Root fracture is a traumatic tooth injury accompanied by a violation of the integrity of its root. Patients complain of increased soreness in the area of the damaged tooth when chewing, biting off food. During the examination, edematous hyperemic mucosa is detected. Vertical percussion in case of root fracture is positive. Pathological mobility of teeth of 1, 2 or 3 degrees may be observed. The diagnosis of “root fracture” is made based on the patient’s complaints, collected anamnesis, clinical examination data, X-ray results and EOD. The choice of treatment tactics depends on the patient’s age, the state of his immune system, the level and direction of the fracture line.
Meaning
Root fracture is a pathological condition that occurs when the integrity of the root is violated. In childhood, a root fracture is diagnosed extremely rarely (0.5%). In adults, dental injuries combined with root fracture are detected in 2% of cases. The main group of patients are people aged 40-45 to 50 years. In 4% of patients, disease is preceded by previously performed endodontic treatment of the canals. Horizontal fractures of the tooth root with localization of a bone defect in the area between the middle third and the tip of the incisors are more common. The fracture of the roots of large and small molars is longitudinal in 80% of cases, while only 10% of the examined patients are diagnosed with an incomplete fracture of the tooth root. A fistula course is formed in every 10 patients who have applied to dentistry. Displacement of fragments was recorded in 3% of cases.
Causes
A fracture of the root of the tooth occurs due to traumatic injuries (injuries of the teeth) when falling, hitting the face. The fracture line usually runs at the level of the middle third of the upper incisors. Very often, root damage is diagnosed with fractures of the alveolar process and the body of the maxillary bone, while a fracture of the root of the tooth is almost always combined with a rupture of the periodontal ligamentous apparatus.
A fracture of the root of the tooth may occur during dental manipulations at the stage of root canal expansion or at the time of pin installation. The application of excessive force leads to a violation of the integrity of the thinned root walls in the longitudinal direction. Also, a common cause of a root fracture is non-compliance with the treatment protocol: restoration of the crown part with a light-curing material in the presence of direct indications for prosthetics, the use of cantilever structures, bridges of a large length of the intermediate part.
Excessive expansion of the channels, their aggressive mechanical processing, uneven distribution of masticatory pressure – all these factors significantly increase the risk of root fracture. The traumatic pressure can be transmitted to the root not only perpendicular, but also parallel to its longitudinal axis. With direct blows, a fracture of the root of the tooth is combined with damage to the alveolar process. Vertical forces develop due to the action of antagonistic teeth at the time of closing of the dentition, provided that there are foci of chewing overload.
Classification
Depending on the direction of the line of damage , root fractures are divided into 4 groups:
- Transverse. The fault line runs parallel to the chewing surface. On the X-ray it is possible to see 1-2 strips of illumination corresponding to the level of damage.
- Vertical. The fragments formed during the fracture of the tooth root are parallel to the longitudinal axis. Often vertical fractures are combined with damage to the crown.
- Oblique. The root fracture runs at an angle to the axis of the tooth in the buccal-oral or medio-distal direction.
- Comminuted. They are characterized by the formation of several fracture lines intersecting with each other in different directions.
Apical, median and cervical fractures of the tooth root are distinguished by localization.
Symptoms
The clinical picture of a root fracture depends on the level of damage, the condition of the pulp, the degree of displacement of fragments. If a root fracture is combined with damage to the bones of the facial skeleton, abrasions and wounds are determined on the skin. Soft tissues are edematous. The mucous membrane in the area of the root fracture is hyperemic, painful. When the pulp is damaged, patients indicate the appearance of spontaneous pain. As a result of internal hemorrhage, the crown part of the teeth acquires a pink hue.
When the jaws are closed, the soreness increases. The damaged tooth can be located both in the dentition and outside it (with a vestibular or oral tilt). During the examination, the pathological mobility of teeth of the 1st, 2nd or 3rd degree is determined. Dental epithelial attachment with a fracture of the root of the tooth is destroyed, as a result of which periodontal pockets are formed. Bleeding is observed from the gingival furrow. In the absence of treatment, over time, a fistulous passage forms on the mucous membrane in the projection of the fracture line, through which granulations bulge out. With an exacerbation of the inflammatory process, suppuration is noted.
Diagnostics
Diagnosis of a root fracture includes collection of complaints, clinical examination, EOD. The results of an X-ray examination are decisive in making a diagnosis. As a rule, among the main causes of root fracture, patients indicate traumatic injuries. There are no pathognomonic symptoms with a root fracture. During the physical examination, the dentist reveals a number of nonspecific signs: swelling of the mucous membrane in the fracture zone, positive vertical percussion, pathological mobility of damaged teeth, destruction of the dental epithelial junction, the presence of periodontal pockets. If the root is fractured, the crown part of the tooth may be partially or completely absent. With a vertical root fracture, the fracture line passes through two approximal and masticatory surfaces or in the vestibulo-oral direction. The broken fragments are movable.
With oblique medio-distal fractures of the tooth root, as well as in the case when the fracture lines are perpendicular to the X-ray beam, it is quite difficult to detect a root fracture using targeted X-ray diagnostics. To clarify the nature of the pathology, CT is performed. With horizontal, vertical vestibulo-oral fractures of the tooth root, radiographs reveal the expansion of the periodontal fissure. The zone of rarefaction of bone tissue in the form of a thin strip of enlightenment passes in the area of damage. With late treatment of patients, radiographically in the projection of a root fracture, a bone destruction site with fuzzy contours is determined, signs of root resorption are observed. Targeted radiography is performed twice: at the time of injury and a week later.
EOD results indicate the condition of the pulp. To get the most reliable data, the study is performed several times. Immediately after the damage, the pulp viability indicators are usually reduced (values in the range of 100 µA and higher). Over time, the vitality of the pulp may recover. It is necessary to differentiate a fracture of the root of the tooth with a bruise and dislocation of the tooth, a fracture of the alveolar plate. The examination is carried out by a dentist-therapist and a dentist-surgeon.
Treatment
The tactics of the doctor in case of a root fracture is determined by the nature and localization of the damage, the age of the patient, the level of displacement of fragments. When a transverse fracture of the apical third is detected with a violation of the vitality of the pulp, extirpation of the crown and root pulp, drug and mechanical treatment of the channels, followed by their filling with a temporary calcium-containing paste, is carried out. After obturation of the root canals by lateral or vertical condensation of gutta-percha, surgical intervention is performed, the purpose of which, when the root of the tooth is fractured, is to remove the broken apical fragment. While maintaining the vitality of the pulp, immobilization of the tooth with a special mouth guard or wire splint fixed to 2 intact teeth on both sides of the damaged one using a liquid photopolymer material is shown.
If there are no irreversible changes in the pulp with a transverse-median fracture of the root, in order to provide the necessary conditions for the fusion of fragments, a mouth guard, fiberglass or wire-composite tires are used. In case of detection of signs of non-viability of the pulp, the therapy of a root fracture includes a stage of endodontic treatment, the installation of a pin with reposition, fixation, immobilization of fragments. In case of a vertical or oblique fracture, single-root teeth must be removed. In case of a fracture of one of the molar or premolar roots, tooth-preserving operations are performed. When the tooth is hemisected through the chewing surface by bifurcation in the buccal-oral direction, the crown is cut with a boron. The damaged root is removed. The preserved healthy root is used as a support for prosthetics. The detection of a fracture of the root of a temporary tooth is a direct indication for its removal.
With timely treatment of the patient and professionally planned treatment of horizontal fracture of the root of the tooth of the middle or apical third, the prognosis is favorable. Maintaining the viability of the pulp increases the likelihood of fracture healing, since it is the vital pulp that contributes to the formation of hard tissues in the endodont. With a horizontal cervical fracture of the tooth root, the prognosis is unfavorable. All temporary, as well as permanent single-root teeth with oblique, longitudinal, comminuted root fractures are subject to removal, since there is no fusion of fragments in the dynamics, root resorption with signs of a chronic inflammatory process is observed in patients.
Literature
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- Regenerative Endodontic Procedures for Traumatized Teeth After Horizontal Root Fracture, Avulsion, and Perforating Root Resorption / Tarek Mohamed A Saoud, Sonali Mistry, Bill Kahler, Asgeir Sigurdsson, Louis M Lin // J Endod. — 2016 ;42(10): 1476-1482.link
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