Root Fracture: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Root Fracture Example

Chief Complaint: ______________________________

History of Trauma

• Date and Time: ______________________________
• Location of Injury: ___________________________
• Mechanism of Injury: (e.g., fall, sports, accident): ____________________________
• Initial Care Provided: ________________________

Medical History

• Allergies: _________________________________
• Medications: ______________________________
• Tetanus Status: ___________________________
• Relevant Medical History: ______________________

Dental History

• Previous Dental Injuries: ___________________________

Intraoral Findings

Soft Tissues:

• Lacerations: Minor lacerations noted on the labial gingiva adjacent to tooth #8.
• Bleeding: Localized gingival bleeding near the fracture site.
• Swelling: Mild swelling around the affected area.

Tooth Findings:

• Tooth #8:
  • Mobility: Marked mobility of the coronal fragment due to the cervical third root fracture.
  • Displacement: Coronal fragment was slightly displaced.
  • Percussion: Tender to percussion.
  • Sensitivity Testing (cold, electric pulp test): Negative, suggesting potential pulpal necrosis.

Radiograph

• Periapical and CBCT Imaging:
  • Fracture line confirmed in the cervical third of the root.
  • Coronal fragment displacement observed with partial separation of the root structure.
  • No significant alveolar bone involvement was detected.

Plan

Immediate Management:

1. Repositioning and Stabilization:
   • Repositioned the coronal fragment to align with the apical portion of the root.
   • Applied a flexible splint to stabilize the tooth and ensure immobilization.
   • Splint duration: 4 months due to cervical location of the fracture.
2. Pulp Therapy:
   • Initiated root canal therapy for the coronal fragment to manage pulp necrosis and prevent infection.
3. Soft Diet and Hygiene:
   • Advised a soft diet to minimize mechanical stress on the affected tooth.
   • Recommended chlorhexidine rinse (0.12%) twice daily to promote gingival healing and prevent infection.
4. Medications:
   • Prescribed ibuprofen 400-600 mg every 6-8 hours for pain management.
   • Antibiotics were prescribed (e.g., amoxicillin) if the lacerations or tissue trauma were at risk of infection.

Follow-Up Schedule:

• 4 Weeks: Clinical and radiographic reassessment to monitor splint stability and evaluate initial healing.
• 4 Months: Remove splint and reassess mobility and healing of the root fracture.
• 6-8 Months: Radiographic evaluation to monitor for resorption, healing complications, or ankylosis.
• 1 Year and Beyond: Periodic monitoring for long-term healing and complications, including root resorption or failure of healing.

Warning About Risks Associated with Dental Trauma

Cervical third root fractures carry a high risk of complications such as pulp necrosis, root resorption, and non-healing of the fracture. Close monitoring and timely follow-ups are crucial to address potential issues and improve long-term outcomes.

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