Think a Horizontal Root Fracture Is Tough to Treat?
You’re right! One of the most challenging traumatic injuries to diagnose and treat is the horizontal root fracture. I think it’s pretty confusing, if you ask me.
Many times with a horizontal root fracture, the treatment is actually to do NOTHING. I usually give a horizontal root fracture time to heal on its own and let the body do its thing — as long as the tooth is stable and not mobile.
If the tooth is mobile, and depending on the level of the fracture, you may need to stabilize it for some time with a flexible splint.
Apical fractures have the best prognosis, and then midroot, and then coronal. Why? Well, the apical fractures will be more surrounded by bone and therefore less mobile. And since the fracture will also be far away from any bacterial contamination, this also increases the prognosis. As the fracture moves up the root, the prognosis decreases.
So, the more coronal the fracture, the more mobile the fragment and the more chance of bacterial contamination.
If a tooth with a horizontal root fracture becomes symptomatic and you cannot delay treatment, usually you only have to treat the coronal fragment because the apical fragment remains vital.
Tooth Story: A Case of a Horizontal Root Fracture
Take a look at this case. It serves this perfect example.
This patient presented to my office and had a history of trauma almost 10 years ago. Here’s her post-op radiograph from when I first met her. She already had treatment previously attempted several years prior.
The cardinal rules of root canal therapy (Find all the canals and Get to the end of every single one) were violated in teeth #8 and 9. The canals were located and treated, but they were not instrumented to working length or working circumference.
So, I diagnosed her with Previously Treated #8 and 9 with Asymptomatic Apical Periodontitis #8 and 9.
You can see that the coronal fragment of #8 has a periapical radiolucency, but the apical fragment does not. You can also see that #9 has a periapical radiolucency. I took a CBCT to get a deeper look and this is what I found.
Here is the coronal view of #8…
And the coronal view of #9…
You can see clearly that the working length has not been achieved on either view. And the fracture on #8 is significant. Believe it or not, that tooth had and continues to have no mobility.
The axial view of #8 was a bit shocking and showed me that I was not going to be able to contain my obturation material.
My next steps…
So based on this image, I knew that I would have to obturate #8 with MTA since I needed something that was compatible with the bone — because extrusion was likely.
My treatment plan was to retreat the coronal fragment #8 and retreat #9. I also told her that if there was no healing around #8, and that there is a small chance that I would have to remove the apical fragment surgically in order to have access to the apex of the coronal segment in order to retroprep that area.
Apically, the CBCT confirmed that the apical segment of #8 was fine and that there was a periapical radiolucency on #9.
So, I started treatment, removed the gutta percha, and obtained a working length on both teeth.
I then medicated the teeth with calcium hydroxide for several weeks to ensure proper disinfection.
Following that, I obturated with MTA in tooth #8 and gutta percha in tooth #9.
As expected, the MTA fill appears out of the root, but since MTA is osteoinductive and osteogenic, I was happy with it.
Since follow up is key with these patients, I brought her back at 6 months. Here’s her post-op radiograph.
You can see that the periapical radiolucencies are getting smaller and she is completely asymptomatic. Remember, don’t expect lesions of this size to ever disappear overnight. Bone is slow and lesions like these take lots of time to regenerate back in with bone. I plan on seeing this patient again in another 6 months to see how she continues to improve.
So, tell me how would you treatment plan this case. Would you try to save the teeth? Well, I hope so! And I hope my blogs continue to give you insight on how to save TONS of teeth! (Not subscribed to receive my blog posts every Friday? Click here.)
Tooth Story Takeaways:
- Horizontal root fractures usually do not need to be treated, but when they do, try to treat only the coronal fragment.
- Prognosis for horizontal root fractures goes as follows: apical > midroot > coronal
- Don’t forget to give your bone time to heal and follow up your patients. I plan on watching this patient for the next few years to make sure she gets her bone back.
Until next time!
-Sonia
Hi Sonia,
Thanks for the lesson.
I am wondering how you place the calcium hydroxide to medicate the teeth?????
Thanks,
Hey there!! I use a Vista tip that is flexible that I can place pretty far into the canal. Then I gently express the calcium hydroxide into the canal. I like to use Ultracal from Ultradent. I mention this in my top 10 tools blog where you can see the images and get the link.
-Sonia
Great case thanks
So glad you enjoyed reading this!
-Sonia
I would have thought for sure to extract the tooth. Thanks for going through this case, very informative.
What a great case! I always look forward to learning from your blogs.
And I appreciate you reading!
-Sonia
so you didnt irrigate with Sodium hypochlorite???
and in the follow up does mobility decrease???
Yes I did irrigate with sodium hypochlorite and in this case, there was no mobility. But, yes I would expect it to decrease.
-Sonia
Can u explain more please about how u made sure not to extrude sodium hypochlorite in such case?
Hi Yasmeen – as long as you don’t push your irrigant with force, it really shouldn’t extrude out of the apex. Irrigation should always be delicate.
-Sonia
Hi Sonia,
Thank you for this blog.I am learning so much endo from you that I never did in any of the seminars I had attended before. Thank u for sharing your knowledge with us .Keep going!
Thanks Tamanna! I am so happy you are taking away so much!
-Sonia
Hi, I’ve a root canal done in 2018 Jan & a year later, I felt pain on the area. Over the course of 2019, I had a couple of xrays taken & this year 2020 Oct, the xray showed my root canal has a horizontal crack. Is there anyway to save it? I can attach xrays for yr reference.
Annie,
I am sorry that you are going through this. Unfortunately, this needs a thorough examination that I cannot provide you at this time. Please seek out a consultation from a local endodontist if you still have questions.
Best,
Sonia
Hello doc! In cases of horizontal root fracture how would one be able to know if composite and wire splinting or intraradicular splinting would work better?
Hey there! You always want to use a physiological splint, so I always use a fishing line!
-Sonia
Hello Sonia,
I am scheduled to remove my front tooth next week and replace it with a dental implant. My dentist noticed a horizontal fracture at the root of my crowned tooth. I experienced pain along with a bubble just above the tooth on my gumline a year ago. I was treated with an antibiotic then sent to an endodontist. The endodontist sent me to a periodontist who says removal is my only option. I have no pain whatsoever. The antibiotic cleared the infection. My dentist and the periodontist said the infection has not gone away because the sore on my gum line is still present. They all said the only way to get rid of the infection is to remove the tooth where the source of infection is. I’ m terrified. I have no pain and the tooth is stable. Can it be saved in your opinion? Can I just do nothing? They mentioned the longer I wait I risk bone loss. Can’t this fracture heal on its own? Please help me.
Hi there. Unfortunately, without the proper data, I cannot help you adequately. I would trust your providers. If a tooth is fractured, it cannot heal again. So, that is likely why they are suggesting extraction. If you are confused, please ask your provider for clarification. Thanks.
Dr. Chopra