Who is ready for a tooth story about a horizontal root fracture?

I’ve got a good one for you today, all about how to nail your diagnosis and treatment plan like an expert, so your patient walks out of your office feeling great about their experience — and you can pat yourself on the back, too.

These bad boys are tough to treat, but tough does not equal impossible. Doing it successfully just requires a little help from your endo fairy godmother. (That’s me!)

Is a horizontal root fracture tough to treat?

One of the most challenging traumatic injuries to diagnose and treat is a horizontal root fracture. Working with them can get pretty darn 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. If the tooth is mobile, that’s another story.  

If the tooth IS mobile, you may need to stabilize it for some time with a flexible splint.

Did you know apical fractures have the best prognosis, and then midroot, and then coronal. Why? Well, the apical fractures are more surrounded by bone and therefore less mobile. And since the fracture is also far away from the sulcus, and therefore, bacterial contamination, this also improves the prognosis. As the fracture moves up the root, the prognosis deteriorates.

So, remember this:  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 will still be vital.

Tooth story: A horizontal root fracture and a side of tooth trauma

Take a look at this case. It serves as a perfect example of what I’ve been talking about.

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 not honored here in teeth #8 and 9. The canals were located and treated, but they were not instrumented to working length or working circumference.  I hate when I see this, because I know this patient could have avoided some discomfort, saved money, and spent their time somewhere besides my chair. 

In any case, 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…

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, there was 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. Woohoo! 

Horizontal Root Fracture Tooth Story Takeaways:

In summary, here’s what I want you to take away from this case:

  • 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.

Remember, don’t expect lesions of this size to ever disappear overnight. Bone is slow to grow, and lesions and horizontal root fractures take lots of time to regenerate back in with bone. I plan on seeing this patient again in another 6 months to see how things have progressed. 

How would you treat this case? Would you try to save the teeth? I hope so! 

How Will You Empower Yourself from Here?

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Until next time!