Repair of untreated horizontal root fracture: a case report

Abstract  – We report a clinical case of horizontal root fracture in the mandibular first premolar induced by a traffic accident. The fractured tooth spontaneously healed and diagnosed radiographically after 2 years. Fractured fragments were separated by a narrow radiolucent line and the edges were rounded, and healing of the tooth is likely to be related to interproximal connective tissue healing. Our case is an example of spontaneously healed fracture roots. An interesting finding is that the healing was observed even in the presence of two root canals, the vitality of the pulp was preserved and displacement of fragments were prevented.     

Reattachment using a fragment from an extracted tooth to treat complicated coronal fracture

Abstract –  Reattachment of fragment is the preferred alternative to restore the fractured teeth, offering several advantages. Partial pulpotomy has demonstrated satisfactory results as a conservative treatment for pulp exposures because of trauma. This study reports a case in which the treatment of a complicated coronal fracture was accomplished by partial pulpotomy and reattachment of a dental fragment obtained from an extracted tooth using composite resin. The results show the feasibility of the conservative pulp therapy and the restorative approach.     

年轻恒前牙冠折活髓切断术的临床及组织学研究

目的通过临床和组织病理学研究探讨年轻恒前牙活髓切断术的愈后。方法临床上观察11例露髓冠折的上颌年轻恒中切牙活髓切断术后的牙根形成情况，牙根形成后，行根管治疗术，并对取出的根髓进行常规组织学研究，观察其病理变化。结果所有病例牙根均正常形成，根髓的组织学表现为与正常牙髓相比，出现根髓的退行性变，即成纤维细胞减少，胶原纤维增多，且有的牙髓出现玻璃样变性、钙变和细胞间质的颗粒样变性。结论活髓切断术是年轻恒前牙露髓冠折的首选治疗方法，但在牙根形成后，根髓会出现退行性变，因此，需及时改做根管治疗，为进一步的永久修复做准备。     

Longitudinal study on types of injury, complications and treatment in permanent traumatized teeth with single and multiple dental trauma episodes

Abstract –  The purpose of this study was to compare the type of injuries, complications and treatment in permanent traumatized teeth with single and multiple dental trauma episodes (MDTE). One hundred and fifty-five children, aged 6–14 years, sustaining one or more traumatic episodes to permanent teeth were included in this investigation. After the medical and dental history the patients were examined clinically and radiographically and the diagnosis of trauma, the treatment plan and the applied treatment were recorded. Also, information regarding the number of traumatic episodes, the number of injured permanent teeth and the vitality of the pulp was collected. In follow-ups, traumatized teeth were examined clinically and radiographically to evaluate the treatment applied and to detect any complication. The t -statistic was used to test differences in the mean number of teeth per patient with different types of injury, complications and treatment between permanent traumatized teeth with single and multiple trauma episodes. A 95% probability level was used. The results showed that MDTE significantly affected the mean number of teeth per patient with fractured restoration, root fracture, concussion, pulp canal obliteration, root replacement resorption, filling therapy, surgery and prosthetic treatment. It was concluded that MDTE increase the risk of having certain types of injury, complications and treatment.     

Calcium hydroxide induced apexification with apical root development: a clinical case report

Aim  To report the induction of apical root development by calcium hydroxide in teeth with pulp necrosis and periapical radiolucency.
Summary  A 10-year-old male patient was admitted to the clinic complaining of an intense pain and oedema on the anterior facial region, compatible with an acute dentoalveolar abscess. There was a previous history of dental trauma; only tooth 11 was negative to pulp sensitivity tests. Radiographically, tooth 11 exhibited incomplete root formation, characterized by a wide root canal, thin and fragile dentinal walls, and an extensive, divergent foraminal opening associated with an apical radiolucency. The first appointment focused on urgent local and systemic treatment. Apexification treatment commenced at the second session after 7 days, by means of chemo-mechanical debridement throughout the entire root canal, using K-files and irrigation with a 2.5% sodium hypochlorite solution. Subsequently, a calcium hydroxide paste was applied and changed four times over 8 months, when radiographic examination revealed complete closure of the foraminal opening, resulting in resolution of the periapical radiolucency and associated with 5 mm of additional root development. The root canal was filled by thermomechanical compaction of gutta-percha and sealer. A 3-year follow-up revealed normal periapical tissues and the absence of symptoms.
Key learning points • In young patients, dental trauma may cause pulp necrosis and arrest of root formation.
• Under certain circumstances, chemo-mechanical debridement, including the use of a calcium hydroxide paste, is a valid alternative to mineral trioxide aggregate and or surgery for root-end closure.
• In teeth with incompletely formed roots associated with periapical lesions, calcium hydroxide can induce periapical repair through the closure of the foramen and apical root development.     

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.     

恒前牙断冠粘接的临床及实验研究

目的探讨修复年轻恒前牙冠折的简便过渡性方法。方法临床上共对59颗冠折患牙的牙冠进行粘接，按粘接模式分为3组。其中A组（内部倒凹＋唇侧洞斜面）14颗，B组（内部倒凹＋舌侧排溢道）14颗，C组（内部倒凹＋舌侧排溢道＋唇侧洞斜面）31颗。选择21颗上颌中切牙的离体牙，按临床研究中的3种粘接模式分为3组，每组7颗，进行悬臂梁模型实验，探讨能够承受最大力值的粘接模式。结果临床研究显示，59颗断冠粘接的冠折牙齿有3颗脱落，其中2颗为B粘接模式，1颗为A粘接模式，均为二次外伤所致；其余56颗牙齿观察时间平均为28．3个月，断冠粘接后的牙齿均完好。实验研究显示，A、C粘接模式所能承受的力值明显大于B粘接模式（F=5．161,P=0．017），是目前临床上采取的主要方法。结论“内部倒凹＋舌侧排溢道＋唇侧洞斜面”以及“内部倒凹＋唇侧洞斜面”的粘接模式，为前牙外伤断冠粘接的最佳方式，它能较好地恢复冠折牙的外观、形态及功能，是一种适合于临床恒前牙冠折的、简便的过渡性修复方法。     

An unusual healing of a replanted permanent lateral incisor

Background:  Continued development and healing of an immature permanent tooth root was reported to have occurred. The continued viability of Hertwig's root sheath was thought to be necessary and responsible. Continued development of a tooth root separate from the body of the tooth was reported, but the initiation and development associated with a replanted tooth was not observed.
Methods:  A 9-year-old boy sustained an avulsion injury to his upper right lateral incisor. The tooth was replanted within 5–10 minutes of the incident and was splinted approximately 30 minutes after the injury, and then monitored for 2.25 years.
Results:  The periodontal tissues healed well. Root development was arrested with calcific deposit evident in the pulp canal. A radio-opaque structure, apical to the tooth root, was seen to develop on the radiograph 11 weeks after the initial trauma. The opaque mass continued to develop over the next two years of observation.
Conclusions:  Immature permanent tooth roots show remarkable reparative powers. Clinicians need to be vigilant and close continued monitoring of traumatized immature teeth is recommended.     

Variables affecting endodontic recall

Aim  To determine the recall rate in an endodontic practice and to evaluate specified variables as to their effect on the rate of patients returning for recall.
Methodology  The records of 7105 patients treated by one endodontist between 1975 and 1998 were reviewed. Recorded variables included chart number, patient gender and age, treated tooth number, pulp status, presence of spontaneous pain at initial visit, history of trauma to treated tooth, previous root canal treatment in the treated tooth, and presence of endodontic recall.
Results  The recall rate was 49% for the 5641 patients who completed endodontic treatment. Odds ratio analysis showed that females returned for recall at a rate that was significantly higher than males (52% vs. 44%). Odds ratio and chi square analysis revealed that a diagnosis of pulp necrosis or previous root filling resulted in a higher than expected recall rate while a diagnosis of irreversible pulpitis resulted in a lower than expected recall rate ( p  < 0.001). Patients aged 6–40 years of age returned at a lower rate than expected and those aged 41–80 returned at a higher rate than expected ( p  < 0.001). There was no significant difference in recall rate for patients reporting spontaneous pain or history of trauma with the treated tooth. The type of treated tooth had no effect on patient recall rate.
Conclusions  Forty-nine per cent of patients returned for recall after a minimum of 6 months with patient age, patient gender and pulp status affecting the rate of recall significantly.     

Reattachment of a fractured permanent molar cusp: a 12-month follow-up

Abstract –  A posterior crown fracture due to acute trauma is an uncommon type of dental injury. This case report presents combined endodontic-bioadhesive treatment of a complicated crown fracture of a permanent molar due to a horse riding accident. Endodontic therapy was initiated following surgical removal of the fractured mesiolingual cusp, which was stored frozen until bonding procedures could be carried out. Subgingival and proximal contours of the missing cusp were maintained by an interim glass–ionomer restoration during endodontic therapy. Following root-canal obturation, the fractured cusp was reattached using a total-etch adhesive and composite resin system. The patient was recalled at 1, 3, 6 and 12 months, demonstrating excellent clinical and radiographic findings.     

Exposed human pulp caused by trauma and/or caries in primary dentition: a histological evaluation

Abstract –  The aim of this study was to compare the pulpal reactions after exposure due to trauma and/or caries and to suggest the appropriate treatment options for the management of pulp, in the light of the histological findings in the primary teeth. Fifteen primary maxillary incisors with pulpal exposure were examined with light microscope in a blind study. After the histological evaluation, teeth were divided into three groups for the etiological factors due to the exposure according to the patient's files: trauma group, caries group and caries and trauma group. The inflammatory infiltration was diminished from the pulp chamber towards the apical third of the root canal in all of the examined teeth. Teeth in the trauma group presented fewer inflammatory cells in the root canal in comparison with other groups. It was concluded that the teeth with traumatic pulp exposure were considered as more likely to respond positively to pulpotomy technique. Pulpectomy or extraction seemed to be indicated for the decayed or decayed and traumatically injured teeth.     

Bonding of fractured permanent central incisor crown following radiographic localization of the tooth fragment in the lower lip: a case report

Abstract – This study describes the case of an 8‐year‐old boy who fractured his left maxillary central incisor, exposing the pulp. The trauma also resulted in a cut on his mentum. Radiographic examination revealed the fractured tooth fragment embedded in the lower lip. The fractured tooth, with incomplete root formation, was treated endodontically and received a temporary restoration. After 15 days, the temporary restoration was removed and the fractured tooth fragment was etched with 37% phosphoric acid. A bonding system was then applied to the etched‐fractured tooth surface without polymerization. The same bonding procedure was carried out on the tooth fragment. A layer of flowable resin composite was applied to the fragment, which was positioned on the remaining tooth. The resin composite was then polymerized, finished, and polished.     

Mesiodens as a risk factor in treatment of trauma cases

Abstract –  The presence of mesiodens often results in complications including retention of primary teeth and delayed eruption of permanent teeth, closure of eruption path, rotations, retention, root resorption, pulp necrosis, and diastema as well as nasal eruption and formation of dentigerous and primordial cysts. Less common complications involving the permanent incisors include dilaceration of the developing roots and loss of tooth vitality. Therefore, early diagnosis of mesiodens has particular importance in terms of preventing such complications. However, with respect to surgical removal of mesiodens, ideal timing of intervention – immediate or delayed intervention – remains to be a highly controversial issue. While predisposing factors of dental trauma such as open bite, increasing overjet with protrusion of upper incisors, and insufficient lip closure have been well documented in the literature, there is limited evidence indicating mesiodens as a risk factor in trauma. In this report of two cases, it is aimed to emphasize mesiodens as a risk factor in the treatment of dental trauma besides its effect on prognosis.     

Influence of the type of dental trauma on the pulp vitality and the time elapsed until treatment: a study in patients aged 0–3 years

Abstract  – The purpose of the present study was to determine the influence of the type of trauma on the pulp vitality and the time elapsed until seeking dental care in children aged 0–3 years seen at the Baby Clinic of the Araçatuba Dental School, UNESP. A total of 1813 records were analyzed. Two hundred and three patients, corresponding to 302 traumatized teeth, were assessed clinically and radiographically. Hard-tissue injuries were the most frequent (52%), with a predominance of enamel crown fractures (41.4%), followed by concussions (12.6%) and intrusions (11.6%). Clinical and radiographic examination revealed that 72% of the traumatized teeth maintained pulp vitality. In the case of supporting-tissue lesions, 51.1% of the patients sought care within 1–15 days after injury, while in the case of hard-tissue injuries, 52.7% sought care only after 16 days. The results showed that supporting-tissue injuries had a significant influence on the faster seeking of dental care.     

Traumatic crown fractures in permanent incisors with immature roots: a follow-up study

Abstract – A follow-up study of crown fractured permanent incisors with incomplete root formation was carried out in a group of patients, aged 6–12 years, over a 5-year-period in the Dental Clinic of the University of Verona, Italy. The number of injured patients was 55, representing 84 injured incisors. All patients were followed clinically and radiographically using a standardized follow-up protocol. The most common type of trauma was fracture of enamel and dentine without pulpal exposure (80%) and the most common type of treatment was restoration with the acid-etch composite resin technique (46%). Bonding of the crown fragment was performed in 10 instances (12%). At the 5-year-control all teeth with fracture of the enamel had no pulp complications. Four of 67 teeth (6%) with fracture of the enamel and dentine without pulpal involvement showed pulp necrosis and 1 tooth showed pulp obliteration (1.5%). Eight of 14 teeth (57%) with fractures of the enamel and dentine with pulp involvement showed pulp necrosis. Aesthetically 36 of the restored teeth were deemed satisfactory (43%). In 9 teeth the bonded fragment had to be rebonded. 14 teeth were considered unsatisfactorily restored due to wear of the composite (17%). 34 restored teeth had to be retreated because of a new trauma (40%). In one tooth a previous bonded fragment had to be rebonded. These results confirmed that crown fractures without pulp involvement in permanent incisors with incomplete root formation have a low percentage of pulp complications, while 60% of the teeth with crown fractures with pulp involvement had pulp complications.     

Root healing after horizontal fracture: a case report with a 13-year follow up

Abstract –  Although horizontal root fractures connote a serious trauma to the tooth, they present a favorable prognosis, as the vitality of the pulp remains. Small displacements of the fragments minimize the failure of the healing process; however, even when they occur, the reduction of the diastasis between root fragments is always necessary. A majority of cases are asymptomatic and heal spontaneously even though no therapeutic measures have been adopted. A case of root fracture that was discovered only 1 year after the trauma is presented. Thirteen years later, the tooth is well positioned in the maxillary arch and has kept its pulp vitality despite the obliteration of the root conduct. Expectant management was adopted at the moment of the first examination, and the follow-up of the patient showed it to have been the best choice.     

Dental emergencies presenting to a dental teaching hospital due to complications from traumatic dental injuries

Abstract  – In Jordan, only two surveys of dental trauma have been carried out. The aim of this study was to determine the incidence and pattern of dental emergencies resulting from traumatic injuries, as well as treatment provided to children presenting with these dental emergencies. Over a 1-year period, 620 children presented to our pediatric dental clinics with dental emergencies; 195 (31%) of these emergencies were a consequence of dental trauma to 287 teeth and were included in the study. The average time between the trauma and the dental emergency was 5 months. Pain or sensitivity was the most frequent presenting symptom (31.3%) followed by swelling or sinus tract (17.4%). The age of these patients ranged from 15 months to 14 years, with an average age of 9.3 years. Males accounted for 75.4% of the children in the samples, whereas females accounted for only 24.6%. The main cause of dental trauma was falling during play (58.5%); the least common cause was motor vehicle accidents, accounting for only 1.5% of all injuries. Most of the dental injuries occurred at home (41.5%), around noon time. The most commonly involved teeth were permanent maxillary central incisors accounting for 79.5% of all teeth involved by dental trauma. The most frequently encountered type of trauma in this sample was crown fracture seen in 76.6% of the teeth . Soft tissue injuries were estimated to occur in 16.9% of the children. The treatment received by the children in the sample ranged from no active treatment (6.2%) to elaborate dental procedures such as pulp therapy (41.3%) and prosthetic replacement of missing teeth (5.1%).     

Long-term effects of local pretreatment with alendronate on healing of replanted rat teeth

Background and Objective:  Our previous study showed that topical alendronate, an inhibitor of bone resorption, reduces root resorption and ankylosis for 21 d after replantation of rat teeth. The aim of the present study was to evaluate the long-term inhibitory effects of topical alendronate in the replanted teeth.
Material and Methods:  The rat maxillary first molars were extracted, placed in saline containing 1 m m alendronate (alendronate group) or saline (saline group) for 5 min and then replanted. The maxillae were dissected at 60 and 120 d. Microcomputed tomography horizontal sections at three root levels were analyzed for root and bone resorption, ankylosis and pulp mineralization.
Results:  In the alendronate group at 60 and 120 d, the frequencies of resorption of roots and bone were lower than those in the saline group. The p values show statistical significances of lower frequencies in the alendronate group than in the saline group by chi-square test (see Table 1 ). Ankylosis and pulp mineralization occurred in the alendronate and saline groups. Bone marrow spaces were narrowed in conjunction with bone tissue expansion around the replanted teeth in the alendronate group.  

  Table 1.  Percentage of sites with ankylosis, root resorption, bone resorption and pulp mineralization for the alendronate and saline groups at 60 and 120 d after tooth replantation     

19.

The fate of a mid-root fracture: a case report     

Esti Davidovich  Ilana Heling  Anna B Fuks 《Dental traumatology》2005,21(3):170-173

Abstract –  The present report describes a case of a mid-root fracture in a maxillary central incisor of a 19-year-old patient. The fractured tooth was splinted with composite that was removed only 3 years later, as the patient did not appear for follow-up examinations. At this time, the radiographs revealed a normal periodontal ligament, rounding of the borders of the fragments and pulp obliteration of both fragments. Eight years later, the tooth was clinically normal and blurred calcification of the root canal was disclosed radiographically. After 13.5 years the patient complained of tooth mobility and radiographic examination revealed an advanced cervical root resorption. As no conservative approach was possible at this stage, the patient was referred to a prosthodontist for esthetic rehabilitation.     

20.

Abstracts from other journals     

Editor  : Bernadette Drummond 《International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children》2002,12(2):148-150

The purpose of this study was to assess the awareness of pre-school teachers concerning the management of traumatized teeth. A questionnaire survey of teachers' backgrounds, attitudes/practices and knowledge was distributed to all teachers who attended a dental education program organized by the Singapore Dental Health Foundation. Of a total of 291 teachers surveyed, 29% had received tertiary education, while the rest (71%) had received secondary education. The mean teaching experience was 6·8 ± 6·9 years. About a quarter had previous experience in handling dental trauma. Sixty-three percent admitted having no knowledge of dental trauma; 79% were unsatisfied with their level of knowledge in this area; 95% were keen to have further education in dental trauma, 65% thought a dental trauma emergency should be dealt with as soon as possible. Concerning knowledge, during-office hour emergency services were more familiar (84%) than after-office hour emergency services (15%), as was the concept of management of avulsed teeth (71%) compared to that of fractured teeth (51%). Knowledge about optimal storage media for avulsed permanent teeth was especially poor – being as low as 15%. Using multiple logistic regression analysis, it was found that teaching experience significantly influenced the respondents' self-assessed knowledge and their level of satisfaction with their knowledge ( P  = 0·012). Teachers with more teaching experience had better knowledge about the replantation of permanent teeth ( P  = 0·003). It is recommended that public education targeted at teachers should be carried out to increase dental trauma management awareness.     

The fate of a mid-root fracture: a case report

Abstract –  The present report describes a case of a mid-root fracture in a maxillary central incisor of a 19-year-old patient. The fractured tooth was splinted with composite that was removed only 3 years later, as the patient did not appear for follow-up examinations. At this time, the radiographs revealed a normal periodontal ligament, rounding of the borders of the fragments and pulp obliteration of both fragments. Eight years later, the tooth was clinically normal and blurred calcification of the root canal was disclosed radiographically. After 13.5 years the patient complained of tooth mobility and radiographic examination revealed an advanced cervical root resorption. As no conservative approach was possible at this stage, the patient was referred to a prosthodontist for esthetic rehabilitation.     

Abstracts from other journals

The purpose of this study was to assess the awareness of pre-school teachers concerning the management of traumatized teeth. A questionnaire survey of teachers' backgrounds, attitudes/practices and knowledge was distributed to all teachers who attended a dental education program organized by the Singapore Dental Health Foundation. Of a total of 291 teachers surveyed, 29% had received tertiary education, while the rest (71%) had received secondary education. The mean teaching experience was 6·8 ± 6·9 years. About a quarter had previous experience in handling dental trauma. Sixty-three percent admitted having no knowledge of dental trauma; 79% were unsatisfied with their level of knowledge in this area; 95% were keen to have further education in dental trauma, 65% thought a dental trauma emergency should be dealt with as soon as possible. Concerning knowledge, during-office hour emergency services were more familiar (84%) than after-office hour emergency services (15%), as was the concept of management of avulsed teeth (71%) compared to that of fractured teeth (51%). Knowledge about optimal storage media for avulsed permanent teeth was especially poor – being as low as 15%. Using multiple logistic regression analysis, it was found that teaching experience significantly influenced the respondents' self-assessed knowledge and their level of satisfaction with their knowledge ( P  = 0·012). Teachers with more teaching experience had better knowledge about the replantation of permanent teeth ( P  = 0·003). It is recommended that public education targeted at teachers should be carried out to increase dental trauma management awareness.