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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 881-885  

Apexification and repair of root fracture with mineral trioxide aggregate – A case report with 5-year follow-up

1 Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Kattankulathur, Chengalpattu, Tamil Nadu, India
2 Department of Dental, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, Andaman and Nicobar Islands, India
3 Department of Pedodontics and Preventive Dentistry, SRM Institute of Science and Technology, Kattankulathur, Chengalpattu, Tamil Nadu, India

Date of Submission30-Nov-2020
Date of Decision26-Jan-2021
Date of Acceptance04-Jan-2021
Date of Web Publication05-Jun-2021

Correspondence Address:
V P Hariharavel
Department of Dental, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, Andaman and Nicobar Islands
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpbs.JPBS_789_20

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Young patients are most susceptible to trauma which involves teeth and their supporting structures. Severity can vary from simple enamel fracture to complete tooth avulsion. The treatment modality ranges from a noninvasive procedure to surgical intervention. The present case report describes the unique management, 5-year follow-up, and prognosis of a 10-year-old child diagnosed with lateral luxation and horizontal apical root fracture of maxillary central incisor with open apex.

Keywords: Mineral trioxide aggregate, root fracture, trauma

How to cite this article:
Annamalai S, Hariharavel V P, Ramar K, Samuel V. Apexification and repair of root fracture with mineral trioxide aggregate – A case report with 5-year follow-up. J Pharm Bioall Sci 2021;13, Suppl S1:881-5

How to cite this URL:
Annamalai S, Hariharavel V P, Ramar K, Samuel V. Apexification and repair of root fracture with mineral trioxide aggregate – A case report with 5-year follow-up. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Dec 1];13, Suppl S1:881-5. Available from:

   Introduction Top

Trauma to a tooth can vary from a simple enamel infraction to a complete ex-articulation of tooth (avulsion). Among various types of traumatic injuries, tooth fractures (crown fractures and crown-root fractures) are considered to be the third most common cause of tooth loss.[1] Root fractures are clinically challenging as well as interesting to the clinicians as it involves interdisciplinary approach.[2]

Root fractures occur more frequently in fully erupted permanent teeth with closed apices in which the completely formed root is solidly supported in the bone and periodontium. The consequences of root fracture can be complex because of combined damage to the pulp, dentin, cementum, bone, and periodontium. The reported frequency of root fractures in permanent teeth is only 0.5%–7%, and in deciduous teeth, it is only 2%–4%.[1] Root fractures can be broadly classified as horizontal (transverse), vertical, and oblique. Horizontal root fractures are the most common type and occur mainly in the tooth in the anterior region of the maxilla owing to a frontal impact.[1],[3] Hovland[3] reported that horizontal root fractures in the permanent dentition comprise from 0.2% to 7% of all traumatic injuries to teeth. Maxillary central incisors are more vulnerable and constitutes about 80% of all the dental injuries, followed by maxillary lateral and the mandibular incisors.[4] This mainly happens due to their being in most forward position and getting the maximum impact forces. The classification of horizontal root fracture is based on the location of the fracture line (apical third, middle third, and cervical third of the root) and on the degree of dislocation of the coronal fragment. They occur most commonly in the middle third and rarely in the apical and coronal third of the root.[3],[5] The clinical presentation of horizontal root fracture may vary from a slightly extruded tooth, often lingually displaced to a clinically normal tooth. The tooth is often mobile, and the degree of mobility is determined by the level and location of fracture.[4] The prognosis of the tooth concerned is also influenced by other factors, such as the patient's age, stage of root development, mobility of the coronal fragment, diastasis of the fragments, and proper diagnosis and treatment methodologies. The present case report describes the distinctive treatment approach and 5-year follow-up of maxillary right central with apical root fracture and open apex in a conservative approach using mineral trioxide aggregate (MTA).

   Case Report Top

A 10-year-old girl had reported to our hospital with the chief complaint of pain in her upper front tooth region. History revealed that the patient had traumatic fall 2 years before, leading to fracture and mild mobility of maxillary right central incisor, but no treatment was taken. Clinical examination of the patient revealed extruded and laterally displaced 11 with fracture involving enamel and dentin of the mesial incisal edge. The tooth showed normal mobility, discoloration, and no sign of vitality for electric pulp test. Radiographic examination (intraoral periapical radiograph) revealed fracture in the apical third of the root with open apex and associated periapical radiolucency [Figure 1].
Figure 1: Preoperative intraoral periapical of maxillary incisors

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Treatment option of either root canal treatment followed by peripaical surgery, root resection and root end filling or repair of root fracture and apexification using MTA was explained to patient's parent. As the parents were not willing for surgery, we opted for the apexification and repair of root fracture using MTA. After achieving adequate local anesthesia, access cavity was prepared and working length was determined. The canal was instrumented 2 mm short of radiographic apex using endodontic files with a gentle circumferential filing motion. This is done to avoid overinstrumentation of the fragile dentinal wall near the open apex and to prevent displacement of the apical root fragment and injury to the periapical tissues. An intracanal medicament of calcium hydroxide was placed in the canal, and the access cavity was sealed with temporary filling material for 2 weeks.

In the next visit, root canal was cleaned off the intracanal medicament with saline irrigation and dried with paper points. MTA (white MTA-Angelus, Brazil) was mixed according to manufacturer's instruction and placed in the Canal using MTA Endo Carrier (Dentsply) and condensed using endodontic plugger to the apical end. Radiovisiography (RVG) was taken to confirm the correct placement of MTA and the apical seal [Figure 2]. MTA was added and condensed into the root canal to create 4–5 mm apical plug [Figure 3]. A moist cotton pellet using sterile water was placed over the material, followed by a dry cotton pellet, and the access cavity was sealed with intermediate restorative material.
Figure 2: Intraoral periapical of 11 showing the correct placement of mineral trioxide aggregate

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Figure 3: Intraoral periapical of 11 showing the mineral trioxide aggregate apical plug

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After 24 h, the set MTA was assessed and final obturation of the root canal was done with gutta-percha using lateral condensation technique and access cavity was sealed with Glass-ionomer restorative material (GC, Type II glass-ionomer cement). Coronal restoration of the discolored and fractured crown was done with the acrylic jacket crown. The child was recalled at 3-, 6-, 9-, and 12-month periods, and the teeth were assessed clinically and radiographically. The patient was asymptomatic, and the radiographs showed a reduction in the size of periapical radiolucency [Figure 4]. Radiographic follow-up at the 3rd year showed complete absence of periapical radiolucency in relation to 11 [Figure 5]. Radiographic follow-up at the 5th year revealed the complete healing of the root fracture with calcified tissue and normal periodontal space around the MTA apical seal and the root fragment [Figure 6].
Figure 4: Intraoral periapical of 11 at 12-month review showing root end closure and reduction in periapical radiolucency

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Figure 5: Intraoral periapical of 11 at 3-year review complete healing of the periapical lesion

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Figure 6: Intraoral periapical of 11 at 5-year review. (1) Root end closure. (2) Normal periodontal ligament space surrounding the extruded mineral trioxide aggregate. (3) Healing with interproximal hard tissue formation between the fracture fragments

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   Discussion Top

Impingement of high force upon the root results in root fracture. The root gets separated into coronal and apical fragment as a result of frontal force effect on compression zones labially and lingually or palatally. This has detrimental consequences for the cementum, dentin, pulp, and periodontium.[6] When it comes to treating root fractures, the repair of root dentin much depends on an intact periodontal ligament, from which the hard tissue-forming cells originate.[7] The line of treatment primarily involves repositioning of the fractured segments in as close proximity as possible and stabilizing in that position with a splint to the adjacent teeth for 2–4 months.[5] This splinting allows only micromovements of the segments, thus enabling the cells to proliferate and induce healing without any disturbance. The International Association of Dental Traumatology (Flores et al., 2007) guidelines recommend endodontic treatment only after pulpal necrosis, not as a prophylactic intervention.[8]

Root canal therapy is not recommended on the tooth with horizontal root fracture in the apical third, because research has demonstrated that the pulp will remain vital in most cases with high percentage of successful healing without receiving endodontic treatment.[9] Root-fractured teeth often possess a vital apical fragment, even when the coronal fragment is necrotic. For the current reason, only the coronal fragment of tooth fractured should be endodontically treated. The present recommendation for apical-root, mid-root fracture is root canal treatment of the coronal segment only, if the fractured segment shows no mobility.[9] No treatment guidelines are available for a severely mobile tooth, other than extraction and subsequent replacement with prosthesis. Although the outcome of a horizontal root fracture in the apical one third is generally favorable, complications such as pulp necrosis, radicular resorption, and pulpal canal obliteration can occur.[10]

Endodontic intervention is required for nonhealing fractures. Anderson and Hjorting-Hanser described four types of healing sequelae:[7] (a) healing with calcified tissue (callus formation); (b) healing with interproximal connective tissue, which is characterized by peripheral rounding of the fracture's ends; (c) healing with interproximal bone and connective tissue, radiologically characterized by the clear separation of the two fragments; and (d) interproximal inflammatory tissue/granulation tissue without healing caused by an infected or necrotic pulp.

The use of MTA was recommended in teeth with necrotic pulp and open apices.[11],[12] The suggestions for creating MTA apical plug were based on the advantageous properties of the material such as having an excellent biocompatibility and less cytotoxicity due to its greater alkalinity. The presence of calcium and phosphate ions results in attraction of blastic cells promoting the healing of periapical tissues to a normal condition and providing favorable environment for bone deposition without an inflammatory response.[13],[14],[15] It was also reported that MTA material was surrounded with new cementum formation.[11],[16]

Based on the successful outcome as apexification medicament, MTA has been used for repair of radicular fracture.[17],[18] Cvek et al. had reported that the overfilled root canal filling material between the fragments did not lead to healing or lead to interposition of granulation tissue.[19] In contrast, Sankar et al. and Tezel et al. have reported the hard tissue formation even surrounding the extruded MTA.[11],[16] In the present case, the radiographic examination revealed open apex in the apical fragment, large periapical radiolucency surrounding the fragments, and also there was a gap between the coronal and apical root fragments due to displacement of fractured fragments. Hence, the endodontic treatment using MTA was done, and there was extrusion of MTA between the apical and coronal root fragments as expected. Similar to the previous reports, radiographic follow-up reveals complete healing of the periapical pathology, root end closure, healing with interproximal hard tissue formation between the fractured fragments, and normal periodontal ligament space surrounding the root as well as the extruded MTA. The use of MTA resulted in the successful clinical outcome in the management of apical third root fracture.

Thus, the treatment of root fractures depends on number of factors such as position of fracture line, mobility of tooth, pulpal status, and the material used to treat them. The clinicians must have thorough knowledge and adequate clinical experience to treat them properly. Furthermore, after performing the adequate clinical management, following up the patients for clinical assessment of treatment success is crucial.

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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Andreasen FM, Andreasen JO. Crown fractures. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen: Munksgaard; 1994. p. 2195-56.  Back to cited text no. 1
Davidovich E, Heling I, Fuks AB. The fate of a mid-root fracture: A case report. Dent Traumatol 2005;21:170-3.  Back to cited text no. 2
Hovland EJ. Horizontal root fractures. Treatment and repair. Dent Clin North Am 1992;36:509-25.  Back to cited text no. 3
Molina JR, Vann WF Jr., McIntyre JD, Trope M, Lee JY. Root fractures in children and adolescents: Diagnostic considerations. Dent Traumatol 2008;24:503-9.  Back to cited text no. 4
Andreasen JO. Traumatic Injuries of the Teeth. 2nd ed. Philadelphia, PA: WB Saunders; 1981. p. 119-50.  Back to cited text no. 5
Welbury R, Kinirons M, Day P, Humphreys K, Gregg TA. Outcomes for root-fractured permanent incisors: A retrospective study. Pediatr Dent 2002;24:98-102.  Back to cited text no. 6
Andreasen JO, Hjorting-Hansen E. Intraalveolar root fractures: Radiographic and histologic study of 50 cases. J Oral Surg 1967;25:414-26.  Back to cited text no. 7
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66-71.  Back to cited text no. 8
Görduysus M, Avcu N, Görduysus O. Spontaneously healed root fractures: Two case reports. Dent Traumatol 2008;24:115-6.  Back to cited text no. 9
Bender IB, Freeland JB. Clinical considerations in the diagnosis and treatment of intro-alveolar root fractures. J Am Dent Assoc 1983;107:595-600.  Back to cited text no. 10
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.  Back to cited text no. 11
Annamalai S, Mungara J. Efficacy of mineral trioxide aggregate as an apical plug in non-vital young permanent teeth: Preliminary results. J Clin Pediatr Dent 2010;35:149-55.  Back to cited text no. 12
Mitchell PJ, Pitt Ford TR, Torabinejad M, McDonald F. Osteoblast biocompatibility of mineral trioxide aggregate. Biomaterials 1999;20:167-73.  Back to cited text no. 13
Shabahang S, Torabinejad M, Boyne PP, Abedi H, Mc Millan P. A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide and mineral trioxide aggregate. J Endod 1999;25:1-5.  Back to cited text no. 14
Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod 1995;21:349-53.  Back to cited text no. 15
Tezel B, Uysal S, Turgut MD, Cehreli ZC. Inadvertent MTA extrusion in an immature traumatized permanent incisor. J Clin Pediatr Dent 2010;35:145-8.  Back to cited text no. 16
Bramante CM, Menezes R, Moraes IG, Bernardinelli N, Garcia RB, Letra A. Use of MTA and intracanal post reinforcement in a horizontally fractured tooth: A case report. Dent Traumatol 2006;22:275-8.  Back to cited text no. 17
Roig M, Espona J, Mercadé M, Duran-Sindreu F. Horizontal root fracture treated with MTA, a case report with a 10-year follow-up. Dent Traumatol. 2011 Dec;27(6):460-3. doi: 10.1111/j.1600-9657.2011.01018.x. Epub 2011 Jul 3. PMID: 21722306.  Back to cited text no. 18
Cvek M, Mejàre I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol 2004;20:261-9.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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