Root fractures in children and adolescents: diagnostic considerations

The objectives of this study were to (i) characterize epidemiologic trends in anterior permanent tooth trauma in a sample of children and adolescents (ii) examine the relationship of crown fractures (CF) and concomitant root fractures (RF) to determine if CFs are protective against RFs and (iii) examine the radiographic evidence of RFs to determine the value of obtaining three vertical periapical radiographic projections. This was an 8-year cross-sectional study of patients aged 6-18 with anterior permanent tooth trauma. We examined cases involving maxillary central/lateral incisors for which three clearly diagnostic periapical radiographs were obtained during the initial emergency visit. Two trained and calibrated dentists served as expert examiners for the radiographic assessments. Kappa statistics were used to determine reliability. Tests for association of concomitant crown and root fractures were performed using Likelihood Ratio Chi-Square tests. The final sample included 185 teeth in 114 children. Our demographic and epidemiologic findings were comparable to those of previous studies. Experts reached this consensus: 22 RFs were detected, 9.6% (eight out of 83) teeth exhibited root fractures when no CFs was documented, and 13.7% (14 out of 102) teeth had both CFs and RFs as separate entities. Good examiner reliability was reached confirming the presence of RFs (Kappa = 0.81). The association of concomitant RFs and CFs was odds ratio = 1.97 (P = 0.052). CFs were not protective against RFs; indeed, teeth with CFs were twice as likely to have an RF as those without CFs. As the number of radiographic projections increased, RFs were identified more often; however, our data suggest that there is no reason to suspect a complete RF in preteen children unless the root exhibits clinical signs such as luxation or severe mobility. This study provides solid evidence to support obtaining multiple radiographic projections at different vertical angulations to rule out RFs in children and adolescents when RFs are suspected.