Clinical Research
Healing of Horizontal Intra-alveolar Root Fractures after
Endodontic Treatment with Mineral Trioxide Aggregate
Dohyun Kim, DDS, MSD,* Wonyoung Yue, DDS,* Tai-Cheol Yoon, DDS, MSD, PhD,†
Sung-Ho Park, DDS, MSD, PhD,* and Euiseong Kim, DDS, MSD, PhD*
Abstract
Introduction: The purpose of this retrospective study
was to evaluate the healing type and assess the
outcome of horizontal intra-alveolar root fractures after
endodontic treatment with mineral trioxide aggregate
(MTA) as filling material. Methods: The clinical data-
base of the Department of Conservative Dentistry at
Yonsei University Dental Hospital, Seoul, Korea, was
searched for patients with histories of intra-alveolar
root fractures and endodontic treatments with MTA be-
tween October 2005 and September 2014. Radiographic
healing at the fracture line was evaluated independently
by 2 examiners and was classified into 4 types according
to Andreasen and Hjørting-Hansen. Results: Of the 22
root-fractured teeth that received endodontic treatment
with MTA, 19 cases participated in the follow-up after a
period of at least 3 months. Seventeen of the 19 teeth
(89.5%) exhibited healing of the root fractures. For
each healing type, 7 teeth (36.8%) showed healing
with calcified tissue, 8 teeth (42.1%) showed interposi-
tion of connective tissue, 2 teeth (10.5%) showed inter-
position of connective tissue and bone, and 2 teeth
(10.5%) showed interposition of granulation tissue
without healing. Conclusions: Within the limitations
of this study, intra-alveolar root fractures showed satis-
factory healing outcomes after endodontic treatment
with MTA. MTA could be considered to be suitable filling
material for the endodontic treatment of horizontal
intra-alveolar root fractures. (J Endod 2016;-:1–6)
Key Words
Endodontic treatment, healing, horizontal root fracture,
mineral trioxide aggregate
From the *Microscope Center, Department of Conservative
Dentistry and Oral Science Research Center, Yonsei University
College of Dentistry, Seoul, South Korea; and †Department of
Conservative Dentistry and Endodontics, National Health Insur-
ance Service Ilsan Hospital, Goyang, South Korea.
Address requests for reprints to Dr Euiseong Kim, Micro-
scope Center, Department of Conservative Dentistry and Oral
Science Research Center, Yonsei University College of
Dentistry, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul 03722, South
Korea. E-mail address: andyendo@yuhs.ac
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.11.016
JOE — Volume -, Number -, - 2016
I t is generally known that the prognosis of horizontal intra-alveolar root fractures is
good with proper diagnosis and treatment (1–6). However, there are also
possibilities of pulpal and periodontal complications in the presence of bacterial
contamination, and the sequelae of root fractures can be complex. When the pulp
goes through degenerative changes, necrosis usually only occurs in the coronal
fragment, whereas the pulp of the apical fragment remains vital (7, 8). Therefore, it
is recommended that the endodontic treatment of a root-fractured tooth should be
mainly limited within the coronal fragment (9) with the intention of achieving hard tis-
sue formation between the fragments. Healing of intra-alveolar root fractures can be
divided into 4 types by radiographic and histologic observations (7):
1. Healing with calcified tissue
2. Interposition of connective tissue
3. Interposition of connective tissue and bone
4. Interposition of granulation tissue without healing
The reported frequencies of pulp necrosis in intra-alveolar root fractures were
between 22% and 26% (2, 3, 10), and the healing rates after endodontic treatment
of the coronal fragment ranged from 71% to 84% (4, 5, 8). However, studies that
separately indicated 4 healing types of endodontically treated root-fractured teeth
were rare (5), and from other studies, we could only compute the overall healing
rates.
Until now, dressing with calcium hydroxide (Ca[OH]2) followed by filling with
gutta-percha (GP) and sealer has been regarded as the treatment of choice for the end-
odontic treatment of root-fractured teeth. However, it is difficult to seal the coronal frag-
ment with GP because it is often hard to obtain an apical stop that is similar to the
treatment of immature teeth (8). Considering the short length of the coronal fragment
and the vulnerability for reinfection, it is important to seal the coronal fragment
properly.
In 1993, mineral trioxide aggregate (MTA) was introduced, and it has been widely
used in endodontic procedures because of its superior sealing ability (11), bactericidal
effects (12), and biocompatibility (13). Moreover, it induces the formation of cemen-
tumlike hard tissue when placed adjacent to periradicular tissues (14). MTA has been
recommended for teeth with open apices (15); however, the use of MTA in intra-
alveolar root fractures has only been described in a few case reports (16–20). Some
authors have stated that it is too early to make a comparison of MTA as an
alternative to Ca(OH)2 and GP in root fractures (21). Therefore, the purpose of this
retrospective study was to evaluate the healing type and assess the outcome of horizontal
intra-alveolar root fractures after endodontic treatment with MTA as the filling material.
Materials and Methods
Case Selection
The clinical database of the Department of Conservative Dentistry at Yonsei Univer-
sity Dental Hospital, Seoul, Korea, was searched for patients with histories of horizontal
root fractures and endodontic treatments with MTA between October 2005 and
September 2014. Teeth with previous apical periodontitis, extra-alveolar root fractures,
lost coronal fragments, and root fractures that occurred after endodontic treatment
were excluded from the study.
Horizontal Intra-alveolar Root Fractures 1
Clinical Research
Treatment Protocol
Except for emergency treatments that occurred outside of normal
working hours, all clinical procedures were performed by the endodon-
tic faculty and residents in the Department of Conservative Dentistry,
Yonsei University Dental Hospital. Although there were some differences
among cases, the major concepts and common treatment procedures
were as follows.
At the first visit, the history was taken, and clinical and radio-
graphic examinations were performed. The clinical information
from inspection and percussion as well as the mobility test and sensi-
tivity test using ice or an electrical pulp testing instrument was re-
corded. Periapical radiographs were taken from 2 different angles
(straight and vertical 20 ) to identify possible root fractures. When
the tooth was diagnosed as an intra-alveolar root fracture, the loca-
tion of the fracture line, diastasis between the fragments, and addi-
tional trauma to the tooth were recorded. The coronal fragment
was manually repositioned, and the tooth was stabilized with a resin
wire splint. Endodontic treatment was performed if pulpal complica-
tions (discoloration, increased pain, spontaneous pain, sinus tract,
and/or abscess) were found during the follow-up period. Endodontic
procedures (pulp extirpation, working length measurement, canal
irrigation, and enlargement) were performed and limited to the cor-
onal fragment. When the clinical signs and/or symptoms subsided,
the coronal fragment was filled with MTA. MTA was delivered into
the root canal by an amalgam carrier for a wide one and by a
MTA gun for a narrow one; it was condensed with the bulky side
of a sterile paper point within the premeasured length to the fracture
line. A postoperative radiograph was taken to verify the correct place-
ment of material. After the fragment was obturated to the appropriate
length, a moistened cotton pellet was placed on MTA, and the cavity
was filled with intermediate restorative material. At the next visit, the
setting of MTA was confirmed, and the access cavity was filled with
composite resin. Intracoronal bleaching was performed before the
restoration procedure if needed. The tooth was reinforced with a
full veneer if it had an extensive crown fracture.
Clinical and Radiographic Evaluation
Follow-up examinations were conducted up to 7 years postendo-
dontic treatment. At every recall visit, a routine examination was per-
formed, and periapical radiographs were taken. Clinical data,
including the signs and/or symptoms or loss of function, tenderness
to percussion or palpation, subjective discomfort, mobility, sinus tract
formation, and periodontal pocket formation at follow-up, were re-
corded.
The radiographic evaluation was performed at least 3 months after
endodontic treatment; Andreasen et al (10) suggested that it is possible
to make a reliable determination of the healing type after 3 to 6 months.
At the final follow-up, the radiographic healing at the fracture line was
evaluated independently by 2 examiners according to the methods of
Andreasen and Hjørting-Hansen (7); the healing type was classified
into the following 4 types:
1. Healing with calcified tissue
2. Interposition of connective tissue
3. Interposition of connective tissue and bone
4. Interposition of granulation tissue without healing
The Cohen kappa statistic was used to evaluate the interexaminer
agreement. Any disagreement was resolved by discussion until an agree-
ment between the 2 examiners was reached.
2 Kim et al.
Assessment of Outcome
The criteria for healing included the absence of clinical signs and/
or symptoms and radiographic evidence of healing with calcified tissue,
connective tissue, or connective tissue and bone. The criteria for non-
healing included any clinical signs and/or symptoms or radiographic
evidence of an interposition of the granulation tissue without healing.
If a tooth was extracted because of the failure of the endodontic treat-
ment, it was recorded as nonhealing although the follow-up period was
less than 3 months.
Results
We initially identified 22 teeth in 21 patients (66.7% male,
33.3% female) aged 12–65 years (average = 33.5 years) who
had horizontal intra-alveolar root fractures and who had received
endodontic treatments with MTA between October 2005 and
September 2014. Of the 22 teeth, 19 cases (18 patients) partici-
pated in the follow-up after a period of at least 3 months
(3 months–7 years, average = 3.0 years). The kappa between ex-
aminers was 0.77; this result showed substantial agreement accord-
ing to Landis and Koch (22).
The clinical information and healing type of these 19 evaluated
teeth are presented in Tables 1 and 2. The roots of 19 teeth were all
completely developed. Seventeen of the 19 teeth (89.5 %) exhibited
healing of the root fractures. For each healing type, 7 teeth (36.8%)
showed healing with calcified tissue, 8 teeth (42.1%) showed
interposition of connective tissue, 2 teeth (10.5%) showed
interposition of connective tissue and bone, and 2 teeth (10.5%)
showed interposition of granulation tissue.
Discussion
When the pulp becomes necrotic, endodontic treatment of a
root-fractured tooth should be performed only in the coronal frag-
ment because the pulp of the apical fragment usually remains vital
(7, 8). However, it is difficult to seal the coronal fragment because
it is often impossible to obtain an apical stop, such as in an
immature tooth with an open apex. Ca(OH)2 has been used to
make an apical stop in the immature tooth, but this procedure
has some drawbacks; it takes time for the formation of a
calcified barrier (23), multiple appointments are required, there
is reinfection susceptibility, and it has an adverse effect on the me-
chanical properties of root dentin (24). For these reasons, it has
been proposed that MTA could offer an alternative treatment for
teeth with immature roots or open apices (15). Studies have
observed higher fracture resistance (25), higher success at
inducing apical closure, and greater amount of hard tissue forma-
tion with the use of MTA compared with Ca(OH)2 (26). Despite its
remarkable biological performances, there have been some clinical
problems in using MTA, such as a discoloration potential (27) and
the difficulty of its removal after setting (28) that makes it difficult
to retreat a failed case and prepare post space in a fractured tooth.
We can prevent the complications in a way by limited use of MTA
within the deeper part of a root canal; however, it is inevitable if a
root fracture occurs at the cervical portion of the root. Neverthe-
less, considering the short length of the coronal fragment and
the vulnerability of reinfection in a root-fractured tooth, it is impor-
tant to seal the coronal fragment properly. Hence, MTA may be
appropriate for the endodontic treatment of intra-alveolar root
fractures to improve the prognosis of the teeth.
JOE — Volume -, Number -, - 2016
 Clinical Research
TABLE 1. Clinical Information of 19 MTA-filled Root-fractured Teeth
Fracture Crown Additional Splinting Canal Follow-up Healing
Sex Age Tooth location Diastasis fracture trauma (weeks) dressing (months) type
M 29 9 Apical —* —† Luxation 6 Ca(OH)2 74 1
M 18 8 Middle —* Class III —† 5 —§ 20 1
M 51 10 Coronal —* —† —† —‡ —§ 12 1
M 16 9 Middle >1 mm Class II —† 9 Ca(OH)2 5 1
F 20 9 Middle >1 mm —† —† 9 Ca(OH)2 3 1
M 57 8 Apical —* —† —† 10 —§ 6 1
M 51 8 Middle >1 mm Class II —† 10 Ca(OH)2 86 1
M 29 9 Coronal >1 mm —† Luxation 9 —§ 18 2
F 60 8 Middle >1 mm —† —† 27 Ca(OH)2 7 2
M 27 8 Middle —* —† Luxation 5 —§ 22 2
F 37 9 Middle —* —† —† 6 Ca(OH)2 3 2
M 18 24 Apical —* —† —† 3 Ca(OH)2 9 2
F 28 9 Middle >1 mm Class I Luxation 7 Ca(OH)2 5 2
M 27 9 Middle >1 mm —† Avulsion 5 Ca(OH)2 3 2
F 65 8 Middle —* Class III —† 7 Ca(OH)2 49 2
M 20 25 Apical >1 mm —† Luxation 36 Ca(OH)2 21 3
M 40 8 Middle >1 mm —† —† 3 Triple antibiotics 3 3
M 29 8 Apical >1 mm —† Avulsion 6 Ca(OH)2 74 4
F 12 8 Coronal >1 mm Class II Luxation 19 Ca(OH)2 40 4
1, calcified tissue; 2, connective tissue; 3, connective tissue and bone; 4, granulation tissue; F, female; M, male.
*Amount of diastasis was less than 1 mm.
†
No additional trauma was accompanied.
‡
No splinting was performed.
§
Endodontic treatment without intracanal dressing, or one-visit treatment.

Before the present study, the use of MTA in intra-alveolar root frac-
tures was described in some case reports (16–20). Bramante et al (16)
performed the repair of a horizontal root fracture sealing with MTA. Er-
dem et al (17) and Kusgoz et al (18) each reported 3 cases of root-
fractured teeth treated with an MTA plug. During a follow-up period
of 1 to 3 years, all teeth showed excellent clinical and radiographic heal-
ing. Yildirim and Gencoglu (19) observed that the area near the MTA
and fracture line was fully surrounded with new hard tissue formation.
Healing with the interposition of connective tissue was found in the 10-
year follow-up radiograph although MTA was extruded between the
fragments in Roig et al’s case (20).
This retrospective study also coincided with the previously
described results. Only 2 of 19 teeth (10.5%) exhibited failure in heal-
ing, and the rest of the teeth (89.5%) presented healing of the fracture
line. This was relatively high compared with the previous studies that
reported a 71%–84% healing rate with GP-filled root-fractured teeth
(4, 5, 8). Figure 1A–I shows 3 typical healing cases, and Figure 2A–F
shows 2 cases without healing. Specifically, in the failed cases, the first
case (Fig. 2A–C) had a root fracture accompanied with an avulsion of
the coronal fragment, and, finally, external root resorption occurred.
The second case (Fig. 2D–F) showed a large amount of diastasis at
the first radiograph (Fig. 2D). Evidence of the interposition of granula-
tion tissue was already found around the fracture line at the second
radiograph at the time when the root canal was filled with MTA
(Fig. 2E). The tooth was still functioning after 3.5 years; however, radio-
graphic evidence indicated the interposition of granulation tissue
TABLE 2. Healing Type of 19 MTA-filled Root-fractured Teeth
Healing type n %
Calcified tissue 7 36.8
Connective tissue 8 42.1
Connective tissue and bone 2 10.5
Granulation tissue 2 10.5
Total 19 100
(Fig. 2F). It can be observed that the adjacent root-fractured teeth
showed healing in both cases.
Age has been considered to be an important factor influencing the
healing of intra-alveolar root fractures (2, 3). Most recent clinical
studies involving root fractures included only young patients who
were aged under 20 years (1–4, 6); patients in the case reports
mentioned previously were 8–18 years old (average = 12.3 years)
(16–20). Compared with those studies, patients with varied ages
(12–65 years, average = 33.5 years) participated in the present
study and showed satisfactory results regardless of age.
Some authors have stated that the favorable healing of a root fracture
was related to the retained vitality of the pulp (1, 2, 9). Nevertheless, root
fractures with proper endodontic treatment of the coronal fragment have
shown favorable outcomes (4, 5, 8). The healing process after intra-
alveolar root fractures depends on the pulpal and periodontal responses
at the fracture area and is initiated independently in the pulp and perio-
dontium (10, 29, 30). However, it has been suggested from early
histologic studies that the hard tissue found in the fracture space
consists of cementum, bone, or both together and is most likely
derived from the periodontal ligament; the pulp was not necessary for
the repair of the root (31, 32). Although the number of teeth was
insufficient, the result of the current study confirmed that root-fractured
teeth have good healing outcomes with adequate endodontic treatment.
Andreasen et al (6) analyzed the long-term survival of root-
fractured teeth and assessed the influence of the type of healing and
location of the root fracture. All teeth with hard tissue healing survived
during the observation period (100% survival). For teeth healed with
connective tissue healing, the location of the fracture was shown to
have a significant influence on tooth loss. The estimated 8-year survival
of apical and middle root fractures was more than 80%, whereas the
estimated survival of cervical fractures was 25%. There was a study
that separately indicated 4 healing types of endodontically treated
root-fractured teeth (5). The coronal fragments were filled with GP,
and the distribution of teeth per each healing type was as follows: 4
of a total of 17 teeth (23.5%) with calcified tissue, 6 (35.3%) with

JOE — Volume -, Number -, - 2016 Horizontal Intra-alveolar Root Fractures 3

Clinical Research

Figure 1. The preoperative, postoperative, and final follow-up (more than 2 years) radiographs of healing cases. The arrowheads of each radiograph indicate the
fracture line: (A–C) Healing with calcified tissue. (D–F) Interposition of connective tissue. (G–I) Interposition of connective tissue and bone.

4 Kim et al. JOE — Volume -, Number -, - 2016

 Clinical Research

Figure 2. Two nonhealing cases. The arrowheads of each radiograph indicate the fracture line. (A) The preoperative radiograph of root-fractured maxillary
central incisors. The coronal fragment of the right incisor was avulsed, and the left one was luxated at the time of injury. (B) Endodontic treatment was performed
to both teeth 1 month after trauma, and MTA was filled. (C) The 6-year follow-up radiograph of the central incisors. External root resorption was observed on the
right central incisor, whereas the left one was healed with calcified tissue. (D) The preoperative radiograph of root-fractured maxillary central incisors. (E) End-
odontic treatment was performed on the right incisor 1 month after trauma, and MTA was filled. (F) The 3.5-year follow-up radiograph. The tooth was still func-
tioning; however, it was assessed as ‘‘interposition of granulation tissue’’ in the radiograph.

connective tissue, 2 (11.8%) with connective tissue and bone, and 5
(29.4%) with granulation tissue. In the present study with MTA, the pro-
portion of teeth in each healing type was 36.8%, 42.1%, 10.5%, and
10.5% from type 1 to 4, respectively (Table 2). Even if these data are
not directly comparable, we would expect a better long-term prognosis
with more teeth healed with calcified tissue.
Within the limitations of this study, intra-alveolar root fractures
showed satisfactory healing outcomes after endodontic treatment with
MTA. MTA could be considered to be a suitable filling material for
the endodontic treatment of horizontal intra-alveolar root fractures.
Because this study included only a small number of cases, it is suggested
that further studies using MTA in the intra-alveolar root fractures should
be performed with more cases, other comparative filling materials, and
additional prognostic factors.
Acknowledgments
This research was supported by Basic Science Research Pro-
gram through the National Research Foundation of Korea (NRF)
funded by the Ministry of Education(2015R1D1A1A09057552).
The authors deny any conflicts of interest related to this study.
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