CLINICAL RESEARCH

Mahshid Sheikhnezami, DDS,

Long-Term Outcome of MSc,*† Reza Shahmohammadi,
DDS, MSc,‡ Hamid Jafarzadeh,
Horizontal Root Fractures in DDS, MSc,*† and
Amir Azarpazhooh, DDS, MSc,
Permanent Teeth: A PhD, FRCD(C)*§k

Retrospective Cohort Study

ABSTRACT
SIGNIFICANCE
Introduction: Horizontal root fracture (HRF) is a complex traumatic dental injury that affects
the pulp, dentin, cementum, and periodontal ligament. This retrospective cohort study Horizontal root fractures pose
evaluated treatment outcomes in permanent teeth with HRF. Methods: We analyzed clinical complex challenges in dental
and radiographic data from a dental trauma center (2006–2022). Permanent teeth with HRF care. Positive outcomes hinge
with a follow up of
12 weeks were considered for outcome assessment (defined as clinical on timely identification and
normalcy and radiographic healing at the fracture line). Prognostic factors were identified tailored treatment. Factors
through multivariable logistic regression analyses (P value  .05). Results: 125 teeth from such as incomplete root
103 patients were included. After a median follow-up of 79 weeks, the overall favorable development and prompt
outcome was 92%. This includes teeth that received emergency splinting/repositioning at patient presentation play
baseline (62.2%) and those that received subsequent endodontic intervention for the coronal pivotal roles. These insights
fragment (baseline: 85%; subsequent follow-ups: 91.8%). Being male and incomplete root improve dental practitioners’
development were both significantly associated with a better outcome of splinting/reposi- understanding of managing
tioning (OR 5 2.58; 95% CI, 1.06-6.24 and OR 5 4.37; 95% CI, 1.16-16.41, respectively) and these fractures.
a reduced likelihood of requiring endodontic treatment (OR 5 0.44; 95% CI, 0.20-0.96 and
OR 5 0.24; 95% CI, 0.08-0.76, respectively). Treatment delays surpassing one week were
significantly associated with an increased likelihood of requiring endodontic treatment
compared to timely presentations within 24 hours (OR 5 3.06; 95% CI, 1.07-8.77; P
value , .05). Conclusion: With timely diagnosis and treatment, and close monitoring, HRF
cases can achieve a 92% favorable outcome. Male sex and incomplete root development
correlate with improved baseline outcomes and a reduced need for endodontic treatment. From the *Faculty of Dentistry, University
of Toronto, Toronto, Ontario, Canada;
Conversely, delayed presentation increases the likelihood of requiring endodontic †
Dental Trauma Center, Iranian Academic
intervention. (J Endod 2024;-:1–11.) Center for Education, Culture, and
Research, Mashhad, Iran; ‡Faculty of
KEY WORDS Dental Medicine and Oral Health
Sciences, McGill University, Montreal,
Endodontic treatment; healing; horizontal root fracture; outcome; pulp; traumatic dental injury Quebec, Canada; §Clinical Epidemiology
and Health Care Research, Institute of
Health Policy, Management and
Evaluation, University of Toronto, Toronto,
Traumatic dental injuries cause discomfort, pathologic tooth mobility, functional impairments, and Ontario, Canada; and kDepartment of
esthetic concerns, and may disrupt dental arch integrity1,2. Such injuries impose significant physical, Dentistry, Mount Sinai Hospital, Toronto,
economic, and psychosocial burdens on young individuals, potentially exceeding those from caries and Ontario, Canada
periodontal disease3,4. For example, in both Sweden and Denmark, the annual financial cost to the Address requests for reprints to Dr Amir
healthcare system from traumatic dental injuries ranges from $3.3-4.4 million and $2-5 million per 1 Azarpazhooh, Faculty of Dentistry,
million individuals, respectively5,6. Furthermore, tooth loss due to traumatic dental injuries accounts for University of Toronto, 455–124 Edward
Street, Toronto, ON M5G1G6, Canada.
67% of global productivity losses7. A preservation-oriented approach is crucial for saving affected teeth,
E-mail address: amir.azarpazhooh@
especially during alveolar growth3. dentistry.utoronto.ca
Horizontal root fracture (HRF), also known as transverse root fracture, is a complex traumatic 0099-2399
dental injury affecting the pulp, dentin, cementum, and periodontal ligament. This fracture usually follows Copyright © 2024 The Authors. Published
an oblique orientation along the root surface and presents with mobility, dislocation, and tenderness2,8. by Elsevier Inc. on behalf of American
Emergency treatment involves repositioning the displaced coronal fragment, splinting, and regular follow- Association of Endodontists. This is an
ups. Pulp necrosis is infrequent in the apical fragment but more prevalent in the coronal fragment, open access article under the CC BY-NC-
ND license (http://creativecommons.org/
occurring in approximately 25% of cases requiring endodontic intervention9. Endodontic treatment of the licenses/by-nc-nd/4.0/).
coronal fragment is recommended when the fracture line fails to heal2,10,11. However, in cases where https://doi.org/10.1016/
both coronal and apical pulp tissues are necrotic, treatment becomes challenging. Endodontic treatment j.joen.2024.02.002

JOE  Volume -, Number -, - 2024 Outcome of Horizontal Root Fractures 1

through the fracture may adversely affect the 1. The demographic information comprised of Coronal fragment dislocation was recorded
periodontal tissues. Surgical removal of the age, sex, tooth type, and stage of root as none (0.1 mm), slight (0.2-2.0 mm), or
apical fragment is an alternative option if the development. The latter was classified marked (.2 mm)18.
coronal root fragment provides sufficient using Cvek’s17 criteria as follows: 1 (,1/2 3. Treatment-related information included
support and attachment12,13. root length), 2 (1/2 root length), 3 (2/3 root treatment delay, emergency interventions,
Despite existing dental traumatology length), 4 (wide open apical foramen and splinting with or without repositioning of the
guidelines10,11, there is a lack of nearly complete root length), and 5 (closed dislocated coronal fragment (hereafter
comprehensive literature on managing apical foramen and complete root referred to as splinting/repositioning), the
complicated HRF cases that require development). Stages 1-4 were considered duration of splinting, as well as endodontic
endodontic treatment. This scarcity of incomplete root development. treatment (at baseline or follow-up).
research hinders the development of 2. Trauma-related information included the
evidence-based guidelines for optimal etiology of the injury (traffic accidents, sports
treatment approaches14 and exacerbates activities, falls, fights, or hard object impacts), Outcome Measures and Criteria
dentists’ limited exposure to traumatic dental the location of the fracture line (apical, middle, Radiographic healing of the fracture line was
injuries15,16. Hence, the objective of this or cervical third), concomitant injuries, and categorized into 4 types (I-IV) based on the
retrospective study was to assess the long- the severity of coronal fragment dislocation. classification by Andreasen and Hjorting–
term outcome of teeth with HRF and Concomitant injuries were classified as mild Hansen19. The details are presented in
investigate the prognostic impact of (concussion or subluxation) or severe (lateral Figure 1. The outcome measure was defined
demographic, trauma-related, and treatment- luxation, extrusion, or alveolar fracture). as follows9,20,21.
related variables on healing at the fracture line.

MATERIALS AND METHODS

Study Design
This study is a single-center retrospective
cohort study approved by the Academic
Center for Education, Culture and Research,
Mashhad, Iran.

Population
This study collected data from the Dental
Trauma Center, Academic Center for
Education, Culture, and Research in Mashhad,
Iran, spanning January 2006 to January 2022.
Serving as the primary referral hub for
traumatic dental injuries in northeast Iran, this
center has adopted a collaborative approach
involving general dentists, endodontists, oral
and maxillofacial surgeons, periodontists,
pedodontists, prosthodontists, and
orthodontists for comprehensive care. The
inclusion criteria for patients were as follows.

1. History of trauma to permanent tooth/teeth

leading to sub-crestal HRF, confirmed
through clinical and radiographic evaluation
2. Availability of standard periapical
radiographs and clinical information (notes
and photographs) for HRF cases from the
initial visit to the latest follow-up recall
3. Minimum follow-up period of 12 weeks

Teeth with incomplete clinical or

radiographic records, generalized periodontal
problems, supra-crestal HRF, or those
FIGURE 1 – Radiographic progression of healing in horizontal root fracture cases with different types of healing. This
concomitant with crown or crown-root
figure showcases preoperative (A ), postoperative (B ), and follow-up radiographs (C ) of 4 teeth with HRF. The type of
fractures were excluded.
healing is classified according to Andreasen and Hjorting-Hansen’s19 classification, 1) Case 1 (tooth 1.1): Healing with
calcified tissue, fragments in close contact, and minimal or no visible fracture line (type I). 2) Case 2 (tooth 1.1): Healing
Data Collection with interproximal connective tissue, fragments appear separated by a narrow radiolucent line, and fractured edges
A standardized data collection form was appear rounded (type II). 3) Case 3 (tooth 2.1): Healing with interproximal bone and connective tissue, fragments
completed in Microsoft Excel 2016 for each separated by a distinct bony bridge (type III). 4) Case 4 (teeth 1.1 and 2.1): Nonhealing with interposition of granulation
patient and included the following information. tissue, evidenced by widened space between fragments or radiolucency adjacent to the fracture line (type IV).

2 Sheikhnezami et al. JOE  Volume -, Number -, - 2024

TABLE 1 - Baseline Characteristics of Study Teeth With Horizontal Root Fracture

Frequency Percentage
Variable Categories (n) (%)
No. of teeth N 125 100
Treatment delay Within 24 hours 30 24.0
2-7 days 54 43.2
2-4 weeks 24 19.2
5-12 weeks 11 8.8
.12 weeks 6 4.8
Tooth type Maxillary central incisor 103 82.4
Maxillary lateral incisor 11 8.8
Mandibular central incisor 8 6.4
Mandibular lateral incisor 1 0.8
Mandibular canine 2 1.6
Concomitant injury Mild Concussion 2 1.6
Subluxation 37 29.6
Severe Extrusion 43 34.4
Lateral luxation 43 34.4
Location of the fracture line Cervical third 15 12.0
Middle third 81 64.8
Apical third 29 23.2
Root development Complete 102 81.6
Incomplete 23 18.4
Severity of coronal fragment dislocation None/slight 72 57.6
Marked 53 42.4
Duration of splinting 4-8 weeks 17 13.6
9-12 weeks 31 24.8
.12 weeks 76 60.8
Missing data 1 0.8
Primary endodontic intervention Yes 27 21.6
No 98 78.4
Endodontic intervention performed in follow-up visits Yes 64 51.2
No 61 48.8

1. Favorable outcome: radiographic location of the fracture line, dislocation of the significance level of 5% was considered to
evidence of healing (types I-III) at the coronal fragment, and treatment delay). interpret the results.
fracture line, along with the absence of Anticipating a 22% failure rate for teeth with
clinical signs or symptoms HRF18, we calculated a minimum sample size
2. Unfavorable outcome: radiographic of 113 to prevent overfitting and ensure
RESULTS
evidence of nonhealing (type IV) at the fracture precision and accuracy of the regression Descriptive Results
line and/or the presence of any clinical signs models. To maximize statistical power, we Table 1 provides the baseline characteristics of
or symptoms that necessitate endodontic thoroughly examined 1,887 available charts the study teeth. The study included 103
intervention or tooth extraction at any point and included 125 teeth from 103 patients who patients (64.1% male) with a total of 125 teeth.
during the patients’ follow-up visits met the specified inclusion criteria. At the time of presentation, the median age of
The final dataset was analyzed using patients was 18.0 (IQR: 11–26; range: 7 to
SPSS (Version 27 for Mac; IBM Corp, Chicago, 59 years). Eighty five patients (82.5%) had one
Two endodontists (M.S. and H.J.)
assessed outcomes at specified intervals (up IL). Descriptive statistics such as means, tooth with HRF, 14 patients (13.6%) had two
to 4 weeks, 5-8 weeks, 9-12 weeks, 13- standard deviations (SDs), medians with teeth with HRF, and 4 patients (3.9%) had 3
interquartile ranges (IQR), and percentages teeth with HRF. The main causes of HRF were
24 weeks, 25-52 weeks, more than 52 weeks,
and annually thereafter) based on available were used to summarize continuous and sports activities in 27 patients (26.2%), traffic
clinical and radiographic examinations10,11. A dichotomous variables. The Pearson Chi- accidents in 24 patients (23.3%), falls in 23
Square test was conducted to assess the patients (22.3%), fights in 19 patients (18.5%),
high level of agreement (Kappa 5 89.3%) was
achieved. An independent endodontist (A.A.), unadjusted effect of potential predictors on the and hard object impacts in 10 patients (9.7%).
not involved in patient care, conducted a final outcome of baseline interventions, the need for Maxillary central incisors were most affected
audit of all radiographs. Any disagreements endodontic treatment, and the final overall (n 5 103 teeth, 82.4%). Fracture lines were
outcome. Additionally, multivariable logistic primarily located in the middle third (64.8%),
were resolved through group discussion.
regression analyses were performed to followed by the apical third (23.2%) and
determine the adjusted effect of predictors. cervical third (12%). Concomitant injuries were
Statistical Considerations The results were reported as odds ratios (ORs) observed, including concussion in 2 teeth
For regression analyses, we considered 5 with corresponding 95% confidence intervals (1.6%), subluxation in 37 teeth (29.6%),
variables (sex, stage of root development, (CIs). All statistical tests were two-tailed, and a extrusion in 43 teeth (34.4%), and lateral

JOE  Volume -, Number -, - 2024 Outcome of Horizontal Root Fractures 3

FIGURE 2 – Flowchart illustrating the treatment interventions and outcome of the study teeth with horizontal root fracture

luxation in 43 teeth (34.4%). Among teeth with outcomes with clinical normalcy and these teeth was 10.5 weeks
lateral luxation, 30.2% (n 5 13) also exhibited evidence of radiographic healing (20.4% (IQR: 5.2-22.2).
an alveolar fracture. type I, 28.6% type II, and 13.2% type III).
Of the 64 teeth, 61 met the minimum
2. In total, 64 teeth necessitated endodontic
12-week follow-up criteria. Among them,
treatment. These teeth underwent
Analysis of Treatment Strategies 88.5% (54 teeth) showed favorable outcomes,
pulpectomy in the coronal fragment,
and Resulting Outcomes categorized as 13.1% type I, 23% type II, and
followed by 2–24 weeks of calcium
The median treatment delay was 3 days (IQR: 52.4% type III.
hydroxide medication. The coronal
1-11 days), ranging from 24 hours to .3 years. After a median follow-up of 79.0 weeks
fragments of 57 teeth were obturated with
Specifically, 30 teeth in 28 patients (24% of (IQR: 31.5-243.0), 92% of the overall sample
mineral trioxide aggregate (MTA), while
study teeth) received dental treatment within (125 study teeth) had favorable outcomes. The
gutta-percha and resin-based sealer were
24 hours, while 54 teeth in 42 patients (43.2% rate of favorable outcomes was 86.7% at
used in 7 teeth with fracture lines at the
of study teeth) received dental treatment within 4 weeks (52 of 60 available teeth), 75.0% at 5-
apical third of the root. Composite resin
2-7 days. The remaining cases (41 teeth in 33 8 weeks (42 of 56 available teeth), 84.9% at 9-
was employed for the final restoration.
patients, 32.8% of the study teeth) received 12 weeks (45 of 53 available teeth), 88.8% at
o Among these 64 teeth, 27 teeth received
dental treatment after 1 week. 13-24 weeks (71 of 80 available teeth), 83.9%
endodontic treatment at baseline, in
All study teeth necessitated emergency at 25-52 weeks (52 of 62 available teeth), and
conjunction with splinting/repositioning.
splinting with a semi-rigid splint. Notably, 94.4% at .52 weeks (67 of 71 available teeth).
The reasons included complete pulp
60.8% were splinted for .12 weeks (median Except for 5 teeth that were extracted after a
tissue loss in both the apical and coronal
16.0, IQR: 10.2-24; mean 16.8 6 8.2, range: 5 median follow-up of 32.0 weeks (IQR: 28-
fragments (due to a significantly
to 41 weeks), often due to patient 55.5), a high survival rate of 96% was
dislocated coronal fragment in 4 teeth,
noncompliance or excessive tooth mobility observed.
and misdiagnosis in 6 teeth, leading to a
after initial splint removal. Eighty-six out of 125
full pulpectomy performed by the
teeth (69%) also underwent digital
referring dentist) or evidence of coronal Analysis of Prognostic Factors
repositioning of dislocated coronal fragments.
pulpal necrosis associated with a In initial univariate analyses, age, sex, and root
The following treatment approaches
significant delay in seeking treatment. development stage showed significant
were guided by initial assessments of coronal
o For the remaining 37 teeth, nonhealing at associations with baseline splinting/
fragment dislocation and pulpal status (Fig. 2).
the fracture line was observed after repositioning and the need for endodontic
1. At baseline, 98 teeth received emergency baseline splinting/repositioning, treatment (either at baseline or follow-up
interventions of splinting/repositioning but necessitating endodontic treatment appointments). Treatment delays influenced
did not require endodontic treatment. Of during follow-up appointments. The the need for endodontic treatment. However,
these, 61 teeth (62.2%) had favorable median time to endodontic treatment for concomitant luxation injuries, severity of

4 Sheikhnezami et al. JOE  Volume -, Number -, - 2024

TABLE 2 - Unadjusted Effects of Study Variables on the Need for Endodontic Treatment and Overall Healing in Teeth With Horizontal Root Fracture

Favorable outcome of
emergency
interventions Need for endodontic
(splinting/ treatment (at baseline or Final outcome of the
repositioning) follow-up) overall sample
N (% P P N (% P
Variable Level favorable) Value N (%) Value favorable) Value
Age 18 years 51 (76.5%) .005* 59 (33.9%) ,.001* 59 (94.9%) .256
.18 years 47 (48.9%) 66 (66.7%) 66 (89.4%)
Sex Male 63 (71.4%) .025* 76 (42.1%) .011* 76 (93.4%) .466
Female 35 (48.6%) 49 (65.3%) 49 (89.8%)
Treatment delay Within 28 (71.4%) .557 30 (33.3%) .012* 30 (100%) .109
24 hours
2-7 days 49 (59.2%) 54 (48.1%) 54 (87%)
.1 week 21 (61.9%) 41 (68.3%) 41 (92.7%)
Root development Incomplete 21 (85.7%) .016* 23 (21.7%) .002* 23 (100%) .117
Complete 77 (57.1%) 102 (57.8%) 102 (90.2%)
Severity of coronal None/ 55 (63.6%) .931 72 (48.6%) .500 72 (90.3%) .408
fragment displacement slight
Marked 43 (62.8%) 53 (54.7%) 53 (94.3%)
Location of the fracture line Apical third 23 (62.5%) .388 29 (48.3%) .440 29 (96.6%) .150
Middle 62 (66.1%) 81 (49.4%) 81 (92.6%)
third
Cervical 13 (46.2%) 15 (66.7%) 15 (80%)
third
Concomitant luxation injury Minor 23 (60.9%) .785 39 (59.0%) .242 39 (87.2%) .181
Severe 75 (64.0%) 86 (47.7%) 86 (94.2%)

P values generated using Pearson Chi-Square.

*Statistically significant at P value , .05.

coronal fragment displacement, and location 1. Being male, compared to female, was and resulted in a more favorable outcome in
of the fracture line did not significantly affect the significantly associated with a better baseline intervention (85.7% vs. 57.1%,
outcome of emergency treatment or the need outcome of emergency intervention (71.4% OR 5 4.37; 95% CI, 1.16-16.41).
for endodontic treatment. No variables vs. 48.6%, adjusted OR 5 2.58; 95% CI, 3. Treatment delays surpassing one week,
influenced the final outcomes of study teeth at 1.06–6.24) and a lower likelihood of requiring compared to timely presentations within
their latest follow-up (Table 2). endodontic treatment (42.1% vs. 65.3%, 24 hours, were significantly associated with
Age was excluded from the final adjusted OR 5 0.44; 95% CI, 0.20–96). an increased likelihood of requiring
multivariable models due to its significant 2. Incomplete root development, in endodontic treatment (68.3% vs. 33.3%,
correlation with root development (Pearson comparison to complete root development, OR 5 3.06; 95% CI, 1.07–8.77; P
correlation coefficient 5 0.502, P value , .01). significantly reduced the likelihood of value , .05).
The final analyses (Table 3) revealed the needing endodontic treatment (21.7% vs.
following prognostic variables. 57.8%, OR 5 0.24; 95% CI, 0.08–0.76)
DISCUSSION
TABLE 3 - Adjusted Effects of Study Variables on the Outcome of Baseline Interventions and the Need for Endodontic
This retrospective study affirmed prior findings,
Treatment in Teeth With Horizontal Root Fracture
showing a higher prevalence of HRF in males,
Prognostic P primarily affecting maxillary central incisors,
Outcome factor Level Or (95% CI) Value with fractures mainly located at the middle third
of the roots18,22-25.
Outcome of baseline Sex (Ref: female) Male 2.58 (1.06-6.24) .036*
interventions Root Incomplete 4.37 (1.16-16.41) .029* Previous studies on HRF cases
development demonstrate variability in survival and healing
(Ref: complete) rates, and their prognostic factors9,13,18,20-29.
Need for endodontic Sex (Ref: female) Male 0.44 (0.20-0.96) .040* In the present study, after a median
treatment Root Incomplete 0.24 (0.08-0.76) .015* follow-up of 79.0 weeks, we observed a
development remarkable 96% retention rate for study teeth
(Ref: complete) with HRF. This surpasses previously reported
Treatment delay 2-7 days 1.92 (0.72-5.15) .194 rates ranging from 80%24 to 91%26.
(Ref: within .1 week 3.06 (1.07-8.77) .037*
Furthermore, 92% of the study teeth exhibited
24 hours)
a favorable outcome, as evidenced by
P values generated using multivariable logistic regression. radiographic healing at the fracture line and the
*Statistically significant at P value , .05. absence of clinical signs or symptoms.

JOE  Volume -, Number -, - 2024 Outcome of Horizontal Root Fractures 5

FIGURE 3 – Favorable long-term outcome of 4 complicated horizontal root fracture cases. Cases 1 and 2 present two right central incisors with HRF. Case 1 involves an 11-year-old
male who presented within 24 hours of the injury, while case 2 involves a 10-year-old male who presented 1 week after the injury. Clinical evaluations and radiographic assessments
confirmed marked dislocation of the coronal fragments in both cases (1A-2 A and 1B-2 B). During the repositioning procedure, the loose coronal fragments were avulsed with the entire
pulp of the apical fragment (e.g., arrow in 1C). The following procedures were performed: at baseline: immediate replantation, close reduction, and splinting (1D, 1E, and 2C); at
1 week: pulpectomy, calcium hydroxide medication, and temporary restoration; at 3 weeks: obturation of coronal fragments with MTA and temporary restoration (1F and 2D); at
12 weeks (Case 1) and at 16 weeks (Case 2): splint removal and resin composite restoration. During splint removal of case 2, an undetected HRF was observed in tooth 2.1 (arrowhead
in 2D), not requiring further treatment. The outcome was favorable for both cases. They remained asymptomatic, with type I healing at the fracture lines and pulp canal obliteration in
the apical fragments. Case 1 - at 6 years (1G with mild crown discoloration) and 1H); Case 2 - at 3 years (2E and 2F) and 5 years (2G and 2H). Case 3: A 32-year-old male patient
presented 4 weeks after injury with a HRF in tooth 2.1, which went undetected initially by the referring dentist, resulting in a complete pulpectomy for both the coronal and apical
fragments (3A). The following procedures were performed: at baseline: splinting, calcium hydroxide medication, and temporary restoration (3B); at 6 weeks: obturation of coronal
fragments with MTA and temporary restoration (3C); at 16 weeks: splint removal and resin composite restoration. The final outcome at the six-year follow-up was favorable; the tooth
remained asymptomatic, with type II healing at the fracture line and pulp canal obliteration in the apical fragment (3D). Case 4: A 15-year-old male patient presented with subluxation
(no dislocation), in tooth 1.1, referred 1 day after trauma (4A). A deep periodontal pocket, and a sinus tract associated with a nonhealed HRF from a previous traumatic event (dated
7 months ago) was evident (4B and 4C). The following procedures were performed: at baseline: splinting and medication with calcium hydroxide (4B); at 8 weeks: obturation of the
coronal fragments with MTA and temporary restoration; at 16 weeks: splint removal and resin composite restoration; but due to continued mobility, the tooth was permanently splinted
(4D). The final outcome was favorable; the tooth remained asymptomatic, with type III healing of the fracture line at 6 years (4E) and at 12 years (4F and 4G).

6 Sheikhnezami et al. JOE  Volume -, Number -, - 2024

 In this study, 25% of HRF cases faced (Supplementary Table 1). These findings from the complete extrusion of apical pulp
early complications within the first 5–8 weeks. suggest that the males in our study exhibited tissue often attached to severely dislocated
Notably, endodontic intervention for the characteristics associated with a potentially coronal fragments or inadvertent
coronal fragment, when required at baseline or better outcome. Hence, while our study pulpectomy in symptomatic teeth where
follow-up, led to a favorable outcome in 88.5% presents sex as a potential “risk marker”, we HRF was undetected. In such cases,
of HRF cases. This highlights the importance of do not identify it as a “risk indicator” for HRF attempting to obturate both coronal and
vigilant monitoring during the initial 2 months outcomes. As more data become available in apical fragments poses the risk of material
after splinting and prompt endodontic future research, these observations may extrusion and potential failure. Conversely,
management to address complications and undergo further refinement. surgical removal of the apical fragment
reduce the risk of tooth loss. In this study, 81.6% of teeth had compromises tooth support, incurring
Prior studies primarily focused on complete root development at baseline. additional cost and effort. Our study
assessing the healing rate at the fracture line Research suggests that teeth with incomplete employed a conservative approach for 10
following splinting/repositioning, without root development have a lower likelihood of such teeth, involving intra-canal medication
considering endodontic intervention. Reported HRF compared to those with complete with calcium hydroxide followed by MTA
healing rates vary from 45% to 78% in these development2,9,19. This is likely due to the obturation of the coronal fragment and
studies18,22-25,27,28 (Table 4). Our healing rate of heightened elasticity of the tooth’s socket in permanent restoration. After a median
62% in teeth that solely received emergency immature teeth, potentially reducing HRF follow-up of 248.5 weeks (range: 28 to
interventions of splinting/repositioning at occurrence9,19. Our results also align with prior 450 weeks), these cases showed
baseline falls within this range. Specifically, our studies18,22-24, indicating more favorable successful healing. This suggests that a
results align with rates reported by Majorana outcomes in immature teeth with HRF. This is pulpless apical fragment, when properly
et al.27 and Caliskan et al.25 (60% to 62.5%), but likely due to factors such as a larger volume of sealed against bacterial invasion at the
exceed the 45% presented by Welbury et al.’s28 pulp tissue, greater availability of inflammatory fracture line, does not hinder the healing
due to their inclusion of borderline cases with mediators, proximity to the main vascular process.
both HRF and crown fractures. Contrastingly, supply, and a higher density of the vasculature 2. Excessive tooth mobility upon removing
our rate is lower than the 77–78% reported by system30,31. baseline splinting increases the risk of tooth
Andreasen et al.18,22 and Cvek et al.23,24, Our study revealed a significant loss, particularly when HRF is located in the
possibly due to their inclusion of younger association between treatment delays cervical third of the root20. Notably, 70% of
participants with treatment delays of 5 days. exceeding one week and the subsequent need such cases may necessitate extraction24.
In studies involving HRF cases requiring for endodontic intervention. This contradicts This risk is linked to the healing type, with
endodontic intervention, healing rates ranged previous research18,22-24, which did not connective tissue healing (types II or III)
from 50% to 89%13,21,24-26 (Table 4). Lower identify the impact of delays (often considering diminishing the coronal fragment’s ability to
rates of 50-69% were observed for gutta- up to 5 days) on pulp necrosis. Patient delays withstand forces20,24,29,32. Conversely,
percha-filled teeth with or without intra-radicular in seeking dental treatment may stem from a when teeth with HRF undergo healing with
splinting24,26, while a higher rate of 89.5% was lack of awareness of dental trauma calcified tissue (type I), tooth loss is not
achieved with the use of MTA21. Our study also management. Additionally, the severity of dependent on the fracture’s location20,24.
demonstrated a healing outcome of 88.5% for coronal fragment dislocation influences the This group shows normal mobility after
endodontically-treated teeth after a minimum 3- speed at which patients seek dental care. splint removal, akin to adjacent noninjured
month follow-up. These findings emphasize These findings highlight the need for public teeth2. In 30 teeth with HRF in the middle or
MTA’s potential superiority in promoting education on dental emergencies and cervical third, we observed excessive
successful healing in HRF cases when postdental trauma actions to reduce mobility after removing baseline splinting.
endodontic treatment is required. unnecessary treatment delays. Nevertheless, a To improve survival, permanent splinting
We further examined how patient promising 73% of cases with late referrals still with orthodontic retainers was applied.
characteristics, trauma-related factors, and had a reasonable chance of achieving a After a median follow-up of 139.5 weeks
treatment approaches affect healing outcomes favorable outcome at the fracture line. (IQR: 39.0-277.5; range: 32 to 629), 27
and the need for endodontic treatment in teeth Recent dental traumatology teeth showed type II healing at the fracture
with HRF. guidelines10,11 provide treatment plans for line. However, the remaining three, initially
We observed a more favorable outcome categorized trauma cases. However, limited displaying type II healing, eventually
with emergency interventions among males, guidance exists on managing complicated exhibited a nonhealing type IV pattern and
resulting in a reduced need for endodontic HRF cases13,26. Our study suggests the developed deep periodontal pockets.
treatment. This contrasts with Andreasen potential for healing even in complicated Emphasizing excellent oral hygiene in these
et al.’s18 findings, reporting higher hard tissue cases. Therefore, a preservation approach cases is crucial for preserving periodontal
healing frequency in females. They attributed should be prioritized, especially for individuals health and increasing the chance of tooth
this to less severe trauma and more immature in the critical period of alveolar growth when survival.
root formation in their female patients. In our implant replacement may not be feasible due
We acknowledge the limitations of our
study, distinct clusters of males with potentially to inadequate alveolar ridge dimensions. To
study.
better risk indicators were identified. For emphasize this point, we examined 2
instance, although not statistically significant, subgroups of complicated HRF cases from our 1. The retrospective nature of the chart review
males in our study comprised a higher database (Fig. 3), noting the limitation of a small design introduces potential issues such as
proportion of patients below 18 years of age, sample size in these subgroups. irregular follow-ups, missing data, selection
experienced shorter treatment delays, and had bias, and confounding due to
1. The complete loss of pulp tissue in both
HRF cases with no or slight coronal fragment nonrandomization.
coronal and apical fragments may arise
displacement or incomplete root development

JOE  Volume -, Number -, - 2024 Outcome of Horizontal Root Fractures 7

 TABLE 4 - Summary of the Healing Rate, Prognostic Factors, and Survival Rate of HRF Cases in Previous Studies
8
Sheikhnezami et al.

Type of interventions and resulting rate of

radiographic healing
Minimum
Age range in No. follow-up Splinting/
years of duration Splinting/ repositioning 1 endodontic
Reference (country) (mean ± SD) teeth (months) repositioning intervention Prognostic factors Survival rate
Andreasen et al. 19899 (Denmark) NA 95 2 73.6% NA Age, root development, NA
dislocation, mobility,
crown restoration, and
marginal periodontal
disease
Caliskan et al. 199625 (Turkey) 8-40 56 24 62.5% 57% with gutta-percha filling Baseline pulp sensibility, NA
and intra-radicular splint* concomitant crown
fracture
Cvek et al. 200123 (Sweden) 7-17 (11.4 6 4.2) 208 12 77% NA Baseline pulp sensibility, NA
optimal repositioning, age,
root development,
dislocation, mobility,
diastasis
Cvek et al. 200229 (Sweden) 7-17 (11.6 6 2.9) 94 12 84% NA Pulp sensibility, optimal 56%
repositioning, age, root
development, dislocation,
mobility, diastasis
Welbury et al. 200228 (North 6-19 (11.36NA) 84 12 45% NA Baseline pulp sensibility, HRF at Cervical third: 39%
Ireland) crown fracture, HRF at Middle third: 87%
dislocation HRF at Apical third: 100%
Majorana et al. 200227 (Italy) 2-55 31 6 60% NA root development, diastasis, NA
treatment delay
Cvek et al. 200413 (Sweden) 11-20 (13.66NA) 98 12 NA 76% with gutta-percha filling Gutta-percha overfilling NA
68% with gutta-percha filling
followed by apical surgery
Andreasen et al. 200418,22 7-17 (11.5 6 2.8) 400 12 78% NA Baseline pulp sensibility, NA
(Sweden) optimal repositioning, age,
root development,
dislocation, mobility,
diastasis
Cvek et al. 200824 (Sweden) 7-17 (11.46NA) 534 12 78% 69% with gutta-percha filling Gutta-percha overfilling 80%
JOE  Volume -, Number -, - 2024

and intra-radicular splint*

Wo€lner-Hanssen et al. 201026 8-48 (25.56NA) 32 12 75% 50% with gutta-percha filling for Root development, 91%
(Switzerland) both fragments dislocation
Andreasen et al. 201220 (Sweden) 7-17 492 12 NA NA Age, root development, HRF at Apical third: 89%
dislocation, mobility HRF at middle third: 78%
HRF at middle/cervical
thirds:67%
HRF at cervical third: 33%
Kim et al. 201621 (South Korea) 12-65 (33.56NA) 19 3 NA 89.5% with MTA filling Age, root development NA

*The intra-radicular splinting technique involves stabilizing fractured tooth fragments by connecting them internally using a metal pin and a root canal sealer.
NA, not applicable.
2. In this study, the majority of patients did not where consideration for maxillofacial Validation, Writing – original draft, Project
undergo cone beam computed growth is critical. administration. Reza Shahmohammadi:
tomography (CBCT) at baseline. Although 4. The limited sample size in our subgroup Methodology, Investigation, Validation, Formal
CBCT images excel in detecting fractures in cases with complications may limit the analysis, Writing – review & editing. Hamid
teeth and/or alveolar processes compared strength of clinical recommendations. Jafarzadeh: Conceptualization,
to conventional radiographic images33, our Conducting a large-scale, prospective Methodology, Investigation, Resources,
approach prioritizes periapical radiographs study involving these specific categories of Validation, Writing – original draft. Amir
and thorough clinical examinations in the traumatic dental injuries would be ideal but Azarpazhooh: Conceptualization,
initial evaluation of dental traumatology may not be feasible due to their relatively Methodology, Investigation, Resources,
patients33. Additionally, the extra cost of low incidence. Validation, Writing – review & editing,
CBCT, often not covered by insurance, Supervision.
Despite these limitations, our study has
created a financial barrier for our patients.
several strengths. Conducted in a region-wide
Consequently, we adhere to the guideline
dental trauma center serving a population of
that CBCT should not be routinely used
over 8 million, the study utilized a robust and ACKNOWLEDGMENTS
unless its benefits substantially outweigh
comprehensive dataset spanning 16 years.
potential risks34. Following ALARA (As Low The authors deny any conflict of interest
Our meticulous statistical analyses contribute related to this study. We affirm that we have
As Reasonably Achievable) principles for
to a better understanding of factors influencing no financial affiliation (e.g., employment,
patient radiation doses and considering the
the prognosis of teeth with HRF. Future direct payment, stock holdings, retainers,
need for prompt intervention during the
research could utilize advanced imaging consultantships, patent licensing
baseline visit, we limited CBCT use to
techniques like CBCT or TurboReg analysis35 arrangements, or honoraria), or involvement
specific cases involving clinical ambiguity,
for a comprehensive assessment of root with any commercial organization with a direct
inconclusive 2D radiographic imaging, or
development and bone height in HRF cases. financial interest in the subject or materials
legal cases referred from the forensic
This expanded scope can provide valuable discussed in this manuscript, nor have any
dentistry department.
insights into long-term healing rates and such arrangements existed in the past three
3. Initially, patients were scheduled for follow-
optimal treatment strategies, improving overall years. Funding for this project was provided
ups following dental traumatology
outcomes in dental trauma.
guidelines10,11. However, adherence to by the Dental Trauma Center, Academic
these schedules varied among participants Center for Education, Culture, and Research,
due to factors like residing in remote areas, CONCLUSION Mashhad, Iran. The funding source was not
commute challenges, and noncompliance. involved in the study design; in the collection,
Our investigation indicates generally favorable
Some patients chose recall appointments analysis and interpretation of data; in the
outcomes for permanent teeth with HRF. Male
at their convenience or when experiencing writing of the report; or in the decision to
sex and incomplete root development were
signs and symptoms. Additionally, our 12- submit the article for publication. We would
associated with improved baseline outcomes
week follow-up period, though shorter than like to extend our sincere appreciation to the
and a reduced likelihood of needing endodontic
some studies13,18,24,29 with follow-up treatment. Conversely, delayed presentation
staff of the Dental Trauma Center, Ava
periods of 6 to 12 months, aligns with Khansari, and Jacob Marco for their
increased the need for endodontic intervention.
research suggesting the reliability of invaluable assistance throughout this
These results underscore the importance of
assessments at 3-6 weeks9 or 12 weeks21 timely diagnosis, personalized interventions,
research.
post-trauma. That said, this limitation and close monitoring for optimizing outcomes
pertains to only three cases in our study of teeth with HRF.
and the median follow-up duration in this SUPPLEMENTARY MATERIAL
research was 79 weeks. Nevertheless,
longer follow-ups can offer a more CREDIT AUTHORSHIP Supplementary material associated with this
comprehensive understanding of healing CONTRIBUTION STATEMENT article can be found in the online version at
processes in teeth with HRF, specifically for www.jendodon.com (https://doi.org/10.1016/
Mahshid Sheikhnezami: Conceptualization,
clinical decision-making in young patients j.joen.2024.02.002).
Methodology, Investigation, Resources,

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