The initial treatment of teeth with root fractures is a
relatively simple matter provided attention is paid to a
few principles. An initial assessment must be made as to
whether the fracture line is communicating with the
oral cavity, or that it could potentially communicate
with it due to tooth movement and gingival recession.
Should this be the case, the coronal fragment will
generally need to be removed, and the remaining root
structure assessed on its merits. If the tooth is to be
retained, the tooth should be treated as a deep
crown-root fracture and the remaining root can be
endodontically treated if the root is to be retained.
If the fracture line is not communicating with the
oral cavity, an assessment can then be made of tooth
position and tooth mobility. If the coronal fragment is
displaced, it should be repositioned and splinted. If the
fragment is mobile, it should be splinted. In both
scenarios, the teeth should be relieved from occlusion.
Non-rigid splinting for less than four weeks is now
recommended for most root fractured teeth,
although when excessive mobility of the fragment is
encountered, more prolonged splinting may be
required. Fractures that occur between the alveolar
crest to a distance of 5mm below are the most difficult
to manage and have the poorest long-term prognosis.
However, nothing is lost by splinting these teeth and
assessing their prognosis over time. Longer splinting
times of up to four months are recommended in these
circumstances.
All root fractures that do not communicate with the
oral cavity should be treated as if the pulp is not
irreversibly damaged. Endodontic treatment should not
be initially undertaken for a tooth with a root fracture,
even in the absence of positive pulp sensibility testing,
which is a common finding immediately and for some
time after a root is fractured.
If the root-fractured tooth is neither displaced nor
mobile, then no treatment is necessary in the initial
stage, apart from ensuring that the tooth is free from
the occlusion in all movements. In the absence of
symptoms, follow-up radiographs should be taken at
one month, two months and six months following
trauma, and then at yearly intervals.
Two factors need to be assessed at follow-up
examination: pulp sensibility and tooth mobility. In
general, if pulp necrosis occurs, it will be confined to
the coronal fragment. Should pulp necrosis develop,
temporary filling of the root canal with calcium
hydroxide for four to six months to the level of the
fracture followed by root filling with gutta-percha or MTA
to that level is the treatment of choice. Under
no circumstances should the pulp be removed beyond
the level of the fracture in the first instance as doing so
will compromise the long-term success of treatment. As
a general rule, the closer the root fracture is to the
cervical level the longer the treatment time required. In
those rare cases where the apical fragment also
becomes necrotic, as would be evident radiographically
by the development of a periapical radiolucency as well
as a mid-root radiolucency, a decision must be made
whether to root fill to the fracture site and to remove
the apical fragment, or to include the apical fragment in
the root filling. It has been claimed that prognosis is
poor if the apical fragment has to be removed, although
not all authors agree with this.
If the tooth continues to be mobile after an initial
splinting procedure, consideration can be given to
either prolonging the splinting time or splinting the
crown of the tooth to adjacent teeth in a more
permanent manner. Some long-term discomfort to
biting on a root-fractured tooth is not unusual.
Treatment of root-fractured teeth by the use of
endodontic implants has been recommended in the past
as a means to reduce mobility. However, the long-term
prognosis for these implants is doubtful and their
placement is not recommended.