Monday Morning Trauma- opinions welcomed
Good morning everyone,
Having a pediatric dentist working side by side in our office allows me to see and treat cases that can be somewhat challenging. This young man (14 years young) presented this morning having taken an elbow to the mouth during a basketball game. He indicated that the tooth was loose but was not having any pain. As you can see by the attached radiograph, we have a serious root fracture. I am also attaching a photo of his current occlusion, which also is mess at this time. . Today, we splinted the teeth together so the patient would not lose the coronal portion of his tooth, as we work on his treatment options. Our ultimate goal is to preserve his ridge as best as possible for future implant placement. Our initial thought is to endo the remaining apical root to keep this asymptomatic and preserve the ridge until he is old enough for implant placement. We feel there is not enough apical root left to extrude and support a crown restoration. If we extract everything, our concerns are loss of supportive bone levels, considering he wont be a candidate for implant therapy for quite sometime.
If someone has other options, would be great to hear them.
Cheers!
Sharpie
I have seen cementum bridge repairs similar to calus formation in bone fractures in teeth like this in lectures if the fractured tooth is splinted. I have had no experience one way or the other.
I think it's a great plan. My only question is about the risk of root resorption. I wonder if the following would mitigate the risk or just be overly heroic: endo the retrained root, extrude the root fragment to the level of the crest. Place a Maryland bridge To restore the space. This would help support the bone at the crest and maximize the available papilla.
On 6/19/2017 at 7:26 am, Charles LoGiudice said...I have seen cementum bridge repairs similar to calus formation in bone fractures in teeth like this in lectures if the fractured tooth is splinted. I have had no experience one way or the other.
+1
In this case, I would splint, then have endo do the tx just to cover all bases.
The other option would be a premolar substitution. If the patient has some space issue, then you can extract the central and a mandibular premolar then place the premolar into the central socket and treat like an evulsed tooth. I sat in a lecture that Gregg Kinzer gave on this topic. Here are some references to other case reports
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1990.tb00386.x/abstract
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.2009.00825.x/abstract
http://www.centralohiodentalforum.com/Portals/18/Documents/Managing%20the%20patient%20with%20missing%20or%20malformed%20maxillary%20central%20incisors.pdf
On 6/19/2017 at 8:04 am, Darin O'Bryan said...The other option would be a premolar substitution. If the patient has some space issue, then you can extract the central and a mandibular premolar then place the premolar into the central socket and treat like an evulsed tooth. I sat in a lecture that Gregg Kinzer gave on this topic. Here are some references to other case reports
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1990.tb00386.x/abstract
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.2009.00825.x/abstract
http://www.centralohiodentalforum.com/Portals/18/Documents/Managing%20the%20patient%20with%20missing%20or%20malformed%20maxillary%20central%20incisors.pdf
Inherited just such a case...
Some old bonding to make it look similar to a central, which is only an approximation, and some remaining diastema, and misproportions... but the dude has had this tooth here for 35 years...has always hated it esthetically, but he hasn't moved into comp esthetic tx (he's quite a dental phobe) and it didn't keep him from being repeatedly elected to the city council....
Mark
Great information everyone thank you so much.
WOW on the premolar treatment. Going to review the literature on that!
Thanks again
Sharpie
I had a similar, but more apical fracture in 1965 on #9, courtesy a hockey stick while playing goalie on the frozen Des Plaines River.
When I told my mom my tooth was loose and I need to go to the dentist, she said, "it will be fine, leave it alone." thanks, dr mom.
it took a few weeks to tighten up and I forgot about it.
It is still present with a nice junction between parts.
On 6/19/2017 at 8:13 am, Mark Stockwell said...On 6/19/2017 at 8:04 am, Darin O'Bryan said...The other option would be a premolar substitution. If the patient has some space issue, then you can extract the central and a mandibular premolar then place the premolar into the central socket and treat like an evulsed tooth. I sat in a lecture that Gregg Kinzer gave on this topic. Here are some references to other case reports
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1990.tb00386.x/abstract
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.2009.00825.x/abstract
http://www.centralohiodentalforum.com/Portals/18/Documents/Managing%20the%20patient%20with%20missing%20or%20malformed%20maxillary%20central%20incisors.pdf
Inherited just such a case...
Some old bonding to make it look similar to a central, which is only an approximation, and some remaining diastema, and misproportions... but the dude has had this tooth here for 35 years...has always hated it esthetically, but he hasn't moved into comp esthetic tx (he's quite a dental phobe) and it didn't keep him from being repeatedly elected to the city council....
Mark
Interesting case Mark. They used a maxillary premolar that would be much harder for re-implantation due the root shape. That is why they are using mandibular premolars more often now. I believe the preference is for mandibular 1st bicuspids since they have the more sloped lingual which makes it easier to fit the occlusion and make it look like a central inscisor.
On 6/19/2017 at 8:25 am, Darin O'Bryan said...On 6/19/2017 at 8:13 am, Mark Stockwell said...On 6/19/2017 at 8:04 am, Darin O'Bryan said...The other option would be a premolar substitution. If the patient has some space issue, then you can extract the central and a mandibular premolar then place the premolar into the central socket and treat like an evulsed tooth. I sat in a lecture that Gregg Kinzer gave on this topic. Here are some references to other case reports
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1990.tb00386.x/abstract
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.2009.00825.x/abstract
http://www.centralohiodentalforum.com/Portals/18/Documents/Managing%20the%20patient%20with%20missing%20or%20malformed%20maxillary%20central%20incisors.pdf
Inherited just such a case...
Some old bonding to make it look similar to a central, which is only an approximation, and some remaining diastema, and misproportions... but the dude has had this tooth here for 35 years...has always hated it esthetically, but he hasn't moved into comp esthetic tx (he's quite a dental phobe) and it didn't keep him from being repeatedly elected to the city council....
Mark
Interesting case Mark. They used a maxillary premolar that would be much harder for re-implantation due the root shape. That is why they are using mandibular premolars more often now. I believe the preference is for mandibular 1st bicuspids since they have the more sloped lingual which makes it easier to fit the occlusion and make it look like a central inscisor.
This would have been better no doubt... it is #12 and he has little recollection of what happened. When he first presented maybe 20 years ago it was at first a head scratcher for me... I don't think I had ever heard of such a thing prior....
Mark
Same scenario plus 30 years. We splinted for a short time period then watched closely.Very little color change and no endo but it did ankylose so we did a cerec about 10 years ago to line it back up. You can just barely see the old fracture line on #8. Not saying it would every time but it worked this time.
Good Luck
Jon
Just bounced this off of an Endodontist I really respect. They would splint and monitor with no other tx. If discolors, then treat the coronol portion only. A lot of healing potential in a 14 yo.
On 6/19/2017 at 8:33 am, Marc Thomas said...Just bounced this off of an Endodontist I really respect. They would splint and monitor with no other tx. If discolors, then treat the coronol portion only. A lot of healing potential in a 14 yo.
+1 Gregory
On 6/19/2017 at 8:33 am, Marc Thomas said...Just bounced this off of an Endodontist I really respect. They would splint and monitor with no other tx. If discolors, then treat the coronol portion only. A lot of healing potential in a 14 yo.
I have also seen this work.
Terry
Just a quick note. We reviewed treatment recommendations from Dental Trauma Guide. I have seen plenty of avulsions and all kinds of fractures, always good to review protocol.
Treatment
For root fractures where the coronal fragment have been avulsed out of the socket, please use the treatment guidelines for avulsion. Otherwise, proceed as described below.
- Rinse exposed root surface with saline before repositioning. If displaced, reposition the coronal segment of the tooth as soon as possible.
- Check that correct position has been reached radiographically.
- Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth stabilization is benificial for a longer period of time (up to 4 months).
- Monitor healing for at least 1 year to determine pulpal status. If pulp necrosis develops, then root canal treatment of the coronal tooth segment to the fracture line is indicated.
Patient instructions
- Soft food for 1 week.
- Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1% is beneficial to prevent accumulation of plaque and debris.
Follow-up
- Splint removal and clinical and radiographic follow-up after 4 weeks in apical third and mid-root fractures. However, if the root fracture is near the cervical area, the splint should be kept on for up to 4 months.
- Clinical and radiographic follow-up after 6-8 weeks.
- Clinical and radiographic follow-up after 4 months. If the root fracture is near the cervical area, the splint should be removed at this follow-up.
- Clinical and radiographic follow-up after 6 months, 1 year and yearly for 5 years.
- Follow-up may include endodontic treatment of the coronal fragment if pulp necrosis develops. The decision for endodontic treatment may be taken after 3 months of follow-up if the tooth still does not respond to electrometric or thermal pulp testing and if radiographs show a radiolucency next to the fracture line.
I would definitely consider "no treatment" to be a perfectly good option; I would even consider not splinting this case, if the patient remains pain-free. It's possible to keep a tooth like this indefinitely, as was mentioned previously. Here's one of my patient's teeth that has been fractured for over 5 years
On 6/19/2017 at 8:33 am, Marc Thomas said...Just bounced this off of an Endodontist I really respect. They would splint and monitor with no other tx. If discolors, then treat the coronol portion only. A lot of healing potential in a 14 yo.
My endodontist did the same thing with an RCT to the fracture line and left the apical section intact recently. Seems to be the current thinking.
I'm out of the office so don't have radiographs available, but had this happen about 4 years ago to a 14 year old patient. Splinted and monitored and the tooth is doing well...no discoloration, good stability...one of the benefits of youth!
