Root fracture healing outcome after a revascularization procedure: an 8-year follow-up case report

Pulp revascularization is the traditional protocol for treating immature necrotic teeth; however, it is not the usual management practice for traumatized teeth with horizontal root fracture. This is a case report of an 11-year-old patient subjected to trauma that occurred four years prior to treatment. The trauma led to horizontal root fracture in tooth #11, and the immature tooth #21 became necrotic with periapical radiolucency. Both teeth were treated with revascularization procedures. Each tooth was disinfected with triple antibiotic paste and a coronal seal using mineral trioxide aggregate. During the eight-year follow-up using periapical radiograph and cone beam computed tomography, tooth #21 showed periapical repair with apical closure. The fractured rooted tooth #11 was functional and asymptomatic, with evidence of bone growth inside the fracture line. From this case outcome, revascularization can be a successful treatment modality for traumatized teeth that have either root fracture or necrotic open apex.

Immature root; Open apex tooth; Revascularization; Root fracture; Cone beam computed tomography (CBCT)

1. DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: 1. fractures and luxations of permanent teeth. Dental Traumatology. 2012; 28: 2–12.

2. Robertson A, Andreasen FM, Bergenholtz G, Andreasen JO, Norén JG. Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors. Journal of Endodontics. 1996; 22: 557–560.

3. Andreasen JO, Andreasen FM. Essentials of traumatic injuries to the teeth: a step-by-step treatment guide. 2nd edn. Wiley-Blackwell: Hoboken, New Jersey. 2010.

4. Abbott PV. Diagnosis and management of transverse root fractures. Dental Traumatology. 2019; 35: 333–347.

5. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth. 5th edn. Wiley-Blackwell: Hoboken, NJ. 2019.

6. Andreasen J, Andreasen F, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dental Traumatology. 2004; 20: 203–211.

7. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Root fractures: the influence of type of healing and location of fracture on tooth survival rates—an analysis of 492 cases. Dental Traumatology. 2012; 28: 404–409.

8. Andreasen J. Intra-alveolar root fractures: radiographic and histologic study of 50 cases. Journal of Oral Surgery. 1967; 25: 414–426.

9. Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7–17 years. Dental Traumatology. 2008; 24: 379–387.

10. Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis. Endodontic Topics. 2006; 14: 51–59.

11. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology. 2002; 18: 134–137.

12. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action. Journal of Endodontics. 2007; 33: 377–390.

13. Soares ADJ, Lins FF, Nagata JY, Gomes BPFDA, Zaia AA, Ferraz CCR, et al. Pulp revascularization after root canal decontamination with calcium hydroxide and 2

14. Roig M, Espona J, Mercadé M, Duran-Sindreu F. Horizontal root fracture treated with MTA, a case report with a 10-year follow-up. Dental Traumatology. 2011; 27: 460–463.

15. Saoud TMA, Mistry S, Kahler B, Sigurdsson A, Lin LM. Regenerative endodontic procedures for traumatized teeth after horizontal root fracture, avulsion, and perforating root resorption. Journal of Endodontics. 2016; 42: 1476–1482.

16. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. Journal of Endodontics. 1999; 25: 197–205.

17. Cvek M, Mejare I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dental Traumatology. 2004; 20: 261–269.

18. Lee S, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. Journal of Endodontics. 1993; 19: 541–544.

19. Yildirim T, Gençoğlu N, Firat I, Perk C, Guzel O. Histologic study of furcation perforations treated with MTA or Super EBA in dogs’ teeth. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2005; 100: 120–124.

20. Torabinejad M, Hong C, Ford TP, Kettering J. Antibacterial effects of some root end filling materials. Journal of Endodontics. 1995; 21: 403–406.

21. Kim D, Yue W, Yoon T, Park S, Kim E. Healing of horizontal intra-alveolar root fractures after endodontic treatment with mineral trioxide aggregate. Journal of Endodontics. 2016; 42: 230–235.

22. Andrade ES, de Campos Sobrinho ALP, Andrade MGS, Matos JLF. Root healing after horizontal fracture: a case report with a 13-year follow up. Dental Traumatology. 2008; 24: e1–e3.

23. Cvek M, Andreasen JO, Borum MK. Healing of 208 intraalveolar root fractures in patients aged 7–17 years. Dental Traumatology. 2001; 17: 53–62.

24. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? Journal of Endodontics. 2004; 30: 196–200.

25. Er K, Çelik D, Taşdemir T, Yildirim T. Treatment of horizontal root fractures using a triple antibiotic paste and mineral trioxide aggregate: a case report. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009; 108: e63–e66.

26. Deliperi S, Bardwell DN, Congiu MD. Reconstruction of severely damaged endodontically treated and bleached teeth using a microhybrid composite resin: two-year case report. Practical Procedures and Aesthetic Dentistry. 2003; 15: 221–227.

27. Conde MCM, Chisini LA, Sarkis-Onofre R, Schuch HS, Nör JE, Demarco FF. A scoping review of root canal revascularization: relevant aspects for clinical success and tissue formation. International Endodontic Journal. 2017; 50: 860–874.

28. Chen MH, Chen KL, Chen CA, Tayebaty F, Rosenberg P, Lin L. Responses of immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess to revascularization procedures. International Endodontic Journal. 2012; 45: 294–305.

29. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. International Endodontic Journal. 1996; 29: 125–130.

30. Staffoli S, Plotino G, Nunez Torrijos BG, Grande NM, Bossù M, Gambarini G, et al. Regenerative endodontic procedures using contemporary endodontic materials. Materials. 2019; 12: 908–935.

31. Ruparel NB, Teixeira FB, Ferraz CCR, Diogenes A. Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. Journal of Endodontics. 2012; 38: 1372–1375.

32. Patel S, Brown J, Pimentel T, Kelly R, Abella F, Durack C. Cone beam computed tomography in Endodontics—a review of the literature. International Endodontic Journal. 2019; 52: 1138–1152.

33. Herweijer JA, Torabinejad M, Bakland LK. Healing of horizontal root fractures. Journal of Endodontics. 1992; 18: 118–122.

34. Caliskan MK, Pehlivan Y. Prognosis of root-fractured permanent incisors. Dental Traumatology. 1996; 12: 129–136.

35. Majorana A, Pasini S, Bardellini E, Keller E. Clinical and epidemiological study of traumatic root fractures. Dental Traumatology. 2002; 18: 77–80.

36. Artvinli LB, Dural S. Spontaneously healed root fracture: report of a case. Dental Traumatology. 2003; 19: 64–66.