The Tooth Was Broken, But Not Where Anyone Could See

Quick answer: A front tooth that is loose and slightly displaced after an injury, with no visible chip, may have a fractured root. It takes more than one x-ray angle to find, and the prognosis depends almost entirely on how high up the root the fracture sits.

The call

Friday afternoon football on Moshav Ta'oz. Shai, 15, went up for a header at the same moment as someone else and took the top of their head straight into his mouth.

No blood to speak of, no chipped tooth, nothing visibly wrong. But one upper front tooth felt loose and slightly out of line, and it hurt to bite.

His father nearly did not bring him in. "There's nothing to see" is the reason root fractures get missed.

What we found

The upper left central incisor was mobile — grade II — and displaced backwards by about 1mm. The crown was entirely intact, with not a chip on it. The gum bled slightly at the margin.

The first x-ray, taken straight on, appeared normal.

That is the trap. A root fracture is a fine line running across the root, and unless the x-ray beam passes almost exactly along the plane of that fracture, it does not show. The standard of care is at least two, preferably three, exposures at different vertical angles for any tooth that is loose or displaced without a visible crown fracture.

The second film, angled steeply from below, showed it clearly: a horizontal fracture across the root about a third of the way down from the gum, in the middle third of the root.

The level of the fracture is what determines the prognosis:

• Apical third, near the root tip. Best outlook. The coronal segment is still well supported and often needs little more than monitoring.
• Middle third. Intermediate. Repositioning and prolonged splinting give a reasonable chance of healing.
• Cervical third, close to the gum. Poorest outlook. The upper fragment has little support and the fracture line often communicates with the mouth.

Root fractures can genuinely heal, which surprises people. The two fragments can reunite with hard tissue, with connective tissue, or with bone growing between them. Which of those happens depends largely on how well the fragments are repositioned and how long they are held still.

What we did

Repositioned the coronal fragment under local anaesthetic, easing it forward into alignment and checking against the neighbouring teeth and the bite. An x-ray confirmed the fragments were approximated.

Then a flexible splint — but for four months, not two weeks. Root fractures need considerably longer splinting than other injuries, because the healing is happening inside bone between two fragments rather than in a socket.

Soft diet, no contact sport for the duration, and meticulous cleaning.

We tested the pulp at every review. The coronal fragment initially stopped responding, which is common in the first weeks and does not automatically mean the nerve has died — many recover over three to six months. We deliberately did not start a root canal on that basis alone.

The outcome

The splint came off at four months. The tooth was firm.

At six months it responded to testing again, meaning the pulp had survived. On the x-ray the fracture line had filled with hard tissue.

Had the nerve died, treatment would have been a root canal of the coronal fragment only, down to the fracture line — the apical fragment usually keeps its own blood supply and is left alone.

He is monitored annually. He now plays with a mouthguard.

What to do if this happens to you

1. Be seen even if nothing looks broken. A loose or displaced tooth needs assessing.
2. Ask for x-rays at more than one angle. Root fractures are missed on a single film.
3. Expect a long splint. Four months is normal, not excessive.
4. Do not push for a root canal early. Many of these nerves recover.
5. No contact sport until you are cleared.
6. Commit to annual reviews. Root-fractured teeth are monitored for years.

Loose tooth after a sports injury, with nothing visibly broken? Ramat Beit Shemesh Urgent Dental Care x-rays properly. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh.

Based on real cases treated at the clinic. Names have been changed.