Five-year follow-up of conservative management for root fractures in immature permanent tooth post trauma: A case report and literature review

Abstract

Vertical root fractures in young permanent teeth secondary to dental trauma are rarely documented in the literature. This case report presents an effective conservative management strategy for preserving a young permanent tooth with a cervical vertical root fracture utilizing splinting techniques and long-term follow-up. We report the case of a 6.5-year-old child who presented with a trauma-induced vertical root fracture in the maxillary left central incisor (tooth #21). Over a 5-year follow-up period, successful hard tissue healing and complete root maturation were observed. By detailing the treatment protocol and reviewing relevant literature, this report analyzes the factors influencing vertical root fracture prognosis and highlights the remarkable self-healing capacity of immature teeth. The favorable clinical outcomes demonstrate that conservative management through splinting provides a viable and highly effective therapeutic option for treating vertical root fractures in young permanent dentition.

Keywords

tooth fractures conservative treatment periodontal splints wound healing mixed dentition

Introduction

Root fractures, which are specifically defined as fractures involving both the dentin and cementum of the root, accompanied by injury to the pulp and periodontal ligament at the fracture site, are critical factors leading to tooth loss.¹ The incidence of root fractures in patients ranges between 0.5% and 7%, and the maxillary central incisors are the most frequently affected teeth.² Notably, children and adolescents are the most susceptible to dental trauma due to active physical movements and weak self-protection.³

Root fractures can be classified into horizontal, oblique, vertical, and horizontal-oblique fractures.⁴ Epidemiological studies have revealed that horizontal fractures account for 63.9% of root fractures, followed by oblique fractures (31.9%), while horizontal-oblique and horizontal-vertical fractures are relatively rare, constituting 1.03% each, and incomplete fractures represent 2.06% of cases.⁵

Interestingly, root fractures in immature permanent teeth are relatively uncommon. Once happened, they predominantly manifest as incomplete fractures. This case report highlights a simple and conservative approach to managing a vertical root fracture (VRF) in an immature permanent tooth. Through repositioning of the coronal fragment and stabilization of the fracture using a flexible splint, the patient ultimately demonstrated hard tissue healing. The long-term efficacy of this treatment was consistently assessed over a 5-year follow-up period.

Case report

A 6-year-and-5-month-old boy presented to Shenzhen Children’s Hospital on March 19, 2019, with displacement and Grade III mobility of the maxillary left central incisor (tooth #21) following a fall 4 h prior. No systemic symptoms (e.g. dizziness and vomiting) were reported. The patient had no significant medical history, allergies, or relevant family history.

Clinical examination

The child’s facial morphology was grossly symmetrical. No abnormalities were noted in the range of mouth opening, the pattern of mandibular movement, or the temporomandibular joints. Tooth #21 presented with an intact crown but demonstrated Grade III mobility, floating freely within the alveolar socket, accompanied by gingival laceration and bleeding. Tooth #11 remained unerupted. A 0.3 cm linear laceration of the maxillary labial frenum was observed, with well-approximated edges and minimal bleeding.

Radiographic examination

The periapical radiograph (Figure 1(a)) revealed root development at Nolla stage 7, with a vertical fracture line in the cervical third and an absence of periapical pathology. Diagnosis: VRF of tooth #21.

Figure 1.

Periapical radiographic follow-up of tooth #21 after repositioning and splinting. (a) Baseline (March 19, 2019): vertical fracture line in cervical third (red arrow), Nolla stage 7 root development, no periapical pathology. (b) Two weeks: splint visible, fracture line persistent. (c) Four weeks (immediately prior to splint removal): splint visible in situ, fracture line discernible. (d) Four months: fracture line indistinct (red arrow), canal wall thickening, hard tissue bridging evident, root development advanced to Nolla stage 8. (e) Sixty-five months: fracture line was no longer detectable; root development at Nolla stage 9 (the apical foramen did not close).

Treatment plan and consent

Notwithstanding a VRF line in tooth #21 that communicated with the gingival sulcus and was situated in the cervical third, conservative management was elected due to pulp regenerative potential. Following repositioning and elastic splint stabilization, apexification, apical barrier technique, or regenerative endodontic treatment would be selective based on pulp status. The treatment protocol was implemented after informed consent was obtained from the parents.

Treatment procedure

Under local anesthesia (4% articaine with 1:100,000 epinephrine; Produits Dentaires Pierre Rolland, Merignac, France), tooth #21 was repositioned. Teeth #21, #53, #52, #62, and #63 were cleaned, etched with 37% phosphoric acid gel on the labial surfaces (Ivoclar Vivadent AG, Schaan, Liechtenstein), bonded with total-etch adhesive (3M ESPE, St. Paul, MN, USA), and finally light-cured (Woodpecker LED curing light, 20 s). Elastic splinting was performed for 4 weeks using BIOSPLINT Splinting Ribbons (BIOSPLINT™, Septodont, France) and Filtek™ Z350 XT flowable composite (3M ESPE). Occlusal stops (Fuji IX glass ionomer cement; GC, Tokyo, Japan) were placed on teeth #16 and #26 to prevent traumatic contact, and the patient was instructed to avoid occlusal loading on tooth #21.

Follow-up and subsequent management

Clinical and radiographic evaluations were conducted at 2 weeks, 4 weeks, 4 months, and 65 months post-splinting (Figure 1(b)–(e); timeline in Table 1). Serial follow-up examinations confirmed that tooth #21 remained asymptomatic to percussion, exhibited no mobility, and was free of inflammation. The splint was removed at 4 weeks after the operation. At the 4-month follow-up, radiographic assessment of tooth #21 demonstrated favorable signs of continued root development, characterized by progressive canal wall thickening, partial blurring of the fracture line, and hard tissue bridging. Clinically, the tooth remained asymptomatic and functionally stable. However, subsequent evaluation at 65 months with cone‑beam computed tomography (CBCT; Figure 2) revealed a persistent open apex (Nolla stage 9), extension of the fracture line into the middle third of the root, and a well‑demarcated periapical radiolucency indicative of chronic apical periodontitis. Throughout the follow‑up period, mild localized gingival inflammation with bleeding on probing was noted around tooth #21 and adjacent teeth, though periodontal probing depths remained within physiologic limits (⩽3 mm) and no suppuration or sinus tract was observed. Based on these cumulative clinical and radiographic findings, the diagnosis was revised to chronic apical periodontitis (Figure 3(a)).

Table 1.

Timeline of follow-up.

Date	Clinical symptoms	Auxiliary examination	Treatments
Initial visit	Intact crown with displaced coronal fragment Grade III mobility Percussion tenderness Gingival sulcus bleeding	Nolla stage 7 Distinct vertical root fracture in cervical 1/3	Successful reduction Elastic fixation of #53, #52, #62, #63, and #21
2 Weeks postoperative	Fixation device intact No percussion tenderness No mobility Mild gingival inflammation	Nolla stage 7 Distinct vertical root fracture in cervical 1/3	Oral hygiene education Regular follow-up examinations
4 Weeks postoperative	No percussion tenderness No mobility Mild gingival inflammation	Nolla stage 7 Distinct vertical root fracture in cervical 1/3	Removal of the elastic fixation device
4 Months postoperative	No percussion tenderness No mobility Mild gingival inflammation	Nolla stage 8 Cervical 1/3 fracture line less distinct than prior	Oral hygiene education Regular follow-up examinations
65 Months postoperative	No percussion tenderness No mobility Mild gingival inflammation	Nolla stage 9 Cervical 1/3 fracture line was undetectable Extensive periapical radiolucency	Apicalization procedure for promoting apical closure: regular replacement of Vitapex paste
77 Months postoperative	No percussion tenderness No mobility Mild gingival inflammation	Root development completed The apical foramen closed	Completion of root canal therapy Crown restoration

Figure 2.

CBCT assessment at the 65-month follow-up. (a–c) Multiplanar reconstruction views (axial, coronal, and sagittal) demonstrating calcification within tooth #11. (d) Sagittal view of tooth #21: open apex with a well-defined periapical radiolucency (white arrow). (e) Sagittal view of tooth #21: fracture line in the cervical third exhibiting hard tissue bridging.

Figure 3.

Apexification and definitive root canal treatment of tooth #21. (a) Preoperative radiograph at 65 months post-injury: open apex with a well-defined periapical radiolucency. The white arrow indicated a circumscribed radiolucent lesion at the immature root apex, characterized by distinct margins and a localized loss of trabecular bone pattern. (b) Intraoperative radiograph: Vitapex paste placed within the root canal with controlled extrusion beyond the apex. (c) One-month follow-up radiograph: resorption of the extruded paste. (d) Radiograph at 12 months post-apexification (77 months post-injury): complete apical closure (Nolla stage 10) with successful obturation using gutta-percha and iRoot SP premixed injectable bioceramic sealer.

Apexification was initiated following rubber dam isolation. The pulp chamber was accessed using a BR-31 round diamond bur (MANI, Inc., Utsunomiya, Japan). The root canal was irrigated with 0.9% saline (Kelun, Sichuan, China) and 1% sodium hypochlorite (Langli, Wuhan, China), dried with paper points, and finally filled with Vitapex paste (Neo Dental International, Inc., Fukuoka, Japan). As illustrated in Figure 4, intraoral views obtained 70 months after the initial procedure. At the 77 months post-injury, radiographic assessment confirmed apical closure completed and the absence of periapical pathology. The root canal treatment was then performed. The canal was obturated with gutta-percha and an injectable premixed bioceramic sealer (iRoot SP, Innovative BioCeramix, Inc., Vancouver, BC, Canada). Finally, restoration was conducted (Figure 3(d)).

Figure 4.

Intraoral photographs at 70-month follow-up. (a) Frontal occlusion. (b) Anterior tooth occlusion. (c) Maxillary dentition. (d) Mandibular dentition. (e) Left lateral occlusion. (f) Right lateral occlusion.

Review of the literature

A systematic literature search was performed to identify case reports on traumatic root fractures of maxillary anterior teeth. PubMed was searched from January 1, 2008 to March 1, 2025, using the following strategy: (“Root Fracture” [MeSH Terms] OR “root fracture” [Title/Abstract]) AND (“Maxilla” [MeSH Terms] OR “Incisor” [MeSH Terms] OR “maxillary anterior teeth” [Title/Abstract]) AND “Case Reports” [pt]) NOT (“Crown Fractures” [MeSH Terms] OR “crown-root fracture” [Title/Abstract]). The initial search retrieved 73 records. After screening, studies were excluded if they described non-traumatic fractures, VRFs in previously endodontically treated teeth, primary tooth fractures, or posterior tooth trauma. Nine case reports met the criteria and were finally incorporated into the analysis (Table 2 and Figure 5).

Table 2.

Summary of included case reports.

Authors	Age	Sex	Tooth number	Treatment	Recall period	Evaluation	Supplemental information
Zheng et al.⁶	38 Years	Male	Tooth #21	The coronal and apical fragments of the canal were both chemo-mechanically prepared and obturated using a single cone gutta-percha with iRoot SP (Innovative BioCreamix, Inc., Vancouver, BC, Canada)	24 Months	The patient was asymptomatic, and the radiolucency around the fracture line showed healing on radiography	Spontaneous pain and masticatory discomfort persisted for 3 days; dental trauma derived from a boxing match 15 years ago
Parekh et al.⁷	15 Years	Female	Tooth #21	Initial attempts included preservation of the natural tooth with pulpectomy and calcium hydroxide medicants. Due to poor outcomes, the apical part of the root was surgically removed, and an endodontic implant was placed	8 Months	The tooth showed no mobility and favorable soft-tissue healing	Impact injury 2 days prior
Özler and Cehreli⁸	12 Years	Female	Tooth #11	Repositioning of the coronal fragment of a maxillary central incisor and long-term splinting using a bonded lingual orthodontic retainer wire	7 Years	The patient was asymptomatic and showed radiographic evidence of progressive pulp canal obliteration	A fall 2 h prior
Gharechahi⁹	6 Years	Female	Tooth #21	A composite resin was used to fix the teeth with stainless steel wires for 4 weeks	24 Months	Normal tooth color and position and a positive response to the pulp test	A bicycle accident 1 h prior
Sun et al.¹⁰	7 Years	Female	Teeth #11 and #21	A flexible splint consisting of orthodontic stainless wire (twisted with four pieces of wire with a diameter of 0.025 mm) and composite resin was used to stabilize the mobile coronal segments of teeth #11 and #21 through teeth #55, 54, 53, 11, 21, 22, and 26. GIC was placed on teeth #36 and 46 to relieve the occlusal trauma of teeth #11 and #21	16 Months	Teeth #11 and #21 were asymptomatic and showed normal mobility. The fracture line had faded, hard tissue healing was evident, and suspected partial calcification was observed at the fracture site, but the root canals were still unobstructed	Pain and mobility of the two maxillary central incisors after trauma, exacerbated by touching or biting
Mane et al.¹¹	15 Years	Female	Teeth #11 and #21	Treatment of both the coronal and apical root fragments of tooth #11, followed by RCT of tooth 21. After 12 months, porcelain–metal crowns were fabricated for both teeth #11 and # 21	24 Months	Clinically, there was no tenderness, mobility, depression, sinus tract infection, or swelling. Radiographically, hard tissue healing was observed in the interfragmentary space	The patient had fallen 2–3 months before reporting to the institution
Deshpande and Deshpande¹²	7 Years	Female	Teeth #11 and #21	A 0.3 mm soft, round, stainless steel, flexible arch wire bonded with light-cure resin was used for tooth repositioning and splinting. Antibiotic medication was administered; The patient was recommended to consume a soft diet and was provided with an anti-plaque mouth rinse and anti-inflammatory agents	24 Months	Clinical examination showed no adverse signs or symptoms in the permanent maxillary central incisors. Radiography showed complete root development	The patient had fallen from a bicycle ~15 min prior
Jepsen et al.³	14 Years	Female	Tooth#11	Anti-infective RCT was attempted first, followed by filling of the coronal fragment with MTA. A reevaluation 6 months later showed nonhealing of the fracture. A microsurgical operation was performed to remove the apical root and clean the wound, fill it with xenogeneic bone graft and autogenous bone, and cover it with collagen matrix. Postoperative care included oral hygiene and antibiotics	12 Months	The periodontal condition was stable, the probing depth was normal, the gingival margins and mucogingival conditions were favorable, and there was no scaring formation	The patient had retained the fractured and avulsed part in the mouth for ~3 h prior to replantation
Haghdadi et al.¹³	14 Years	Male	Tooth#11	At the initial visit, a previously applied MTA in the coronal segment was removed under local anesthesia, and calcium hydroxide was applied. After a 2-week follow-up, apical necrosis was confirmed at the second visit. The apical segment was cleaned and sealed with MTA. Subsequently, CollaPlug fibers were placed between the two segments, and the coronal segment was sealed again with MTA	24 Months	Clinical examination revealed no signs of edema, erythema, or sinus tracts. Oral radiographic examination indicated that the radiolucent lesions on tooth #11 had healed with fibrous tissue	A car accident 5 years prior

GIC: glass ionomer cement; MTA: mineral trioxide aggregate; RCT: root canal treatment.

Figure 5.

PRISMA flow diagram of the literature search strategy for traumatic root fracture case reports (PubMed, January 1, 2008–March 1, 2025).

Discussion

This case further demonstrates that near-VRFs in immature permanent teeth can achieve hard tissue healing and continued root development through a biologically conservative approach—precise repositioning combined with elastic splinting. Radiographic resolution of the fracture line, progressive apical formation, and sustained functional integrity align with established criteria for calcific healing,^14,15 mirroring the healing trajectory observed in horizontal root fracture cases reported by Sun et al.¹⁰ and Deshpande and Deshpande,¹² thereby underscoring the pivotal role of “anatomical repositioning + physiological fixation” in determining prognosis. Notably, the fracture was confined to the cervical third of the root, with coronal displacement ⩽1 mm and repositioning completed within 4 h post-injury—all parameters falling squarely within the optimal window for calcific healing (displacement <2 mm, incomplete root development, and prompt repositioning). These findings robustly validate the dual anatomical–biological principles articulated by Andreasen et al.,^14,15 providing clinically actionable evidence to guide decision-making in the management of traumatic root fractures in immature permanent teeth.

Elastic splinting was applied to tooth #21 and four adjacent teeth (#53, #52, #62, #63) using a 0.4-mm fiber-reinforced splint for 4 weeks. This configuration minimized shear micromotion at the cervical fracture site while preserving physiological mobility. Although shorter than the International Association of Dental Traumatology (IADT) 2020 recommendation of 4 months for cervical-third fractures,¹⁶ the five-tooth anchorage provided biomechanically sound stabilization by counteracting lever forces and distributing occlusal loads. Although a retrospective series of 512 teeth suggested that prolonged immobilization might enhance hard tissue deposition,¹⁷ that study had limited subgroup numbers and a follow-up truncated at 24 months; it is therefore insufficient to invalidate single cases in which calcific healing is obtained after 4 weeks. Because overlong splinting increases plaque accumulation and the risk of replacement resorption, we favored an “early functional stimulation” strategy, compensating for the shortened fixation time with laser Doppler flowmetry (LDF) monitoring of pulpal blood flow. No increase in mobility or replacement resorption was observed over 65 months, preliminarily indicating that “short-term splinting + LDF surveillance” is viable in selected cases. Multicenter randomized controlled trials are still required for validation.

Fracture orientation is also considered prognostic. The present “near-vertical-oblique” pattern parallels the literature reporting that “cervical fractures show better healing than transverse fractures because their engagement with the middle third of the root increases coronal fragment stability.”¹⁸ CBCT clearly depicted the line running from the lingual groove obliquely toward the apical third, offering a far larger surface area than a typical horizontal fracture. Root fracture healing patterns are dependent on fracture type and location. The favorable outcome herein contrasts distinctly with complex cases described by Jepsen et al.³ and Haghdadi et al.,¹³ which necessitated multiple interventions, including mineral trioxide aggregate (MTA) apical barrier placement or microsurgical management. This may have provided a broader three-dimensional scaffold for blood-clot retention and subsequent calcific bridging, while the fracture surface could generate a “self-locking” effect under functional loading, reducing secondary displacement of the coronal segment—an anatomical basis for the success observed after only 4 weeks of splinting.

With respect to imaging, we strictly followed the IADT schedule, that is, 4 weeks, 6–8 weeks, 4–6–12 months, then annually for 5 years,¹⁹ utilizing periapical radiographs as the primary diagnostic and monitoring tool. Consistent with the as low as reasonably achievable (ALARA) principle and IADT guidelines,^19,20 CBCT was deliberately reserved for critical decision points where conventional radiographs proved inconclusive regarding fracture configuration or healing status. For instance, CBCT identified an early periapical radiolucency at the cervical fracture site when periapical images remained unremarkable, demonstrating its indispensable value in detecting subtle pathology in complex cervical-third fractures.^21,22 This selective strategy reflects a balanced approach: avoiding unnecessary radiation exposure in diagnostically clear phases while leveraging three-dimensional imaging precisely when clinical uncertainty arises. We acknowledge that routine CBCT is neither mandated nor recommended for all root fractures; its application must be clinically justified. Looking ahead, integrating deep learning models (e.g. ResNet50) into chairside workflows holds promise for enhancing diagnostic precision, reducing interpretive variability, and further optimizing radiation stewardship in traumatic dental injury management.²³ Between the 4- and 65-month evaluations, radiographic reviews could not be performed at the ideal intervals due to practical challenges, including issues with patient compliance and geographical distance. Although remote communication confirmed the absence of clinical symptoms such as tooth discoloration, gingival fistula, or pain, the possibility of asymptomatic pathological changes cannot be entirely ruled out.

The inherent biological resilience of immature permanent teeth was reaffirmed in this case. The wide apical foramen and rich collateral vascular network allow the apical pulp tissue to survive transient coronal pulp ischemia through a “stress-shielding” mechanism.¹⁶ LDF monitoring detected restored pulpal blood flow in tooth #21 as early as 2 weeks post-trauma (Figure 6), providing objective justification for an initial conservative observational approach. This finding precisely aligns with the literature reporting high sensitivity (81.8%—100%) and specificity (100%) of LDF for pulp vitality assessment in immature permanent teeth.²⁴ Nevertheless, at the 65-month follow-up, periapical radiolucency emerged along with a progressive decline in LDF values, clearly indicating the long-term risk of pulp necrosis specific to VRFs. Given that root development had reached Nolla stage 9, apexification was subsequently performed on tooth #21.

Figure 6.

Longitudinal pulp vitality monitoring of tooth #21 via LDF. LDF values (perfusion units) plotted against time post-injury. An initial rise in pulp blood flow during weeks 2–4 likely reflects active revascularization and reparative inflammatory response following tooth repositioning and stabilization. Subsequent gradual decline correlates with physiological apical constriction during root maturation and progressive loss of pulp vitality, culminating in periapical radiolucency evident at 65 months.

Material selection for apexification should be rigorously individualized. MTA forms a dense, stable biomineralized barrier with superior apical sealing capacity, showing a high clinical success rate of 94.7% and a shorter treatment duration. However, it requires advanced technical proficiency, specialized equipment, and incurs higher costs. Conversely, a calcium hydroxide-iodoform paste named Vitapex offers excellent flowability for irregular apical configurations. However, our rationale for selecting Vitapex in this case was rooted in its well-documented capacity to promote biomimetic tissue regeneration. As demonstrated by Okamoto et al.,²⁵ calcium hydroxide-iodoform pastes actively induce an apical mineralized barrier composed of collagen, calcium carbonate, and hydroxyapatite, which closely mimics the bilaminar structure and mineral density of natural cementum. The sustained release of calcium hydroxide endows it with antimicrobial and mineralization-inducing properties. It has advantages in cost-effectiveness and technical accessibility. However, its resorbable nature prevents permanent sealing, has a higher risk of overfilling, and presents a comparatively lower long-term success rate (76.9%).^26,27

In this case, Vitapex was selected based on its targeted antimicrobial efficacy in the context of periapical chronic inflammation and practical constraints regarding clinical resources. Its role was explicitly defined as a transitional inducer (not a permanent root canal filling material). The observed Vitapex overfilling was directly because of to high flowability. Although histopathological evidence indicates that overfilled material can be gradually phagocytosed by macrophages without long-term sequelae,²⁸ transient inflammatory reactions remain a clinical consideration. In accordance with the IADT 2020 guidelines and contemporary evidence,¹⁹ for immature permanent teeth at Nolla stage 9 (constricted apical foramen), an optimized strategy should prioritize MTA for single-visit apical barrier formation or consider advanced bioceramic alternatives with enhanced handling properties (e.g. iRoot BP Plus).²⁴ This case underscores a crucial clinical principle: optimal decision-making requires the dynamic integration of apical foramen morphology, infection status, patient compliance, resource availability, and operator expertise to achieve safe, efficient, and truly personalized outcomes. Furthermore, it reaffirms the indispensable necessity of long-term, protocol-driven follow-up for teeth affected by root fractures.

This case illustrates the complex pathological progression and long-term prognosis associated with root fractures in young permanent teeth, as evidenced by pulp necrosis and periapical radiolucency in tooth #21, alongside pulp canal calcification in the adjacent tooth #11. At 4 months, the fracture line in tooth #21 showed gradual healing, with root development reaching Nolla stage 9. This suggested preserved partial pulp vitality and satisfactory periapical repair, consistent with the strong regenerative potential of young pulp.¹⁵ However, periapical radiolucency observed at the 65‑month follow‑up indicated progressive pulp necrosis. Potential mechanisms include incomplete restoration of pulpal blood supply after initial partial healing, leading to ischemic necrosis of the remaining pulp tissue, as well as a persistently open apical foramen that may have allowed bacterial invasion via retrograde infection through the apex or lateral canals, triggering chronic apical periodontitis and subsequent periapical bone resorption.^29,30 Notably, necrotic pulp can release endogenous toxins and bacterial metabolites, which continuously irritate the periapical tissues through the open apex, creating a chronic inflammatory environment that ultimately leads to the formation of periapical radiolucency.^31,32

The possible mechanisms for pulp canal calcification observed in tooth #11 in the present case and in tooth #11 with a horizontal root fracture reported by Özler and Cehreli⁸ (Table 2) include: transmission of traumatic force through alveolar bone or the periodontal ligament, indirectly injuring the pulpal neurovascular bundle and triggering a defensive repair response that results in calcified foci³³; and diffusion of inflammatory mediators (e.g. IL‑1β and TNF‑α) from the chronic apical periodontitis of tooth #21 through the jawbone to the adjacent periapical area, stimulating odontoblasts toward abnormal mineralization and accelerating reparative dentin formation, ultimately leading to pulp canal calcification.³⁴ Furthermore, the distinctive physiology of young permanent teeth—such as high metabolic activity and abundant fibroblasts—may predispose them to excessive calcium salt deposition and abnormal mineralized tissue formation following injury.³⁵

Although tooth #21 developed pulp necrosis following a cervical–root fracture, apical third horizontal fractures typically preserve coronal pulp vitality while the detached fragment undergoes calcification without periapical radiolucency.³⁶ This contrast reflects preserved apical vascular supply sustaining pulp viability and driving reparative mineralization—a mechanism paralleled by pulp canal obliteration in tooth #11 of this report. These findings confirm that fracture location, not morphology alone, critically determines pulp healing potential. Accurate prognosis requires integrated evaluation of fracture level, apical foramen maturity, and early vitality assessment. Long-term monitoring and individualized management are therefore essential for optimizing outcomes in root-fractured young permanent teeth (Supplemental Material).

In summary, this case, evaluated clinically, radiographically, and pulp status, demonstrates that a cervical–root fracture in an immature permanent tooth with <1 mm displacement can achieve calcific healing after only 4 weeks of flexible splinting, provided reduction is timely and blood-flow monitoring is employed. LDF can detect early vascular recovery and prevent premature endodontic intervention. CBCT at strategic time-points offers three-dimensional evidence to guide precise decisions. These findings provide new evidence for extending the “short-splint-functional stimulation” protocol, but larger, multicenter, long-term studies are still needed to define optimal splint duration, blood-flow thresholds, and imaging indications, ultimately establishing a universally applicable treatment pathway for root fractures in immature permanent teeth.

Conclusions

Root fractures occurring after dental trauma often have uncertain treatment outcomes. However, immature permanent teeth with root fractures typically achieve a good long-term prognosis when managed with conservative treatment. We recommend prioritizing minimally invasive approaches to preserve the pulp to promote continued root maturation. Regular clinical and radiographic examinations are crucial for monitoring healing progress and determining the prognosis of the fracture.

Limitations

Although we strictly followed the IADT guidelines when scheduling the patient’s follow-up, the patient sometimes missed the appointment because of inconvenient transportation. Consequently, pulp status changes during critical healing phases could not be fully documented, introducing potential gaps during the longitudinal assessment of the patient’s healing. Despite repeated oral hygiene instruction, the child’s oral hygiene remained worse, with six new cavities emerging. Owing to the socioeconomic burden, parents refused dental treatments, which might influence the long-term prognosis. It should be noted that the conclusions drawn from this review are based on low-level evidence (case reports), and the non-systematic inclusion of studies may introduce selection bias.

Supplemental Material

sj-docx-1-sco-10.1177_2050313X261441764 – Supplemental material for Five-year follow-up of conservative management for root fractures in immature permanent tooth post trauma: A case report and literature review

Supplemental material, sj-docx-1-sco-10.1177_2050313X261441764 for Five-year follow-up of conservative management for root fractures in immature permanent tooth post trauma: A case report and literature review by Bingna Lin, Cong Liu, Li Chen and Li Zhang in SAGE Open Medical Case Reports

Footnotes

Acknowledgements

We sincerely thank the patient and their family for their informed consent and support regarding the publication of this case report.

Author note

I, Li Zhang, confirm that I am the sole corresponding author for this manuscript. I am responsible for communication with the journal during submission, peer review, and publication, and I will ensure post-publication correspondence is handled appropriately.

ORCID iDs

Cong Liu

Li Zhang

Ethical considerations

The study protocol was approved by the Ethics Committee of Shenzhen Children’s Hospital (approval no. 2025(014)).

Consent for publication

Written informed consent was obtained from the patient’s parents. All procedures were conducted in accordance with relevant guidelines and regulations.

Patient perspective

The parents expressed gratitude for the conservative management that preserved their child’s natural tooth, noting minimal disruption to daily activities during treatment. They emphasized the importance of clear communication and regular monitoring throughout the 65-month follow-up.

Author contributions

Bingna Lin, Cong Liu, and Li Chen: contributed equally to this work and should be considered co-first authors. Bingna Lin: responsible for case screening and collection, patient follow-up tracking, assistance in clinical procedures, literature review, and drafting the initial manuscript. Cong Liu: responsible for literature review, assistance in case data collection and organization, and assistance in revising and refining the initial manuscript draft. Li Chen: participated in the recording of clinical examination data and contributed to supplementing the discussion section of the manuscript. Li Zhang: led the design and implementation of the treatment plan, provided critical revisions to the manuscript, and gave final approval of the version to be published.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

References

Dhindsa

Garg

Poddar

, et al. Management of root fractures in young immature permanent teeth: three case reports. Int J Clin Pediatr Dent 2024; 17(3): 352–356.

Chute

Toshniwal

Gade

, et al. Repair of incomplete horizontal mid-root fracture of maxillary central incisor with mineral trioxide aggregate: a follow up report. J Conserv Dent 2014; 17(4): 393–395.

Jepsen

Schneider

Dommisch

, et al. Management of a central incisor with horizontal root fracture for esthetic and functional rehabilitation. Int J Periodontics Restorative Dent 2016; 36(1): 65–73.

Andreasen

Mejàre

, et al. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol 2004; 20(4): 203–211.

Doğan

Callea

Kusdhany

, et al. The evaluation of root fracture with cone beam computed tomography (CBCT): an epidemiological study. J Clin Exp Dent 2018; 10(1): e41–e48.

Zheng

Shen

BP.

Conservative endodontic management using a calcium silicate bioceramic sealer for delayed root fracture: a case report and review of the literature. World J Clin Cases 2021; 9(8): 1835–1843.

Parekh

Sathyanarayanan

Manjunath

MT.

Clinical management of mid-root fracture in maxillary central incisors: case reports. Int J Oral Sci 2010; 2(4): 215–221.

Özler

Cehreli

ZC.

Conservative management of a cervical horizontal root fracture by long-term stabilisation: a case report. Aust Endod J 2022; 48(2): 338–341.

Gharechahi

Horizontal root fracture accompanied by luxation of coronal fragment in a maxillary central incisor: a case report. J Dent Res Dent Clin Dent Prospects 2013; 7(4): 244–247.

10.

Sun

Liu

Zhou

, et al. Management of oblique root fracture in the middle third of two maxillary immature central incisors with severe caries in mixed dentitions: a case report. J Clin Pediatr Dent 2024; 48(4): 214–221.

11.

Mane

Shetty

Borkar

, et al. Healing after horizontal root fracture of maxillary central incisor: a case report with 24-month follow-up. Cureus 2023; 15(8): e43373.

12.

Deshpande

Flexible wire composite splinting for root fracture of immature permanent incisors: a case report. Pediatr Dent 2011; 33(1): 63–66.

13.

Haghdadi

Mokabberi

Rad

SAB

. Conservative management of horizontal root fracture: a case report. Clin Case Rep 2024; 12(12): e9625.

14.

Andreasen

Ahrensburg

Tsilingaridis

Root fractures: the influence of type of healing and location of fracture on tooth survival rates—an analysis of 492 cases. Dent Traumatol 2012; 28(5): 404–409.

15.

Pedrosa

NOM

Santos

Coste

, et al. Healing and long-term prognosis of root-fractured permanent teeth: a retrospective longitudinal study. Clin Oral Investig 2024; 28(4): 209.

16.

Abbott

PV.

Diagnosis and management of transverse root fractures. J Endod 2019; 45(12s): S13–S27.

17.

Isaksson

Koch

Bakland

, et al. Effect of splinting times on the healing of intra-alveolar root fractures in 512 permanent teeth in humans: a Scandinavian multicenter study. Dent Traumatol 2021; 37(5): 672–676.

18.

Fagundes

Ddos S

de Mendonça

de Albuquerque

, et al. Spontaneous healing responses detected by cone-beam computed tomography of horizontal root fractures: a report of two cases. Dent Traumatol 2014; 30(6): 484–487.

19.

Bourguignon

Cohenca

Lauridsen

, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol 2020; 36(4): 314–330.

20.

Hayashi

Arai

Chikui

, et al. Clinical guidelines for dental cone-beam computed tomography. Oral Radiol 2018; 34(2): 89–104.

21.

May

Cohenca

Peters

OA.

Contemporary management of horizontal root fractures to the permanent dentition: diagnosis—radiologic assessment to include cone-beam computed tomography. J Endod 2013; 39(3 suppl): S20–S25.

22.

Shokri

Salemi

Taherpour

, et al. Is cone-beam computed tomography more accurate than periapical radiography for detection of vertical root fractures? A systematic review and meta-analysis. BMC Med Imaging 2024; 24(1): 286.

23.

Cao

, et al. Diagnosis of in vivo vertical root fracture using deep learning on cone-beam CT images. BMC Oral Health 2022; 22(1): 382.

24.

Ghouth

Duggal

BaniHani

, et al. The diagnostic accuracy of laser Doppler flowmetry in assessing pulp blood flow in permanent teeth: a systematic review. Dent Traumatol 2018; 34(5): 311–319.

25.

Okamoto

Naito

Duncan

, et al. Microstructural evaluation of the mineralized apical barrier induced by a calcium hydroxide paste containing iodoform: a case report. J Endod 2024; 50(2): 243–251.

26.

Warner

Al-Salehi

SK.

Management of open apex in a central incisor using mineral trioxide aggregate. Dent Update 2011; 38(1): 50–52, 54.

27.

Doumari

Dhoum

El Hajjoui

, et al. Use of calcium silicate-based materials in the management of open apices: a case report. Cureus 2025; 17(6): e86471.

28.

Chang

Lee

, et al. Long-term observation of the mineral trioxide aggregate extrusion into the periapical lesion: a case series. Int J Oral Sci 2013; 5(1): 54–57.

29.

Andreasen

Kahler

Pulpal response after acute dental injury in the permanent dentition: clinical implications-a review. J Endod 2015; 41(3): 299–308.

30.

Liao

Yue

, et al. Self-repaired process of a traumatized maxillary central incisor with pulp infarct after horizontal root fracture monitored by laser Doppler flowmetry combined with tissue oxygen monitor. J Endod 2017; 43(7): 1218–1222.

31.

Barros

Velasquez-Espedilla

Oliveira

, et al. Impact of type 2 diabetes mellitus on apical periodontitis size, endotoxin levels, and bacterial load in root canals with necrotic pulp. J Endod 2025; 51(8): 1036–1043.

32.

Yilmaz

Aksu

Karahan

, et al. Association between serum cytokine levels with pulp necrosis and apical periodontitis in sickle cell disease. Sci Rep 2025; 15(1): 41149.

33.

Abreu

MGL

Fernandes

Antunes

, et al. Prevalence of pulp canal obliteration after traumatic dental injuries: a systematic review and meta-analysis. Braz Oral Res 2024; 38: e092.

34.

Samuel

Ervolino

de Azevedo Queiroz

ÍO

, et al. Th1/Th2/Th17/Treg balance in apical periodontitis of normoglycemic and diabetic rats. J Endod 2019; 45(8): 1009–1015.

35.

Shi

Hou

BX.

[Causes, diagnosis and treatment strategies for dental pulp calcification]. Zhonghua Kou Qiang Yi Xue Za Zhi 2022; 57(3): 220–226.

36.

Taori

Nikhade

Chandak

, et al. Management of untreated horizontal root fracture: a case report. Cureus 2022; 14(8): e28133.

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