How Are Root Fractures and Fracture Lines Classified?
Root fractures in pediatric patients can be classified primarily as either shallow or deep fractures, depending on the observed location of fracture lines by the pediatric dentist or maxillofacial surgeon. These fractures involve the cementum, dentin, and pulp layers. The fracture lines can be horizontal, oblique, or vertical, reflecting the impact of trauma on the child. Vertical root fractures are more likely to occur in already treated teeth, such as those that have undergone endodontic treatment or restoration. In contrast, horizontal and oblique fracture lines are less common in pediatric patients but can still occur due to traumatic dental injuries or forces (TDI).
How to Do Diagnosis and Radiographic Detection?
When dealing with a tooth exhibiting root fractures in a child, it is not uncommon for the electric pulp testing procedure to yield no response. In such cases, the pediatric dentist must explore various possibilities to arrive at an appropriate diagnosis.
In the scenario of a root-fractured tooth, three potential situations should be considered:
A. The pulp tissue in the root canal is likely severed at the fracture site, resulting in a severed pulp tissue.
B. The vital pulp tissue may remain unsevered at the fracture site, and there are no apical fragments causing subluxation.
C. The vital pulp remains intact, and there may be slight displacement of apical fragments, but without clear subluxation or dislocation.
To accurately assess these possibilities, the most effective diagnostic method involves utilizing two-dimensional (2D) radiographic techniques.
Root fractures are typically diagnosed using 2D radiographs such as intraoral periapical radiography (IOPA) or orthopantomogram (OPG). However, modern dentistry recommends cone beam computed tomography (CBCT) for more accurate detection of root fractures. This is particularly crucial in pediatric cases, where conventional 2D radiography may not accurately visualize or detect the displacement of coronal segments. CBCT, being a 3D imaging technique, offers enhanced visualization of fracture lines, ensuring a more comprehensive diagnosis that could be missed with traditional 2D radiography. If a dentist opts for 2D radiography in pediatric cases, focusing on visualization from multiple angles is advisable to improve diagnostic accuracy. Recent dental research indicates that identifying complex fracture lines, which can pose clinical challenges for pediatric dentists, may be most effectively achieved through the use of CBCT radiographic modalities. Otherwise, these fracture lines might only become apparent several months later when the child exhibits persistent symptoms such as dental treatment failure, pain, or swelling in the affected tooth.
When Are Dental Splints Required?
Splints may be deemed necessary to stabilize a traumatized tooth following a pediatric dental injury, but they are typically required only for severe or complicated cases. Dental splints come in rigid or flexible forms and support, protect, or immobilize teeth that have become mobile or shaky.
How Are Traumatic Injuries Managed in Children?
The dentist may also contemplate repositioning and stabilizing the fractured crown or coronal segments in a child. Depending on the depth of the fracture and the stability of the crown segment, the dentist may extend the fixation for up to three months, considering the child's prognosis. Six months after repositioning and fixation, the dentist verifies the absence of pulp necrosis. If pulpal necrosis is present, indicating the vital pulp or root canal tissue has necrosed, endodontic or root canal treatment becomes necessary for both young primary and permanent teeth.
What Are the Characteristics of Dental Splinting Indicated for Children’s Teeth?
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Pediatric dentists and oral surgeons often employ flexible splinting as a technique to aid in healing, preferring it over rigid and compound dental splints. This choice is made to optimize pulp and periodontal healing while ensuring a smooth recovery. The pediatric dentist or surgeon provides postoperative oral hygiene instructions for proper care of the splints.
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An ideal splint for use in children should possess several key characteristics to ensure optimal functionality and patient comfort. Firstly, it should allow for easy fabrication within the child's mouth without causing additional trauma to impacted or traumatized teeth. The absence of active forces, such as those exerted by orthodontic appliances, is crucial to prevent any unnecessary pressure on the impacted tooth. Moreover, the splint should maintain physiologic mobility in the impacted tooth to avoid exerting force on it.
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In addition to functionality, the splint must be non irritating to the soft tissues surrounding the tooth, including the periodontium and gingival region. Construction from non-carcinogenic materials is essential to ensure the safety of the child. It should also be designed not to interfere with the child's occlusion while providing easy accessibility for endodontic access and vitality testing by the dentist.
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Practical considerations include easy cleaning and affordability. The splint should be easy to clean to maintain oral hygiene effectively. Simultaneously, it should be economical or inexpensive, yet capable of providing adequate patient comfort and esthetic appearance. Lastly, easy accessibility to the child is paramount, facilitating both the initial placement of the splint and subsequent oral hygiene maintenance around it. In summary, an ideal splint for children should balance these characteristics to promote effective treatment and ensure the well-being of the young patient.
Conclusion:
Accurate diagnosis is crucial for the straightforward treatment of deep root fractures in children. Dental injuries, such as loosened or replanted teeth, those undergoing significant or minor endodontic surgical procedures, or possibly fractured teeth, often require dental splinting. The decision for splinting is typically based on the judgment of dental professionals, including pediatric dentists and oral surgeons.
