Vertical Root Fracture !
Vertical Root Fracture !
Vertical Root Fracture !
A CHALLENGE IN DIAGNOSIS
Definition
Classification of longitudinal fractures
Types of VRFs
Incidence
Predisposing Factors
Diagnosis
Diagnostic Tests
Prevention
Recent Advances
Treatment Planning
Conclusion
DEFINITION
A vertical root fracture is defined as a longitudinal fracture in the root whereby the fractured segments are
incompletely separated ; it may occur bucco-lingually or mesio-distally;it may cause an isolated periodontal
defect(s) or sinus tract ; it may be radiographically evident.
AAE Glossary of Endodontic Terms
CLASSIFICATION OF LONGITUDINAL TOOTH FRACTURE
VRF is differentiated from a split root in that the segments associated with the fracture are not completely separated.
Cohen’s Pathway of Pulp,12th edition
VRFs are typically detected in the bucco-lingual plane of
the tooth, and less commonly in the mesio-distal Plane.
Leubke RG. Vertical crown-root fractures in posterior teeth. Dent Clin North Am 1984;28:883-94.
TYPES OF VRFs.
.
A. Coronally located VRF B. Midroot VRF C. Apically located VRF
extending apically as far extending along the extending coronally as
as the coronal1/3rd of middle 1/3rdof the root far as the apical 2/3rds of the
the root. root.
INCIDENCE
• .
The most susceptible sites and tooth groups are ;
The incidence of VRF increases with age and is most in patients who are older than 40
years of age
Natural Iatrogenic
Challenging
• The diagnosis of vertical root fracture can be problematic, and it often requires prediction
rather than definitive identification.
• The clinical scenario of vertical root fracture may resemble that of a periodontal disease or of a
failed root canal treatment.
• So it is important to differentially diagnose vertical root fracture from other similar clinical
conditions.
Importance of Early Diagnosis
Accurate and timely diagnosis is crucial in VRF cases, allowing the extraction of the tooth or root before
extensive damage to the alveolar bone occurs.
When the tooth is extracted after extensive damage has already occurred, bone regeneration procedures may
be required, adding additional cost and time to the restoration
process.
Diagnosis is usually confirmed through the clinical signs and radiographic
features. But not all the typical signs of a fractured root may be present in each
case.
So, the combination of clinical signs, symptoms and radiographic features may
provide a clue for the diagnosis of vertical root fracture.
HISTORY & CLINICAL EXAMINATION
Tenderness on mastication
Swelling
Sinus tract
Location of sinus tract associated with a VRF is more coronal than sinus tract associated
with a chronic apical abscess .
In four clinical retrospective case series, coronally located
sinus tracts were found in 13% to 35% of these cases.
Meister F, Lommel TJ, Gerstein H: Diagnosis and possible causes of vertical root fracture, Oral Surg Oral Med Oral Pathol Oral Radiology ,Endod
,1980
Tamse A: Iatrogenic vertical root fractures in endodontically treated teeth, Endod Dent Traumatol , 1988
Tamse A, Fuss Z, Lustig J, et al: An evaluation of endodontically treated vertically fractured teeth, J Endod 25:506, 1999.
Testori T, Badino M, Castagnola M: Vertical root fractures in endodontically treated teeth: a clinical survey of 36 cases, J Endod1, 1993.
Deep,narrow and isolated periodontal pocket
▪ Periodontal Pocket ▪ Vertical Root Fracture Pocket
Tamse A. Iatrogenic vertical root fractures in endodontically treated teeth. Endod Dent Traumatol 1988;4:190-6.
The American Association of Endodontists stated in 2008 that a sinus
tract and a narrow, isolated periodontal probing defect associated with
a tooth that has undergone a root canal treatment, with or without post
placement, can be considered pathognomonic for the presence of a
VRF.
DIAGNOSTIC TESTS
1.Direct visualization
2. Dye Test
3. Pulp testing
4. Bite test
5. Trans illumination test
6. Periodontal probing test
7. Tracing the sinus tract
8. Radiographs
9.Exploratory Surgery
DIRECT VISUALIZATION
• A sharp probe may aid in identifying the fracture line where separation has n
occurred.
DYE TEST
syndrome.
Gutta percha, endodontic explorer, etc., may be used to trace the sinus tract back to its origin
RADIOGRAPHIC FEATURES
In longstanding cases in which the bone destruction is extensive, the VRF may result in a split root
whereby the segments of the root separate, resulting in radiographic evidence clearly revealing an
objective split root
Other radiographic features include:
Clinical and Radiographic Characteristics of Vertical Root Fractures in Endodontically and Nonendodontically Treated Teeth,Wan-Chuen
Liao, et al,JOE1999
Limitations of Periapical radiographs
A periapical radiograph can detect a fracture line only in 35.7% cases. The
reasons for this may be,
CBCT imaging would visualize fracture when the width of fracture is greater than
0.15mm and when a voxel size of 0.2 mm is used
(Talwar et al., 2016)
Present status and future directions: vertical root fractures in root filled teeth Shanon Patel et al, International Endodontic Journal,2022
Limitation of CBCT
Imaging artefacts such as beam hardening due to the presence of radio-densematerials (i.e., gutta percha,metal
posts) and/or motion/misalignment artefacts reduce the image quality.
(Khedmat et al., 2012; Schulze et al., 2011; Wang et al., 2011).
Present status and future directions: vertical root fractures in root filled teeth Shanon Patel et al, International Endodontic Journal,2022
Exploratory Surgery
Full
thickness
flap raised
Granulation
tissue VRF may
removed often be
directly
visualized.
Vertical root fractures: An update review Anu Dhawan, Sumit Gupta, Rakesh Mittal 2014 | Volume : 2 | Issue : 3 | Page : 107-113
PREVENTIO
▶
N
Avoiding or correcting all the etiological factors provides the best prevention.
This may include
Over-preparation
of the canal for a Nightguards may
Extensive dowel, selection be used in
cutting of dentin of an improper patients with
during dowel and bruxism to
preparation of traumatic seating minimize the risk
canal of of VRFs
intra-canal
restorations
Kishen A. Mechanisms and risk factors for fracture predilection in endodontically treated teeth. Endodontic topics 2006;13:57-83.
TREATMENT PLANNING
Any delay may increase the potential for additional periradicular bone loss and
potentially compromise the placement of an endosseous implant.
These materials have a similar elastic modulus to dentine due to the presence of a homogenously
distributed matrix of nano-ceramic particles. As a result, these materials may act as a stress
absorber which may reduce stress within the root dentine under load.
However, these observations have only been evaluated in vitro, and further clinical studies are
required to determine whether these effects are translatable into clinical practice.
CONCLUSION
• The symptoms and/or clinical signs of VRF, particularly in the early stages, can make a confident
diagnosis of VRF challenging.
• CBCT may be useful to diagnose the radiographic features of periradicular bone loss
pathognomonic of a VRF.
• High-level evidence for prevalence, diagnosis and management of VRFs is lacking.
• Therefore,there is a need for well-designed clinical studies assessing the presentation, as well as the
prognosis of VRFs managed with different treatment protocols.
Reference
Patel S, Bhuva B, Bose R. Present status and future directions: vertical root fractures in root filled
teeth. Int Endod J. 2022 May;55
Khasnis SA, Kidiyoor KH, Patil AB, Kenganal SB. Vertical root fractures and their management.
Journal of conservative dentistry: JCD. 2014 Mar;17(2):103.
Corbella S, Del Fabbro M, Tamse A, Rosen E, Tsesis I, Taschieri S. Cone beam computed tomography
for the diagnosis of vertical root fractures: a systematic review of the literature and meta-analysis.
Oral surgery, oral medicine, oral pathology and oral radiology. 2014 Nov 1;118(5):593-602
Remya C, Indiresha HN, George JV, Dinesh K. Vertical root fractures: A review. Int J Contemp Dent
Med Rev. 2015;2015.