Prognosis of root-fractured permanent incisors — prediction of healing modalities

Abstract A population of 85 patients, comprising 95 root-fractured permanent incisors followed up to 11 years, was studied prospectively for the type of fracture healing that occurred (i.e. union of the fragments by interposition of hard tissue (HT) or connective tissue (CT), or nonunion characterized by interposition of granulation tissue between the fragments (GT)). Initial treatment was provided according to established treatment guidelines by the attending oral surgeon at the emergency room. Follow-up examination and treatment were provided by 2 of the authors. It appeared that GT could be diagnosed after approximately 3 weeks, while HT or CT could be diagnosed approximately 6 weeks after trauma. Many factors considered one at a time were found to have a significant or nearly significant effect on the type of fracture healing that occurred. However, a multivariate regression analysis revealed that the following factors were significantly related to fracture healing by HT: a large diameter of the apical foramen and severity of luxation of the coronal fragment (concussion/subluxation > lateral luxation > extrusion); fracture healing by CT: the presence of restorations in the injured teeth at the time of injury and the presence of marginal periodontal disease; and fracture nonhealing by GT: type of fixation (i.e. orthodontic band fixation versus acid etch or no fixation), antibiotic therapy, a constricted apical foramen, increased loosening of the coronal fragment, and stage of root development (GT never occurred in teeth with open apices). It was previously demonstrated following luxation injuries that type of luxation, stage of root development and type of fixation (orthodontic bands versus acid etch or no fixation) determined the prognosis of pulp survival. It therefore appears that the general factors that are able to predict the type of healing seen after root fracture are the same as those after luxation injuries, supporting the hypothesis that root fractures are another form of luxation injury, this time of only the coronal fragment.     

Treatment of traumatized permanent incisors with crown and root fractures: a case report

Abstract – A case report of the treatment of permanent incisors with crown and root fractures is presented. A radiolucent lesion at the fracture lines was treated with calcium hydroxide in the coronal fragments for 18 months. Clinically, the teeth became firm and the radiographic results after 2 years showed healing of the lesion and hard tissue filling in the space at the fracture lines.     

Traumatic injuries to permanent incisors

Abstract The prevalence of traumatic injuries to permanent incisors and their distribution according to type and some clinical factors, were analysed in a total population of 2798 patients, aged 6–21 years, examined over a 5-year period in the Dental Clinic of the University of Verona, Italy. The material consisted of case histories and radiograms taken during the examination of injured teeth. The number of injured patients was 178 (131 males and 47 females), the number of injured incisors was 326. The prevalence of injuries was 7.3%. A very large number of dental injuries occured to children aged between 6 and 13 years. The ratio of boys to girls was 2.7:1. Most frequent causes of injuries were falls and traffic accidents. Most injuries involved two teeth. About 80% of the teeth were maxillary central incisors. The most common type of injury was non complicated crown fracture. In 87 cases (48%) there was an associated injury to soft tissue. Alveolar fractures occurred in 22 cases (12%). Traumas involving periodontal ligament constituted nearly 40% of the total. This study noted the following points: 1) preventive education programs should be instituted in the region, directed at parents and school teachers, to inform them about the problems of dental trauma and to obtain cooperative attitude to treatment and good motivation in controls; 2) the necessity to unify the diagnostic and therapeutic protocol to provide reliable information in clinical investigations, to permit valid comparison with other studies and to improve the long-term prognosis of many cases.     

Long-term follow-up of conservative treatment of severely traumatized maxillary incisors

Abstract We present the case of a 26-year-old man who at the age of 9 suffered severe trauma to both maxillary central incisors. The underlying malocclusion was skeletal and classified as dental Class II/1 with severe crowding. Both the maxillary central incisors and the two lower first premolars were extracted and the patient was treated with an edgewise appliance for 2 years. Acceptable occlusal relationships were achieved following orthodontic and adjunctive treatment which consisted of reshaping the maxillary lateral incisors with composite materials and grinding the canines to resemble lateral incisors. A critical evaluation of the esthetic and functional results at the age of 26 years is presented.     

An investigation of root-fractured permanent incisor teeth in children

Abstract  – The aim of this retrospective study was to determine the type of healing which occurred in root-fractured permanent incisor teeth in children. The objectives were to determine whether gender, age, stage of root development or location of the fracture affected the healing type. The method involved careful scrutiny of clinical records and radiographs of children who attended a unit of paediatric dentistry in a dental hospital. Relevant information was entered onto a data collection sheet. The results were tabulated and analysed by the χ ²-tests using the SPSS statistical package. The results are based on 34 root-fractured teeth in 33 children aged 8–15 years. Root development was incomplete in 27 of the root-fractured teeth and complete in seven teeth. A good healing outcome was seen in 27 (79.4%) of the teeth and poor healing in 7 (20.6%). The only factor which was found to be statistically significantly related to healing was the stage of root development. It can be concluded that root-fractured teeth with immature roots have a better chance of showing good healing than teeth with mature roots.     

Repair of untreated horizontal root fractures: two case reports

Abstract – Intra-alveolar root fractures of incisor teeth are more frequent than other dental injuries. These case reports describe two untreated horizontal root fractures of the maxillary right central incisors. Patients reported accidental trauma, which occurred several years ago. These fractures were discovered during a routine full-mouth radiographic survey. Teeth were asymptomatic and tested vital to electric pulp tests     

Impact resistance of crowned endodontically treated central incisors with internal composite cores

Abstract The impact fracture resistance of crowned endodontically treated teeth with composite cores but without posts, that had either no coronal dentin remaining or a 1mm dentin collar was compared to that of unrestored, caries free teeth. The teeth were struck mid-labially to simulate a common trauma situation using a pendulum device and fracture1 resistance determined by calculation of absorbed energies. No significant difference was found between the intact teeth and the-crowned root treated teeth with composite core and a 1mm dentin collar. Crowned loot treated teeth with a composite core but no coronal dentin had significantly reduced fracture resistance (p < 0.05). Teeth with the dentin collar mainly fractured obliquely from the bueeal crown margin to a point coincident with the simulated alveolus, representing a clinical situation which would allow retention rather than extraction of the tooth.     

Repair characteristics of horizontal root fracture: a case report

Abstract  – Radicular fractures in permanent teeth are uncommon injuries among dental traumas, comprising 0.5–7% of the cases. Fracture occurs most often in the middle-third of the root and rarely at the apical-third. The present paper reports a clinical case of a horizontal radicular fracture located between the middle- and apical-third of a upper left-central incisor followed-up for over 3 years. The tooth was extracted owing to periodontal reasons. Histomorphologically, it showed pulp-vitality preservation and root healing by hard-tissue deposition.     

Different clinical outcomes following root fractures of adjacent incisors: a case report

AIM: To report different patterns of root fracture healing in adjacent maxillary central incisors with distinct post-treatment outcomes. SUMMARY: To describe the case of a 12-year-old girl who presented with an avulsed coronal fragment of tooth 11 and root fractures in the middle thirds of teeth 11 and 21. Four months after initial treatment, she was referred for specialized endodontic care. Tooth 11 presented no clinical or radiographic signs of pulp breakdown. However a sinus tract was found related to the middle root third of tooth 21, indicating pulp necrosis in the coronal fragment. The coronal fragment was root filled and periapical surgery was performed to remove the apical fragment. Twelve months after the clinical procedures and 16 months after trauma, hard tissue healing was evident in tooth 11 region. Bone healing was also satisfactory in the periapical region of tooth 21. *Even adjacent teeth may display different reaction patterns after trauma. *The prognosis of root fractures is variable and different clinical approach may be required to preserve teeth with fractured roots.     

Investigation of lay knowledge of the management of avulsed permanent incisors

Abstract The prognosis of replanted avulsed permanent incisors depends largely on prompt and appropriate emergency management. The aim of this study was to investigate lay knowledge and attitudes in this respect. Postal questionnaires were sent to all physical education teachers, school nurses and secretaries, attendants in swimming baths and leisure centres and to 220 parents of teenage children in a defined area of North West England. The overall questionnaire response rate was 86.9%. Knowledge of methods of dealing with this problem was generally inadequate in both parents and the other groups. Although 53.6% of respondents claimed to have received first aid training only 3.1% could remember dental injuries being included. There was evidence that dental health education in this field can be effective, since the highest mean knowledge score was found in the 1 1.5% of respondents who recalled receiving advice from sources such as posters, magazines and newspapers. More than 80% of the respondents stated that they would not want to replant an avulsed incisor themselves, the main reason being lack of knowledge and training. It is suggested that there is a need for potentially effective dental health education in relation to this problem.     

Survival of avulsed permanent maxillary incisors in children following delayed replantation

Abstract The purpose of this study was to identify the variables that significantly influenced the survival of incisors replanted after extended extraalveolar duration at The Hospital for Sick Children, Toronto, Canada, between June 1988 and December 1993. Survival analysis was used to identify variables that significantly influence the retention of replanted incisor teeth. Survival was defined as the time that elapsed between the replantation of an avulsed incisor and the time it was finally lost. Information on 9 variables was collected for 3H patients (25 males; 13 females) and 52 replanted permanent maxillary incisors. The mean extraalveolar duration for the sample was 123 min. The mean follow-up interval was 942 days (range: 364–2126 days). Incisors replanted with open apices had a significantly decreased survival compared with teeth with mature apices (P=0.04; relative risk 4.2). There was also a significant association between increased survival and obturation of the root canal with gutta-percha and sealer P=0.006 relative risk 10.0). A trend towards improved survival of replanted incisors was found for children older than I 1 years old at the time of replantation (P= 0.09; relative risk 2.8). These results are consistent with previous studies and may assist clinicians and parents in the decision-making process associated with the management of avulsed teeth in children.     

Survival of intentionally retained permanent incisor roots following crown root fractures in children

Retaining tooth roots, following crown loss, confers a number of benefits including the preservation of alveolar bone. Intentional root retention in adults has been widely investigated but little is known about this treatment approach in children. Therefore, the aim of the present study was to investigate the clinical outcomes associated with permanent anterior root retention in a young population. The study group comprised 53 children who had received treatment in the paediatric dentistry clinic, Charles Clifford Dental Hospital, Sheffield, UK, over the past 10 years, following a complicated crown root fracture of a permanent maxillary incisor at or below the gingival margin. Data relating to patient age at crown root fracture, gender, previous trauma history, tooth vitality, treatments performed and clinical outcomes were obtained retrospectively using patient records. The mean age of the subjects at initial crown root fracture was 12.1 years (range 8.3–15.8 years) and there were more than twice as many males (n = 37, 70%) as females (n = 16, 30%). In just over half of the cases seen (n = 29, 54%), the tooth involved was already nonvital at the time of crown root fracture. For the majority of these nonvital teeth (n = 27, 93%), primary treatment had comprised placement/replacement of a calcium hydroxide root dressing. The remaining two teeth did not require root treatment as a satisfactory gutta percha root filling was already present. A variety of treatments was undertaken for the 24 vital roots: in 15 (63%) cases the pulp was extirpated and calcium hydroxide placed; three (12%) cases were subject to a pulpotomy; five (21%) cases were left untreated with the hope that vitality would be maintained following gingival healing and in one case the radicular pulp was extirpated and immediately obturated with gutta percha. The mean time that the roots were kept under review was 2.6 years (± 1.57, range 0.6–6.8). During this period, only five roots (9%) had to be removed due to persistent periapical infection. There were no complications associated with the five cases where vital root submergence had been permitted but all three cases which had initially undergone a pulpotomy subsequently presented with pulpal necrosis necessitating pulpal extirpation and calcium hydroxide therapy. These findings indicate that efforts to retain permanent anterior roots in a young population are justified in view of the high clinical success rate of over 90% over a 2‐year period.     

Resorption and mineralization processes following root fracture of permanent incisors

Abstract The records of 85 patients treated for 95 root fractures of permanent incisors and followed regularly for up to 11 years were studied with respect to healing events after injury. The radiographic exposure best suited for disclosing root fractures in the apical third of the root was a steep occlusal exposure, while a conventional bisecting angle periapical exposure was optimal for revealing fractures in the cervical third. It is concluded that both exposures should, therefore, be used at the initial examination at the time of injury. Root resorption processes were observed in 60% of the material and could usually be detected within one year after injury. These preceded fracture healing and obliteration of the apical and/or coronal root canals. The changes observed represented one or more of four resorption entities: 1) external surface resorption, characterized by the rounding of the fracture edges mesially and/or distally; 2) internal surface resorption, manifested as rounding of the fracture edges centrally, in the apical and coronal root canals, at the intersection between the pulp canal and fracture line; 3) internal tunneling resorption, going behind the predentin layer and burrowing along the root canal walls of the coronal fragment; and 4) transient apical breakdown of the apical lamina dura. While the resorption processes were self-limiting and required no treatment, the pattern of resorption and pulp canal obliteration appeared to be decisive for the type of fracture healing. Thus, all resorption entities collectively and internal tunneling resorption particularly were significantly related to healing at the fracture site by interposition of connective tissue. However, when seen alone, internal surface resorption was significantly related to fracture healing by hard tissue union. The different root resorption entities may represent osteoclastic activity connected with the ingrowth of new vascularized connective tissue into the fracture site or the coronal part of the root canal.     

Laser Doppler flow investigation of fractured permanent maxillary incisors

Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood-flow (PBF). Dental injury has been associated with losses of pulpal sensibility. The purpose of this study was to assess the outcome of splint therapy on tooth fracture type-related PBF values. In 15 trauma patients, a single maxillary incisor treated by repositioning and splinting was investigated by LDF to assess local PBF values. Perfusion units were taken in four sessions, on the day of splint removel, and 12, 24 and 36 weeks after splint removal. Analysis of the tooth fracture type-related PBF measurements revealed root fractures to be associated with a significant decrease (P < 0.05) and uncomplicated crown fractures to be associated with a significant increase in PBF values (P < 0.05), while complicated crown fractures showed no significant difference between the session-related values (P > 0.05). The main findings of this study suggest splint therapy of root fractures of the central maxillary incisor to be associated with a short- and long-term decrease in PBF values. The LDF may become useful in the detection of transient ischaemic episodes and the identification of teeth at risk for adverse sequelae such as avascular necrosis and tissue loss.     

Outcomes for root-fractured permanent incisors: a retrospective study

PURPOSE: The objective of this study was to assess the outcomes for treated root-fractured permanent incisors with respect to pulp vitality, root tissue union, and tooth survival and to examine the effects of clinical and radiographic parameters and rigid splinting on the outcome. METHODS: Eighty-four teeth were identified and data extracted from case notes prior to transfer to an SPSS data base for analysis. The odds ratios for each factor were calculated and the significance of differences was determined. Tooth loss and relevant risk variables were examined using Cox's regression model and Kaplan-Meyer survival curves. RESULTS: Fourteen (17%) had fractures in the apical third, 47 (56%) in the middle third, and 23 (27%) in the coronal (gingival) third. Twenty-four (29%) also had crown fractures involving enamel and dentine. Crown fractures were identified as significant risk factors for pulp vitality. Loss of pulp vitality, horizontal displacement, and extrusive displacement of the coronal fragment were significant risk factors for hard root tissue union. Survival was poorest with gingival third fractures with 14 (61%) of these teeth being lost. Splinting rigidly had no significant effect on pulp vitality and type of root tissue healing. CONCLUSIONS: Loss of pulp vitality was significantly associated with enamel-dentine crown fracture. Hard root tissue union was significantly affected by pulp necrosis and luxation of the coronal fragment. Survival was poorest for root fractures within the gingival third of the root. Splinting with rigid fixation had no significant effect on pulp vitality and type of root tissue union.     

Prognosis of root-fractured permanent incisors--prediction of healing modalities

A population of 85 patients, comprising 95 root-fractured permanent incisors followed up to 11 years, was studied prospectively for the type of fracture healing that occurred (i.e. union of the fragments by interposition of hard tissue (HT) or connective tissue (CT), or nonunion characterized by interposition of granulation tissue between the fragments (GT)). Initial treatment was provided according to established treatment guidelines by the attending oral surgeon at the emergency room. Follow-up examination and treatment were provided by 2 of the authors. It appeared that GT could be diagnosed after approximately 3 weeks, while HT or CT could be diagnosed approximately 6 weeks after trauma. Many factors considered one at a time were found to have a significant or nearly significant effect on the type of fracture healing that occurred. However, a multivariate regression analysis revealed that the following factors were significantly related to fracture healing by HT: a large diameter of the apical foramen and severity of luxation of the coronal fragment (concussion/subluxation greater than lateral luxation greater than extrusion); fracture healing by CT: the presence of restorations in the injured teeth at the time of injury and the presence of marginal periodontal disease; and fracture nonhealing by GT: type of fixation (i.e. orthodontic band fixation versus acid etch or no fixation), antibiotic therapy, a constricted apical foramen, increased loosening of the coronal fragment, and stage of root development (GT never occurred in teeth with open apices). It was previously demonstrated following luxation injuries that type of luxation, stage of root development and type of fixation (orthodontic bands versus acid etch or no fixation) determined the prognosis of pulp survival. It therefore appears that the general factors that are able to predict the type of healing seen after root fracture are the same as those after luxation injuries, supporting the hypothesis that root fractures are another form of luxation injury, this time of only the coronal fragment.     

Fracture resistance of human incisors and premolars: morphological and patho-anatomical factors

Abstract – 305 extracted human front teeth and premolars were investigated for their dynamic resistance to fracture. Morphological factors, such as the anatomical class of tooth and root lengths, and patho-anatomical factors, such as infractions, occlusal and cervical abrasions, composite and amalgam restorations and damage resulting from previous traumatic impacts, were taken into consideration. A comparison of stability after a defined impact stress showed that maxillary canines and premolars had the highest resistance to fracture; this differs significantly from the resistance of maxillary and mandibular incisors. The root length correlates directly with fracture energy and therefore to stability. Composite restorations with an adhesive joint were found to increase the resistance of a tooth to fracture, but amalgam restorations had a weakening effect. Cervical wedge-shaped defects of the tooth cause considerable destabilization, but occlusal abrasion and infractions have only a moderate weakening influence. Previous traumatic stress reduces the resistance to fracture of a tooth by up to 85%. The fracture patterns generated were very similar to clinically observed tooth fractures, indicating the results to be clinically relevant.     

Prevalence of traumatic injuries to the permanent incisors in candidates for orthodontic treatment

Abstract  – The dental records made on presentation of 1367 consecutive patients (731 females and 636 males) for orthodontic treatment at a private orthodontic practice between 1998 and 2002 were examined for data relating to trauma to the permanent incisors. The results showed that 10.3% of these patients had suffered from dental trauma before the onset of orthodontic treatment. The highest prevalence of dental trauma was determined in the 11–15 years age group, corresponding to the dental developmental stage of the late mixed dentition. The most frequently affected teeth were the maxillary central incisors (79.6%), and the most common types of trauma were fracture of enamel–dentin without pulpal involvement (42.7%) and fracture of enamel (33.8%). Compared to patients with normal overjet and adequate lip coverage, the frequency of dental trauma was significantly higher in patients with increased overjet and adequate lip coverage ( P  = 0.028) or with increased overjet and inadequate lip coverage ( P  = 0.003). The results of the present study indicate that a significant percentage of candidates for orthodontic treatment, and especially those with increased overjet and inadequate lip coverage, suffer trauma to their permanent incisors before the onset of orthodontic treatment. It might also be concluded that preventive orthodontic treatment of such patients should be initiated and completed before the age of 11, i.e. in the early to middle mixed dentition.     

Replantation of permanent incisors in children using Emdogain®

Abstract –  The aim of this study was to determine whether application of an enamel matrix protein derivative, Emdogain^® (Biora AB Malmo, Sweden) to the root surface of avulsed permanent incisors would improve postreplantation outcomes in a pediatric population. Between June 1999 and May 2002, 25 avulsed permanent maxillary incisors (22 centrals and three laterals) were treated with Emdogain^® and followed for up to 32 months, mean duration 20.6 months (range: 6.9–32.5 months). Mean patient age at the time of treatment was 12.0 years (range: 7.7–17.6 years) and mean extra-alveolar duration was 185 min (range: 100–300 min). At the end of their follow-up each of the replanted incisors demonstrated radiographic evidence of replacement root resorption and clinical evidence of ankylosis. None of the replanted teeth were affected by inflammatory root resorption and there was no evidence of infection. When compared with the control samples from Barrett and Kenny ( Endod Dent Traumatol 1997;15:269–72.) and Andersson et al. ( Endod Dent Traumatol 1989;5:38–47.) this sample treated with the Emdogain^® protocol demonstrated significantly less root resorption than either of the control samples ( anova , P  < 0.0001). Although the Emdogain^® protocol did not produce periodontal regeneration, it did eliminate inflammatory resorption and infection and led to significantly less root resorption compared with the two historical controls.     

Prognosis of permanent teeth in the line of mandibular fractures

Abstract A total of 45 mandibular fracture patients with 54 teeth in the fracture line were evaluated retrospectively. One tooth in the fracture line was lost in the accident, 6 were extracted later and 47 could be saved (87%). At the follow-up examination 38% of the teeth were diagnosed to have pulp necrosis, which was found more frequently in the older patients and in cases in which the time elapsing between the injury and the follow-up was longer. Pulp necrosis was also more frequent in cases in which the fracture line ran through the apex or dislocation of the fracture parts existed after the injury.