From: Marga Ree
To: ROOTS
Sent: Wednesday, March 23, 2005 9:32 PM
Subject: [roots] 1 year follow-up of two horizontal root fractures

I have posted this case before, but wanted to add this one to the discussion whether or not to remove the apical
fragments. In this case I left them in situ, but had to do surgery to resolve the patient's symptoms.- Marga

This 21 year old man was involved in a bar fight. His dentist made a splint and did an attempt to perform rct, but he
was not able to instrument the apical parts. (page 1)  He referred the patient to me.

•Consultation:
11 (#8) and 21(#9) horizontal root fractures
•21 (#9) uncomplicated crown fracture
•12 (#7) apical periodontitis

First thing I did is remove the splint, C&S 11 and 21, place Ca(OH)2 and make a filling of composite in # 21.
After 1  month I obturated # 11 and 21 completely with MTA, 12 with gp and AH26 (page 2)

After 3 months he returned for a follow-up, and complained about sensitivity upon biting and palpation of # 11. There
was a pocket buccal of # 11 till the fracture level. I decide to raise a flap and clean the fracture gaps. I removed
the granulation tissue with a lot of embedded root fragments and extruded MTA.

I applied Emdogain, because I was hoping to prevent apical downgrowth of the epithelium.  (page 3 and 4)
Rad on page 4 is immediate follow-up after surgery

1 year follow-up (page 4 and 5): Probing depths of 2 mm, no sensitivity, patient can function without any problems,
radiographs show healing. - Marga








Fantastic Marga ...............I am sure in most parts of the world the patient would have lost his tooth and would now
be having a prosthesis.

You removed the initial splint placed by the refg.dentist and the clinical images don't show a fresh splint So how did
you manage to prevent the mobility during function?? - Sachin

Thanks Sachin!
The splint was already 4 weeks in place, and was applied in a way that it didn't serve it's purpose, to put it mildly.
It was more a source of plaque retention and tissue irritation.

In addition, according to this paper of Cvek and Andreasen, there is no benefit of splinting for more than 4 weeks. I
adjusted the teeth out of direct and excursive occlusion.- Marga


Dent Traumatol. 2004 Aug;20(4):203-11.

Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning,
splinting type and period and antibiotics.

Andreasen JO, Andreasen FM, Mejare I, Cvek M.

Department of Oral and Maxillofacial Surgery, University Hospital (Rigshospitalet), Copenhagen, Denmark. rh11323@rh.dk

This is the second part of a retrospective study of 400 root-fractured permanent incisors. In this article, the effect
of various treatment procedures is analyzed. Treatment delay, i.e. treatment later than 24 h after injury, did not
change the root fracture healing pattern, healing with hard tissue between fragments (HH1), interposition of bone
and/or periodontal ligament (PDL) or pulp necrosis (NEC). When initial displacement did not exceed 1 mm, optimal
repositioning appeared to significantly enhance both the likelihood of pulpal healing and hard tissue repair (HH1).
Significant differences in healing were found among the different splinting techniques. The lowest frequency of healing
was found with cap splints and the highest with fiberglass or Kevlar splints. The latter splinting procedure showed
almost the same healing result as non-splinting. Comparison between non-splinting and splinting for non-displaced teeth
was found to reveal no benefit from splinting. With respect to root fractures with displacement, too few cases were
available for analysis. No beneficial effect of splinting periods greater than 4 weeks could be demonstrated. The
administration of antibiotics had the paradoxical effect of promoting both HH1 and NEC. No explanation could be found.
It was concluded that, optimal repositioning seems to favor healing. Furthermore, the chosen splinting method appears
to be related to healing of root fractures, with a preference to pulp healing and healing fusion of fragments to a
certain flexibility of the splint and possibly also non-traumatogenic splint application. Splinting for more than 4
weeks was not found to influence the healing pattern. A certain treatment delay (a few days) appears not to result in
inferior healing. The role of antibiotics upon fracture healing is questionable. Copyright Blackwell Munksgaard, 2004.
Thanks Marga

Luckily I had a patient today with an accident injury and a horizontal Root fracture in 11 and a crown fracture in 21(
rad.image attached). There is 1degree mobility in 11 and the perio probing is 1mm buccal........................What do
u suggest?? My treatment planning is split for 4 weeks and observe and if required endo on the coronal segment ( when?
is what you suggest).

Two questions regd this

1: How soon should I look for pulpal symptoms .If the healing of this horizontal fracture takes a long time what are
the chances of the appearance of pulpal symptoms during this healing phase?

2: If the coronal pulp starts degeneration what would be the clinical symptoms and what would be the pulp tester
readings ?

Anymore suggestions that I am not asking for are also most welcome...........:-) - Sachin

Hereby a slide of my friend and colleague Michiel de Cleen on the occurence of pulp necrosis in horizontal root
fractures, which is less than 30%. So usually the best approach is to do nothing, and to follow-up very carefully,
because there is a big chance for the tooth to maintain vital. If the coronal segment becomes non-vital, then perform
an endo in the coronal part. You will see the usual signs, e.g. discoloration, radiolucency on fracture level, sinus
tract, symptoms etc. The apical segment will show often pulp canal obliteration after a while.- Marga



I forgot to say that if there is no displacement of the coronal segment, you can also refrain from splinting. See
Andreasen et al:
Comparison between non-splinting and splinting for non-displaced teeth was found to reveal no benefit from splinting.
Good luck, Marga

Thanks Marga. I have decided to put a splint considering the age of the patient ( 23 yrs )  as a precaution I decided
in favour of the splint. - Sachin