Case report: 12-year healing of fractured immature incisor after conservative care

An immature maxillary right central incisor with a displaced mid-root fracture continued to develop and heal with calcified tissue over 12 years of conservative dental management, according to a case report from Hefei Stomatological Hospital in China. It remained asymptomatic and functional at the final examination, when the patient was 19, with a positive response to electric pulp testing, complete root development, apical closure and a normal-appearing periodontal ligament space. The outcome followed initial repositioning and flexible splinting, an unusually long period of stabilization caused by repeated splint failures, and another traumatic episode during healing.

Because the report describes only one patient, it cannot establish how frequently this result occurs or demonstrate that conservative care caused it. The boy attended the dental clinic about five hours after the November 29, 2012 injury. He had pain and increased mobility of the upper anterior teeth during chewing, along with a lower-lip laceration and mild swelling.

Oral examination showed that the coronal fragment of the right central incisor was partially extruded and had grade 2, or moderate, mobility. Both central incisors were tender to percussion, and sulcular bleeding was present. The neighboring maxillary left central incisor, #21, had increased mobility without displacement and was diagnosed as a concussion injury.

Initial periapical radiography showed an oblique fracture through the middle third of the immature root of #11, labio-palatal displacement of the coronal fragment and widening of the periodontal ligament space. The root was incompletely developed and had an open apex. The boy’s medical and family histories were unremarkable.

Clinicians chose a conservative strategy intended to preserve the pulp and periodontal tissues while retaining the tooth’s capacity for continued biological development. After cleaning and irrigating the injured area, they gently repositioned the displaced coronal fragment to restore anatomical alignment. The tooth was stabilized with a passive flexible splint composed of six braided 0.2-millimeter stainless-steel wire strands bonded to adjacent teeth with composite resin.

The splint extended to the left central incisor and to bilateral primary canines and primary molars, increasing stability and distributing occlusal forces while allowing physiological mobility. A postoperative periapical radiograph confirmed satisfactory alignment of the fracture fragments. The patient and parents were instructed to avoid loading the anterior teeth, maintain oral hygiene and attend regular clinical and radiographic follow-up examinations.

The early healing phase was complicated by limited compliance and repeated breakage of the splint. The precise dates of the individual failures were not consistently retained in the clinical records. As a result, the splint placed on the day of the injury remained in place for approximately five months, from November 29, 2012, until its removal on April 16, 2013.

This was considerably longer than the approximately four weeks generally recommended for a mid-root fracture, and the report emphasizes that the extended period resulted from breakage and delayed attendance rather than an intentional protocol. At removal, the tooth had reduced mobility, but the boy occasionally reported spontaneous discomfort. Electric pulp testing produced a value of 15.

Radiographs showed partial re-establishment of periodontal ligament continuity, although the fracture line remained visible. Despite the intermittent discomfort, the tooth continued to respond positively to pulp sensibility testing, and clinical and radiographic examinations showed no evidence of pulp necrosis, infection, inflammatory change or periapical pathology. The patient and his parents also declined the planned endodontic access, so the clinicians continued observation rather than entering the root canal.

Later examinations showed that the boy was asymptomatic, the fracture line was becoming less apparent and root development was continuing. The authors note an important distinction in how they interpreted the pulp findings: electric pulp testing assesses neural responsiveness rather than proving histologic vitality. In this case, the positive response was assessed together with symptoms, percussion findings, radiographs and the absence of signs of infection or necrosis.

On January 9, 2015, roughly two years after the original trauma, the patient sustained another episode affecting the maxillary anterior region, although the mechanism was not documented. Tooth #11 was mildly tender to percussion and had grade 0–1 mobility, but it remained responsive to pulp sensibility testing. Its crown color was unchanged, and no sinus tract had formed.

Radiographs showed slight widening of the periodontal ligament space without displacement of the fracture segments, root resorption or periapical pathological changes. In response to these findings, the clinicians continued conservative monitoring. Subsequent images showed further root maturation, reduced visibility of the fracture line and maintained calcified-tissue healing.

The reinjury therefore caused temporary symptoms but was not followed by a documented loss of sensibility response or development of radiographic pathology. At the final 12-year follow-up in February 2025, the patient was 19 years old and tooth #11 remained asymptomatic and functional. Clinical examination found normal crown color and physiological mobility, with no tenderness to percussion or palpation, swelling or sinus tract.

The patient reported normal masticatory function without discomfort, and electric pulp testing produced a value of 10, comparable with the contralateral tooth. The final periapical radiograph showed complete root development with apical closure, calcified healing at the fracture site and a normal-appearing periodontal ligament space. There was no evidence of pulp necrosis, inflammatory or replacement root resorption, ankylosis or periapical pathology.

The crown had a satisfactory appearance, and the surrounding gingival tissues appeared healthy. On serial radiographs, the healing pattern was consistent with healing by calcified tissue, recognized through progressive radiopacity, reduced fracture-line visibility, no persistent radiolucent line and maintenance of the periodontal ligament space. The case’s principal contribution is its duration and the unusual combination of circumstances surrounding the healing process rather than a new treatment method.

The authors note that longitudinal evidence on root fractures in immature permanent teeth remains limited. They cite earlier reports involving conservative treatment with shorter follow-up, preservation of pulp tissue in horizontal root fractures of maxillary incisors over 13 years, and a two-stage treatment of a more complicated crown-root fracture with an additional horizontal mid-root fracture followed for five years. A large case series cited in the paper reported 10-year survival rates of 89% for root fractures in the apical third, 78% in the middle third and 67% in the cervical third.

The present report adds an account of 12 years of continued root development to radiographic apical closure in a middle-third fracture complicated by initial displacement, prolonged stabilization and a second traumatic episode. As a single observation, however, it cannot determine the usual frequency of this outcome or establish a causal effect of the treatment approach. Several limitations restrict the conclusions that can be drawn.

As a case report, the findings cannot establish causal relationships or predict outcomes for other children, and the individualized management may not apply to teeth with pulp necrosis, infection, severe displacement or different fracture characteristics. Assessment relied on conventional two-dimensional periapical radiographs obtained without rigid standardization of projection geometry, meaning that root maturation, fracture healing and periodontal ligament changes were evaluated by visual comparison of serial images. Terms such as “complete healing” must therefore be understood within that imaging limitation.

Detailed periodontal-probing records and the precise dates of individual splint breakages were also unavailable. Cone-beam computed tomography was not used because conventional radiographs were considered sufficient for clinical monitoring while limiting radiation exposure in a young patient. The case neither demonstrates nor supports the safety of routinely extending stabilization beyond recommended periods; its favorable outcome occurred in one selected tooth under continued clinical review, while clinical and radiographic findings remained reassuring.

Subject of Research: Long-term healing of a mid-root fracture in an immature permanent maxillary central incisor after conservative management

Article Title: Long-term conservative management of a mid-root fracture in an immature maxillary central incisor: a 12-year follow-up case report

Article References: Xie, L., & Wei, Y. (2026). Long-term conservative management of a mid-root fracture in an immature maxillary central incisor: a 12-year follow-up case report. Frontiers in Pediatrics, 14, Article 1962051. https://doi.org/10.3389/fped.2026.1962051

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1962051

Keywords: dental trauma, immature permanent tooth, root fracture, pediatric dentistry, pulp sensibility, root development, calcified tissue healing, tooth splinting, long-term follow-up, case report, Long-term, conservative