Horizontal Root Fractures: To Treat or Not to Treat, That is the Question! But What is the Answer?

It is not uncommon to see people with fractures to anterior teeth, usually as a result of a traumatic incident. A blow to the teeth can result in a crown fracture, partial or complete avulsion, a fracture to the root or some combination. These incidents create a lot of angst for both the patient, their families, and often for the dental team. They require an accurate diagnosis, speedy treatment plan, and definitive treatment, usually unexpected in a busy patient day.

Horizontal root fractures are one such result of a traumatic injury, usually to maxillary anterior teeth in active children. Rarely are these so called horizontal fractures actually horizontal. Most often they are oblique fractures, with the fracture extending from a more apical position on the buccal to a more coronal position on the palatal (see figure 1).

Figure 1
21 HRF

Figure 2
21 CBCT2

The diagnosis usually confirmed by visualization of the fracture from a radiograph. Clinically there may be little in the way of symptoms, most often some degree of percussion sensitivity and increased mobility. The clinical finding most pertinent to the prognosis is the location of the palatal extent of the fracture. This can be seen accurately only with a CBCT. Another clue is how the tooth probes. Deep probing depths, especially if the fracture can be probed or felt with an explorer likely dooms the tooth to extraction. Normal probing with the most coronal position of the fracture below the osseous crest is more hopeful.

This case presented to our office within the last year. The 10-year-old boy had sustained a traumatic blow to the tooth. The clinical exam revealed tooth #21 was percussion and palpation positive, normal probing depths, a positive response to cold tests, and normal colour. The mobility was minor at class I. PA and CBCT radiography showed an immature root form with an oblique root fracture which was 1-2 mm below the palatal crest of bone.

Cvek and Andreasen, Dental Traumatology 2008 24:194(4), looked at 534 cases of horizontal root fractures in patients aged 7-17. After 10 years there was an 80% survival rate with healing of the fracture by hard tissue, likely osseous replacement. They found that the more apical the fracture location, the better the survival rate.

The clinical and radiographic findings in our patient lead us to a conservative treatment plan. Guidelines from the International Association of Dental Traumatology (IADT), in agreement with the AAE, recommends splinting of the tooth for 4 weeks in as normal a position as possible as quickly as possible and then monitoring of pulpal vitality for a period of one year.

Our patient’s tooth mobility was relatively minor so splinting was not imperative. The bite was adjusted to eliminate any fremitus while maintaining contact. Because of the normal tooth colour and response to cold, the pulp was deemed vital. Subsequently, the decision was made to simply monitor this tooth. The patient was re-evaluated at one week, 4 weeks, and 12 weeks for pulpal vitality, mobility, colour, and radiographic appearance. Further 3 month monitoring for at least a year is recommended. To date, the tooth is surviving well.

Hopefully, this conservative approach will allow for further root formation and repair of the fracture line. The parent was instructed to look for colour changes or increased sensitivity to percussion and/or palpation. These types of changes might indicate that the pulp was necrotic and further endodontic intervention required. The ability to maintain this tooth in a normal tooth position without submergence, in a normally developing maxillary arch, at least until full facial growth has occurred is a great result for the patient.


About the Author, Dr. Howard Bittner, DMD, CAGS

Dr. Bittner was born and raised in the Surrey / Langley area. Following his pre-dental training at Simon Fraser University, he received his Doctor of Dental Medicine from the University of British Columbia in 1982 and his Certificate in Advanced Graduate Studies in Endodontics from Boston University’s Goldman School of Dental Medicine in 1995.
Dr. Bittner was in private practice in general dentistry for 11 years in Langley before his Endodontic specialty training. He has been practicing Endodontics since 1995.
In his free time, Dr. Bittner loves to participate in a variety of sports including most recent, golfing! He also enjoys being a grandfather to 3, which if you ask him is just the best!

On March 1, 2017, posted in: News for Doctors by