxilla or mandible, traumatic brain injury, cervical spine injury, and/or facial soft tissue injury. Long-term follow-up is paramount to achieving a functional occlusion and optimal dental health following injury.

The risk of healing complications in primary teeth with root fractures: A retrospective cohort study

BACKGROUND/AIM

Primary teeth are frequently affected by traumatic dental injuries. Root fractures are rare and have a reported incidence of 2% in the primary dentition. Hence, there is limited evidence on this topic. This study aims to evaluate the risk of healing complications in primary teeth with root fracture and to identify possible sequelae in the permanent dentition following root fracture in the primary dentition.

MATERIALS AND METHODS

A retrospective analysis of a cohort of 53 patients with 74 root fractured primary teeth. The standard follow-up program included clinical and radiographic examination after 4 weeks, 8 weeks, 6 months, and 1 year after the trauma and when the patient was 6 years of age. The following complications were registered: pulp necrosis (PN), pulp canal obliteration (PCO), ankylosis with replacement root resorption (ARR), infection-related root resorption (IRR), premature tooth loss (PTL), and repair-related resorption (RRR).

STATISTICS

The Kaplan-Meier and Aalen-Johansen estimators were employed. The level of significance was 5%.

RESULTS

A total of 74 teeth were included. 42 teeth were extracted at the initial examination. Risks estimated after 3 years: PTL 45.9% [95% CI: 28.8-63.0], PCO 12.9% [95% CI: 2.3-23.4], PN 14.9% [95% CI: 3.9-25.9], RRR 2.6% [95% CI: 0.0-7.5]. No teeth showed ARR or IRR. All complications were diagnosed within the first year. Most common sequelae in the permanent dentition was demarcated opacities, with an estimated risk of 20% [95% CI: 8.2-41.3].

CONCLUSIONS

There is a low risk of healing complications following a root fracture in the primary dentition. Root fractures often result in early extraction of the coronal fragment. The remaining apical fragment will undergo a physiological resorption. Aside from opacities, there is a low risk of sequelae in the permanent dentition.

Management and saving a traumatized poor prognosis maxillary central incisor for 18 years: A patient-centered treatment

Key clinical message

With today's increasing desire to preserve natural teeth, managing teeth with a poor prognosis is a new challenge for clinicians. A dentist's attention to patient-centered care is essential, which improves dental outcomes.

Abstract

Nowadays, patients' interest in preserving their natural teeth has increased. In the patient-centered care model, the clinician should consider the patient's preferences and values in the treatment plan. This strengthens the patient's responsibility toward his own body, resulting in more patient satisfaction and effective cooperation. Therefore, the skill of saving teeth with a poor prognosis, in which there was no other choice but to extract them, becomes essential in patients who want to preserve their natural teeth. This case report presents the successful 18-year treatment and management of a maxillary central incisor of a 17-year-old male with a horizontal root fracture, who was incompletely treated in another medical center when the trauma occurred. The patient presented to us after 6 months. Due to the short length of the root, the patient underwent regenerative endodontic treatment first, but he did not attend follow-ups. Finally, after 8 years, the patient returned with symptoms of infection and periapical radiolucency. The apical part of the root was resorbed during this time. Finally, it was decided to place an apical plug with MTA. MTA was extruded from the apical part of the root canal during the placement of the apical plug. In the 1-, 2-, 4-, and 10-year follow-ups, the patient was completely asymptomatic, and the radiolucent periradicular lesion had healed. However, the extruded MTA was still present in the radiographic images without interfering with the healing process. Finally, the tooth has remained functional for 18 years.

Indications for root canal treatment following traumatic dental injuries to permanent teeth

The dental pulp may respond favourably or unfavourably to traumatic dental injuries. The most serious unfavourable responses are pulp necrosis and infection of the root canal system. These cause apical periodontitis and/or external inflammatory resorption of the tooth. The following injuries require root canal treatment as part of their emergency management-(A) complicated crown fractures (but some may be suitable for conservative pulp treatments, such as pulp capping, partial pulpotomy or pulpotomy), (B) complicated crown-root fractures, (C) supra-crestal coronal third root fractures and (D) injuries where pulp necrosis is predictable or highly likely to occur AND where there has been damage to the root surface and/or periodontal ligament with the aim of preventing external inflammatory resorption. This latter group of injuries are avulsion, intrusion, lateral luxation with a crown fracture, extrusion with a crown fracture (all in fully developed teeth) plus avulsion with a crown fracture and intrusion with a crown fracture (both in incompletely developed teeth). All other injuries should not have root canal treatment commenced as part of the emergency management, but they must be reviewed regularly to monitor the pulp for any adverse changes to its status, particularly pulp necrosis and infection of the root canal system.

Dental Root Injuries Caused by Osteosynthesis Screws in Orthognathic Surgery-Comparison of Conventional Osteosynthesis and Osteosynthesis by CAD/CAM Drill Guides and Patient-Specific Implants

BACKGROUND/AIM

The primary aim was to evaluate the prevalence and localisation of dental injuries caused by osteosynthesis screws during orthognathic surgery, comparing two different CAD/CAM planning/surgical approaches through retrospective evaluation of post-operative computed tomography.

MATERIAL AND METHODS

This study considered all patients who underwent orthognathic surgery from 2010-2019. The examination for dental root injuries between conventional osteosynthesis (Maxilla conventional cohort) and osteosynthesis with patient-specific implant (Maxilla PSI cohort) was performed by evaluating the post-operative CT scans.

RESULTS

A total of 126 patients were included in the study. Among the 61 patients of the Maxilla conventional cohort, 10 dental root injuries in 8 patients (13.1%) were detected in the post-operative CT scan, representing 1.5% (n = 10/651) of the osteosynthesis screws inserted in proximity of the alveolar crest. No dental injury occurred following osteosynthesis in the 65 patients of the Maxillary PSI cohort (n = 0/773 screws) (p < 0.001). During a mean follow-up period of 13 months after primary surgery, none of the injured teeth showed evidence of periapical alterations and no endodontic treatments were necessary.

CONCLUSIONS

Maxillary positioning using CAD/CAM-fabricated drill/osteotomy guide and osteosynthesis with PSI can significantly reduce the risk for dental injury compared to the conventional procedure. However, the clinical significance of the detected dental injuries was rather minor.

Establishment of Narrow Root Fracture Models Using Modified Temperature Cycling Method and Diagnosis Using Different Cone-Beam CT Units

AIM

Using a modified thermal cycling method to establish narrow root fracture models and evaluate the diagnosis efficiency of them using four different cone-beam CT (CBCT) units. Methodology. Fifty-six intact teeth were selected, and the crowns of the teeth were embedded using general purpose acrylic resin. 50 root fracture models were established by soaking these teeth in liquid nitrogen and hot water cyclically; 6 teeth were used as the negative control. All the 56 teeth were scanned with the smallest voxel size of four different CBCT units (NewTom VGi, Planmeca Promax 3D Max, Kavo 3D eXam, and Soredex Scanora3D). 10 teeth were randomly selected, and the roots were sliced using slow-speed saw to obtain horizontal root sections. Scanning electron microscope (SEM) was used to measure the width of the fracture lines (FLs). The CBCT images were evaluated for the presence or absence of fracture lines. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the diagnosis of FLs using the four CBCT units.

RESULTS

Fifty narrow root fracture models were successfully established, and 25 root sections with 45 FLs were acquired. The width of FLs was from 3.43 μm to 143 μm; 32.2% of the points had width under 25 μm, while only 9.6% of them had width over 75 μm. The accuracy was 0.41, 0.54, 0.41, and 0.30 for NewTom VGi, Planmeca Promax 3D Max, Kavo 3D eXam, and Soredex Scanora3D, respectively.

CONCLUSIONS

The modified temperature cycling method is a simple and effective method to establish narrow root fracture models, and the diagnosis efficiency for these narrow fracture lines was quite poor using all the four different CBCT units.

Root Fractures in the Primary Teeth and Their Management: A Scoping Review

(1) Background: Traumatic dental injuries constitute a major global health problem. Primary deciduous teeth of the upper frontal group are frequently affected by trauma, especially at an early age. It is important to treat primary traumatic injuries because early tooth loss can lead to aesthetic and functional alterations. The most common injuries are extrusion, lateral luxation, and intrusion. Root fracture is a less common complication that can lead to tooth extraction if not properly diagnosed and managed. However, there are a lack of data regarding primary root fracture treatment. The literature was reviewed to study the current knowledge on the treatment of these injuries, and to propose an operative protocol based on the results obtained. (2) Methods: A literature search was performed on Web of Science, PubMed/MEDLINE, and SCOPUS. The research focused on the following features: age of the patient; localization of the root fracture and type of displacement suffered (intrusive, extrusive, or lateral); type of emergency treatment or diagnostic test performed and their compliance with IADT guidelines; follow-up duration. (2) Results: Only 8 articles fully met the inclusion criteria, with a total of 46 patients and 62 root fractures. Out of a total of 62 root fractures, regarding only upper incisors, the most common treatment was splinting (n = 39) for a period ranging from 3 weeks to 3 months (with an average of six weeks). No treatment was performed for 23 of the root fractures. The splinting performed in most of the included cases was semi-rigid, with the splint held in place using a composite resin material. An orthodontic splint using brackets and 0.5 mm stainless steel wire was used in only in one study. (4) Conclusions: We deduced that the root fracture of primary teeth is a rare traumatic dental injury that can cause numerous complications, such as eruptive problems in the permanent teeth. Correct radiological diagnosis, immediate repositioning and semi-rigid splinting could be conservative methods to prevent premature tooth loss in very young patients.

Regenerative endodontic procedures for two traumatized mature anterior teeth with transverse root fractures

Background

Regenerative endodontic procedures (REPs) are an alternative treatment in immature traumatized teeth with necrotic pulp/apical periodontitis. However, this procedure has been infrequently reported in multiple transverse root fractures of mature teeth. This case report describes management of a patient with multiple horizontal root fractures in 2 maxillary central incisors that were successfully treated with REPs.

Case presentation

A 17-year-old girl had a history of traumatic injury to mature teeth 11 and tooth 21 resulting in multiple transverse root fractures. Clinical examination showed that both teeth responded to electric and thermal pulp sensibility tests with prolonged severe pain and were tender to percussion and palpation. Periapical radiographic examination showed both teeth were fully developed and had multiple transverse fractures in the mid-root. The pulp diagnosis was consistent with symptomatic irreversible pulpitis. REPs were initiated with only the coronal fragments treated to preserve pulp vitality in the apical fragment for potential pulp tissue regeneration. After REPs, clinical signs/symptoms subsided, and the two teeth were followed for 48 months when cone beam computed tomography (CBCT) imaging was also undertaken. At the last review, the case demonstrated root fractures healing with calcified tissue and pulp calcification in the apical fragments. Both teeth were stable and in function.

Conclusions

REPs have the potential to be used to treat traumatized and symptomatic mature permanent teeth that have sustained transverse root fractures.

The Role of ICG Angiography in Decision Making About Skin-Sparing in Pediatric Acute Trauma

BACKGROUND

Indocyanine green (ICG) angiography has proven useful in assessing skin flap perfusion in plastic and reconstructive surgeries. This research aimed to explore its role in decision making about skin-sparing in children's acute trauma.

METHODS

A total of 19 patients suffering with acute trauma from January 2019 to September 2021 were retrospectively assessed. Both ICG angiography and clinical judgment were performed to evaluate skin tissue viability. The intraoperative decisions for each case depended on the specific condition of the traumatic wound, including tissue perfusion, skin defect area, and location of the wound. Postoperative vascular imaging software was used to quantify the tissue perfusion, and the duration of postoperative follow-up was from 6 to 18 months.

RESULTS

Among them, 18 (94.7%) patients experienced treatments according to ICG angiography and did not develop postoperative necrosis. One case with right forearm trauma suffered from partial necrosis. Hypertrophic scar and local infection were the independent complications, which were managed by symptomatic treatment.

CONCLUSION

ICG angiography may reduce the risk of postoperative necrosis and renders a promising adjunctive technique for surgeons to make reasonable decisions in skin sparing in acute pediatric trauma.

Application of X-ray image measurement in the early diagnosis of sports injury of ankle ligament

Objectives:

To study the value of X-ray analysis method of ankle fracture based on injury mechanism to improve the imaging diagnosis level of ankle fracture.

Methods:

This study was conducted from January 2016 to December 2019. It included 105 cases of fractures caused by sprained ankle joints. Their age was between 21-81 years with an average of 49.5 years, The traditional X-ray analysis method (Group-A) and the injury mechanism-based ankle fracture X-ray analysis method (Group-B) were used to analyze X-ray image data. Group-B also performed Weber classification and Lauge-Hansen classification on cases. Installment.

Results:

Of the 105 patients with ankle fractures, 97 patients in Group-B were able to make Lauge-Hansen classification. Of these 97 ankle fractures, 137 were found in Group-A, and 158 were found in Group-B. The wrong diagnosis of fracture in Group-A was 18%, and the wrong diagnosis of fracture in Group-B was 0.5%. There was a statistically significant difference between the two groups (P <0.05).

Conclusion:

The X-ray analysis method of ankle fractures based on injury mechanism can effectively improve the detection rate of hidden ankle fractures and high fibular fractures, and reduce the missed diagnosis, which is superior to the traditional X-ray analysis methods. At the same time, Weber classification, Lauge-Hansen classification and staging can be made for most cases, which is conducive to guiding clinical treatment.

Dental undergraduate students' ability in the diagnosis of root fractures: Comparative analysis of different imaging methods

OBJECTIVE

The aim of this study was to evaluate the diagnostic ability of dental undergraduate students to detect horizontal and oblique root fractures (ORFs) using different imaging techniques.

MATERIALS AND METHODS

Nine teeth were selected and randomly divided in three groups in order to create a fracture line without fragments separation: control (without fracture), horizontal root fracture (HRF), and ORF. The root fracture was created using perpendicular force and was confirmed by transillumination. A model with two adjacent teeth was created, and different imaging techniques were performed: conventional periapical radiograph; mesially and distally shifted periapical radiographs; cone-beam computer tomography (CBCT). Twenty students that had participation on dental trauma clinic at the year of 2019 were invited to identify root fractures by a five-point scale: (i) fracture definitely not present, (ii) fracture probably not present, (iii) uncertain whether fracture is present or not, (iv) fracture probably present, and (v) fracture definitely present. Data were analyzed by Kappa test for agreement evaluation.

RESULTS

Comparing each student to the gold standard, there was a variation in reproducibility and performance from poor to substantial (0.042-0.667). Reproducibility values ranged from poor to good for all periapical radiographs both in the diagnosis of ORF (-0.33-0.667) and in HRF (0-1).

CONCLUSIONS

In CBCT images, the students' ability was lower in HRF detection in comparison with the oblique ones. The students showed limited capacity to diagnose root fractures; however when CBCT was used, the performance was more satisfactory than when periapical radiographs were used.

A three-dimensional finite element analysis of stress distribution in maxillary central incisor with a horizontal mid root fracture after various management protocols

Context

The incidence of root fractures is about 1.2%-7% in permanent teeth and horizontal mid root fractures are most common in maxillary anteriors.

Aims

This study aims to evaluate the stress distribution in a maxillary central incisor with mid root fracture after various management protocols using three-dimensional finite element (FE) analysis.

Materials and Methods

Four three dimensional FE models were constructed: Model 1-Normal tooth, Model 2-tooth with horizontal mid root fracture, Model 3-tooth with horizontal mid root fracture, coronal fragment filled with Biodentine, and access cavity sealed with composite resin cement and apical fragment left untreated and Model 4-tooth with horizontal mid root fracture restored with intraradicular fiber post as a splint and access cavity sealed with composite resin cement. The properties of materials were assigned and a force of 100 N was applied at 45° angle to the longitudinal axis of the tooth onto the palatal surface incisal to the cingulum.

Statistical Analysis

Von-Mises stress along the length of the root analyzed and compared.

Results

The maximum stress distribution was observed at the palatal end of the coronal radicular fragment in both without treatment and with biodentine treatment. The stress distribution was concentrated more at the junction of the splinted area in the intraradicular fiber post splinted model.

Conclusions

The model with intraradicular fiber post as a splint exhibited more stress concentration at the splinted area due to bending forces. These stresses may adversely affect the healing around the fracture site and affect the longevity.

Conservative management of a cervical horizontal root fracture by long-term stabilisation: A case report

Cervical root fractures are often more difficult to manage than fractures of the apical and middle third of the root, due to the weak chance of healing with dental hard tissue between fragments, and the likelihood of subsequent infection of the root canal system. This case report describes the management of a cervical horizontal root fracture by repositioning the coronal fragment of a maxillary central incisor, and long-term splinting using a bonded lingual orthodontic retainer wire. Throughout the 7-year stabilisation period with clinical and radiographic follow-up, the tooth has remained asymptomatic with radiographic evidence of progressive pulp canal obliteration. In applicable cases, long-term stabilisation of the fractured coronal fragment with a fixed orthodontic retainer may offer a minimally invasive solution to maintain pulp vitality, function and aesthetics until cessation of growth or until a more comprehensive, multidisciplinary approach is required.

Sweet tooth: DNA profiling of a cranium from an isolated retained root fragment

Sampling of healthy multi‐rooted teeth is recommended for the genetic identification of human skeletal remains. However, this may not always be possible, as in the reported case consisting of an isolated human cranium found in an aggregate crushing and processing plant in Piedmont, Northwest Italy. The cranium displayed significant weathering, suggesting a post‐mortem interval of several years, and was edentulous with the exception of the apical root fragment of the upper left canine, consequence of an antemortem horizontal fracture. Prolonged decalcification of the root fragment followed by powder‐free DNA extraction from ~10 mg of root tip tissue led to the recovery of >10 ng of high molecular weight human DNA, in comparison with ~0.01 ng of DNA per mg of bone powder obtained from the petrous portion of the temporal bone. Quantity and quality of DNA isolated from apical tooth tissue enabled multiple genotyping, including a reportable female STR profile, mitochondrial DNA analysis, and ancestry‐informative insertion/deletion polymorphisms. Although the cranium remained unidentified after DNA comparisons, our findings confirm that apical tooth tissue is a promising source of DNA, easily obtained through a powder‐free extraction protocol. Results also indicate that root tips should not be overlooked in challenging identification cases, even in the presence of compromised tooth specimens.

Conservative Non-Surgical Management of Horizontal Root-Fractured Maxillary Incisors in a Young Male with Angle Class II, Division 2, Malocclusion

Horizontal root fractures are a rare emergency in a dental office. The injury involves periodontal ligament, cementum, dentine and pulp. The healing is influenced by the location of the root fracture, the displacement of the fragments and the status of the pulp. This report presents a clinical case of horizontal fractures to both maxillary central incisors due to an act of violence. The type of occlusion has avoided a severe diastasis of the coronal parts with a subsequent damage to the pulp and periodontum. The fractures were treated with an orthodontic splint without any further therapy and hard tissue healing was observed. A careful diagnosis and well-timed treatment planning usually allow a cost-efficient and biologically-oriented therapy with a favorable outcome.

Effect of splinting times on the healing of intra-alveolar root fractures in 512 permanent teeth in humans: A Scandinavian multicenter study

BACKGROUND/AIM

Long-term splinting of teeth with intra-alveolar root fractures has been considered important for the deposition of hard tissue between the root fragments. The aim of this study was to compare the healing outcomes in teeth with intra-alveolar root fractures relative to splinting times in three dental centers in Scandinavia, using historical data.

MATERIALS AND METHODS

A total of 512 maxillary and mandibular incisors from three dental trauma centers were included in the study. Two of the centers used long-term splinting protocols of two to three months while the other center used a short-term splinting protocol of one month or less. Three outcomes were evaluated: (1) Healing with hard tissue (dentin and/or cementum). (2) Healing with connective tissue (periodontal ligament) interposition with or without bone between the fragments. (3) Non-healing due to the coronal pulp being necrotic and infected with granulation tissue interposed between the fragments.

RESULTS

The mean splinting times were 18, 81, and 110 days in the three centers. Long-term splinting resulted in hard tissue healing more frequently than short-term splinting. Short-term splinting resulted in more connective tissue/bony healing than long-term splinting, while there was no difference in the frequency of non-healing between long-term and short-term splinting protocols.

CONCLUSIONS

While the results suggest that long-term splinting favors hard tissue deposition, one cannot, however, conclude that long-term splinting definitely favors hard tissue healing since the treatment protocols were not randomized among the three centers. More clinical studies on the role of splinting time need to be done.

Dental injuries in paediatric mandibular fracture patients

Purpose

Dental injuries (DIs) are associated with facial fractures, particularly mandibular fractures. As paediatric mandibular fractures have special features, we sought to clarify the occurrence and types of DIs among this patient group. We assessed how age, injury type, and fracture location affects the occurrence of DIs and thereby defined which patients are most susceptible.

Methods

This retrospective study included patients < 18 years with a recent mandibular fracture. Predictor variables were gender, age group, mechanism of injury, type of mandibular fracture, and other associated facial fracture(s). Types and locations of DIs and tooth loss due to injury were also reported.

Results

DIs were detected in 34.7% (n = 41) out of 118 patients. Patients with tooth injury had on average 3.5 injured teeth. A total of 16.2% of injured teeth were lost, typically at the time of the injury. Loss of at least one tooth was seen in approximately 10% of patients. Avulsion was the most common cause of tooth loss (52.2%). Non-complicated crown fracture (50.7%) was the most common DI type. Statistically significant associations between studied variables and DIs were not detected.

Conclusion

DIs are common and often multiple in paediatric mandibular fracture patients regardless of background factors. DIs often lead to tooth loss. Prompt replantation of an avulsed tooth, early detection of DIs, and prevention of tooth loss whenever possible are important to avoid permanent tooth defects.

Radiographic evaluation of immature traumatized incisors following different endodontic treatments

BACKGROUND/AIMS

Indirect pulp capping, pulpotomy, and apexification are three common endodontic treatments for immature traumatized incisors. They all affect tooth root development to some extent. The aim of this retrospective study was to compare the influence of these treatments on root development of immature permanent incisors following dental trauma.

MATERIALS AND METHODS

Twenty-one indirect pulp capping, 48 pulpotomy, and 58 apexification cases with a mean age of 8.4 ± 1.0 years and median follow up of 12 months were included. NIH ImageJ with TurboReg plug-in was used to correct angular differences between the pre-operative and recall periapical radiographs, and to calculate variations of root length, dentin wall thickness, and apical closure. Kruskal-Wallis ANOVA followed by pairwise comparisons was applied to compare the radiographic variations. The type of apical closure was assessed qualitatively and analyzed using Fisher's exact test.

RESULTS

The apexification group had a lower trend toward apical closure than the other two groups (P < .05). It also showed thinner dentin wall thickness compared with the pulpotomy group (P = .001). There was no significant difference between pulpotomy and indirect pulp capping in the trend to apical closure (P > .05) or dentin wall thickness (P = .775). There was no significant difference in the variation of root length among the three groups (P = .06). There was a moderate correlation between the treatment and the type of apical closure (Cramer's V Coefficient = .375). Pulpotomy tended to form a normal apical constriction rather than a calcific barrier while apexification showed the opposite inclination. Indirect pulp capping had no specific inclination toward any type of apical closure.

CONCLUSIONS

Apexification resulted in an abnormal root development mostly by affecting the dentin wall thickness and apical closure. Pulpotomy was beneficial for normal root development of immature traumatized teeth.