Root fractures in children and adolescents: diagnostic considerations

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.

Is use of CBCT without proper training justified in paediatric dental traumatology? An exploratory study

BACKGROUND

Proper skills in radiographic diagnosis are essential for optimal management of dental trauma.

AIM

To assess diagnostic accuracy obtained by paediatric dentists using Cone Beam Computed Tomography (CBCT) without specific training and to compare this with their performance using intraoral radiographs.

METHODS

Intraoral and CBCT images of 89 teeth, spread over twenty dental trauma cases were presented in random order to nine paediatric dentists. Diagnostic findings were compared with those of a benchmark reference. Sensitivity and specificity were calculated and compared using paired t-tests.

RESULTS

Overall, observers' diagnostic performance was rather poor with significantly higher sensitivity when using 2D images (P = 0.017). Performance differed considerably according to the type of pathology. Using either imaging modality, sensitivity for diagnosing apical pathology and root fractures was high while the opposite was seen for inflammatory root resorption, root cracks and subluxations. Statistically significant differences between imaging modalities were seen for root fractures (P = 0.013) and apical pathology (P = 0.001), in favor of 3D, and for crown fractures (P = 0.009) in favor of 2D.

CONCLUSION

Overall poor performance of paediatric dentists indicates that additional training in radiographic diagnosis is required. In order to justify the use of CBCT to increase diagnostic performance, proper training of the paediatric dentist is mandatory.

Management of Untreated Horizontal Root Fracture: A Case Report

Traumatic dental injuries often occur to the teeth and their supporting tissues and they are the main reasons for an emergency visit to a dental clinic. Horizontal root fractures usually are characterized by a fracture line that is perpendicular to the long axis of the root. Root fractures are diagnosed through clinical and radiographic examination. Treatment depends on the position of the fracture, the extent of root involvement, correct diagnosis, clinical management, and radiographic follow-up. This article presents endodontic management of horizontal root fracture using a fibre post. A 28-year-old male patient presented with a horizontal fracture of the maxillary left central incisor at the junction of the apical and middle third of the root. Root canal treatment followed by MTA apexification of the coronal fragment and fibre post gave satisfactory results.

Apexification and Repair of Root Fracture with Mineral Trioxide Aggregate - A Case Report with 5-Year Follow-up

Young patients are most susceptible to trauma which involves teeth and their supporting structures. Severity can vary from simple enamel fracture to complete tooth avulsion. The treatment modality ranges from a noninvasive procedure to surgical intervention. The present case report describes the unique management, 5-year follow-up, and prognosis of a 10-year-old child diagnosed with lateral luxation and horizontal apical root fracture of maxillary central incisor with open apex.

Diagnosis and Management of Traumatic Dental Injuries Using Intraoral Radiography and Cone-beam Computed Tomography: An In Vivo Investigation

INTRODUCTION

The aim of this study was to compare periapical radiographs (PRs) and upper standard occlusal (USO) radiographs with cone-beam computed tomographic (CBCT) imaging on clinicians' confidence in the diagnosis and management of traumatic dental injuries (TDIs).

METHODS

This study included 35 maxillary anterior teeth from 25 patients with at least 1 PR (parallax view) and a CBCT scan. Fourteen patients also had a USO radiograph. Ten examiners selected a diagnosis and treatment plan, which were compared with a reference standard. Sensitivity, specificity, positive and negative predictor values, and receiver operating characteristic analysis were used to determine the diagnostic accuracy.

RESULTS

CBCT imaging exhibited significantly higher sensitivity than both conventional radiographic techniques combined (PRs and PRs + USO radiographs) for all diagnoses (TDI: 99% vs 84%, lateral luxation: 80% vs 34%, extrusions: 92% vs 42%, and cortical plate fracture: 58% vs 1%) other than horizontal root fractures in which the results were close to statistical significance (88% vs 69%). CBCT imaging was significantly more accurate for all diagnoses (TDI: 91% vs 70%, lateral luxations: 83% vs 61%, extrusive luxations: 92% vs 68%, alveolar cortical plate fractures: 78% vs 48%, and horizontal root fractures: 93% vs 82%). Examiners had the most confidence with CBCT imaging and the least confidence in diagnosing using PRs + USO radiographs than with PRs alone. Agreement with management plans was significantly better using CBCT imaging compared with PRs and PRs + USO radiographs.

CONCLUSIONS

CBCT imaging improved the clinical diagnosis of TDIs. The addition of USO radiographs to PRs did not improve the diagnosis of TDIs in this investigation. CBCT imaging improved confidence in the diagnosis of TDI cases and treatment planning compared with conventional radiography.

Prevalence of traumatic crown injuries in German adolescents

OBJECTIVES

Although dental trauma and its unfavorable sequelae are considered major public health problems worldwide, the published data on the prevalence of traumatic crown injuries (TCIs) in Germany are lacking. Therefore, the present study assessed the prevalence of TCIs among adolescents in Bavaria, Germany.

MATERIAL AND METHODS

Ethical approval and parental consents were obtained, and population-based information from 10- (N = 1158), 12- (N = 416), and 15-year-olds (N = 1302) from two different cohort studies performed in Bavaria (GINIplus/LISA and LAGZ) were examined for the presence of TCIs, dental caries, and restorations. Statistical comparisons were made using Mann-Whitney U test and Wilcoxon signed-rank test.

RESULTS

The prevalence of TCIs was 6.3% in the 10- and 12-year-old children and 14.0% in 15-year-old children, and a higher prevalence was observed in boys than in girls. Most (87.5%) of the traumatized teeth were maxillary incisors. The caries prevalence was low in all three populations.

CONCLUSION

The prevalence of TCIs in Bavarian adolescents at a low risk for caries was found to be low.

CLINICAL RELEVANCE

Dental trauma is a prevalent event in children and adolescents, and incisors are the most affected teeth. Therefore, dental practitioners should be able to manage the spectrum of traumatic injuries.

Alcohol consumption at age 11-12 years and traumatic dental injuries at age 15-16 years in school children from East London

AIM

To explore the association between alcohol consumption at age 11-12 years and traumatic dental injuries (TDI) at age 15-16 years.

METHODS

Data of 635 adolescents who participated in phases I and III of the Research with East London Adolescents Community Health Survey (RELACHS), a longitudinal school-based survey of a representative sample of adolescents from East London, were used for this study. Information on socio-demographic characteristics and alcohol consumption was obtained from questionnaires in phase I when adolescents were 11-12 years of age. Data on TDI and clinical characteristics (incisor overjet and lip coverage) were taken from clinical examination in phase III when adolescents were 15-16 years of age. The association between (lifetime and last month) alcohol consumption and TDI was assessed in crude and adjusted logistic regression models.

RESULTS

Overall, 14.5% of adolescents had ever consumed alcohol and 3.5% had consumed alcohol the month before the baseline survey, whereas 17% of adolescents had experienced TDI by age 15-16 years. No significant association of alcohol consumption with TDI was seen in these adolescents for either lifetime (adjusted odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.45-1.67) or last month consumption of alcohol (adjusted OR: 0.86; 95% CI: 0.28-2.69).

CONCLUSION

This study did not support the association between alcohol use and TDI in adolescents.

Management of Horizontal Root Fracture in the Middle Third via Intraradicular Splinting Using a Fiber Post

Radicular fractures in permanent teeth are uncommon injuries and account for only 0.5-7% of dental traumas. These fractures commonly result from a horizontal impact and are transverse to oblique in direction. Their incidence is more in the middle third of the root than at the apical and cervical thirds. This paper describes a case of complicated crown fracture of maxillary incisors along with horizontal root fracture at the middle third of maxillary right central and lateral incisor. The fractured root fragments of the upper right central and lateral incisor were united with the help of a glass fiber post after receiving an endodontic treatment. The other two incisors were treated endodontically followed by post endodontic restorations. Eventually the four incisors were restored with porcelain fused to metal crowns. A one-year follow-up revealed a well stabilized assembly of the root fragments and the post.

Evaluation of a digital learning object (DLO) to support the learning process in radiographic dental diagnosis

AIMS

Studies have shown that inappropriate therapeutic strategies may be adopted if crown and root changes are misdiagnosed, potentially leading to undesirable consequences. Therefore, the aim of this study was to evaluate a digital learning object, developed to improve skills in diagnosing radiographic dental changes.

MATERIALS AND METHODS

The object was developed using the Visual Basic Application (VBA) software and evaluated by 62 undergraduate students (male: 24 and female: 38) taking an imaging diagnosis course. Participants were divided in two groups: test group, which used the object and control group, which attended conventional classes. After 3 weeks, students answered a 10-question test and took a practice test to diagnose 20 changes in periapical radiographs.

RESULTS

The results show that test group performed better that control group in both tests, with statistically significant difference (P = 0.004 and 0.003, respectively). In overall, female students were better than male students. Specific aspects of object usability were assessed using a structured questionnaire based on the System Usability Scale (SUS), with a score of 90.5 and 81.6 by male and female students, respectively.

CONCLUSIONS

The results obtained in this study suggest that students who used the DLO performed better than those who used conventional methods. This suggests that the DLO may be a useful teaching tool for dentistry undergraduates, on distance learning courses and as a complementary tool in face-to-face teaching.

Diagnosis of acute dental trauma: the importance of standardized documentation: a review

In 1985 Andreasen and Andreasen published a paper on the diagnosis of luxation injuries and outlined the importance of standardized clinical, radiographic, and photographic techniques. Now 30 years later, these recommendations remain current in the International Association of Dental Traumatology (IADT) guidelines for the management of dental trauma and describe circumstances surrounding the time of injury, the extent of trauma (e.g., type of luxation injury), healing potential (e.g., stage of root development) as well as information concerning subsequent treatment. The purpose of this review was to include findings for other types of trauma and to discuss more recent studies that augment and/or improve on the original findings from 30 years ago. The present review discusses the use of a standardized clinical registration (pulpal sensibility testing, laser Doppler flowmetry, mobility testing), radiographic survey, and photographic registration of the traumatized patient. Moreover, the value of digital radiographs and recent developments in computer tomography with respect to possible enhancement of the trauma diagnosis are discussed.

Intraradicular Splinting with Endodontic Instrument of Horizontal Root Fracture

Introduction. Root fractures, defined as fractures involving dentine, cementum, and pulpal and supportive tissues, constitute only 0.5–7% of all dental injuries. Horizontal root fractures are commonly observed in the maxillary anterior region and 75% of these fractures occur in the maxillary central incisors. Methods. A 14-year-old female patient was referred to our clinic three days after a traffic accident. In radiographic examination, the right maxillary central incisor was fractured horizontally in apical thirds. Initially, following local infiltrative anesthetics, the coronal fragment was repositioned and this was radiographically confirmed. Then the stabilization splint was applied and remained for three months. After three weeks, according to the results of the vitality tests, the right and left central incisors were nonvital. For the right central incisor, both the coronal and apical fragments were involved in the endodontic preparation. Results. For the right central tooth, both the coronal and apical root fragments were endodontically treated and obturated at a single visit with white mineral trioxide aggregate whilst the fragments were stabilized internally by insertion of a size 40 Hedstrom stainless-steel endodontic file into the canal. Conclusion. Four-year follow-up examination revealed satisfactory clinical and radiographic findings with hard tissue repair of the fracture line.