Root fractures
Complex healing patterns due to concomitant injury to the pulp, periodontal ligament, dentine and cementum.
Fractures can occur:
- in the apical 1/3
- in the middle 1/3
- in the coronal 1/3
- vertical fractures
- Each of these types of fracture have different management issues
- Radiographs at two different angulations are required to diagnose fracture type and location
MANAGEMENT
1. Coronal 1/3 fractures These have a poor prognosis, there is communication with the pulp and the oral cavity via the the free gingivae. This allows the ingress of bacteria which can lead to irreversible pulpitis and periapical pathology. If possible, remove the coronal fragment and assess where the level of the tooth is. If the fracture is < 2mm subgingival then there is a possibility of retaining the tooth but this will need RCT and post placement. Occasionally orthodontic extrusion or apical surgery can be used to provide a restoration to a fractured root. If the remaining root is unrestorable extract.
2. Middle 1/3 fractures These have a variable prognosis, if there is periodontal pocketing, bacteria will ingress down the free gingivae and cause pulpitis and pulpal necrosis. If there is a minimally displaced middle 1/3 fracture, this can be splinted with a rigid splint for ~ 12/52 after manual repositioning. This cannot be repositioned after 24-72 hours as the tooth will become 'fixed' in position.
Regular monitoring is required including pulp sensibility tests. If there is evidence of pulpal necrosis, the tooth needs root treating but this can be performed to the level of the fracture. The apical portion is less likely to lose vitality.
3. Apical 1/3 fractures These carry the best prognosis as there is less chance of bacteria ingress. Treatment is as for middle 1/3 fractures
4. Vertical fractures These are almost universally terminal, extraction is required.
Prognosis of root fractures:
- Pulpal necrosis in about 25% of cases— related to displacement of the coronal fragment and mature root formation
- Healing by hard tissue union is optimal, interposition of connective tissue is acceptable
- It is not presently known how the different forms of healing affect the life expectancy.