Hopeless Prognosis? Root fracture in the immature permanent dentition
Trauma Management
Dental Traumas in the immature permanent dentition are sadly common. Correct diagnosis and management can make a great difference for the child for the rest of their life.
To go through each classification of trauma and management would take a few blogs. As such, we are going to provide some example cases over the next few posts to help guide you.
Initial Presentation
This young man presented to us for a second opinion after his mother was informed that #11 and 21 needed to be extracted due to their hopeless prognosis and his poor dental compliance (Medical History: Autism Spectrum Disorder, ADHD, Epilepsy). He would not have tolerated a denture and as such, the options previously offered, would have left him with no front teeth for several years.
The initial injury occurred 2 days before he presented to our clinic. Delayed presentation, such as this, will greatly complicate the management and prognosis of dental traumas. Most injuries are best managed within 24 hrs for optimal outcomes. Some of the images below are limited as his compliance throughout his appointments has been hit and miss!
Initial radiograph provided to us. We generally like to standardise our images, but could not justify the radiation exposure for him to get an ‘ideal image’.
After clinical and radiographic examinations it was determined that the diagnoses were:
Mid root fractures and moderate extrusion (3mm) of #11 and 21. The coronal sections were palatally luxated into traumatic occlusion. There were negative responses to vitality testing
We discussed different options with his mother but unfortunately optimal treatment under general anaesthetic was not possible due to financial constraints. As such, we offered to attempt repositioning of the coronal sections under protective stabilisation. We do not generally like to take this approach, however, the alternatives would have been no treatment or extractions with the public system under general anaesthetic.
Treatment Provided
We managed to get local anaesthetic in with some difficulty (he had already had several attempts at other clinics over the previous few days). We then manually repositioned the teeth as best we could. Keep in mind that we did not have a very compliant child and healing had already started to occur due to the delayed presentation. Therefore we were unable to reposition them in their original position and the best we could achieve was to get them out of traumatic occlusion with a ~2-3mm gap between the crowns and root sections. We subsequently placed a flexible splint and off he went!
Immediately after limited repositioning and splinting with a ligature wire.
Reviews
We had significant reservations here. Many factors were working against us:
The delayed presentation precluded ideal repositioning and would have resulted in additional trauma due to his traumatic occlusion over several days. Furthermore, pushing the teeth against tissues that had started to heal at the time of treatment
His limited compliance
Severe injuries to very immature teeth (shorter roots and more complex endodontic treatment if required, however, this can also lead to better pulpal prognosis)
But lets see what happened!
4 weeks post-op. No significant healing is apparent, but no pathology can be seen either.
8 Week Review. We opted to remove the splint here as the stability of the coronal fragments was sound. It is a delicate balance sometime to know how long to leave the splint in cases such as this. The IADT says that for coronal root fractures it can be left for up to 4 months.
If you compare the initial image, there is definite signs of healing of both fragments. The root sections have continued to develop and there is some narrowing of the space between the coronal and root fragments.
16 Week Review. Ongoing signs of healing. He now also has some positive responses to vitality testing. In saying that it, is a challenge to test him and get a reliable result…
16 months post injury. There are fantastic signs of unification now between the fragments.
2.5 years (30 months) post injury. We would not like to have to attempt endodontic treatment for him, however, we can see excellent signs of healing and complete unification of the fragments.
2.5 Year Review The teeth are definitely elongated , however, they are very stable with positive vitality testing
A happy camper but an even happier mother!
Summary
This case, shows the magnificent capacity of healing in young children. Did we do ideal trauma treatment here? Definitely not. We did what we could in a very challenging case and we all got very lucky.
The main takeaway from this case is that there is excellent capacity for healing in young children. The better we can manage dental traumas in the immature permanent dentition the better the outcomes we can get . Managing them can be a challenge and we have created a course to help practitioners better diagnose and treat dental traumas: Primary and Permanent Dental Trauma — Kids Dental Tips
We hope this case report has been helpful for you