Managing Root Fractures in Permanent Teeth: Treatment Options, Splinting and Prognosis

The management of root fractures in permanent teeth aims primarily to preserve tooth vitality and encourage healing between the fractured fragments through the formation of hard tissue. This is considered the most favourable outcome following a root fracture (Versiani et al., 2008). In immature permanent teeth with an open apex, an additional treatment goal is to allow continued root development and physiological closure of the apex (Popescu et al., 2017).

For horizontal root fractures, the treatment approach depends on several factors, including the location of the fracture line, the amount of remaining coronal tooth structure, the position of the fracture in relation to the alveolar crest, and the vitality of the pulp (Andreasen et al., 2007).

Apical Third Root Fractures

In apical root fractures, the apical fragment is usually not displaced. As a result, these fractures may be overlooked clinically and discovered during routine radiographic examination (Prithviraj et al., 2014).

Clinically, the tooth is usually asymptomatic and shows little or no mobility (Popescu et al., 2017). When the blood supply to the apical fragment remains intact, there is a high probability that the fragment will remain vital (IADT, 2020).

There are two main clinical situations associated with apical-third fractures. In the first, the tooth presents with no mobility, no displacement, and no symptoms. In this situation, treatment consists of observation and regular follow-up. Spontaneous healing is reported to occur in most cases of apical root fractures (Cardoso & Rocha, 2004).

In rare cases where the pulp becomes necrotic, surgical removal of the apical fragment may be indicated, followed by apexification and root canal filling of the coronal segment (Andreasen et al., 2007). The risk of pulp necrosis in the coronal segment is relatively low, reported to be approximately 25% (Popescu et al., 2017).

The second situation occurs when the tooth is displaced and mobile. In this case, repositioning and stabilisation with a flexible splint for four weeks is recommended (IADT, 2020). Necrosis of the apical segment is uncommon because its blood supply is usually maintained (Hovland, 1992).

Overall, horizontal root fractures in the apical third have the most favourable prognosis for maintaining pulp vitality and achieving root healing (Andreasen et al., 2007).

Middle Third Root Fractures

In middle-third root fractures, the treatment approach depends on the degree of separation between the fragments, the amount of displacement and mobility of the coronal fragment, and the vitality of both the coronal and apical segments (Hovland, 1992).

When there is no mobility or displacement and only a small diastasis between the fragments, observation and regular follow-up are usually sufficient (Berman, 2007).

If the coronal fragment is displaced, repositioning and immobilisation should be performed under local anaesthesia to avoid causing pain (Berman, 2007). The coronal fragment should be gently repositioned using firm digital pressure, after which its position should be confirmed radiographically before splinting (IADT, 2020).

If resistance is encountered during repositioning, an associated alveolar bone fracture should be suspected. In such cases, surgical reduction may be required before repositioning and splinting (Biner et al., 2011). Repositioning can also help restore revascularisation of the coronal pulp when its blood supply has been interrupted (Biner et al., 2011).

For middle-third root fractures, a flexible splint is generally applied for four weeks (Andreasen et al., 2007).

Pulpal Complications and Endodontic Management

The vitality of both the coronal and apical fragments must be monitored during follow-up, as different healing outcomes may develop during the first three months following the injury. This highlights the importance of repeated clinical, radiographic, and pulp vitality assessments (Brandini et al., 2009).

For example, the coronal fragment may show a negative response to pulp testing, crown discolouration, and radiolucency around the fracture line (Biner et al., 2011). In contrast, the apical segment may maintain a normal periodontal ligament space without signs of inflammatory root resorption (Biner et al., 2011).

In this situation, the radiolucency should be monitored through follow-up radiographs to confirm whether an infection is progressing. If pulpal necrosis is confirmed in the coronal segment, apexification can be performed to create an apical seal. This can be achieved using either an MTA plug or calcium hydroxide (Cvek et al., 2008). The vital apical fragment can then be left untreated. This treatment approach has been reported to achieve success rates of up to 94% (Cvek et al., 2008).

Alternatively, if both the coronal and apical fragments become necrotic and clinical and radiographic signs of infection are present in both segments, treatment becomes more complex (Westphalen et al., 2008).

Initially, root canal treatment through both the coronal and apical fragments was used. However, this approach can be technically difficult and has demonstrated lower success rates because of the possibility of further separation between the fragments (Berman, 2007).

Therefore, apicectomy, involving surgical removal of the apical fragment, combined with endodontic treatment of the coronal segment may be considered (Westphalen et al., 2008).

Cervical Third Root Fractures

Cervical-third root fractures are among the most challenging root fractures to manage and generally have the poorest prognosis (Canoglu et al., 2007). Treatment depends on several factors, including whether the fracture line is exposed to the oral cavity, the amount of remaining root length, and whether the coronal fragment is present (Malmgren et al., 1991).

When the coronal fragment is present and the fracture is located below the crestal bone, reduction and splinting for four weeks and up to four months may be required to provide adequate stability to the coronal fragment (IADT, 2020).

When the coronal fragment is absent, the fracture is located above the alveolar crest, and sufficient root length remains, endodontic treatment followed by post and crown restoration may be considered (Parolia et al., 2010). If exposure of the coronal margin is required, gingivoplasty or an apical flap may be performed to improve aesthetics and function (Parolia et al., 2010).

When the fracture line is located below the alveolar crest, adequate space must be created to allow proper seating of the coronal restoration while maintaining the biological width. Several treatment options can be considered.

Crown lengthening involves removing approximately 1–2 mm of bone around the root to expose the fracture and create adequate restorative space (Hempton & Dominici, 2010).

Orthodontic extrusion is considered one of the most predictable treatment options and is relatively easy to perform. It involves gradually moving the fractured root segment coronally to expose the fracture line and allow restoration (Malmgren et al., 1991).

Surgical extrusion may also be considered; however, it is generally not recommended because of the potential for excessive bone loss (Hempton & Dominici, 2010).

If the fracture is located in an unfavourable position and insufficient root length remains to achieve an appropriate crown-to-root ratio, extraction may be necessary when conservative treatment is not possible. Decoronation has also been suggested as an alternative approach, as it preserves the apical root segment and can help maintain alveolar bone for possible future implant placement (Malmgren, 2000).

The prognosis for spontaneous healing of cervical root fractures is poor, with reported rates of approximately 2–9% (Berman, 2008). This is attributed to the limited formation of hard tissue between the fragments, bacterial contamination from the oral cavity, and the mobility of the short coronal fragment (Prithviraj et al., 2014).

Splinting in Root Fracture Management

The main purpose of splinting is to reposition a displaced tooth and prevent further injury to the periodontal ligament and pulp during the healing process (Andreasen et al., 2007). Splinting is considered an important treatment approach for maintaining the tooth in its correct position while providing patient comfort and allowing normal function during healing (IADT, 2020).

Although there has been some controversy regarding the influence of splint type and duration on the healing outcome of root-fractured teeth (IADT, 2012), current evidence supports the use of a short-term flexible splint in most traumatic dental injuries, including root fractures (DiAngelis et al., 2012).

Different types of splints have been used for root fractures, including 0.4 mm stainless steel wire with composite resin, titanium splints, fibre splints, and orthodontic bracket splints (Brown & Mackie, 2003).

An ideal splint should be easy to fabricate, attach, and clean. It should also allow pulp vitality testing and access for endodontic treatment when necessary (Kahler et al., 2016). Furthermore, the splint should not interfere with occlusion or cause irritation to the surrounding soft tissues (Kahler et al., 2016).

In conclusion, the management of root fractures in permanent teeth depends largely on the location of the fracture, displacement of the fragments, pulp vitality, and the amount of remaining tooth structure. While apical and middle-third fractures generally have favourable outcomes when appropriately managed, cervical fractures remain more challenging and often require multidisciplinary treatment. Careful repositioning, appropriate splinting, regular vitality testing, and long-term follow-up are essential for achieving the best possible prognosis.

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