Treatment of an Oblique Root Fracture in a Maxillary Central Incisor Using Bioceramic Cement: Case Report and 2-year Follow-up

Abstract

Root fractures are common in dental trauma cases, and treatment depends on fracture location and extent, requiring proper knowledge for effective management. This study reports the case of an oblique root fracture in the maxillary left central incisor due to dental trauma after a fall. Clinical and radiographic evaluations revealed mild cervical crown darkening, Grade I mobility, mild extrusion, and negative cold-sensitivity tests, indicating pulp necrosis. Cone-beam computed tomography showed a hypodense line compatible with a root fracture, and the diagnosis was asymptomatic apical periodontitis. Endodontic treatment involved chemical-mechanical preparation and root canal filling with Bio-C Sealer (Angelus, Brazil) using the single-cone technique. After 2 years, follow-up showed no symptoms or hypodense images. Accurate diagnosis, timely treatment, and proper management are essential for successful outcomes in oblique root fractures.

Introduction

Root fractures involve cementum, dentin, and pulp, accounting for 0.5%–7% of all traumatic dental injuries affecting permanent dentition.[1,2] The highest incidence occurs in anterior teeth, usually due to frontal impact.[3] Horizontal root fractures are more frequent in vital teeth than in nonvital teeth. These fractures rupture the root’s rigid structures, dividing the tooth into apical and coronal segments and are more common in the middle third of the root.[4] Diagnosis relies on tooth mobility, coronal fragment displacement, and sensitivity to palpation over the root and fracture line. Radiographic examination is essential for detecting the lesion.[5]

There are four types of healing responses: healing with calcified tissue, promoting union of the fracture; healing with connective tissue; healing with connective and calcified tissue, and healing with granulation tissue.[6] The lack of healing in the region can be due to an infection in the fracture line, which results in the formation of inflammatory granulation tissue between fragments, causing their separation and increasing crown mobility.[1]

The initial treatment of root fractures involves repositioning the coronal fragment, if displaced, and immobilizing it with a rigid splint. In cases of dental trauma, complete endodontic treatment is indicated only when pulp necrosis has occurred. However, there are situations where selective endodontic interventions are more advisable for vital pulps, aiming to preserve their vitality.[7,8]

Bioceramic materials are commonly used in root fracture cases due to their sealing capacity and biocompatibility with periradicular tissues. These cements also promote mineralized barrier formation in periradicular tissues through hydroxyapatite formation, leading to an apical plug and reduced treatment time.[9] Satisfactory results have been reported.[10,11]

The present study describes a clinical case of an oblique root fracture in the middle third of a left central incisor, which was submitted to endodontic therapy and sealing with bioceramic cement.

Case Report

A 26-year-old female sought dental care for pain in tooth 21, following a fall from standing height <24 h prior. In the first session, physical examination revealed pain on palpation, mild extrusion of tooth 21, and lower lip edema [Figure 1a]. In the second session, tooth 21 showed cervical darkening and Grade I mobility [Figure 1b].

Figure 1.

(a) Initial appearance of tooth 21 showing mild extrusion and edema in the lower lip. (b) Tooth 21 exhibiting the onset of cervical darkening

The tooth showed a negative response to cold testing with Endo-Frost (Wilcos, Brazil) on three occasions (1, 30, and 90 days), indicating pulp necrosis. The percussion test was also negative. Initial radiographs showed no alterations. Cone-beam computed tomography (CBCT) revealed an oblique fracture in the middle third, with a buccal-palatal inclination [Figure 2a and b]. The diagnosis was apical periodontitis associated with an oblique root fracture in tooth 21.

Figure 2.

(a) Cone-beam computed tomography (CBCT): axial view of the oblique fracture line in the middle third. (b) CBCT: Sagittal view of the oblique fracture line in the middle third. (c) Radiographic odontometry of tooth 21. (d) Final radiography

Endodontic treatment involved chemical-mechanical preparation of the entire root canal. After anesthesia with 4% Articaine (1:100,000; DFL, Brazil) and absolute isolation, access was made using a 1012 diamond tip (KG Sorensen, Brazil), followed by irrigation and chemical decontamination with 2% chlorhexidine gel (Biodinâmica, Brazil) and 0.9% sterile saline (Jp Farma, Brazil).

Initial instrumentation was performed with #15 and #20 hand files (Maillefer, Switzerland) and the working length was established with an electronic apex locator Romiapex A-15 (Quimidrol, Brazil), obtaining a length of 30 mm from the incisal edge to the apex. This measurement was confirmed by radiographic odontometry [Figure 2c].

Mechanical instrumentation was performed with R25 and R50 reciprocating files (VDW, Germany). The final irrigation protocol included three 20 s cycles each with 2% chlorhexidine gel, liquid ethylenediaminetetraacetic acid trisodium (Maquira, Brazil), and 2% chlorhexidine gel, followed by a final cycle with 5 mL of sterile saline, using the EasyClean device (Easy Equipamentos Odontológicas, Brazil) for mechanical agitation.

After instrumentation and final irrigation, excess moisture was removed using a sterile absorbent paper point (Tanari, Brazil) and the canal was filled with Bio-C Sealer (Angelus, Brazil) using the single-cone technique. Final radiography showed proper filling of the root canal [Figure 2d]. The crown was reconstructed with Filtek Bulk Fill Flow (3M ESPE, USA) to seal the canal entry, and Forma A2D composite resin (Ultradent, Brazil) was applied to the palatal surface to seal the crown.

After 2 years of follow-up, the patient remains asymptomatic and the CBCT continued to show the absence of periapical lesion [Figure 3a-c].

Figure 3.

(a and b) Sagittal view of a 2-year follow-up scan showing the absence of a periapical lesion. (c) Axial view of a 2-year follow-up scan showing the absence of a periapical lesion

Discussion

For horizontal fractures, immediate endodontic intervention is often postponed, as pulp necrosis incidence is slightly above 20%, with clinical and radiographic follow-up recommended.[9] Pulp necrosis and infection rates are low, and the pulp is more likely to survive a root fracture than luxation. Endodontic treatment is considered when the tooth fails to respond to cold sensitivity testing.[1]

In pulp necrosis cases, infection control is essential for tissue repair. Mechanical agitation with instruments such as EasyClean improves intracanal disinfection and apical cleaning compared to ultrasonic irrigation.[8,9] Due to the lack of apical constriction, sealing the coronal fragment is challenging. A bioceramic sealer was selected for its antimicrobial properties, lower microleakage, and effective sealing in moisture, also promoting osteogenesis and cementogenesis for biological sealing.[5]

Bio-C Sealer (Angelus, Brazil) was used in this case, despite its drawbacks of tooth darkening and removal difficulty, which could affect retreatment. These issues were temporarily mitigated as the tooth had mild discoloration and the canal was carefully filled.[11]

The prognosis of teeth with fractured roots is also influenced by the location of the fracture line, by displacement of the fragments, the tissue pulpar response and by the patient’s general health conditions.[7] Follow-up may reveal problems with pulp and periodontal healing, such as root canal obliteration and external and internal root resorption.[1]

Correct diagnosis and treatment are vital for a good prognosis of horizontal fractures, with follow-up required in the first 5 years’ posttreatment.[4] Treatment was initiated soon after trauma, resulting in a good prognosis. Two years later, the patient is symptom-free, and tomography showed no periapical changes. Follow-up of horizontal root fractures treated with bioceramic cement (up to 10 years) has shown satisfactory results.[9,11]

This case demonstrates the effective management of an oblique root fracture, with 2-year follow-up showing no periapical lesion or symptoms, confirming treatment success. Timely diagnosis, prompt intervention, and thorough follow-up are crucial for teeth with such fractures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.