Conservative Approach and Management of Cervical Root Fracture, Case Report

Root fracture is a radiographic finding of dental trauma by which the cementum, dentin and pulp tissues will be separated through an oblique, vertical, or horizontal plane at the apical, medium, or coronal level (1-3). The apical and medium transverse fracture can be allocated using occlusal radiograph, while the bisecting angle exposure is used to detect the cervical fracture type (1). Furthermore, Cone Beam Computed Tomography CBCT can be of great benefits for better visualization and determination of the site, direction, and extension of the fracture line especially for complicated cases (1, 4). Clinically, the crown position could be sometimes displaced with visible mobility and tenderness, and pulp test is usually negative except for a few cases in which indicates high percentage of pulp survival (1).

Indeed, the vertical fracture followed by the cervical transverse type are considered with the worst prognosis (2, 3). To date, the common management of the former is achieved via extraction (1), although recently there are successful attempts to reunite the two fragments through the use of bioactive root canal filling materials and endodontic fibre-post along with full crown coverage (5, 6), while the treatment of the latter mainly depends on repositioning the coronal segment in case of displacement then applying a flexible splint usually for four weeks, but can be extended up to four months if the fracture site is close to the cemento-enamel junction(1). Regular monitoring of the broken root is mandatory and, thus, any sign of necrosis clinically or radiographically necessitates an endodontic treatment mostly limited to the coronal segment aiming for apexification at the fractured surface; the reason for this is the difficulty to determine an accurate working length at an irregular and oblique root fracture plane (1, 7, 8). On the other hand, if the root fracture is located over the alveolar crest, the excision of the coronal fragment will become inevitable. Subsequently, an orthodontic traction, crown lengthening, or surgical repositioning of the remaining root accompanied with gingival recontouring or osteoplasty can be carried out to relocate the fracture plane in more appropriate coronal position through which the intracanal fibre-post and the full crown coverage will be better seated with respect to the biological width and marginal gingiva (1, 9, 10). On the other hand, the development of immature permanent incisors and the radicular pulp should be maintained after removing the coronal fragment. Therefore, it is advisable to perform partial pulpotomy using either of calcium hydroxide dressing or non-staining calcium silicate followed by reinforced glass ionomer or composite restoration aiming for apexogenesis. However, in the severe and non-restorable cases, coronectomy can be a suitable option to maintain the alveolar bone for subsequent implant installation (1).

In fact, research is still ongoing to maximize the survival rate of the teeth undergone root fracture. Hence, this case study reported a successful conservative management of cervical root fracture in the upper left central incisor located at the same level of alveolar crest in 18-year-old male.