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Dental Traumatology. 2019;35:333–347.	 wileyonlinelibrary.com/journal/edt	 	 | 	333© 2019 John Wiley & Sons A/S and 
American Association of Endodontists
1  | INTRODUC TION
Root fractures are defined as a fracture of a tooth that involves the 
dentin, cementum, and pulp.1 Root fractures may occur in any direc‐
tion or orientation, and they are generally classified as vertical frac‐
tures (usually also involving the crown) or transverse (often called 
horizontal) root fractures. Vertical fractures will not be discussed 
in this article because these injuries usually require extraction of 
the tooth and replacement with a prosthesis. Although the other 
group of fractures are commonly called transverse or horizontal root 
fractures, it is important to understand that such fractures can occur 
as oblique fractures with varying orientations (eg, more apical to‐
ward the palatal surface, more apical toward the labial surface, and 
so on). In the interest of simplicity in this article, the general term 
root fracture is used to discuss transverse, horizontal, and oblique 
fractures. The aim of this article was to review the relevant literature 
regarding such root fractures in the permanent dentition and to pro‐
vide guidelines for their management.
Root fractures are not a very common injury to the teeth, with 
studies reporting the proportion of root fractures among all dental 
 
Received:	12	May	2019  |  Accepted:	17	May	2019
DOI: 10.1111/edt.12482 
C O M P R E H E N S I V E R E V I E W
Diagnosis and management of transverse root fractures
Paul V. Abbott
UWA School of Dentistry, The University 
of Western Australia, Nedlands, Western 
Australia, Australia
Correspondence
Paul V. Abbott, UWA School of Dentistry, 
The University of Western Australia, 
Nedlands, WA 6009 Australia.
Email: paul.v.abbott@uwa.edu.au
Abstract
Background: Root fractures are not a common injury, but a thorough understand‐
ing of their etiology, healing responses, diagnosis, management, and prognosis is 
essential.
Review: The prognosis is largely related to the patient’s age; degree of displacement, 
if any, of the coronal fragment; and the location and orientation of the fracture. The 
more apical the fracture is located, the better the prognosis. Teeth with root fractures 
located supracrestally may have the worst prognosis, but their management and out‐
come depend on many factors, with the most influential factor being the ability to 
restore the tooth because the coronal fragment usually needs to be removed. In con‐
trast, root fractures located in the apical and middle thirds and those subcrestally in the 
coronal third of the root have a good prognosis and usually require little, if any, treat‐
ment apart from immediate repositioning (if the coronal fragment has been displaced) 
and stabilization. Monitoring of root‐fractured teeth over time is essential to determine 
the healing response and to assess whether the pulp survives or not. In some cases, 
the pulp in the coronal fragment may necrose and become infected, thus requiring root 
canal treatment, but this should only be done to the fracture line. Pulp necrosis and 
infection typically occur within the first 3‐4 months if it is a direct result of the trauma. 
However, pulp necrosis and infection can also occur many years later, in which case it 
is likely to be a result of bacterial penetration via cracks or breakdown of restorations.
Conclusion: Overall, root fractures should be managed conservatively unless they 
are located supracrestally.
K E Y W O R D S
dental trauma, healing, periodontal ligament, pulp necrosis, root fracture
This article is being published concurrently in Journal of Endodontics. The articles are identical. Either citation can be used when citing this article. 
http://crossmark.crossref.org/dialog/?doi=10.1111%2Fedt.12482&domain=pdf&date_stamp=2019-10-16
334  |     ABBOTT
injuries ranging from 1.2% to 7.0% in the permanent dentition.1‒6 
Some studies regarding the incidence of dental injuries have not re‐
ported any root fractures although it is not clear whether they did 
not occur or they were just not considered in the study design, such 
as retrospective studies in which only clinical examinations were 
performed and radiographs were not taken.7,8 It is also possible 
that some root fractures may not be diagnosed at the time of initial 
trauma management because they can only be seen via radiographic 
imaging techniques and at times the fracture may not be evident 
immediately after the accident if there has not been any displace‐
ment of the coronal fragment. Hence, if adequate radiographs and/
or computed tomographic scans are not taken and if the teeth are 
not regularly reviewed in the early posttrauma period, then root 
fractures may remain undetected. Notwithstanding this, a root frac‐
ture is a significant injury that requires dentists to have a thorough 
understanding of the mechanisms that lead to this type of fracture, 
the tissue responses to the fracture, the management options for the 
different types of root fractures, and the prognosis of these injuries.
Root fractures are a result of direct trauma to a tooth when there 
is a horizontal, frontal impact, usually with a hard object or during a 
fight.1,9 Small and sharp objects concentrate the force of impact to a 
smaller area on the tooth, and this typically causes a fracture rather 
than displacement of the tooth. If the root is the site of impact, then 
a root fracture is likely to occur. If a hard but blunt object strikes the 
crown of the tooth, the increased area of resistance to the force in 
the crown causes the force of the impact to be transmitted to the 
tooth root, resulting in a root fracture, which is most likely to occur 
in the coronal (cervical) third of the root.1
Root fractures may occur as a concurrent injury with another in‐
jury to the same tooth and specifically to the coronal fragment of 
the root (ie, the fragment coronal to the root fracture). Such injuries 
could be a crown fracture, concussion, subluxation, lateral luxation, 
extrusion, or avulsion of the coronal fragment (Figure 1). The most 
common concurrent injuries are likely to be concussion or sublux‐
ation, but, unfortunately, studies reporting the incidence of the var‐
ious dental injuries (see earlier) have not reported how often these 
concurrent injuries occur to teeth with root fractures.
Root fractures involve many different tissues in both the teeth 
and the supporting structures. Hence, there will be complex heal‐
ing patterns involving the many different tissues, namely, the 
dentin, cementum, dental pulp, periodontal ligament (PDL), and 
bone. When a root fracture occurs, the hard tissues of the tooth 
root (ie, the dentin and cementum) fracture, whereas the soft tis‐
sue of the tooth (ie, the dental pulp) may have a variety of injuries 
depending on whether the coronal fragment of the root has been 
displaced or not.
If there has been no displacement of the coronal fragment of the 
root, then the pulp in that fragment may not be damaged to any ex‐
tent apart from a localized acute inflammatory response at the frac‐
ture site or it may have hemorrhage and bruising. However, if there 
has been displacement of the coronal fragment of the root, then the 
pulp may be stretched, or it may be completely severed (lacerated) at 
the fracture site1,10; this leads to the coronal fragment of the tooth 
having a reduced or severed blood supply, which, in turn, could lead 
to pulp necrosis. In some cases, the pulp’s blood supply to the coro‐
nal fragment may recover, and then the pulp in the coronal fragment 
may heal. In other cases in which there has been pulp necrosis, sub‐
sequent infection of the root canal system may occur if there is a 
pathway for bacteria to enter the tooth. This is certainly possible be‐
cause the traumatic incident may also have caused cracks, fractures, 
or displacement of the tooth.
The apical fragment of the tooth root is usuallynot affected by 
the injury because all the forces of the impact have been absorbed 
at the fracture site.10 The pulp's neurovascular bundle at the apical 
foramen will not be stretched, severed, or harmed because the api‐
cal fragment is not displaced, so the pulp in this fragment usually 
Significance
Transverse, or horizontal, root fractures are uncommon, 
but as with all dental injuries, they require appropriate man‐
agement, which in turn requires a thorough understanding 
of the injury. This article discusses the classification, diag‐
nosis, tissue responses to, and prognosis of transverse root 
fractures. The management of transverse root fractures 
depends on many factors, particularly the level of fracture 
in the root. Conservative management should be the first 
approach unless the fracture is located supracrestally.
F I G U R E 1   A schematic diagram 
showing the concurrent injuries that may 
occur to the coronal fragment of teeth 
with transverse root fractures
     |  335ABBOTT
remains clinically normal.11‒20 Likewise, the PDL around the apical 
fragment will not be damaged.10
The PDL at the fracture line and surrounding the coronal frag‐
ment will be damaged when there is a root fracture, and the extent 
of the damage will vary at different levels of the root; in the region of 
the fracture, there will be at least some acute inflammation, but the 
damage may be more extensive if there has been concurrent con‐
cussion, subluxation, luxation, or avulsion of the coronal fragment.
It is also likely that the alveolar bone may be damaged. The injury 
could be localized to the bone adjacent to the root fracture, or it 
may be more extensive, again depending on the presence of con‐
current concussion, subluxation, luxation, or avulsion of the coronal 
fragment. The alveolar socket wall may also be fractured, and this is 
most likely to be the labial wall because it is usually very thin. Hence, 
a complex series of injuries may be associated with the root fracture.
2  | CL A SSIFIC ATION OF ROOT 
FR AC TURES
Traditionally, root fractures have been classified according to the lo‐
cation of the root fracture and specifically whether the fracture is 
located in the apical, middle, or coronal third of the tooth root.1 This 
classification is useful because the management and prognosis for a 
root fracture vary according to its location. The more apical fractures 
generally require the least management and have the best prognosis, 
whereas coronal root fractures require the most complex management 
and may have the worst prognosis. This classification also allows the 
analysis of cases for research purposes, which can then translate to a 
better understanding of the injuries and more appropriate manage‐
ment strategies.
Notwithstanding the usefulness and long‐term use of the pre‐
viously described classification system, it does have 1 shortcoming, 
which is related to fractures within the coronal third of the root. The 
management and prognosis of fractures in this part of the root are 
dependent on the very specific location of the fracture with respect 
to the crestal bone level. Root fractures that are located subcre‐
stally (ie, within the bony socket) have a much better prognosis than 
those located supracrestally (ie, outside the bone socket). This is a 
result of several factors, such as the lack of root length of the cor‐
onal fragment, the lack of bone, and the lack of PDL to retain the 
coronal fragment if the fracture is located supracrestally so there 
is no possibility of PDL repair and stabilization of the coronal frag‐
ment. This was highlighted many years ago by Andreasen.21 Another 
major factor is the possible presence of bacterial infection because 
supracrestal root fractures typically communicate with the gingival 
sulcus and thus the mouth in general. This implies that infection of 
the fracture site is likely, and this can result in infection of the pulp 
in both the coronal and apical root fragments. Hence, a more ag‐
gressive approach to managing supracrestal root fractures is usually 
required (see later).
In light of these factors, the following modified classification 
of root fractures is proposed (Figure 2) and will be used in this 
article:
1. The apical third of the tooth root.
2. The middle third of the tooth root.
3. The coronal third of the tooth root.
a Subcrestal.
b Supracrestal.
2.1 | Responses to Root Fractures
Andreasen et al1 have described 4 types of responses of the tooth 
and its associated tissues after root fractures. These responses have 
been confirmed in many studies.11‒20 The 4 responses (Figure 3A‐D) 
are as follows:
1. Healing with hard dental tissue.
2. Healing with connective tissue.
3. Healing with bone and connective tissue.
4. No healing where granulation tissue (inflammatory tissue) forms 
in the fracture line as a result of pulp necrosis and infection of the 
pulp space in the coronal fragment.
F I G U R E 2   A schematic diagram showing the location of apical, 
middle, and coronal third root fractures with coronal third fractures 
divided into subcategories of subcrestal and supracrestal fractures
336  |     ABBOTT
These 4 responses are the immediate and short‐term responses. 
In the long‐term, a fifth response may occur, and, therefore, it should 
be included in the discussion of events after a root fracture. This 
fifth response is as follows:
5. Late pulp necrosis and infection of the coronal fragment (Figure 
4A‐D): initial healing with hard tissue, connective tissue, or 
bone and connective tissue in which the pulp in the coronal 
fragment survives the injury, but it later undergoes necrosis 
F I G U R E 3   A schematic representation of the 4 types of responses that may occur after a root fracture. In all cases, some cementum 
remodeling and repair may also occur at the periphery of the fracture line, creating rounded corners. Pulp canal calcification typically occurs 
in the apical fragment and in the coronal fragment, except when pulp necrosis occurs soon after the injury. A, Healing with hard tissue; 
reactionary dentin forms on the walls of the root canal over the fracture line to provide some union of the fractured segments. B, Healing 
with connective tissue derived from the PDL and possibly from the pulp. C, Healing with interposition of bone and connective tissue; this 
may occur in young patients as the alveolar process grows vertically. A PDL space is usually evident on both fragments across the fracture 
line. D, No healing but granulation tissue forms as part of an inflammatory response to pulp necrosis and infection of the root canal system in 
the coronal fragment. External inflammatory resorption of the coronal fragment may occur, especially around the canal opening, resulting in 
an open “apical foramen” at the fracture line
F I G U R E 4   Middle third root fractures in the maxillary left and right central incisors. The trauma to these teeth occurred 25 y before the 
patient presenting to the author. The maxillary left central incisor likely healed with calcified tissue (ie, internal repair) and remained free of 
pathosis over the 42 y of follow‐up. Note the pulp canal calcification in both the apical and coronal fragments. The maxillary right central 
incisor likely healed with connective tissue after the injury. Pulp canal calcification also occurred in both its fragments. Then, 25 y later, 
the pulp in the coronal fragment had necrosed and became infected, probably as a result of infractions in the crown of the tooth, leading 
to secondary acute “apical” periodontitis at the apical end of the coronal fragment. Routine root canal treatment was performed in the 
coronal fragment only, and the canal was filled with gutta‐percha and cement. A, On presentation to the author 25 y after the injury. B, The 
postoperative radiograph on completion of the root canal treatment. C, Follow‐up 9 y after the root canal treatment was completed, which 
was 34 y after the injury. D, Follow‐up 22y after the root canal treatment was completed, which was 47 y after the injury. There were no 
clinical or radiographic signs of pathosis of either tooth. (D reprinted with permission from Cvek et al10)
(A) (B) (C) (D)
     |  337ABBOTT
and becomes infected, leading to granulation tissue in the 
fracture line. This may occur many years after the injury.
The type of response will depend on several factors. Healing is 
dependent on the response of the pulp and the PDL, which compete 
to repair the injury.
1. Healing with dental hard tissue is the most ideal response 
(ie, healing occurs with dentin and cementum; Figures 3A and 
5A‐D). This is most likely to occur when there has been no 
displacement of the coronal fragment or only very minimal 
displacement with good repositioning after the accident. It may 
also occur in cases with significant displacement of the coronal 
fragment if there has been immediate or no significant delay 
in repositioning and stabilizing the coronal fragment. If there 
has been no displacement, the pulp tissue is unlikely to have 
been damaged. When there has been minimal displacement, 
the pulp may be stretched slightly but will maintain its blood 
supply. If there has been more substantial displacement, the 
blood supply to the coronal fragment will be severed, but 
revascularization may occur once the coronal fragment has 
been repositioned. Contamination of the wound with micro‐
organisms is unlikely in these cases (unless there has been a 
concurrent crown fracture), and, therefore, the odontoblasts 
in the pulp have favorable conditions in which to produce 
reparative dentin to reunite the apical and coronal fragments. 
It is a similar process to the formation of a dentin bridge, 
except the dentin typically forms along the canal walls at the 
fracture line rather than across the pulp space (ie, it forms in 
a vertical manner rather than horizontally). It is also similar to 
a bone callus, and it can stabilize the fracture. At the same 
time, the PDL will attempt to repair itself at the periphery 
of the fracture, with the most likely response being some 
remodeling with minor resorption at the edges of the fracture 
to create rounded corners plus new cementum, which may 
help to unite the 2 fragments. The pulp in the apical fragment 
of the root remains normal because the blood supply at the 
apical foramen has not been affected. Pulp canal calcification 
(also called obliteration) also usually occurs over time in both 
fragments. In a large study of 400 teeth with root fractures, 
healing with hard tissue occurred in 30% of the teeth.17 This 
healing response can be diagnosed within 6 weeks of the 
injury.14
2. Healing with connective tissue (Figures 3B and 6A, B) is the more 
likely response to a root fracture with displacement of the coronal 
fragment. The displacement may be extrusion, lateral luxation, or 
avulsion. In extrusion and lateral luxation cases, the pulp will be 
quite stretched or severed completely depending on the amount 
of displacement. When the coronal fragment has been avulsed, 
the pulp will be completely severed. Once the coronal fragment 
has been repositioned and stabilized (see later), the pulp may un‐
dergo repair by revascularization as long as there are no bacteria 
present at the fracture line or within the coronal fragment. Some 
of the pulp may grow into the space of the fracture, but the PDL 
cells are usually the dominant contributor to the healing reaction 
such that connective tissue derived from the PDL grows into the 
fracture line. In these cases, there is no union of the fractured 
segments, but the coronal fragment can still be quite stable. 
Remodeling via resorption at the edges of the fracture is com‐
mon, and this creates rounded corners. In some cases, there may 
be some cementum formation, which may unite the 2 fragments 
to some extent. The pulp in the apical fragment of the root re‐
mains normal because the blood supply at the apical foramen has 
not been affected. Pulp canal calcification also usually occurs over 
time in both fragments. In a large study of 400 teeth with root 
fractures, healing with connective tissue occurred in 43% of the 
teeth.17 This type of healing response can usually be diagnosed 
within 6 weeks of the injury.14
F I G U R E 5   Four examples of subcrestal coronal third root fractures that healed with calcified tissue (ie, internal repair). All teeth 
responded to electric pulp tests, and they had normal mobility with no clinical signs of pathosis. A, A maxillary right central incisor 18 mo 
after the injury occurred. B, A maxillary left lateral incisor 5 y after the injury occurred. C, A maxillary right central incisor 25 y after the 
injury occurred. D, A maxillary left central incisor 50 y after the injury occurred. (B‐D reprinted with permission from Cvek et al10)
(A) (B) (C) (D)
338  |     ABBOTT
3. Healing with bone and connective tissue (Figures 3C and 7) typi‐
cally occurs if the root fracture has occurred before the comple‐
tion of growth of the alveolar bone; hence, this response is only 
observed when root fractures occur in young patients. Essentially, 
the coronal fragment erupts normally as the usual alveolar down‐
growth process occurs, but the apical fragment remains in the po‐
sition it occupied at the time of the injury. For this to occur, there 
must be no union of the fragments and no bacteria present in the 
pulp. A PDL space is often visible radiographically around the 2 
fragments, including across the fracture line. Pulp canal calcifica‐
tion and rounding of the corners of the fragments at the edges of 
the fracture line are common. It is likely that the blood vessels of 
the pulp in the coronal fragment anastomose with blood vessels 
in the tissue that grow into the space between the root fragments 
and hence establish a new blood supply. The pulp in the apical 
fragment of the root remains normal because the blood supply at 
the apical foramen has not been affected. Pulp canal calcification 
also usually occurs over time in both fragments. In a large study of 
400 teeth with root fractures, healing with bone and connective 
tissue occurred in 5% of the teeth.17
4. No healing (Figures 3D, 8A, B, and 9A and E) of the fracture oc‐
curs if the pulp of the coronal fragment becomes necrotic and in‐
fected. When this happens, granulation tissue forms between the 
2 fragments (ie, in the diastasis or space at the fracture line). The 
granulation tissue typically also extends into the bone adjacent 
to the fracture line giving the appearance of a radiolucency ex‐
tending laterally. This inflammatory reaction is the same process 
that occurs within the periapical tissues whenever the root canal 
system becomes infected in teeth without root fractures, except 
that it is occurring at the fracture site rather than in the periapical 
tissues. The coronal fragment effectively has a new “apical fora‐
men,” which is now located at the fracture line rather than at the 
apical end of the root, which is why the reaction occurs at this site. 
Some external inflammatory (infection‐related) resorption of the 
coronal fragment may occur, especially around the canal opening, 
resulting in a wide or open “foramen” at the fracture line. External 
inflammatory resorption and/or remodeling of the cementum may 
also occur at the periphery of the fracture line to create round 
corners. The 2 fragments will not be joined if the coronal pulp 
becomes necrotic and infected soon after the injury.
Infection of the root canal system in the coronal fragment can 
occur by several means. It is typically caused by bacterial contam‐
ination at the time of the injury or immediately afterward. If the 
fracture is located supracrestally, then dental plaque in the gingival 
sulcus may be the source of bacteria because the fracture line is usu‐
ally located at the base of the gingival sulcus. This may also occur in 
some subcrestal root fractures.
Infection of the root canal system ofthe coronal fragment may 
also be a result of cracks and/or fractures of the crown of the tooth 
because both cracks and fractures can be pathways for bacteria to 
F I G U R E 6   Two examples of middle third root fractures that 
healed with the interposition of connective tissue. Both teeth had 
normal mobility with no clinical signs of pathosis. A, A maxillary 
right central incisor 6 y after the injury occurred. This tooth 
responded to electric and cold pulp tests. B, The maxillary left 
central incisor 42 y after the injury occurred. This tooth did not 
respond to pulp tests. (A reprinted with permission from Cvek 
et al10)
(A) (B)
F I G U R E 7   An example of a subcrestal coronal third root 
fracture that healed with the interposition of bone and connective 
tissue. A maxillary left central incisor 15 y after the injury occurred. 
This tooth did not respond to pulp tests, and it had normal mobility 
with no clinical signs of pathosis. (Reprinted with permission from 
Cvek et al10)
     |  339ABBOTT
enter the tooth. This may occur for root fractures at all levels of the 
tooth root.
Pulp necrosis and infection of the root canal system can occur 
soon after the injury (Figures 8 and 9) or many years later (Figure 4); 
see later for more details. If it occurs soon after the injury, it can 
often be diagnosed after about 3 weeks14 although it is typically 
noted after 3 to 4 months.13 This indicates that the pulp in the cor‐
onal fragment did not survive the injury, and bacterial contamina‐
tion probably occurred at the time of the injury or at least very soon 
afterward.
In these scenarios, the pulp within the apical fragment is usu‐
ally unaffected by the infection process in the coronal fragment al‐
though pulp canal calcification may occur.10‒20 Dentin may be laid 
down over the coronal opening of the apical fragment as a protective 
mechanism.
In a large study of 400 teeth with root fractures, no healing as a 
result of pulp necrosis and infection of the root canal system in the 
coronal fragment occurred in 22% of the teeth.17
5. Late pulp necrosis and infection (Figure 4) can occur many 
years after the injury occurs. When a pulp necroses and be‐
comes infected many years later, this indicates that the pulp 
initially survived the injury and continued to function (usually 
with pulp canal calcification also occurring) until some other 
event occurred to allow bacteria to enter the tooth system. 
The typical “other event” is likely to be a restoration breaking 
down (eg, if there had been a crown fracture restored with 
composite resin), an infraction extending to dentin, periodontal 
disease, and so on. Hence, the infection is not a direct result 
of the trauma and root fracture; rather, it is a secondary or 
indirect result of the overall situation after trauma to the tooth.
No studies have reported the specific incidence of late pulp necrosis 
and infection after root fractures.
3  | PROGNOSIS
The frequency of pulp necrosis and infection of the root canal sys‐
tem after root fractures is relatively low. The pulp is more likely to 
survive a root fracture than a luxation injury.1,22 Andreasen et al1 
listed 15 studies that reported the frequency to be as low as 4% 
and ranging up to 55% in 1 study. Ten of these studies reported pulp 
necrosis in 18%‐26% of the teeth, with only 4 studies reporting more 
than 26%. The 15 studies had a combined total of 1017 teeth, with 
only 274 (26.9%) teeth developing pulp necrosis (ie, only about 1 in 
4 teeth with root fractures). Hence, the prognosis for the pulp in 
root fractured teeth is good and emphasizes the recommendation to 
not remove the pulp as part of the emergency management. Instead, 
a “wait and see” approach should be taken in order to monitor the 
tooth to see if signs of pulp necrosis and infection develop. These 
teeth can always have root canal treatment done at a later time when 
a definitive diagnosis of pulp necrosis and infection has been made. 
There is no advantage, and no evidence or sense, in commencing 
root canal treatment early or as a “preventive measure.” Such an ap‐
proach is contraindicated because it removes the most important 
tissue (the dental pulp), which can provide the best healing outcomes 
(ie, internal repair with hard tissue).
Pulp survival is dependent on the age of the patient at the time 
of the fracture with younger teeth having a better prognosis. This is 
likely because of the better vascularity and wider root canals assist‐
ing pulp revascularization at the fracture site.
Pulp canal calcification is quite common after root fractures with 
reports ranging from 69% to 73%.14,23,24 The process typically occurs 
soon after the injury. It is usually well advanced by 9‐12 months and 
approaches full density after 2 years.24 This calcification should not 
be considered as a poor outcome or an indication of a poor prognosis 
because calcification is a positive sign that the pulp has survived. 
Only a viable pulp is capable of producing dentin, so pulp canal cal‐
cification should be considered as a normal physiological response. 
It may complicate root canal treatment if this becomes necessary in 
the future, but this is not a reason to remove the pulp when calcifica‐
tion is noted because the pulp may never undergo necrosis or it may 
survive for many years. Root canal treatment of calcified canals can 
be performed by skilled operators with modern techniques and the 
assistance of magnification and illumination.
Teeth that have had root fractures commonly have some root 
resorption. However, this is not usually of any clinical consequence 
because it is typically a transient surface resorptive process; when 
external surface resorption occurs, it results in rounded corners or 
F I G U R E 8   An example of a middle third root fracture in a 
maxillary right central incisor in which the pulp in the coronal 
fragment necrosed and became infected soon after the injury 
occurred. This resulted in the interposition of granulation tissue 
and the need for root canal treatment of the coronal fragment. 
The coronal fragment has also been displaced. A, On presentation 
to the author 3 mo after the injury. Root canal treatment had 
been started by the referring dentist. B, After 12 mo of calcium 
hydroxide intracanal medication of the coronal fragment. A good 
hard tissue barrier has formed at the apical end of the coronal 
fragment, and the root canal filling has been completed using gutta‐
percha and cement. The coronal fragment has also moved back into 
a more normal position
(A) (B)
340  |     ABBOTT
edges of the root at the ends of the fracture line. When internal 
surface resorption occurs, it results in rounding of the fracture 
edges at the junction between the root canal and the fracture line; 
this can occur in both the apical and coronal fragments. Hence, 
although the overall reported incidence of all types of resorption 
is quite high (about 60%), this figure is misleading because much 
of the resorption is transient and just a part of the remodeling 
process.1
Some teeth with root fractures may develop external inflam‐
matory resorption, external replacement resorption, or internal 
inflammatory resorption.1 However, these types of resorption are 
usually a result of concurrent injuries such as luxation or avulsion 
of the coronal fragment with subsequent damage to the cementum 
and PDL, rather than being caused by the fracture itself. In the case 
of inflammatory resorption, infection of the root canal system leads 
to the resorptive process (ie, it is not the root fracture per se that 
causes the resorption).
The main preinjury factors affecting the healing of root frac‐
tures are the stage of root development (especially the diameter of 
the pulp lumen at the fracture site) and the patient's age.16,17 The 
younger the patient and the wider the root canal, then the more fa‐
vorable the tooth is for healing with hard tissue.
Factors associated with the injury that affectthe prognosis are 
the stage of root development, type of concurrent injury if present, 
degree of displacement (if present) of the coronal fragment, the di‐
astasis between the fragments after the fracture, mobility of the 
coronal fragment, and the response to pulp sensibility tests.16,17 The 
location of the fracture is not a factor affecting healing outcomes, 
except when the fracture is located supracrestally in the coronal 
third; such fractures have the worst prognosis of all root fractures 
because of the lack of PDL and bone to support the coronal frag‐
ment, as discussed previously.1,21 Teeth with coronal third fractures 
also have a higher risk of being lost if there is subsequent trauma 
to the tooth, even if only a minor injury19 or if the patient develops 
F I G U R E 9   An example of an apical third root fracture in a maxillary left central incisor in which the pulp in the coronal fragment 
necrosed and became infected soon after the injury occurred. This resulted in the interposition of granulation tissue and the need for root 
canal treatment of the coronal fragment. A, On presentation to the author 3 mo after the injury. B, The tooth was discolored as a result of 
the trauma and the pulp necrosis. C, After 12 mo of calcium hydroxide intracanal medication of the coronal fragment. A good hard tissue 
barrier has formed at the apical end of the coronal fragment, and the root canal filling has been completed using gutta‐percha and cement. 
Interestingly, the apical fragment has resorbed as part of the inflammatory and repair processes after the injury and infection of the root 
canal system. D, Internal bleaching achieved good color modification. E, Four years after the root canal treatment was completed (ie, 5 y 
after the injury). There were no clinical or radiographic signs of pathosis
(A)
(D) (E)
(B) (C)
     |  341ABBOTT
periodontal disease. An analysis of root fractured teeth from the 
Dental Trauma Guide website25 is summarized in Table 1, and this 
shows that 31% of the teeth with coronal third fractures were lost 
over 10 years, whereas only 8.7% of teeth with midthird root frac‐
tures were lost over the same period of time.
The presence of restorations in a tooth at the time of injury has 
been reported to be predictive of the healing response, as has the 
presence of periodontal disease at the time of injury.14 Teeth in these 
situations are more likely to heal with connective tissue rather than 
by hard tissue union, presumably because the pulp may have been 
compromised by previous trauma, dental caries, restoration, and/or 
periodontal disease. Teeth with restorations also have the potential 
for no healing of the fracture because bacterial penetration through 
the restoration:tooth interface may occur if the restoration is not 
ideal; this, in turn, can lead to pulp necrosis and infection of the root 
canal system followed by the formation of granulation tissue in the 
fracture line.
Treatment can also affect the prognosis of root fractured teeth, 
with the most favorable healing reported to be associated with 
optimal repositioning and splinting that does not require forceful 
application. Delays in seeking treatment did not affect the overall 
healing outcomes18 although this is likely to be affected by the injury 
factors mentioned previously (eg, teeth with displacement of the 
coronal fragment are likely to be more affected by treatment delay). 
Antibiotics did not help healing and even had a slight negative effect, 
as reported in 2 studies.14,18 Hence, antibiotics are not indicated for 
a root fracture, and they should not be prescribed unless the patient 
has another injury that specifically requires them (eg, a fully devel‐
oped avulsed tooth in which antibiotics are indicated to help prevent 
external inflammatory resorption).26
The 10‐year survival rate for all root fractures is approximately 
87%25 (Table 1). More studies are needed to investigate this fur‐
ther, but many clinicians who are very experienced in managing 
dental trauma cases anecdotally report that root fractured teeth 
can last for many, many years provided there is no further trauma 
to the tooth and provided the patient does not develop periodon‐
tal disease. The level of the root fracture is likely to be an import‐
ant factor, with the more coronally located fractures, especially 
those with supracrestal root fractures, being more susceptible to 
these problems.
Data presented on the Dental Trauma Guide website25 regarding 
root fractures indicate the following:
1. Incompletely developed teeth: only 13 teeth from 11 patients 
have been analyzed. Because of the limited number of cases, 
they were not divided into apical, middle, and coronal third 
root fractures. The low number of cases is highly suggestive 
of this type of injury being extremely rare in young children 
whose teeth have not fully developed. The data also sug‐
gest that the prognosis for these teeth is extremely good 
because none of the 13 teeth were lost over the 10‐year 
follow‐up period, none of them had external resorption or 
ankylosis, none had bone loss, and there were no cases of 
pulp necrosis and infection of the root canal system. After 
1 year, 4 teeth (31%) had pulp canal calcification. At the 
3‐year follow‐up, 2 further teeth showed pulp canal calci‐
fication (cumulative total = 46%). After 10 years, 3 more 
teeth had pulp canal calcification for a cumulative total of 
9 teeth (69%). As mentioned earlier, this calcification is a 
normal physiological response, and it indicates that the pulps 
in these teeth survived and continued to function.
2. Fully developed teeth: a total of 75 teeth have been analyzed over 
10 years. Most of these teeth had middle third root fractures (46, 
62%) with 16 (21%) in the coronal third and 13 (17%) in the apical 
third of the roots. Unfortunately, the coronal third fractures were 
not divided into subcrestal and supracrestal fractures, so these 2 
subgroups were considered together.
Uncommon problems reported in the fully developed teeth with root 
fractures were as follows:
TA B L E 1   Summary of the data from the dental trauma guide website showing some of the long‐term outcomes for teeth with transverse 
root fractures
No. of teeth
No. of years of 
follow‐up
Apical third root fracture
Middle third root 
fracture
Coronal third 
root fracture
13 46 16
Tooth loss 1 0 2 1
3 1 3 1
10 1 4 5
Pulp necrosis and infection of the root 
canal system
1 2 12 5
3 3 14 5
10 3 14 5
Pulp canal calcification 1 2 16 2
3 5 24 4
10 9 25 9
Note: The numbers are cumulative over the follow‐up periods of 1, 3, and 10 y.
342  |     ABBOTT
1. Bone loss was evident for 19% of the coronal third fractures, 
6% of the middle third fractures, and none of the apical third 
fractures.
2. Ankylosis and replacement resorption were evident in 2.5% of the 
middle third fractured teeth but none for the coronal and apical 
third fractures.
3. There were no cases with external inflammatory resorption.
Table 1 summarizes the other findings for the 75 fully developed teeth 
over the 10‐year follow‐up period. These data show the very good 
prognosis for teeth with root fractures because only 10 teeth (13%) 
were lost over this period of time with half of them being coronal third 
fractures. Pulp canal calcification is likely to occur if the pulp does not 
necrose; in the middle third group, only 7 (17%) of the 42 surviving 
teeth did not have calcification or pulp necrosis after 10 years, whereas 
25 teeth (60%) had calcification and 14 teeth (33%) had necrosed and 
become infected. For apical third root fractures, 9 (75%) of the 12 sur‐
viving teeth had pulp canal calcification, and 3 (25%) had pulp necrosis 
and infection of the root canal system. Eleven teeth with coronal third 
root fractures survived; 82% of these had pulp canal calcification, and 
5 (18%) had pulp necrosis and infection of the root canal system.
4  | E X AMINATION AND DIAGNOSIS OF 
ROOT FR AC TURESWhenever a patient presents after trauma to the teeth and mouth, it 
is essential that a comprehensive clinical and radiographic examina‐
tion be undertaken. This includes a thorough history, which can help 
to alert the clinician to particular types of injuries that may be pre‐
sent. The clinical examination should include all standard tests such 
as a visual examination, periodontal probing, percussion, palpation, 
mobility, pulp sensibility tests, transillumination to detect enamel in‐
fractions, checking of the occlusion, and so on. Particular features 
that may be associated with root fractures include the following:
1. Increased mobility and/or displacement of the coronal fragment 
(but this may also resemble displacement of the entire tooth 
without a root fracture).
2. Tenderness to percussion may indicate injury to the PDL, such as 
concussion or subluxation of the coronal fragment.
3. Transient coronal discoloration may occur, either red or grey.
4. Bleeding from the gingival sulcus may indicate subluxation of the 
coronal fragment.
Pulp sensibility testing is essential to perform at the initial posttrauma 
appointment because the results of these tests can be useful for pre‐
dicting the long‐term prognosis of the pulp. Initially, teeth with root 
fractures and no or only minor displacement will usually respond to 
pulp tests. However, if there has been displacement of the coronal 
fragment, then it is likely that the tooth will not respond to cold and 
electric pulp tests. It is important to understand that this lack of re‐
sponse should not be interpreted as the tooth having pulp necrosis, 
and they should not be used to indicate root canal treatment at this 
early stage. The response to pulp sensibility tests at the immediate 
posttrauma appointment should be noted for 3 reasons. First, a lack of 
response indicates that the tooth has suffered an injury and the pulp’s 
nerve supply has been affected, at least temporarily. Second, a lack 
of response is important for assessing healing complications because 
teeth that do respond have a significantly reduced risk of the pulp ne‐
crosing later. Thirdly, the results of these tests provide a baseline set 
of data to which future tests results can be compared, and this allows 
long‐term monitoring and reassessment of the pulp status.
Root fractures will not be evident clinically, even if they are mo‐
bile, tender to percussion, and so on. It is usually not possible to 
clinically distinguish between tooth displacement because of a root 
fracture from displacement caused by a luxation injury. This high‐
lights the essential need to take radiographs. The standard “trauma 
series” of periapical radiographs should be taken during the immedi‐
ate posttrauma examination; this includes periapical, eccentric, and 
occlusal radiographs. Root fractures are often best seen on occlu‐
sal radiographs, especially if the fracture is in the apical or middle 
third of the root.1,25 A bisecting angle periapical radiograph may be 
needed to visualize a coronal third root fracture.1,25
When there has been no displacement of the coronal fragment, 
some root fractures may not be evident during the initial clinical and 
radiographic examinations. However, they may become evident at 
subsequent follow‐up examinations because of the inevitable in‐
flammatory response that will occur in the fracture line.23,27,28 This 
can lead to slight separation of the apical and coronal fragments, 
which may then be visible on radiographs. This highlights the need 
to review teeth with root fractures after 7‐14 days with further 
radiographs.
Cone‐beam computed tomographic (CBCT) imaging may help to 
show a root fracture, especially if there has not been any displace‐
ment of the coronal fragment.29 However, such imaging techniques 
will not always be readily available, and they are unlikely to change 
the management of the case because nondisplaced coronal frag‐
ments do not normally require any specific immediate management 
apart from occlusal relief (see later). Hence, CBCT imaging is not es‐
sential. However, the recent use of CBCT imaging has highlighted 
that the labial cortical plate of the alveolar socket may also fracture 
in conjunction with a root fracture. This is not surprising, given the 
nature of the injury and the thin bone wall that is typically present. 
Such bone fractures are most likely to occur when the coronal frag‐
ment has been displaced.
5  | EMERGENCY MANAGEMENT
When a tooth has been diagnosed as having a root fracture, the 
emergency management will depend on several factors. The most 
important factors will be displacement of the coronal fragment 
and the level of the root fracture. If the coronal fragment has been 
avulsed, then it should be managed in the same manner as for an 
avulsed tooth.1 However, the apical fragment does not require any 
     |  343ABBOTT
specific treatment in this scenario. Coronal fragments that have 
been laterally luxated or extruded should be repositioned back into 
their sockets.1
The level of root fracture is important because it dictates the 
emergency and subsequent treatment. Root fractures in the apical 
and middle thirds plus those that are subcrestal in the coronal third 
of the root should be managed in a conservative manner. The man‐
agement of 3 types of root fracture is the same, whereas fractures 
that are located supracrestally in the coronal third must be managed 
differently (see later). Thus, the value of the proposed classification 
outlined previously becomes apparent.
Root fractures in the apical third, middle third, and subcrestal 
coronal third should be managed as follows:
1. Repositioning and splinting: if the coronal fragment is not 
displaced and not mobile, then splinting is not required 
although it will not harm the tooth if a splint is placed. 
However, when the coronal fragment has been displaced 
or is mobile (ie, subluxated), then stabilization with a splint 
is indicated. A simple splint will suffice as long as it holds 
the fragment in its correct position. Simple splints can be 
made by using a stainless steel wire that is bonded with 
composite resin to the labial surface of the affected tooth 
and anchored in the same manner to 1 or 2 teeth on either 
side of the affected tooth. Ideally, the splint should not allow 
any movement of the coronal fragment. If the labial wall of 
the bone socket has also fractured, then this type of splint 
will also stabilize the bone fragments. Rigid stabilization is 
important because it provides the most ideal conditions for 
healing with hard tissue; if movement of the fragments oc‐
curs, then it is less likely that this type of healing response 
will occur. The length of time to splint the tooth has been 
questioned in recent years. Traditionally, 2‐3 months was 
recommended for root fractures at all levels of the root.21 
However, studies that have analyzed the effects of the splint‐
ing time have reported that shorter splinting periods did not 
affect the outcome for root fractures.16,19 Hence, 4 weeks 
is now generally recommended for fractures in the apical 
and middle thirds but up to 4 months for fractures in the 
coronal third, especially when close to the cervical margin 
of the tooth.30 However, despite these recommendations, 
no harm from longer splinting times has been shown, so in 
order to create better conditions for healing by hard tissue, 
it is suggested that clinicians consider leaving splints in place 
for 3 months in all cases and possibly for 4 months for a 
fracture that is very close to the cervical part of the root 
(but still subcrestal).1
2. Root canal treatment should not be commenced at the emer‐
gency appointment for these root fractures. As outlined pre‐
viously, the prognosis for pulp recovery is quite good, and, 
therefore, the pulp should be provided with the opportunity 
to heal and continue to function. Maintaining the pulp in the 
tooth also allows for the possibility of hard tissue repairwith 
dentin along the canal walls at the fracture site, which is the 
most favorable healing response.
3. Antibiotics are not indicated for teeth with root fractures because 
it is unlikely that the wounds will be infected, except if the coronal 
fragment has been avulsed. Studies have shown that the use of 
antibiotics may even have a slight negative effect on pulp heal‐
ing.14,18 Therefore, they should be avoided unless there is another 
injury present that requires the use of antibiotics to prevent infec‐
tion or external inflammatory resorption.
4. Reviews of the healing response are essential and should be per‐
formed at intervals of 4 weeks while the splint is in place and then 
at 3‐month intervals for the first 12 months. If no adverse find‐
ings become evident in that time, then annual reviews for 5 years 
should be arranged. Ideally, the tooth should be continually reas‐
sessed every 3‐5 years thereafter.
Supracrestal root fractures in the coronal third of roots pose some 
particularly difficult management situations and decisions. The main 
problem is the location of the fracture, which effectively leaves a very 
short root with little or no PDL attachment to bone. Hence, the coronal 
fragment will be very mobile, and the pulp of both fragments will be 
susceptible to bacterial infection through the fracture line. Hence, a 
more aggressive approach to managing supracrestal root fractures is 
usually required. This typically implies that the coronal fragment will 
need to be removed because healing is unlikely to occur. In consider‐
ing this, the major factor will be the suitability of the remaining root 
for restoration with a functional and esthetic restoration that does not 
cause periodontal problems and can be adequately maintained by the 
patient with normal oral hygiene procedures. The options for managing 
a supracrestal root fracture are as follows:
1. Attempt to retain the coronal fragment, but this is unlikely to 
be successful for the reasons outlined previously.
2. Remove the coronal fragment immediately and assess whether 
the tooth can be adequately restored.
a If the remaining root is not suitable for restoration, then it 
should be extracted, and the site can be managed prosthet‐
ically with an osseo‐integrated implant, a bridge, or a remov‐
able partial denture depending on the individual patient’s 
circumstances (the specific site, the mouth in general, the sys‐
temic health, finances, and so on).
b If the remaining root is suitable for restoration, root canal 
treatment should be performed followed by one of the fol‐
lowing options to restore the tooth: restoration with a post‐
retained core and crown, periodontal (crown lengthening) 
surgery followed by restoration with a post‐retained core 
and crown, or orthodontic extrusion followed by periodontal 
(crown lengthening) surgery and then restoration with a post‐
retained core and crown.
Most cases will require 1 of the last 2 options because it is usually not 
possible to simply restore these teeth with a crown without supple‐
mentary procedures such as surgery and/or orthodontics. Particular 
factors to consider with periodontal surgery are the depth of the 
344  |     ABBOTT
fracture and the likely esthetic result because the gingival margin may 
not match the adjacent teeth. Orthodontic extrusion of the remaining 
root was first proposed by Heithersay in 1973.31 When considering 
this procedure, the remaining root length, the length of post required, 
and the length of the clinical crown must all be considered in order to 
ensure there are adequate crown:post and crown:root ratios for res‐
toration and stability of the tooth.32 The emergence profile is another 
important aspect because the cervical diameter of the root at the level 
of the fracture may be less than the diameter at the natural gingival 
margin (Figure 10). Hence, the restoration will have greater divergence 
from the gingival margin toward the incisal edge,32 thus possibly creat‐
ing esthetic and cleansing issues for the patient. The latter may lead to 
inflammation, which will be difficult to resolve. The more tapered the 
root is, the greater the effect will be and the more unsuitable the root 
becomes for these procedures.
Once the tooth has been restored, recall examinations of the 
periapical healing response are essential and should be performed 
after 6 months and then after another 12‐24 months. If no adverse 
findings become evident in that time, then ideally the tooth should 
be continually reassessed every 4‐5 years thereafter in the same 
manner as any tooth that has had root canal treatment and a com‐
prehensive restoration.
6  | FOLLOW‐UP MANAGEMENT
As outlined previously, all teeth that have had root fractures should 
be reviewed at regular intervals just as all traumatized teeth should 
be. The main tissues to assess over the long‐term will be the pulp 
(unless root canal treatment has been done), the PDL, and the gingi‐
vae (especially if the fracture is near the gingival margin).
When assessing the pulp, cold and electric pulp sensibility tests 
are essential and should be performed at each review appointment. 
A periapical radiograph should also be taken to assess the pulp and 
periapical tissues plus the tissues in and adjacent to the fracture line. 
It is likely that pulp canal calcification will become evident in both 
the apical and coronal root fragments. As discussed earlier, this is 
a favorable response, and it does not indicate the need for any in‐
tervention. If any signs of a radiolucency or resorption become ev‐
ident, then appropriate treatment should be commenced. This will 
usually mean root canal treatment (see later) unless the resorption is 
replacement resorption with ankylosis, in which case extraction will 
be indicated at some stage.
The PDL will usually heal as outlined earlier, but it needs mon‐
itoring to ensure it remains healthy. The periapical radiographs are 
used to assess the PDL in conjunction with percussion, palpation, 
and mobility tests. If there has been any displacement of the coro‐
nal fragment, then the possibility of external inflammatory and/or 
external replacement resorption and ankylosis must be considered. 
The nature and degree of the displacement are key factors, which 
will be evident from the history and the emergency management of 
the tooth. These types of resorption may occur early in the follow‐
up period, or they may occur many years later. Hence, regular radio‐
graphic reviews are essential.
Periodontal probing is also essential, especially in cases with cor‐
onal third root fractures. The patient must maintain excellent oral 
hygiene to prevent plaque formation on the tooth because this could 
lead to premature loss of the tooth (because of the effective short 
root) or infection of the root canal system via the fracture if suffi‐
cient gingival recession occurs to provide a pathway for bacteria to 
reach the fracture.
7  | ROOT C ANAL TRE ATMENT, IF 
REQUIRED
Root canal treatment is only required in about one quarter of cases, 
as discussed earlier, because most pulps survive and function nor‐
mally after root fractures. The typical response is pulp canal calcifi‐
cation, but this is not an indication for root canal treatment.
The need for root canal treatment arises within the first 
3‐4 months after the injury (Figures 8 and 9) or many years later 
(Figure 4). In both situations, only the coronal fragment needs the 
root canal treatment because the pulp in the apical fragment is usu‐
ally unaffected and does not become necrotic. Hence, root canal fill‐
ing and filling procedures should only be performed to the fracture 
line.
When the pulp necroses and becomes infected soon after the 
injury, the pulp lumen of the coronal fragment at the fracture line is 
usually relatively wide open. The actual size will depend on the age 
F I G U R E 1 0   A schematic diagram showing the potential effect on the emergence profile if a tooth root is orthodonticallyextruded after 
a supracrestal coronal third root fracture and before restoration with a post‐retained core and crown. The more tapered the root is, the 
greater the effect will be and the more unsuitable the root becomes for these procedures
     |  345ABBOTT
of the patient and the stage of root development at the time of the 
necrosis. Hence, it is very similar to an immature tooth root with a 
wide open apical foramen, except that the “foramen” is now at the 
fracture line. Therefore, the root canal treatment procedures need 
to be modified to manage the wide open foramen at the fracture line 
by 1 of the following methods:
1. The use of several long‐term calcium dressings to encourage 
the formation of a hard tissue barrier across the opening 
before completing the root canal filling with a conventional 
technique, such as lateral compaction of gutta‐percha and 
cement (Figures 8 and 9).
2. Placement of an artificial barrier (eg, a hard‐setting bioceramic 
material) at the opening before filling the remaining root canal 
with a conventional technique.
Both of these techniques appear to be associated with favorable 
outcomes. The latter technique is technically more difficult to per‐
form and has the risk of extrusion of the artificial barrier material 
into the tissues between the 2 root fragments, which may lead to 
ongoing inflammation, a foreign body reaction, or delayed healing. 
Hence, this technique should only be attempted by experienced 
specialist practitioners in order to avoid such complications. The 
former technique creates a natural hard tissue barrier, which helps 
to confine the root filling materials to within the tooth root. This 
is important because healing has been shown to be more predict‐
able if the root filling material had not extruded into the fracture 
line.20 It can be performed by most practitioners without the need 
for specialist training or extensive experience. One or 2 extra ap‐
pointments may be required, and the overall treatment time will be 
longer, but these should be weighed against the very predictable 
outcomes and the simplicity of this technique. One advantage of 
this technique is that the long‐term use of calcium hydroxide helps 
to ensure maximum antibacterial action has been obtained be‐
cause this has been shown to improve treatment outcomes.33 If an 
artificial barrier technique is used, then calcium hydroxide should 
still be used as an intracanal medicament for a period of time be‐
fore root filling to ensure no viable bacteria remain in the canal.
When the pulp necroses and becomes infected many years after 
the trauma, there has most likely been some pulp canal calcification 
before the pulp necrosis (Figure 4). Hence, the root canal typically 
has a very small opening at the fracture line, so the long‐term cal‐
cium hydroxide or the artificial barrier techniques are not required. 
Notwithstanding this, the pulp canal calcification may complicate 
the treatment because it may be difficult to locate the canal orifice 
and then to negotiate the canal to the fracture line. However, once 
the canal has been located and negotiated, routine root canal treat‐
ment can be completed, and the access cavity can be restored.
Very occasionally, teeth with root fractures may develop pulp 
problems in the apical fragment. This could be irreversible pulpitis 
or an infected root canal system. If either of these occur, then the 
options are to perform root canal treatment of both the coronal and 
apical fragments or to perform root canal treatment of the coronal 
fragment and surgically remove the apical fragment (Figure 11). 
Fortunately, the apical fragment rarely has such problems and there‐
fore does not normally require any treatment.
Cvek et al10 reported one case where the pulp recovered after 
the root fracture and had internal hard tissue repair but then the 
tooth developed irreversible pulpitis 5 years later as a result of car‐
ies. The entire pulp was removed and root canal treatment was per‐
formed to the apical fragment. No complications were reported and 
the lack of extrusion of any material through the fracture line con‐
firmed the earlier internal hard tissue repair.
However, in another case reported by Cvek et al,10 there was no 
internal repair with hard tissue and when the entire root canal was 
treated to the apical foramen, there was considerable extrusion of 
root filling materials out through the fracture line which resulted in 
inflammation and separation of the two fragments. The apical frag‐
ment and the excess material then had to be surgically removed. At 
the 4‐year review appointment, radiographic signs of healing were 
evident.
Cvek et al20 reviewed a series of 98 teeth with middle third and 
apical third root fractures. They reported that no healing occurred 
when the root canals of both fragments were filled. They noted that 
the lack of healing was related to extrusion of the root filling mate‐
rials and/or necrotic debris through the fracture line. This caused 
F I G U R E 11   A schematic diagram of 
the options for endodontically managing 
pulp necrosis and infection of the root 
canal system in teeth with root fractures. 
A, Root canal treatment of the coronal 
fragment only (ie, treat to the fracture 
line). B, Root canal treatment of both the 
apical and coronal fragments. C, Root 
canal treatment of the coronal fragment 
and surgical removal of the apical 
fragment
346  |     ABBOTT
persistent radiolucencies in the adjacent tissues. In contrast, 76% of 
cases healed when only the coronal fragment was filled. If the apical 
fragment had been removed surgically, healing was evident in 68% 
of the cases. Hence, there is good evidence available to show that 
only the coronal fragment should be endodontically treated in the 
first instance and the apical fragment should be left alone unless 
there is a very specific reason for treating it.
Teeth that have had pulp necrosis may also have some discolor‐
ation of the crown. If so, internal bleaching can be performed after 
the root canal treatment has been completed and before restoration 
of the access cavity (Figure 9B and D).
All teeth with root fractures that have had root canal treatment 
should be followed up in the usual manner; first, ensure that heal‐
ing of the tissues in and adjacent to the fracture line occurs. This 
is mainly assessed by radiographic observation of the radiolucency 
disappearing and normal bone and PDL forming (Figures 4, 8, and 
9). Second, these teeth should be monitored over the long‐term to 
ensure the tooth is stable and that no further infection of the root 
canal system occurs (Figures 4C, D and 9E). As with any tooth that 
has had root canal treatment, these teeth will have at least a resto‐
ration in the access cavity. They may also have other coronal resto‐
rations if the crown had fractured during the accident that caused 
the root fracture or if there has been any caries. Restorations have a 
finite life span, and they will break down over time; this can provide 
pathways for bacteria to enter the tooth and reinfect the root canal 
system along with causing inflammation in the tissues surrounding 
the apical end of the coronal fragment. Thus, regular reviews should 
be performed every 4‐5 years after healing has been confirmed.
8  | CONCLUSION
Teeth with horizontal, oblique, or transverse root fractures have a 
very good long‐term prognosis if the fracture is located in the apical 
or middle third of the root or if the fracture is located subcrestally in 
the coronal third of the root. Immediate repositioning (if displaced) 
and stabilization of the coronal fragment are essential because this 
provides the best situation for healing. Various healing responses 
have been reported with the most ideal being internal hard tissue 
repair with dentin. Some cases may have pulp necrosis with infection 
of the root canal system in the coronal fragment. These can be man‐
aged with root canal treatment. Supracrestalroot fractures are the 
most difficult to manage and usually require removal of the coronal 
fragment, root canal treatment of the remaining root, and then a res‐
toration. However, orthodontic and/or periodontal treatment is also 
usually	required	to	facilitate	the	restoration.	Figures	4‒9	illustrate	a	
range of cases with excellent long‐term survival with most of them 
not requiring any treatment, and those that did require root canal 
treatment demonstrate healing and stability over time.
ACKNOWLEDG MENTS
The authors deny any conflicts of interest related to this study.
ORCID
Paul V. Abbott https://orcid.org/0000‐0001‐5727‐4211 
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How to cite this article: Abbott PV. Diagnosis and 
management of transverse root fractures. Dent Traumatol. 
2019;35:333–347. https ://doi.org/10.1111/edt.12482