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Case 2
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Root Fracture inthePrimary Dentition
BACKGROUND INFORMATION 1
Trauma Prevention
• While many parents may believe that their
children are taking preventive measures to avoid
injury, such as bicycle helmets, the truth is that
reports by children often reveal that when
unsupervised, injury prevention measures are
often not followed (Ehrlich etal. 2001)
• Studies have revealed that mouth guards are an
effective primary protective measure at reducing
the rate of dentoalveolar injuries, yet in some
instances only 1–5% of children participating in
sports actually wear mouth guards during practices
(Fakhruddin etal. 2007; Spinas and Savasta 2007)
• Falls are typically the most common type of
injury, and while the anecdotal belief is that
increased supervision will prevent injuries,
reports in the literature cite that only about 20%
of parents believe increased supervision will
Figure 4.2.1 Facial photograph.
A. Presenting Patient
• Four‐year‐, six‐month‐old Caucasian male
(Figure4.2.1)
• New patient presenting as an emergency
prevent falls/injuries (Eberl etal. 2009)
• There is a reported peak in incidence of dental
trauma during preschool years of as high as
35% (Hargreaves etal. 1999)
OrOfacial Trauma
B. Chief Complaint andHistory ofPresent Injury
• Mother states, “My son knocked his teeth yesterday,
and now they look brownish.” The child was playing at
the mall playground and fell. The injury was witnessed
by the mother. There was no loss of consciousness
and no complaint of pain
C. Social History
• Patient has no siblings
• Mother is the primary caregiver and stays at home
• Low socioeconomic status
D. Medical History
• History of recurrent otitis media infections
• No known drug or food allergies, no medications,
vaccinations are up to date
E. Medical Consult
• Not applicable
F. Dental History
• Child has seen dentist since the age of 18 months
• Fair oral hygiene with little adult supervision
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• Diet is age appropriate
• Uses toothpaste containing fluoride twice daily
• Lives in optimally fluoridated area
• No prior history of orofacial trauma
• Child’s behavior is age appropriate, and he is curious
about dental instruments
FUNDAMENTAL POINT 1
Health History after Oral Trauma
• Confirm that tetanus immunizations are up to
date. If the last tetanus booster was five or more
years prior and the wound is contaminated with
soil/debris, another tetanus toxoid booster is
indicated (American Academy of Pediatrics 2011)
• Rule out closed head injury and refer for medical
consult if the patient is positive for any of the
following (Centers for Disease Control and
Prevention 2017):
Amnesia
Nausea/vomiting
Headache
Lethargy/irritability/confusion
Loss of consciousness
Occlusal Evaluation ofPrimary Dentition
•
No significant findings
Other
• Caries‐free dentition
FUNDAMENTAL POINT 2
Examination ofDental Trauma
• Take adequate radiographs to clearly image all
involved teeth
• Rule out other injuries, e.g. soft tissue lacerations, alveolar fractures, etc.
• Vitality testing is of questionable value on
primary teeth, and recognition of pulpal necrosis
is typically based on clinical presentation
(Pugliesi etal. 2004)
Diagnostic Tools
I.
• Periapical radiograph shows root fracture in the
middle third of the maxillary right and left primary
central incisors (Figure4.2.3)
• Vitality tests deferred
Extraoral Exam
G.
• Soft tissue injuries: mild contusions on upper lip
H. Intraoral Exam
Soft Tissues
• Mild plaque accumulation on buccal surfaces of
maxillary molars
Hard Tissues
• Traumatized teeth: maxillary right and left primary
central incisors–class I mobility (Figure4.2.2)
Figure 4.2.2 Intraoral photograph of maxillary right and left
primary central incisors.
Figure 4.2.3 Radiograph showing root fractures of maxillary
right (arrow) and left primary central incisors.
J. Diagnosis
Maxillary right and left primary central incisors: middle
root fractures
K. Treatment
• No treatment is indicated at this time (see Flowchart
B: Root Fractures at the end of this chapter)
• Discharge instructions: soft diet and avoid incising on
injured segment until instructed otherwise. Watch for
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OrOfacial Trauma
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clinical signs such as presence of parulis or fistula,
mucosal inflammation or swelling, increased mobility,
or color change. Pain medication as needed for
discomfort
• Follow‐up treatment: follow‐up within four weeks to
reassess healing and potential need for future treatments (McTigue and Thikkurissy 2018)
L. Prognosis andDiscussion
• Root fractures located on the apical third present a
good prognosis. Teeth with root fractures in the
middle segment should be observed closely as in the
case presented. The more coronal the fracture is, the
worse the prognosis. Cases in which there is significant mobility of the coronal segment and/or mobility
of the coronal segment result in poor outcomes
BACKGROUND INFORMATION 2
Dental Root Fractures
• Root fractures traditionally heal by one of four
means:
1. Calcified tissue (bony healing)
2. Interposition of connective tissue
3. Interposition of bone and connective tissue
4. Interposition of granulation tissue
• The most common forms of root fracture
healing are calcified tissue and interposition of
connective tissue (Cvek etal. 1995)
• Splinting primary teeth should be attempted
only after careful risk : benefit analysis, including:
1. Patient cooperation
2. Ability to provide adequate isolation if a resin
splint is used
3. Parental compliance with needed follow‐up care
• While some studies have shown success with
primary tooth splinting, medico‐legal considerations must be discussed with caregivers
M. Complications andAlternative
TreatmentPlan
If the fracture had been located in the coronal third,
the recommendation would be to remove the
coronal segment because the prognosis is poor.
There is some controversy as to whether apical
segments need to be removed. Direct visualization
of the apical segment would facilitate extraction,
while poor or no visualization could result in damage
to permanent tooth bud
FUNDAMENTAL POINT 3
Complications ofDental Trauma
• Tooth discoloration is a common post‐traumatic
complication
• Dark gray discoloration of primary incisors soon
after injury may fade and does not warrant
immediate treatment
• Discoloration noted soon after injury is not
representative of denitive pulpal diagnosis
(Holan 2004)
• Tooth discoloration that rst appears well after the
trauma may be indicative of changes in pulp
vitality and potential necrosis (Soxman etal. 1984)
• All teeth involved in injury must be re‐assessed
for potential pulpal injury
Self‐Study Questions
1. What are the situations in which extraction of
tooth and/or segments is warranted?
2. Would management differ if discoloration had
occurred 26 months after injury?
3. When is splinting of primary teeth indicated?
Answers are located at the end of the case
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Self‐Study Answers
1. As the fracture is placed more coronally, the
prognosis worsens for the tooth. Furthermore, the
aspiration risk must be assessed. Parents should
be made aware of the possibility for the need to
remove the coronal and/or entire segment at a later
date if no treatment is immediately rendered
2. Per the International Association of
DentalTraumatology (IADT) guidelines (www.
iadt‐dentaltrauma.org), transient discoloration
immediately following injury is not uncommon.
This discoloration is most often reddish or grayish.
Discoloration that occurs well after the traumatic
Bibliography
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12. http://
dx.doi.org/10.1542/peds.2011‐1752
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
Cvek M, Andreasen JO, Borum MK. 1995. Healing of 208 intra‐
alveolar root fractures in patients aged 7–17 years. J Endod
21(7):391–3.
Eberl R, Schalamon J, Singer G et al. 2009. Analysis of 347
kindergarten‐related injuries. Eur J Pediatr 168:163–6.
Ehrlich PF, Longhi J, Vaughan R, Rockwell S. 2001. Correlation
between parental perception and actual childhood patterns
of bicycle helmet use and riding practices: implications
for designing injury prevention strategies. J Pediatr Surg
36(5):763–6.
Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. 2007. Use of
mouthguards among 12‐ to 14‐year‐old Ontario schoolchildren. J Can Dent Assoc 73(6):505.
injury may be indicative of pulpal necrosis and
results in inflammatory resorption despite the
patient remaining asymptomatic
3. Splinting primary teeth should be attempted
only after careful risk : benefit analysis, including
patient cooperation and behavior, ability for
adequate isolation if a resin splint is used, and
parental compliance and understanding of the
need for follow‐up care. While some studies have
demonstrated success with splinting primary
teeth, full medico‐legal considerations need to be
discussed with parents/caregivers
Hargreaves JA, Cleaton‐Jones PE, Roberts GJ et al. 1999.
Trauma to primary teeth of South African pre‐school children. Endod Dent Traumatol 15(2):73–6.
Holan G. 2004. Development of clinical and radiographic signs
associated with dark discolored primary incisors following
traumatic injuries: a prospective controlled study. Dent
Traumatol 20(5):276–87.
McTigue D, Thikkurissy S. 2018. Trauma. In: The Handbook of
Pediatric Dentistry, 5th edition. Nowak AJ, Casamassimo
PS (eds) Chicago: American Academy of Pediatric Dentistry.
Pugliesi DM, Cunha RF, Delberm AC, Sundefeld ML. 2004.
Influence on the type of dental trauma on the pulp vitality
and the time until treatment: a study in patients ages 0–3
years. Dent Traumatol 20(3):139–42.
Soxman JA, Nazif MM, Bouquot J. 1984. Pulpal pathology in
relation to discoloration of primary anterior teeth. ASDC J
Dent Child 51(4):282–4.
Spinas E, Savasta A. 2007. Prevention of traumatic dental
lesions: cognitive research on the role of mouthguards during sport activities in paediatric age. Eur J Paediatr Dent
8(4):193–8.
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Case 3
Complicated Crown Fracture, Permanent Tooth
A
Figure 4.3.1 (A, B) Facial photographs.
A. Presenting Patient
• Eight‐year‐, seven‐month‐old African‐American female
(Figure4.3.1)
• New patient presenting as an emergency
B. Chief Complaint andHistory ofPresent
Injury
• Mother reports, “My daughter fell off her bicycle and
broke her tooth”
• Child fell while riding her bike at her grandmother’s
house about three and a half hours ago. The grandmother had no transportation so the patient waited
until her mother returned home from work to come to
the clinic. The accident was witnessed by her 12‐year‐
old cousin. There was no loss of consciousness
C. Social History
• Patient is in third grade
• Lives at grandmother’s house with mother, one
younger sibling, and two cousins
• Mother works two jobs and provides for all in household; the grandmother is the primary care giver
• Low socioeconomic status
D. Medical History
• No significant findings, no known food or drug
allergies, no medications, vaccinations are up to date
B
FUNDAMENTAL POINT 1
History forTrauma
• Rule out closed head injury and refer for medical
consult if patient is positive for any of the
following (Centers for Disease Control and
Prevention 2017):
Amnesia
Nausea/vomiting
Headache
Lethargy/irritability/confusion
Loss of consciousness
• Ask patient and parent if they know where the
broken tooth fragment is. Rule out aspiration or
impaction of the fragment in soft tissue wounds
of the lips or tongue
• Conrm that tetanus immunizations are up to
date if there are soft tissue injuries contaminated
with soil (American Academy of Pediatrics 2011)
E. Medical Consult
• Not applicable
F. Dental History
• No dental home
• Mother reports infrequent dental exams through local
school program
• Diet high in refined carbohydrates
• Poor oral hygiene
• Child reports brushing with fluoridated toothpaste
once per day
• Community water is optimally fluoridated
• No previous history of dental trauma
G. Extraoral Exam
• No significant findings
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H. Intraoral Exam
Soft Tissues
• No significant findings
Hard Tissues
• No obvious carious lesions
• Traumatized tooth: maxillary right permanent central
incisor–complicated fracture (pulp exposure), class II
mobility (Figure4.3.2)
Occlusal Evaluation ofMixed Dentition
• No significant findings
Other
• Poor oral hygiene with extensive plaque accumulation
I. Diagnostic Tools
• Periapical radiograph demonstrates immature apices
of maxillary incisors (Figure4.3.3)
• Percussion tests
Maxillary permanent lateral incisors: negative
Maxillary permanent central incisors: +2
• Vitality tests: deferred
J. Diagnosis
Maxillary right permanent central incisor: complicated
crown fracture with subluxation
FUNDAMENTAL POINT 2
Examination forCrown Fracture Injuries
• Take adequate radiographs that clearly show all
involved teeth, including periapices
• Note apical development because it impacts
treatment selected (see Flowchart C: Crown
Fracture Injuries at end of this chapter) and
prognosis. Pulp survival is more likely in luxated
teeth with immature apices. Pulp canal obliteration
is the most common sequela to luxation injuries
to immature permanent teeth
• Rule out other injuries, e.g. root fractures,
alveolar fractures
• Vitality tests frequently yield false‐negative
results for up to three months following an injury
(Flores etal. 2007)
A
Figure 4.3.2 (A, B) Intraoral photographs showing maxillary right
permanent central incisor–complicated fracture (pulp exposure).
Figure 4.3.3 Periapical radiograph demonstrating immature
apices of maxillary incisors.
B
BACKGROUND INFORMATION 1
Treatment forCrown Fractures
• Optimal care indicates treatment as soon as
possible after the injury. Patient behavior, lack of
availability of facilities and materials, or management
of more serious injuries may delay treatment.
Successful outcomes have been reported when
treatment of complicated crown fractures is delayed
up to several days, so the clinician may elect to defer
treatment until the following morning, if necessary,
to assure optimal treatment
• The treatment objective is to complete a
debridement of inflamed or infected pulp
tissue while maintaining healthy pulp tissue.
This is particularly important in immature teeth
in order for complete root maturation (apexogenesis) to occur
(Cvek 1978; Flores et al. 2007)
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OrOfacial Trauma
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K. Comprehensive Treatment
• See Flowchart C: Crown Fracture Injuries at the end
of this chapter
• Maxillary right permanent incisor: partial pulpotomy
(Cvek technique, see Fundamental Point 3 and
Chapter 3: Complex Pulp Therapy)
Isolate tooth with rubber dam
Gently remove 1.5–2 mm of pulp tissue with sterile
bur and copious irrigation with, ideally, sterile water
(Figure4.3.4)
Use wet cotton pellet to control hemorrhage
Cover pulp with calcium hydroxide, followed by
glass ionomer
Assure an excellent seal with composite resin
provisional restoration (Figure4.3.5). Final restoration may be completed at the same appointment if
it can be done atraumatically. However, final restoration should be deferred if tooth is mobile
Prescribe over‐the‐counter acetaminophen or
ibuprofen for pain, as needed
Figure 4.3.4 Partial pulpotomy technique.
Follow‐Up Treatment
•
Two‐week postoperative visit:
Clinical exam: assess vitality with cold and electric pulp
tests; assess color, mobility, and pain to percussion
Complete final restoration of tooth if not done at
first appointment
• Six‐week postoperative visit:
Clinical exam: repeat assessment above
Radiographic exam: assess for signs of pulp necrosis, periapical radiolucency, or inflammatory resorption, and for continuing root development
• Repeat same postoperative assessments at six
months and one year
L. Prognosis andDiscussion
Prognosis depends on maintaining vitality of the
•
pulp in the maxillary right permanent central incisor.
The goal is to achieve full root maturation by
removing inflamed pulp tissue while retaining
healthy pulp in the root canal and crown. While a
direct pulp cap may be simpler and quicker to
perform than a partial pulpotomy, the consequences
of failure (pulp necrosis) are dire in a tooth with an
immature apex. Lacking a vital pulp makes the
chances of the tooth achieving complete root
maturation markedly decreased. Afalse‐negative
response to vitality tests is possible for up to three
months. Continuing root development in immature
teeth is a sign of a positive treatment outcome
(Flores etal. 2007)
Figure 4.3.5 Composite resin provisional restoration.
Discharge Instructions
• Avoid incising on injured tooth until tenderness resolves
• Instruct parents to watch for clinical signs including
tooth discoloration and presence of parulis or fistula
• Instruct parents and child to report increased pain or
mobility
• Improve diet and oral home care and, identify dental
home
M. Common Complications andAlternative
Treatment Plans
• An excellent seal is required to prevent bacterial
contamination of the pulp tissue by saliva. Fracture
lines extending subgingivally and lack of tissue fluid
control can complicate placement of a secure, sealed
restoration. Pulp necrosis will inevitably occur if the
restoration is not completely sealed. Close follow‐up
is critical because inflammatory resorption can rapidly
destroy the thin root if the pulp becomes necrotic
• In cases of an immature permanent incisor with a
necrotic pulp, a partial pulpotomy is not indicated
because it is a vital technique. In immature teeth,
revascularization can be attempted by first disinfecting
the root canal space with antibiotic paste and then
stimulating bleeding to form a scaffold for the
ingrowth of healthy connective tissue. If successful,
this technique enables the root to mature
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physiologically (apexogenesis). Another option is to
induce apexification, which is the placement of a
mechanical barrier at the root apex against which root
canal filling materials are placed. The use of mineral
FUNDAMENTAL POINT 3
Partial Pulpotomy
• Only a superficial layer of inflamed pulp tissue is
removed, leaving healthy pulp tissue in the coronal
chamber and root canal space
• Copious irrigation and a sharp, sterile bur are used
to minimize injury to the remaining pulp
trioxide aggregate (MTA) enables the clinician to
perform this apexification procedure in one step (see
Chapter 3: Complex Pulp Therapy for more
information on managing complicated crown fractures)
• The access preparation is deep enough (1.5–2 mm)
to contain the wound dressing (CaOH or MTA) and
glass ionomer seal
(Cvek 1978; Flores et al. 2007)
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Self‐Study Questions
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OrOfacial Trauma
1. How quickly must a partial pulpotomy be performed to assure optimal healing?
2. What complications compromise the success of a
partial pulpotomy?
3. Can a tooth treated by a partial pulpotomy be
completely restored immediately?
4. What are the options for treatment of an immature
permanent incisor with a totally necrotic pulp?
Answers are located at the end of the case
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Self‐Study Answers
1. Optimal healing occurs if the partial pulpotomy
is performed soon after the injury. However,
positive outcomes have been reported when this
treatment was delayed days to weeks after the
injury. Best practice is to complete the procedure
as soon as adequate assistance and facilities are
available. This may mean deferring treatment until
the following day
2. To succeed, a partial pulpotomy must be performed as aseptically as possible. Primary causes of
failure include inadequate isolation and lack of an
absolute seal by the temporary restoration
3. It may be possible to complete the final
restoration on a tooth treated with a partial
pulpotomy; however, since luxation injuries
Bibliography
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12. http://
dx.doi.org/10.1542/peds.2011‐1752
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
frequently accompany such severe crown fractures,
deferring the final restoration until the periodontal
ligament has healed is recommended
4. A partial pulpotomy is a vital technique and is
not indicated when the pulp is totally necrotic. In
immature teeth, revascularization can be attempted
by first disinfecting the root canal space with antibiotic paste and then stimulating bleeding to form
a scaffold for the ingrowth of healthy connective
tissue. If successful, this technique enables the root
to mature physiologically (apexogenesis). Another
option is to induce apexification, which is the
placement of a mechanical barrier at the root apex
against which root canal filling materials are placed.
The use of MTA enables the clinician to perform this
apexification procedure in one step
Cvek M. 1978. A clinical report on partial pulpotomy and
capping with calcium hydroxide in permanent incisors with
complicated crown fractures. J Endod 4:232–7.
Flores MT, Andersson L, Andreasen JO etal. 2007. Guidelines
for the management of traumatic dental injuries. I. Fractures
and luxations of permanent teeth. Dent Traumatol 23:66–71.
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