How Are Root Fractures Diagnosed? A Guide to Clinical and Radiographic Assessment

Accurate diagnosis of a root fracture is essential, as these injuries can easily be overlooked and may sometimes only be discovered during routine radiographic examination. Early diagnosis through a thorough clinical and radiographic assessment can help improve treatment outcomes and the prognosis of the affected tooth (Andreasen et al., 2007).

Diagnosing root fractures can be particularly challenging in trauma patients, especially during a child’s first dental visit following an injury. Anxiety, pain, and distress may make the examination more difficult (Prithviraj et al., 2014). Therefore, the assessment should begin with a careful evaluation of the patient’s overall condition and the circumstances surrounding the injury.

Initially, the practitioner should examine the patient for signs of bleeding, facial lacerations, and hematoma (Cardoso & Rocha, 2004). The child and parent should be reassured before obtaining a complete medical and trauma history. The trauma history should include when the injury occurred, the exact time if possible, where it happened, and how the injury occurred (IADT, 2020). This information may also be important for legal purposes when completing a trauma report and can help determine whether bacterial contamination has occurred, which may require tetanus vaccination or systemic antibiotic treatment (Fuss et al., 2007).

An extraoral examination should also be carried out to rule out facial bone fractures, facial asymmetry, and condylar fractures, which may present with limited mouth opening (Cardoso & Rocha, 2004). Since dental trauma can sometimes be associated with neurological consequences, the practitioner should also ask about symptoms such as loss of consciousness, drowsiness, or vomiting following the injury (IADT, 2012).

Intraoral Examination

Following the extraoral examination, an intraoral assessment should be carried out. The gingiva, frenum, and oral mucosa should be examined for lacerations, hematoma, or embedded tooth fragments (IADT, 2020).

A common clinical feature of root fractures is bleeding from the gingival sulcus. The affected tooth may also appear slightly extruded or displaced lingually following a labial impact (Andreasen et al., 2007). The degree of displacement and mobility depends on the severity of the impact and the position of the fracture line in relation to the crestal bone (Andreasen et al., 2007).

Patients with root fractures are often asymptomatic; however, pain on percussion and palpation may be present (Lertchirakarn et al., 2003).

In horizontal root fractures, the location of the fracture line can influence the degree of mobility and displacement. Fractures in the apical third usually present with little or no displacement or mobility. In contrast, middle-third fractures may present with slight extrusion and displacement of the coronal fragment (Kamburoglu et al., 2009). Cervical-third fractures can result in displacement and varying degrees of mobility, ranging from mild to severe (Kamburoglu et al., 2009).

Because these clinical findings may be similar to those seen in luxation injuries, it is not always possible to distinguish the type of trauma through clinical examination alone. Therefore, radiographic examination is necessary to confirm the diagnosis (IADT, 2020).

Radiographic Examination

Radiographic examination is a key component in the diagnosis of dental trauma, including root fractures (IADT, 2020). For a root fracture to be visible radiographically, the X-ray beam must be aligned with the plane of the fracture (Andreasen et al., 2007).

Unfortunately, some root fractures may initially be missed because the fractured fragments remain in close proximity. In such cases, the fracture may only become visible later when separation between the fragments increases (Versiani et al., 2008).

Several radiographic approaches can be used to improve the detection of root fractures. One approach is the **multi-directional technique**, which includes a central periapical radiograph and two additional periapical radiographs taken at different horizontal angles, approximately 15–20 degrees from the conventional beam (Andreasen et al., 2007).

Another approach involves taking two periapical radiographs from different angles in addition to an occlusal radiograph (IADT, 2020).

Cone-beam computed tomography (**CBCT**) has also been discussed as a diagnostic option for trauma patients. Its advantages include increased diagnostic accuracy, high resolution, reduced scanning time, and the elimination of superimposition from surrounding structures (Likubo et al., 2009). However, its use in paediatric dentistry is limited by factors such as higher cost, the need for specialised equipment and training, and increased radiation exposure to the patient (IADT, 2020).

Pulp Testing

Pulp testing can also form part of the diagnostic assessment. However, it may be difficult to perform accurately in a traumatised child because anxiety and pain can affect the patient's response and may result in false-positive findings (Malhotra et al., 2011).

In other cases, pulp testing immediately after trauma may produce a negative response due to transient damage to the pulp rather than permanent loss of vitality (Malhotra et al., 2011). Despite these limitations, pulp tests should be performed at the time of injury to establish a baseline for comparison during future follow-up appointments (IADT, 2020).

A normal pulp response is generally expected to return within approximately six weeks following the injury (Fuss et al., 2007).

References

• Andreasen FM, Andreasen JO, Cvek M. Root fractures. In: *Textbook and Color Atlas of Traumatic Injuries to Teeth*. Andreasen FM, Andreasen JO, eds. Copenhagen: Blackwell Publishing Ltd, 2007: pp. 337–371.

• Cardoso M, Rocha MJ. Federal University of Santa Catarina follow-up management routine for traumatized primary teeth - Part 1. *Dental Traumatology*. 2004;20:307–313.

• Fuss, Z., Lin, S. and Tsesis, I. (2007). Intra-alveolar root fractures. In: *A Clinical Guideline to Dental Traumatology*. Berman, L.H., Bianco, L. and Cohen, S., eds. Mosby Elsevier: pp. 12–26.

• Lertchirakarn, V., Palamara, J.E. and Messer, H.H., 2003. Patterns of vertical root fracture: factors affecting stress distribution in the root canal. *Journal of Endodontics*, 29(8), pp.523–528.

• Malhotra, N., Kundabala, M. and Acharaya, S. (2011). A review of root fractures: diagnosis, treatment and prognosis. *Dental Update*, 38, pp.615–628.

• Versiani, M.A., Sousa, C.J.A.D., Cruz‐Filho, A.M., Perez, D.E.D.C. and Sousa‐Neto, M.D., 2008. Clinical management and subsequent healing of teeth with horizontal root fractures. *Dental Traumatology*, 24(1), pp.136–139.