How to Remove Gutta Percha Like a Boss
January 24, 2023
Long-Term Recalls and the Mother of All Endodontic Periapical Lesions
January 26, 2023
Who is ready for a tooth story about a horizontal root fracture?
I’ve got a good one for you today, all about how to nail your diagnosis and treatment plan like an expert, so your patient walks out of your office feeling great about their experience — and you can pat yourself on the back, too.
These bad boys are tough to treat, but tough does not equal impossible. Doing it successfully just requires a little help from your endo fairy godmother. (That’s me!)
Is a horizontal root fracture tough to treat?
One of the most challenging traumatic injuries to diagnose and treat is a horizontal root fracture. Working with them can get pretty darn confusing, if you ask me.
Many times with a horizontal root fracture, the treatment is actually to do NOTHING. I usually give a horizontal root fracture time to heal on its own and let the body do its thing — as long as the tooth is stable. If the tooth is mobile, that’s another story.
If the tooth IS mobile, you may need to stabilize it for some time with a flexible splint.
Did you know apical fractures have the best prognosis, and then midroot, and then coronal. Why? Well, the apical fractures are more surrounded by bone and therefore less mobile. And since the fracture is also far away from the sulcus, and therefore, bacterial contamination, this also improves the prognosis. As the fracture moves up the root, the prognosis deteriorates.
So, remember this: The more coronal the fracture, the more mobile the fragment, and the more chance of bacterial contamination.
If a tooth with a horizontal root fracture becomes symptomatic and you cannot delay treatment, usually you only have to treat the coronal fragment, because the apical fragment will still be vital.
Tooth story: A horizontal root fracture and a side of tooth trauma
Take a look at this case. It serves as a perfect example of what I’ve been talking about.
This patient presented to my office and had a history of trauma almost 10 years ago. Here’s her post-op radiograph from when I first met her. She already had treatment previously attempted several years prior.
The cardinal rules of root canal therapy (Find all the canals and Get to the end of every single one) were not honored here in teeth #8 and 9. The canals were located and treated, but they were not instrumented to working length or working circumference. I hate when I see this, because I know this patient could have avoided some discomfort, saved money, and spent their time somewhere besides my chair.
In any case, I diagnosed her with Previously Treated #8 and 9 with Asymptomatic Apical Periodontitis #8 and 9.
You can see that the coronal fragment of #8 has a periapical radiolucency, but the apical fragment does not. You can also see that #9 has a periapical radiolucency. I took a CBCT to get a deeper look, and this is what I found.
Here is the coronal view of #8…
And the coronal view of #9…
You can see clearly that the working length has not been achieved on either view. And the fracture on #8 is significant. Believe it or not, that tooth had and continues to have no mobility.
The axial view of #8 was a bit shocking and showed me that I was not going to be able to contain my obturation material.
My next steps…
Based on this image, I knew that I would have to obturate #8 with MTA since I needed something that was compatible with the bone — because extrusion was likely.
My treatment plan was to retreat the coronal fragment #8 and retreat #9. I also told her that if there was no healing around #8, there was a small chance that I would have to remove the apical fragment surgically in order to have access to the apex of the coronal segment in order to retroprep that area.
Apically, the CBCT confirmed that the apical segment of #8 was fine and that there was a periapical radiolucency on #9.
So, I started treatment, removed the gutta percha, and obtained a working length on both teeth.
I then medicated the teeth with calcium hydroxide for several weeks to ensure proper disinfection.
Following that, I obturated with MTA in tooth #8 and gutta percha in tooth #9.
As expected, the MTA fill appears out of the root, but since MTA is osteoinductive and osteogenic, I was happy with it.
Since follow up is key with these patients, I brought her back at 6 months. Here’s her post-op radiograph.
You can see that the periapical radiolucencies are getting smaller and she is completely asymptomatic. Woohoo!
Horizontal Root Fracture Tooth Story Takeaways:
In summary, here’s what I want you to take away from this case:
- Horizontal root fractures usually do not need to be treated, but when they do, try to treat only the coronal fragment.
- Prognosis for horizontal root fractures goes as follows: apical > midroot > coronal
- Don’t forget to give your bone time to heal and follow up your patients. I plan on watching this patient for the next few years to make sure she gets her bone back.
Remember, don’t expect lesions of this size to ever disappear overnight. Bone is slow to grow, and lesions and horizontal root fractures take lots of time to regenerate back in with bone. I plan on seeing this patient again in another 6 months to see how things have progressed.
How would you treat this case? Would you try to save the teeth? I hope so!
How Will You Empower Yourself from Here?
I hope my blog continues to inspire you and offer you insight into how to save more teeth (or run your business better! Or do more and better endo. Point blank. period).
But consuming without taking action doesn’t do much.
So take empowering action now and subscribe to my email list for weekly endo tips, tricks, and insights! Subscribe here.
Until next time!
-Sonia
31 Comments
Hi Sonia,
Thanks for the lesson.
I am wondering how you place the calcium hydroxide to medicate the teeth?????
Thanks,
Hey there!! I use a Vista tip that is flexible that I can place pretty far into the canal. Then I gently express the calcium hydroxide into the canal. I like to use Ultracal from Ultradent. I mention this in my top 10 tools blog where you can see the images and get the link.
-Sonia
I would have thought for sure to extract the tooth. Thanks for going through this case, very informative.
What a great case! I always look forward to learning from your blogs.
And I appreciate you reading!
-Sonia
so you didnt irrigate with Sodium hypochlorite???
and in the follow up does mobility decrease???
Yes I did irrigate with sodium hypochlorite and in this case, there was no mobility. But, yes I would expect it to decrease.
-Sonia
Can u explain more please about how u made sure not to extrude sodium hypochlorite in such case?
Hi Yasmeen – as long as you don’t push your irrigant with force, it really shouldn’t extrude out of the apex. Irrigation should always be delicate.
-Sonia
Hi, I’ve a root canal done in 2018 Jan & a year later, I felt pain on the area. Over the course of 2019, I had a couple of xrays taken & this year 2020 Oct, the xray showed my root canal has a horizontal crack. Is there anyway to save it? I can attach xrays for yr reference.
Annie,
I am sorry that you are going through this. Unfortunately, this needs a thorough examination that I cannot provide you at this time. Please seek out a consultation from a local endodontist if you still have questions.
Best,
Sonia
Great case thanks
So glad you enjoyed reading this!
-Sonia
Hi Sonia,
Thank you for this blog.I am learning so much endo from you that I never did in any of the seminars I had attended before. Thank u for sharing your knowledge with us .Keep going!
Thanks Tamanna! I am so happy you are taking away so much!
-Sonia
Hello doc! In cases of horizontal root fracture how would one be able to know if composite and wire splinting or intraradicular splinting would work better?
Hey there! You always want to use a physiological splint, so I always use a fishing line!
-Sonia
Hello Sonia,
I am scheduled to remove my front tooth next week and replace it with a dental implant. My dentist noticed a horizontal fracture at the root of my crowned tooth. I experienced pain along with a bubble just above the tooth on my gumline a year ago. I was treated with an antibiotic then sent to an endodontist. The endodontist sent me to a periodontist who says removal is my only option. I have no pain whatsoever. The antibiotic cleared the infection. My dentist and the periodontist said the infection has not gone away because the sore on my gum line is still present. They all said the only way to get rid of the infection is to remove the tooth where the source of infection is. I’ m terrified. I have no pain and the tooth is stable. Can it be saved in your opinion? Can I just do nothing? They mentioned the longer I wait I risk bone loss. Can’t this fracture heal on its own? Please help me.
Hi there. Unfortunately, without the proper data, I cannot help you adequately. I would trust your providers. If a tooth is fractured, it cannot heal again. So, that is likely why they are suggesting extraction. If you are confused, please ask your provider for clarification. Thanks.
Dr. Chopra
I have a fractured root. The tooth is crowned and the crown is also connected to the tooth beside it. I don’t know the number, but it is next to my front tooth. My dentist referred me to a dentist who specializes in implants assuming it couldn’t be repaired. I’ve been babying the tooth for about 6 months. I’m pretty sure it’s bad. I floss daily and use listerine and salt water rinse. How long do you think the tooth will last before it will become infected. Both the fractured tooth and the one beside it are loose. Gum tissue is healthy. Thank you
Marilyn,
Unfortunately, I do not have enough information to give you an honest answer. I would have to personally evaluate you. If you still have questions, please ask your dentist. Best of luck!
-Sonia
What MTA product do you like and how do you get it down in the teeth predictably and in the position you want it. Thanks!
I typically use Pro Root MTA with a MAP system.
-Sonia
Hello Sonia,I was diagnosed with a horizontal fracture on my last visit to the dentist.The only option to treat it was extraction which I turned down as it is not causing me great pain or sensitivity.I have been brushing my teeth with demineralization toothpaste and I am taking vitamin K2 supplements.Is there any chance the affected tooth will survive?
Shane,
Unfortunately, I do not have enough information to give you a proper answer. I do not want to misguide you in any way. Good luck.
-Sonia
Hi Sonia,
Great article.
I think I may have one of these horizontal cracks in #10. I bit into something and few months ago and felt and nerve type pain into my head. Scared me.
Went to Dentist for cleaning and he examined. Could not see and crack in xray and wants to monitor the issue. It’s been and few weeks abd I have been very careful.
Question: what exactly should I do? Obviously, I want to save my front tooth!
And, what kind of specialist handles this issue?
Thank You
Jeff Fishman
Jeff,
If you are concerned, you may want to see an endodontist and get a 3D image to see if your tooth is ok. That would be my approach. I hope that helps.
-Sonia
Very cool case! Thanks for sharing. You really are a rockstar.
Aw, thank you so much, Iliana!
Hey .. wonderful case done …I have a question in my mind ..how do we check whether the apical fragment is vital or not ?
Thanks Shipra! You can check by seeing if there is a lesion or if it becomes tender to percussion.