A Hopeless Case?

“In traumatic dental injuries, not only it is important to know when to treat a case (endodontically-speaking); it is equally important to know when not to treat it.” – Martin Trope

Before considering extraction of a tooth with root fracture, no matter how bad it looks on the x-ray, the following treatment approach must be considered in order to give the tooth another chance:

1) reduction: repositioning the tooth back into the socket,

2) fixation: stabilizing the tooth with a flexible splint for four weeks (if the fracture is in the middle or apical third area), or for four months (if the fracture is in the cervical third area),

3) relief of occlusion: to minimize further damage to the PDL and the protective layer of the root, and

4) recall: monitoring clinically and radiographically in 6-8 weeks, 4 months, 6 months, 1 year and yearly for 5 years.

After three months of follow-up, endodontic treatment of only the coronal segment should be considered if the tooth continues to be unresponsive to vitality testing, appears discoloured, and/or develops periapical pathosis (radiolucency) around the fracture line.

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The tooth above has remained asymptomatic and functional 2 years after the endodontic treatment and 3 years after sustaining a traumatic injury. I always remind myself of what Ian Linde would say when considering all options for cases that appear hopeless on the radiograph: “Implants should replace missing teeth not teeth.”

(Resource: The Dental Trauma Guide: your interactive tool to evidenced based trauma treatment.)


6 responses to “A Hopeless Case?

  • Ali Sarraf

    Dr E. on the pre-op xray I see what may be a root tip next to the lateral incisor. The root tip is gone on the follow up xrays. Was it excavated?

    • Dr E

      Yes, the root tip has been removed during surgery. Ideally, you would do root canal in an orthograde fashion on teeth with horizontal root fractures and up to the fracture line since most apical segments remain vital. But in this case, the operator has felt that there was no need for retaining the apical segment of the root.

  • Mario Barresi

    Can you explain how this tooth was treated?

    • Dr E

      If a tooth with horizontal root fracture becomes necrotic (symptoms, bilateral lesion at the level of fracture, crown discolouration, etc.), endodontic treatment is warranted. The most successful outcome is obtained when the root canal treatment is done up to the level of fracture and not beyond the fracture line and involving the apical segment. The coronal portion should be treated as in an immature tooth (i.e. CaOH apexification or MTA plug and obturation with gutta-percha or resin). If symptoms continue after this stage or a periapical lesion develops around the remaining root, surgical extraction of the apical segment will be done.

      In the case above, apical surgery has been performed including the removal of the apical root portion and removal of the granulation tissue, and the coronal segment is completely retrofilled by MTA.

  • ellen

    just curious – how much time elapsed from the time of injury to the time of treatment?

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