Periodontal and endodontic perspectives of vertical root fracture: A case report.

Vertical root fractures are more commonly encountered following endodontic treatment and in teeth without endodontic treatment, with habits like bruxism and eating coarse, hard food. The teeth most predisposed to fracture are the premolars of the maxilla and mandible, the mesial roots and mesiobuccal roots of the mandibular molars, maxillary molars and the mandibular incisors. Timely identification of cracked teeth and fractures is the key since it permits a conservative and preventive approach. Delay in diagnosis and treatment will result in the involvement of the underlying periodontium, causing periodontal pockets, abscess formation, and bone loss, thereby further complicating the outcome. Appropriate diagnosis, education, and counseling of the patient by the dentist and coronal restoration following root canal treatment are mandatory to prevent the loss of teeth in patients. The prognosis of multirooted teeth is more favorable. Affected single-rooted teeth may, however, require immediate extraction. MEDLINE database and Scopus search (www.scopus.com) were performed using the key words “vertical root fracture” or “longitudinal root fracture.” Text book chapters were manually checked.

The vertical root fractures resulting as from trauma, as from the “cracked tooth syndrome”, are spotted within the “iatrogenic periodontal lesions” according to the Al-Fouzan (1) classification. The stereo microscope, an optical microscope variant typically exploiting the light reflected from the surface of an object rather than that transmitted through it (2), in the reported case has revealed the best tool to perform the resolving three-dimensional examination of the tooth. Aim of this paper is to describe a vertical root fracture, not otherwise detectable. A second upper molar, has been endodontically treated, because of the presence of an endo-periodontal lesion. Even though the treatment was performed according the standard protocol, after two years the lesion persisted and the tooth was extracted. After the extraction, the tooth was diaphanized to be observed with the stereomicroscope (Leica LED2000). The investigation clearly showed a vertical fracture, starting directly from the cervical line and a small hole on the distal surface of the root palatal cone. Mean values of measurements taken in 15 randomly points at 1x, 4x and 8x magnification were made. The fracture resulted to be long 9,79 mm and to have a mean width of 0,37 + 0,07 mm externally, and 0,15 + 0,02 mm internally. The mean area of the hole resulted of 0,85 mm2. All the analytical procedure was validated by t-student test, showing a p value < 0,0001. This vertical root fracture represented the unexpected pathway between the pulp and periodontal tissues and sure it caused the endodontic treatment failure, with tooth loss. It appears clear that a good diagnosis, following exactly the proto- col stated in the literature, together with the patient’s compliance, are crucial basis to face such clinical challenge.

Analysis of Factors Associated with Cracked Teeth

Clinical and Radiographic Characteristics of Vertical Root Fractures in Endodontically and Nonendodontically Treated Teeth

Occlusal and behavioral factors associated with vertical root fractures in endodontically treated teeth: A retrospective matched case-control study.

Vertical Root Fractures

CBCT Patterns of Bone Loss and Clinical Predictors for the Diagnosis of Cracked Teeth and Teeth with Vertical Root Fracture

The aim of this study was to investigate the occurrence of vertical and horizontal root fractures using cone-beam computed tomography (CBCT). We reviewed the CBCT images of 51 patients who were examined by CBCT for the diagnosis of root fracture. The occurrences of vertical and horizontal root fractures were investigated concerning the pulpal vitality and the kind of tooth, and analyzed by cross-tabulation. The fracture direction of vertical root fracture and the fracture angle were also investigated, and analyzed by cross-tabulation and Kruskal-Wallis test, respectively. The occurrence of vertical and horizontal root fractures was statistically significantly different between vital tooth and non-vital tooth (p = 0.044). The occurrence of vertical and horizontal root fractures was also different among anterior, premolar, and molar teeth (p = 0.004). The kind of tooth on traumatized tooth was only anterior teeth and the number was larger on horizontal root fracture. The occurrence of vertical and horizontal root fractures on non-traumatized tooth was different among the kind of tooth (p = 0.007), and the number of vertical root fracture was larger than that of horizontal root fracture on premolar teeth. Fracture direction was not different, but the fracture angle was different among the kind of tooth on vertical root fracture (p = 0.027). The results suggested that the number of vertical root fracture was larger on non-vital tooth and that of horizontal root fracture was larger on vital tooth. The number of vertical root fracture was larger on premolar teeth.

To evaluate retrospectively the prevalence of vertical root fractures (VRFs) in a cohort of patients during apical surgery and the factors possibly associated with VRF. The sample consisted of 944 root filled teeth belonging to 768 patients (49.3% males and 50.7% females; mean age 43.5±11.2years, range 22-68years), consecutively referred for endodontic surgery over a six-year period. All patients underwent a clinical assessment of their signs and symptoms. Periapical radiographs of teeth that were candidates for endodontic surgery were taken. Sixty-eight teeth with VRF were identified. Vertical root fractures were identified in pre-surgical screenings in 32 cases (47.1%), and these did not undergo surgery. Another 36 cases of VRF were noted during the intervention for root-end resection. The influence of posts, post type, tooth type, periodontal probing defects, spontaneous pain, sinus tract and follow-up duration was assessed using a logistic regression analysis. Vertical root fractures occurred significantly more frequently (P<0.001) when a post was present (61 VRF out of 377 teeth with post, prevalence 16.2%) than in teeth without a post (1.2%). Threaded posts and cast posts were significantly more involved in VRF than fibre, silica or carbide posts (P<0.001). Most fractures (80.9%) occurred 1-5years after root canal treatment. Sinus tracts, probing defects and spontaneous pain were significantly more associated with VRF cases than with nonfractured teeth. In the present group of teeth, the major risk for VRF was represented by posts retained by actively engaging the canal via mechanical design (thread) or by frictional fit (cast).

This study aimed to investigate cracked teeth and vertical root fracture observable on micro-CT images of extracted roots of mandibular incisors, after fiber post removal. Thirty mandibular incisors were selected with any degree of slight incisal wear inspected with the aid of a stereomicroscope under 12x magnification, in order to have a group of young adult specimens according to the criteria of Hugoson et al. A sample of twelve mandibular incisors were selected, aged between 20 and 30 years old, with similar dentine volume and thickness. The specimens were scanned in a micro-computed tomography (micro-CT) device and submitted to root canal shaping, root canal filling, post space preparation, post placement and post removal. From a total of six experimental endodontic timepoints until post removal of 12 mandibular incisors, 64,800 cross-sectional images were analyzed and no vertical root fracture (VRF) or cracked tooth were detected. Micro-CT assessment after ex vivo fiber post removal did not detect vertical root fracture or cracked tooth formation in the root canal walls of mandibular incisors. This study highlighted that fiber post removal per se was not able to propagate VRF or cracked tooth formation or promoted any interruption of the integrity of human root dentin.

Vertical root fracture in an endodontically treated tooth originates from the root at any level and is considered a frustrating and vexing complication in endodontic therapy. Many times, it is difficult to achieve an accurate diagnosis and to differentiate the fracture from other clinical entities. However, usually combination of cervicaly located sinus tract combined with a narrow deep periodontal defect present is highly suggestive of a vertical root fracture. When the diagnosis of a vertical root fracture is made, usually years after all endodontic and restorative procedures have been completed, extraction of the tooth or root should be done in a timely manner to minimize the bone loss in the surrounding bone. This bone loss may compromise subsequent implant placement in the area. This chapter will emphasize the importance of achieving an accurate and timely vertical root fracture diagnosis and will describe the more typical signs, symptoms, and radiographic features that are suggestive for vertical root fracture diagnosis in the susceptible teeth and roots.

Vertical root fractures (VRFs) often occur in endodontically treated teeth and in patients older than 40 years of age. However, VRFs in teeth without endodontic treatment are relatively uncommon. VRFs are difficult to diagnose as the symptoms are non-specific or often delayed. The most common radiographic findings are thickening of the periodontal ligament, deep, localized, vertical bone loss, and localized periradicular bone loss. The explicit feature for detecting VRFs is direct visualization of a radiolucent fracture line on radiographs. However, the fracture line can be difficult to directly visualize in conventional diagnostic methods such as periapical radiographs. If unrecognized, VRFs can lead to frustration and inappropriate endodontic treatment. The two cases reported here demonstrate that the use of cone beam computed tomography (CBCT) successfully diagnoses VRFs on teeth without representative clinical and periapical radiographic findings. The clear fracture line can be discerned from the images of CBCT. Thus, CBCT imaging is useful in rapid diagnosis of VRFs and designing of further treatment.

Diagnosis and Treatment of Endodontically Treated Teeth with Vertical Root Fracture: Three Case Reports with Two-year Follow-up

Although vertical root fracture (VRF) is mostly found in endodontically treated teeth, it also occurs spontaneously. If VRF is recognized after endodontic treatment, it is considered to be iatrogenic and can lead to legal trouble. However, legal problems can be averted if the dentist can prove that the VRF existed before endodontic treatment. This case report describes an unusual, spontaneous VRF in an endodontically treated tooth and presents a useful tip for determining whether a fracture is iatrogenic. We performed nonsurgical endodontic treatment on a mandibular first molar with irreversible pulpitis. After 6 months, the patient revisited with localized swelling, and we diagnosed VRF of the mesial root. We extracted the tooth and prepared it for microscopic examination. We found gutta-percha in the fracture line of the transversely sectioned root, and it appeared to have penetrated to the fracture line through the force generated from the filling. The patient was informed and agreed that the fracture occurred spontaneously before treatment. This case demonstrates the time point of VRF occurrence by identifying the presence of gutta-percha in the fracture line. We suggest that this procedure can be used to demonstrate whether VRFs in endodontically treated teeth are spontaneous or iatrogenic.

Vertical Root Fracture in Buccal Roots of Bifurcated Maxillary Premolars from Condensation of Gutta-percha