Alternatives to Management of a Horizontal Root Fracture



20-YEAR-OLD FEMALE presented with the chief complaint that “I fell off my bike two months ago and my tooth hurt for a while and has been loose ever since.” This was the patient’s first visit to the dentist since the accident. She had no significant medical history, no known allergies to medications, and was taking no medications daily.
The patient had a history of regular dental visits every year. The types of past dental therapy included root-canal therapy, restorations, extractions, fixed prostodontics, sealants, and implants. The patient had a history of trauma to the right anterior region four years earlier, and #7 had been lost and replaced with an implant.
The extra-oral exam was within normal limits. The intra-oral exam was also within normal limits; there were no lesions, edema, or abnormalities noted. All probing depths were 3 mm or less, and oral hygiene was excellent.
The dental exam revealed that #10 had no response to cold or hot stimuli and was tender to percussion. Also, #10 was tender to palpation on the buccal gingiva at the mid-root level. There was class 2 mobility on #10.
Multiple periapical radiographs of #10 were taken for evaluation. The horizontal root fracture in the middle third of #10 was evident (see Figure 1). Radiographically, the horizontal fracture appeared like a football-shaped radiolucency. There was no periapical pathology at the apex of #10. The space between the fractured segments appeared minimal. A widened PDL was apparent surrounding the fracture site, but the PDL remained intact. There was no significant bone loss in the anterior region. FIGURE 1: Showing the horizontal root fracture in the middle third of #10. The angulation of the cone in radiographic detection of a horizontal root fracture is critical. In order to successfully diagnosis a horizontal root fracture the cone must be between 20 degrees and +10 degrees. Therefore, if you suspect a horizontal root fracture, it is a good idea to take multiple radiographs (see Figure 2).


Treatment To facilitate pulpal and periodontal ligament healing, the coronal and apical segments were repositioned in as close proximity as possible, and a rigid splint of composite was placed on the buccal surface of #9 through #11. This was verified radiographically. The rigid splint should be placed for two to four months. If a long period has elapsed between the injury and treatment, it is unlikely that the two segments can be returned to their original position, therefore compromising the long-term prognosis of the tooth.
The tooth was isolated without anesthesia, and access was made. Upon entry into #10 no heme was noted. The patient was comfortable until the #10 file was placed beyond 15 mm. A radiograph was taken, and it showed that the file was at the fracture site. It was apparent at this point that the coronal segment was necrotic and the apical segment had maintained its vitality. Extirpation of the coronal pulp short of the fracture line was performed, using only sterile saline to maintain the vitality of the pulp tissue in the apical segment. Calcium Hydroxide was placed in the coronal segment to induce a hard tissue closure between the fractured segments. The patient was advised to avoid masticating in that area and to try to maintain a soft diet.
When the patient returned on a six-week recall, she was asymptomatic. The splint was replaced and the calcium hydroxide was changed. A periapical radiograph showed no sign of periapical radiolucency.
The patient returned for a twelve-week recall and was asymptomatic. Again, the rigid splint and calcium hydroxide were changed.
The patient returned for a four-month recall. Tooth #10 was healing uneventfully, and no pathology was apparent at its apex. After splint removal, it was noted that #10 was now class 1 mobility. Upon entry into #10, the canal appeared clean and dry. The coronal segment was rinsed and re-instrumented to the fracture line. A hard tissue barrier was evident at the fracture site. The coronal segment was obturated with calcium-hydroxide-based cement (see Figure 3). The tooth was closed with composite, and the patient was placed on a six-month recall. At the six-month recall, the patient was comfortable and no pathology had developed. FIGURE 3: Showing the obturation of the coronal segment. Complications—such as pulp necrosis and root-canal obliteration—may arise, and every case is different. Clinical considerations to be evaluated for each case are age, degree of dislocation, mobility, level of fracture, type of fixation, and patient motivation. The success rate for treatment varies but has been reported to be approximately 74 percent. This case illustrates one alternative to treating and managing a horizontal root fracture. There are other options for treatment (see Figure 4). FIGURE 4: Illustrating alternative treatments.