Management of a Coronal Horizontal Root Fracture With Complicated Crown Fracture: A Case Report With 2‐Year Follow‐Up

ABSTRACT

Timely and appropriate management of coronal‐third horizontal root fractures in children, including rigid splinting and root canal treatment with bioceramic obturation, can lead to successful healing and preservation of tooth function, even in cases traditionally considered to have a poor prognosis.

1. Introduction

Traumatic dental injuries (TDIs) present a significant challenge in pediatric dentistry, especially among children aged 8–12 years, who show the highest incidence [1]. The prevalence of TDIs varies dramatically across different populations, ranging from 2.4% to 58.6%, with root fractures making up 0.5%–7% of permanent tooth injuries [2, 3]. Horizontal root fractures, which are most commonly found in the middle third of roots, represent the majority of these cases [4]. Factors contributing to these injuries typically include falls, sports collisions, vehicular accidents, and physical altercations, often requiring emergency intervention [5]. The maxillary anterior region is particularly susceptible due to its anatomical positioning, and inadequate management of these injuries may lead to long‐term functional and aesthetic complications [6, 7]. Moreover, the International Association of Dental Traumatology (IADT) guidelines emphasize that combined injuries—such as a horizontal root fracture concomitant with a complicated crown fracture—need a modified protocol combining both pulp‐preserving and splinting strategies to alleviate the negative synergistic effects on pulp vitality and periodontal healing [8].

In considering diagnosis, horizontal root fractures usually involve the displacement of the coronal segment while maintaining the integrity of the apical region, often accompanied by damage to the periodontal ligament (PDL) and alveolar bone [5]. Classification systems focus on the location of the fracture and the mobility of the coronal segment as critical determinants [9]. Diagnostic protocols merge clinical assessments with advanced imaging techniques, such as intraoral periapical radiography or cone beam CT, which reveal radiolucent fracture lines [10]. Vitality testing is essential for assessing pulp status post‐trauma, and mobility grading provides guidance for estimating prognosis [11]. According to IADT, initial radiographic assessment should include at least two periapical views at different angulations plus an occlusal film to confirm fracture location and fragment displacement; three‐dimensional imaging may be reserved for cases where two‐dimensional images are inconclusive [8].

The therapeutic approach to managing these injuries initially centers on stabilizing the coronal fragment through semi‐rigid or rigid splinting [12]. Despite these interventions, multifactorial healing challenges may arise due to concurrent damage to dentin, pulp, cementum, and PDL [13].

2. Case Examination

This case presents a 10‐year‐old girl who sustained significant dental trauma to her maxillary anterior teeth following a fall at school. A general dentist initially managed her condition by placing a rigid splint from canine to canine and applying a pulpal dressing to the site of pulpal exposure. Three weeks later, the patient was referred to the Endodontics Department of Mashhad School of Dentistry for comprehensive treatment. During this visit, sensitivity tests were done on all four anterior teeth, yielding negative results. Additionally, percussion and periapical tests were performed, which also indicated no response from the affected teeth. The upper left central had suffered from a complicated crown fracture.

3. Methods

3.1. Investigation

Radiographic evaluation revealed a complex crown fracture in the maxillary left incisor characterized by horizontal and vertical fractures extending to the proximity of the crown‐root junction (Figure 1A,B). Notably, a correlation exists between the fracture area and the PDL, indicating compromised periodontal status. The coronary section demonstrated grade II mobility.

FIGURE 1.

(A, B) Two Periapical radiographs with different angles demonstrating a horizontal root fracture (HRF) with a clear connection to the periodontal ligament (PDL), proximity to the gingiva, coronal and apical segments separation, and PDL widening; (C) Intraoral photograph of the affected tooth, revealing exposed pulp following the removal of the pulpal dressing. Notable swelling of the papillary gingiva and slight migration into the fracture site are observed, along with evident displacement, extrusion, and rotation of the tooth.

Since the coronal piece exhibited Grade II mobility, it indicated a poor prognosis. The probing depth of the affected tooth is shown in Table 1. However, considering the patient was only 10 years old and still in adolescence, the treatment plan prioritized retaining the tooth.

TABLE 1.

Probing depth measurements (mm) of the affected.

Probing site	Mesial	Distal	Buccal	Palatal
Depth (mm)	5	4	4	3

This approach aimed to preserve the tooth's function and support the patient's ongoing dental development. Given the extended exposure of the pulp due to the crown fracture, along with the close connection of the fracture to the PDL and its proximity to the coronal and oral biome, it was determined that crown root treatment was necessary to decrease the risk of pulp necrosis and prevent further complications.

3.2. Treatment

Following consultation with a periodontal specialist regarding the tooth's maintainability and a restorative specialist for its restorability, coronal root canal treatment was scheduled. Although a general dentist initially managed the patient with a rigid canine‐to‐canine splint and pulpal dressing, after 3 weeks without improvement in PDL status, the rigid splint was carefully removed and a flexible splint, constructed from 0.4 mm stainless steel wire and composite resin, was applied, planned for 4 weeks to facilitate physiological tooth movement and PDL repair, with strict avoidance of bonding agents on gingival margins to prevent plaque accumulation. An access cavity was distally prepared in the maxillary left first incisor. The working length was determined using the Apex Locator (FindPex, Eighteeth, Changzhou, China) and K‐file #60 (MANI, INC., Utsunomiya, Japan) and confirmed by radiography (Figure 2A). The canal was instrumented briefly using a K‐file #60 to avoid weakening the remaining coronal dentin structure. Canal irrigation was carried out using 5.25% sodium hypochlorite and normal saline during instrumentation. The canals were then obturated with Cold Ceramic (SJM, Iran) up to the working length, and the entire canal was filled with this bioceramic sealer (Figure 2B).

FIGURE 2.

(A) Radiographic view of working length measurement with K‐file #60; (B) Final periapical radiograph demonstrating the completion of canal filling with cold ceramic material to the cementoenamel junction.

4. Conclusion

4.1. Outcome and Follow‐Up

At the 2‐month follow‐up, the rigid splint, which had provided essential stabilization during the initial 4‐week healing period, was removed. Clinical and radiographic assessments indicated satisfactory PDL healing, reflecting successful tissue integration and an overall favorable prognosis for the affected tooth (Table 2).

TABLE 2.

Probing depth measurements after 4 weeks of follow‐up.

Probing site	Mesial	Distal	Buccal	Palatal
Depth (mm)	3	3	3	2

Following confirmation of adequate healing and the absence of symptoms related to the apical fragment, the tooth was restored with composite resin under complete isolation using a rubber dam. Given the successful healing of the coronal segment and the absence of pathological mobility, composite resin was selected as the preferred restorative material. This choice was particularly suitable considering the patient's adolescent age, favoring a conservative and minimally invasive approach that preserves tooth structure. Alternative restorative options, such as fixed dental prostheses, would require intracanal access and preparation that could compromise the integrity of the coronal section seal. Therefore, fixed prostheses were deemed contraindicated in this case to avoid jeopardizing the long‐term prognosis of the tooth.

At the 2‐year follow‐up appointment, radiographic evaluation demonstrated successful repair of the fracture, as evidenced by complete calcification of the apical fragment. Clinical assessments indicated that all adjacent anterior teeth responded positively to palpation and pulp vitality tests, while negative apical tests suggested no signs of apical pathology (Figure 3). Probing depths remained within normal limits, and the gingival tissues exhibited no signs of inflammation or excessive bleeding upon probing.

FIGURE 3.

(A) Intraoral photograph displaying slight discoloration of the tooth, with no signs of gingival inflammation. (B) Clinical assessment indicating normal probing depth and tooth mobility within the expected range. (C) Periapical radiograph illustrating apical section calcification and a normal PDL appearance, indicating effective treatment outcomes.

The timely intervention for crown root treatment was crucial in preserving the affected tooth. The favorable outcomes observed at the 2‐year follow‐up highlight the effectiveness of the treatment protocol utilized.

5. Discussion

Preserving natural teeth and restoring the oral cavity to a functional state is a primary goal in dentistry. Extraction and replacement with an osseointegrated implant should always be considered a last resort, after all other options for retaining the natural tooth have been exhausted. When treating fractured teeth, the main objective is to maintain their position within the dental arch. Recent advancements in bonding agents, restorative resins, and new materials such as fiber posts and dual‐cure resin cement have provided clinicians with a range of treatment options for managing fractured roots [14].

However, the chosen approach carries inherent limitations and potential risks that warrant critical appraisal. Cold Ceramic exhibits excellent short‐term sealing ability and biocompatibility, promoting hard‐tissue regeneration; yet histological studies report significantly lower cementum and PDL formation compared to MTA (87.5% vs. 58.3% PDL formation, p = 0.05) [15]. Moreover, its longer setting time may prolong the period of coronal microleakage and risk bacterial ingress in the early postoperative phase [16]. Handling characteristics—such as material consistency and placement challenges in narrow root‐fracture gaps—can also compromise the seal and complicate retreatment.

The prognosis in horizontal root fractures depends on factors including patient age, root development stage, fragment mobility, and interfragmentary diastasis [17]. Although flexible splinting for 4 weeks supports periodontal repair, up to 25% of root‐fractured teeth develop pulp necrosis within 3 to 4 months, necessitating timely endodontic treatment of the coronal fragment to prevent infection‐related resorption [18]. External inflammatory resorption occurs in 10% to 15% of cases, particularly when fragment displacement persists, underscoring the need for radiographic monitoring at 4, 8, and 12 weeks [8, 19]. While Cold Ceramic demonstrates excellent short‐term sealing ability, its long‐term performance remains less well characterized than mineral trioxide aggregate, suggesting that future comparative studies are warranted [20]. In cases of persistent mobility or nonunion, alternative strategies such as surgical repositioning or partial root resection with subsequent prosthetic rehabilitation should be considered [9].

According to the classification proposed by Andreasen et al. [17], the fracture in this case can be categorized as type 3 healing, which involves healing by the interposition of bone and connective tissue, and despite the communication between the PDL and the fracture line, both the apical and coronal segments continued their respective healing processes.

One of the key determinants of the positive outcome in this case study is the use of Cold Ceramic, which has been evaluated and confirmed in the literature to have high biocompatibility and sealing ability [20].

This case demonstrates that with appropriate treatment, even teeth with a poor prognosis can be effectively managed to achieve normal function. This is particularly important given that a significant number of TDIs occur in children and adolescents. Rushed or aggressive approaches to treatment can lead to compromised occlusion development, highlighting the need for careful consideration and a thorough understanding of the etiopathogenesis, tissue responses, treatment protocols, and prognosis associated with horizontal root fractures [21].

Given the lifelong risk of late complications—such as root resorption, ankylosis, or secondary fracture—patient education and long‐term follow‐up are imperative. Future interventions may include endodontic retreatment of the coronal segment, internal bleaching for discoloration, or ultimately extraction and implant placement once craniofacial growth is complete [8].

Author Contributions

Ali Chamani: conceptualization, data curation, investigation, validation. Maryam Forghani: conceptualization, methodology, supervision, validation, visualization. Reza Shakiba: conceptualization, formal analysis, writing – original draft, writing – review and editing. Mohammad Hossein Davarian: conceptualization, formal analysis, project administration, supervision, validation, visualization, writing – original draft, writing – review and editing.

Consent

Written and verbal informed consents were obtained from the patient's guardians to publish this case following the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Chamani A., Forghani M., Shakiba R., and Davarian M. H., “Management of a Coronal Horizontal Root Fracture With Complicated Crown Fracture: A Case Report With 2‐Year Follow‐Up,” Clinical Case Reports 13, no. 9 (2025): e70907, 10.1002/ccr3.70907.

Data Availability Statement

The data supporting this study's findings are available upon reasonable request from the corresponding author.