7.2
Horizontal Root Fracture
Peng‐Hui Teng
Objectives
At the end of this case, the reader should be able to diagnose and manage root fracture cases and be able to formulate a follow‐up protocol for such injuries.
Introduction
A 45‐year‐old male presented with mild intermittent throbbing pain associated with his upper left central incisor (UL1). He had also noticed that the tooth had discoloured.
Chief Complaint
The patient was asymptomatic when he presented to the clinic. There had been previous episodes of spontaneous pain; each episode lingered for a few minutes before the pain resolved by itself. He recalled a history of trauma to the UL1 tooth more than 10 years ago after being accidentally elbowed while playing football.
Medical History
Unremarkable.
Dental History
The patient was a regular dental attender, with a minimally restored dentition.
Clinical Examination
The crown of the UL1 had greyish discolouration. The tooth was unrestored. It was not tender to percussion and responded negatively to pulp sensibility testing. There was no swelling or sinus tract associated with the UL1. The adjacent maxillary teeth were asymptomatic and responded normally to sensibility testing. The periodontal probing depths and mobility of UL1 and the adjacent maxillary teeth were within the normal range. Clinical findings associated with root fracture were listed in Table 7.2.1.
Radiographic evaluation (Figure 7.2.1) revealed an oblique fracture line at the middle third of the root of the UL1. The radiolucent line was more evident in the mesial aspect crossing the root canal centrally and was less discernible at the distal half of the root. The root canal of UL1 was patent and clearly visible from the radiograph. There was no displacement of the coronal and apical segment. The periodontal ligament (PDL) space was intact and no periapical radiolucency was associated with the UL1. There was no abnormality detected for the adjacent teeth (UL2 and UL3). No sign of alveolar fracture was seen in the radiograph. A periapical radiograph of UR1 and UR2 was also taken to rule out any traumatic dental injuries (TDI) and periapical radiolucency (Figure 7.2.1). A list of radiographic findings associated with root fracture can be found in Table 7.2.2.
A small field‐of‐view (FOV) cone beam computed tomography (CBCT) scan was taken to assess the true nature of the injury (Figure 7.2.2). The CBCT scan confirmed the presence of an oblique root fracture in the mid‐root level. The root fracture was incomplete and only involved the labial aspect of the root canal.
Table 7.2.1 Clinical features of a horizontal root fracture.
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Table 7.2.2 Radiographic features of a horizontal root fracture.
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Diagnosis and Treatment Planning
What is the diagnosis?
A diagnosis of horizontal root fracture with necrotic coronal segment was reached for the UL1.
Why was a cone beam computed tomography scan taken?
The latest International Association of Dental Traumatology (IADT) guidelines recommend taking a parallel periapical radiograph, two additional periapical radiographs at different horizontal and/or vertical angulations and a standard occlusal radiograph for the assessment of root fracture (Bourguignon et al. 2020). Conventional radiographs such as standard occlusal radiographs are subjected to various limitations and errors, such as image elongation or foreshortening, cone cutting, overlapping and anatomical noise. Moreover, conventional radiographs could only assess the proximal aspect of the tooth, which is not always the case in complex TDI such as root fracture. For instance, an oblique root fracture in the sagittal plane could easily be missed by a conventional radiograph, even with the help of a parallax technique. A root fracture will only be detected if the x‐ray beam passes directly through the fracture line.
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