Journal of Dental & Oro-facial Research Vol 12 Issue 1 Jan 2016 JDOR

MSRUAS 33

CASE REPORT

ROOT FRACTURE IN PRIMARY TEETH Prahlad.Gadicherla1*, M. Mala Devi2,

*Corresponding Author Email: drprahladg@gmail.com

Contributors:

1,Reader, Department of

Pedodontics & Preventive

Dentistry,Faculty of Dental

Sciences,M.S.Ramaiah University

of Applied Sciences, Bangalore-54.

2,P.G.Student, , Department of

Pedodontics & Preventive

Dentistry,Faculty of Dental

Sciences,M.S.Ramaiah University

of Applied Sciences, Bangalore-54.

.

ABSTRACT

Dental traumatic injuries are not uncommon in children. When addressing

problems involved with trauma to the primary dentition, we as Pediatric dentist not

only have the responsibility of only looking in to the trauma to tooth but also to

comfort the child and parents in the acute state, to avoid inducing dental fear and

anxiety in young children who may be experiencing their first dental problem, and

to minimize the risk of further damage to the permanent teeth. We present a case of

3.5 year old reported to our OPD experiencing pain in her maxillary central incisors

following traumatic injury after a fall.

Keywords: primary incisor, root fracture, diagnostic dilemma

INTRODUCTION

Radicular fracture involves dentin, cementum and pulp

that may be present either in the radicular apparatus only

or involves coronal portion of the tooth (crown root

fracture). Maxillary central incisors are more commonly

involved with incidence reported being 80% in the

permanent dentition 1. These sorts of root fractures are

relatively uncommon among dental traumas, comprising

0.5–7% of the injuries affecting the permanent dentition

where as in the primary dentition, root fractures are as rare

as about 2–4%, due to the plasticity of the developing

alveolar bone 2.

The occurrence of root fracture is most frequent at the age

of 3–4 years where physiologic root resorption has begun,

thereby weakening the root 1. Diagnosis of root fractures

always presents a formidable challenge for the clinicians

because most of the root fractures remain asymptomatic.

A young child is often difficult to examine and treat due

to lack of co-operation because of fear. The situation is

distressing to both the parent and the child. A child’s

maturity and ability to cope with the emergency situation,

the time for shedding of the injured tooth and the

occlusion, are all important factors that influence

treatment 3.

CASE REPORT:

A 3.5-year-old girl reported to the out-patient

Department of Pedodontics and Preventive Dentistry,

Faculty of Dental Sciences, M S Ramaiah University of

Applied Sciences, Bangalore, with the chief complaint of

a broken tooth in upper front tooth region since three days.

Medical history and Dental history was nothing in

particular. Childs’ father gave the history of fall while

playing 2 days back and the tooth got fractured. The child

was conscious with no signs of vomiting or any change in

behaviour. The child started having pain after a day in that

fractured tooth and the pain was not relieved in any

medication.

Clinical examination revealed fair oral hygiene;

the patient was in primary dentition stage, the maxillary

left incisor was noticed with fracture involving enamel,

dentine and pulp extending subgingivally (Fig1).

Investigation carried out included intraoral periapical

radiograph. Radiographic assessment revealed a

horizontal radiolucent line in the middle third of the

maxillary right central incisor, and a horizontal fracture on

the right central incisor at the apical third of the root. The

succedaneous permanent incisors were noted at stage

Nolla’s stage 4 (crown 3/4 complete) (Fig2)..

Based on clinical and radiographic

examinations, the patient was diagnosed with horizontal

root fractures in maxillary right central incisor and

Journal of Dental & Oro-facial Research Vol 12 Issue 1 Jan 2016 JDOR

MSRUAS 34

complicated crown fracture in maxillary left primary

incisors.

The treatment plan was drawn to be the pulpectomy

procedure for the left central incisor. Considering the

patient age and cooperation the maxillary right central

incisor was planned to keep under follow up observation.

Fig 1: Pre-operative photograph showing Fracture with

relation to 61

Fig 2 Pre-operative radiograph showing Fracture with

relation to 61 involving pulp and horizontal root fracture

with relation to 51 in apical third

DISCUSSION:

The prevalence of avulsion out of all types of

traumatic luxation injuries to primary teeth ranges

between 5.8% and 19.4%. This is due to the factors like

pliable alveolar bone and vertically placed incisor teeth.

However root fracture in primary tooth is less common if

present they are most frequent at the age of 3–4 years

where physiologic root resorption has begun, thereby

weakening the root 4.

Over and above the trauma to the primary tooth

will results in sequelae not only to itself but also to the

developing permanent tooth germs which lies in close

proximity to the roots of the primary teeth .The prevalence

of developmental disturbances of permanent teeth

secondary to primary tooth trauma is reported to be

between 12% and 69%, depending on the severity and type

of the injury as well as the developmental stage of the

permanent tooth 1. Tooth malformation, impacted teeth,

and eruption disturbances in the developing permanent

dentition are some of the consequences that can occur

following severe injuries to primary teeth and/or alveolar

bone 3.

Consequences in the primary dentition

comprised: colour changes, pulp necrosis, pulp canal

obliteration, gingival retraction, permanent displacement

after luxation, pathological root resorption as well as

disturbances in physiological root resorption and lastly

premature tooth loss 5. In a long-term study of 255

traumatized primary teeth, 23% of the corresponding

erupted permanent teeth showed developmental

disturbances. The highest prevalence was found after

intrusive injuries of primary teeth 6.

In case of complicated crown fracture, size of

the pulp chamber, stage of root development and degree

of root resorption should be taken in to consideration while

planning the treatment. However, treatment decisions are

often based on the child’s cooperation and on the further

life expectancy of the affected primary tooth 7.According

to IADT guidelines,in very young children with immature,

still developing roots, it is advantageous to preserve pulp

vitality by pulp capping or partial pulpotomy. This

treatment is also the choice in young patients with

completely formed roots. Calcium hydroxide is a suitable

material for such procedures. Both treatments should be

considered whenever possible, otherwise extraction is

indicated 8. However extraction of the maxillary incisor is

always last resort as premature extraction of this will not

only will affect the aesthetics, speech and leads to space

loss but also will impair the quality of life of the children9.

In the present case considering the age of the child ZOE

pulpectomy was carried out with relation to left maxillary

central incisor and restored with GIC (Fig3 &4).

Fig 3 Post operative radiograph shoeing ZOE pulpectomy

in relation

Fig 4 Post-operative photograph

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MSRUAS 35

In case of root fracture, according to IADT guidelines the

treatment recommendation If the coronal fragment is

displaced, extract only that fragment. The apical fragment

should be left to be resorbed 8. If the coronal fragment is

not displaced, the root is complete, and the patient

cooperates, a semi rigid wire-composite splint may be

indicated. In this case, it is important to inform the parents

that the tooth will maintain certain mobility until its

normal replacement. In most cases, root fracture is

associated with crown displacement and gingival

laceration. Extraction of only the coronal fragment is the

treatment of choice. The apical fragment is left to be

resorbed physiologically 10.

In the present case, Horizontal root fracture of

right maxillary central incisor was noticed at the apical

third. No crown displacement or mobility was noticed.

And the occlusion was checked for any contact on the

particular teeth. Since over jet and overbite was

satisfactory the patient was kept under soft diet and regular

follow up every week to ensure that the healing of the root

fracture with relation to right maxillary central incisor is

uneventful. Along with homecare instructions and

chlorhexidine mouth rinse were prescribed. The patient is

been followed up for past 4 months without any

complains.

CONCLUSION:

The root fracture should be managed

conservatively to promote a functional and aesthetic

resolution, thereby minimizing the financial, physical, and

psychosocial costs that would result from providing space

maintenance. Over and above in the primary dentition,

there is no satisfactory evidence to indicate the superiority

of any one treatment. As a way to limit damage, do not

interfere with the tooth germ development.

REFERENCES

1. Andreasen JO, Andreasen FM. Essentials of

traumatic injuries to the teeth. Copenhagen:

Munksgaard; 1990. p. 168.

2. Poi WR, Manfrin TM, Holland R, Sonoda CK.

Repair characteristicsof horizontal root

fractures: a case report. Dent Traumatol

2002;18:98–102.

3. Dental Trauma Guidelines- Revised 2012.

International Association of Dental

Traumatology

4. Xin Liu, Jing Huang, Yudi Bai, Xiaojing Wang,

Andrew Baker3, Faming Chen1, Li-an Wu.

Conservation of root-fractured primary teeth—

report of a case. Dental Traumatology 2013; 29:

498–501

5. Borum MK, Andreasen JO. Sequelae of trauma

to primary maxillary incisors. I. Complications

in the primary dentition. Endod Dent Traumatol

1998; 14: 31-44.

6. FloresMT. Traumatic injuries in the primary

dentition. Dent Traumatol 2002;18: 287-298.

7. Flores MT, Andreasen JO, Bakland LK, Feiglin

B, GutmannJL, Oikarinen K, et al. Guidelines

for the evaluation and management of traumatic

dental injuries. Dent Traumatol 2001;17:1-4.

8. Flores MT, Malmgren B, Andersson L,

Andreasen JO, Bakland LK, Barnett F,

Bourguignon C, DiAngelis A, Hicks L,

Sigurdsson A, Trope M, Tsukiboshi M, von Arx

T. Guidelines for the management of traumatic

dental injuries. III. Primary teeth. Dent

Traumatol 2007.

9. Holan G, Needleman H L.Premature loss of

primary anterior teeth due to trauma- potential

short and long term sequelae.Dental

Traumatology 2014;30:100-106.

10. Harding AM, CampJH. Traumatic injuries in the

preschool child. Dent Clin North

Am1995;39:817-35.