vertical root fracture

1. VERTICAL ROOT FRACTURE :
A CHALLENGE IN DIAGNOSIS

2. CONTENTS
 Definition
 Classification of longitudinal fractures
 Types of VRFs
 Incidence
 Predisposing Factors
 Diagnosis
 Diagnostic Tests
 Prevention
 Recent Advances
 Treatment Planning
 Conclusion

3. 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.
DEFINITION
AAE Glossary of Endodontic Terms

4. CLASSIFICATION OF LONGITUDINAL TOOTH FRACTURE
Rivera and Walton,2009
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

5. VRFs are typically detected in the bucco-
lingual plane of the tooth, and less commonly
in the mesio-distal plane.
(von Arx & Bosshardt, 2017)

6. LEUBKE’S CLASSIFICATION
Based on separation of fragments
• Complete fracture
• Incomplete fracture
Relative to position of alveolar crest
• Intra- osseous fracture
• Supra- osseous fracture
Leubke RG. Vertical crown-root fractures in posterior teeth. Dent Clin North Am 1984;28:883-94.

7. .
C. Apically located VRF
extending coronally as
far as the apical 2/3rds of the
root.
TYPES OF VRFs.
A. Coronally located VRF
extending apically as far
as the coronal1/3rd of the
root.
B. Midroot VRF
extending along the
middle 1/3rdof the root

8. INCIDENCE
Vertical root fracture is more commonly associated
with root filled teeth than teeth with (non-)vital
pulps.
(Chanet al.,1999; Cohen et al., 2006; Yoshino et al., 2015)
.

9. The most susceptible sites and tooth groups are;
 maxillary and mandibular premolars,
 mesial roots of the mandibular molars,
 mesio-buccal roots of the maxillarymolars,
 mandibular incisors
Tamse A, Fuss Z, Lustig J, Kaplavi J. An evaluation of endodontically treated vertically fractured teeth. Journal of endodontics. 199
Jul1;25(7):506-8.
The incidence of VRF increases with age and is most in patients
who are older than 40 years of age
(PradeepKumar et al., 2016; Yoshino et al., 2015).

10. PREDISPOSING FACTORS
Natural Iatrogenic
 Shape of root cross section
 Occlusal factors
 Preexisting microcracks
 Root Canal Treatment
 Excessive Root Canal Preparation
 Microcracks caused by Rotary Instruments
 Uneven thickness of remaining dentin
 Methods of obturation
 Types of spreader used
 Post design
 Crown design

11. Diagnosis
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.

12. 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.
Early diagnosis is particularly important when
• implants are a part of the future restorative process;
• when an extraction is performed at an early stage, the uncomplicated placement of an implant is more likely.
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.

13. 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.

14. HISTORY & CLINICAL EXAMINATION
 Mild pain or dull discomfort on the affected
side of tooth
 Tenderness on mastication
 Swelling

15.  Sinus tract
Location of sinus tract associated with a VRF is more coronal than sinus tract
associated with a chronic apical abscess .

16. 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.

17. Deep, narrow and isolated periodontal pocket

18. ▪ Periodontal Pocket ▪ Vertical Root Fracture Pocket
• Develops due to bacterial
penetration into fracture.
• Pockets are deep and with
narrow coronal opening.
• Pocket is often located at
buccal or lingual
convexity of tooth.
• As a result of bacterial biofilm
• Pockets are typically wider
coronally and relative
loose.
• Pocket is present at mesial
or distal aspects of tooth.
• Affects group of teeth • Affects single tooth

19. • As reported by Tamse & colleagues typical VRF pocket was observed in 67%
of VRF cases.
Tamse A. Iatrogenic vertical root fractures in endodontically treated teeth. Endod Dent Traumatol 1988;4:190-6.
• Rigid metal periodontal probing is ineffective in probing VRF and a flexible probe
should be used .

20. 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.

21. 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

22. DIRECT VISUALIZATION
• Fracture is clearly visible when separation of fragments has occurred.
• A sharp probe may aid in identifying the fracture line where separation has not occurred
• Direct visual examination (with good
illumination and magnification) of tooth
especially the marginal ridges is important.

23. Methylene blue or gentian violet used to
highlight the cracks.
However, a long time (at least 2–5 days) is
needed to be effective and may require placement
of a provisional restoration.
This may weaken the tooth integrity and further
spread the crack. Another disadvantage is difficult
esthetic restoration.
DYE TEST

24. VITALITY TESTS
• Pulp vitality tests can be helpful in diagnosing a VRF (especially in
sound teeth) as fracture line may extend to the pulp causing
inflammation and necrosis.
• Diagnostic information may be obtained when the patient complains of a
sharp, sudden pain, especially while chewing.

25. BITE TEST
Here, the patient is asked to bite on various items such as
a toothpick, cotton roll, orange wooden stick or the
commercially available Tooth Slooth.
Pain on biting after the pressure has been withdrawn is
a classical sign
Symptoms may be elicited when pressure is applied to an
individual cusp.

26. In transillumination, the tooth is cleaned and a
fiber-optic or other light source is applied directly
on the tooth.
A crack will block the transmission of light, and
structurally sound teeth (including those with craze
lines) will transmit the light throughout the crown.
TRANS ILLUMINATION TEST

27. Probing with periodontal probe or a no. 25 silver cone may reveal
a narrow, isolated, periodontal defect in the gingival attachment.
TRACING THE SINUS TRACT
Gutta percha , endodontic explorer, etc., may be used to trace the sinus tract
back to its origin
PERIODONTAL PROBING TEST

28. RADIOGRAPHIC FEATURES
In the early stages, radiographic findings are unlikely because,
(1)the rootcanal filling may obstruct the detection of the fracture
(2) the bone destruction which is limited in the buccolingual plane may be obstructed by
the superimposed root structure.
Early stage VRF
• No obvious change +/− subtle crestal bone loss
• Thickening of the periodontal ligament along axial
root wall(s)

29. Early versus late radiographic
presentation of a VRF-associated
bone defect.
(A, B).- At an early stage, a bone defect
(red) is not likely to be detected in a
periapical radiograph, as the root will
overlap with the defect.
(C, D) At later stages, when major
damage has occurred to the cortical plate,
the bone defect may be large enough to
extend beyond the silhouette of the root.
( E)appear as a radiolucent defect along
the root.
Bone Resorption

30. One of the most typical radiographic signs is a J-shaped or
halo radiolucency, which is a confluence of periapical and
periradicular bone loss
In addition, the pocket now approximating the fracture, which was
initially tight and narrow may become wider and easier to detect
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

31. Other radiographic features include:
Existence of a fracture line;
Separated root fragments;
Space beside a root filling;
Double images of external root surface;
Vertical bone loss.
Separation of root fragments
Clinical and Radiographic Characteristics of Vertical Root Fractures in Endodontically and Nonendodontically
Treated Teeth,Wan-Chuen Liao, et al,JOE1999

32. Limitations of Periapical radiographs
A periapical radiograph can detect a fracture line only in 35.7% cases. The
reasons for this may be,
i. Superimpositions of root canals on fracture line
ii. X-ray beam not parallel to the plane of fracture
iii. Fracture line present in the fused root superimposed by radiopaque
anatomic structures
iv. Location of fracture line precludes the use radiograph.

33. Cone beam computed tomography (CBCT) overcomes the limitations of PRs by
providing undistorted images, which are not susceptible to anatomical noise and
enable the clinician to view the tooth from multiple planes and angles
(Durack & Patel, 2012).
 Results showed better sensitivity and specificity of CBCT scans
than PRs in the detection of VRFs in unfilled teeth, when a voxel
size of 0.2 mm was used.

34. • The sensitivity and specificity of VRF diagnosis in assessing gutta-percha filled canals were
32% and 68%
• The sensitivity and specificity of VRF diagnosis in assessing the empty canals (without
gutta-percha) were 72% and 96% .
• And concluded that intracanal filling materials such as gutta-percha reduce the diagnostic
ability of vertical root fractures. Hence, it is recommended to remove those materials from root
canals before imaging to improve the diagnostic potential of CBCT.
Scientific world journal 2018

35. Present status and future directions: vertical root fractures in root filled teeth Shanon Patel et al, International Endodontic Journal,2022

36. 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.
Limitation of CBCT
(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
Minimal beam hardening and scatter
associated with fiber post retained
tooth compared to cast gold in sagital
and axial CBCT views.

37. Exploratory Surgery
Full
thickness
flap raised
Granulation
tissue
removed
VRF may
often be
directly
visualized.

38. PREVENTION
▶ Avoiding or correcting all the etiological factors provides the best prevention.
This may include
Extensive
cutting of
dentin during
preparation of
canal
Over-preparation
of the canal for a
dowel, selection of
an improper
dowel and
traumatic seating
of
intra-canal
restorations
Nightguards may
be used in
patients with
bruxism to
minimize the risk
of VRFs
KishenA. Mechanisms and risk factors for fracture predilection in endodontically treated teeth. Endodontic topics 2006;13:57-83.

39. When a VRF is determined to be present, extraction of the affected tooth or root is
recommended as soon as possible.
Any delay may increase the potential for additional periradicular bone loss and
potentially compromise the placement of an endosseous implant.
Attempts to “repair” a fracture by filling the crevice with a variety of restorative
materials have been reported; however, none of these repairs is considered a reliable
long-term solution.
TREATMENT PLANNING

40. Conclusion
It must be kept in mind that this is a single case study and the observation period of two years is
quite short. Thus, it is difficult to extrapolate a single case to a more general conclusion. For a
general recommendation, whether this is a suitable treatment option for VRF, more cases over a
longer period of time need to be monitored. Nevertheless, intentional extraction and filling the
fracture gap with Biodentine followed by replantation is a new clinical treatment option for
teeth which have to be extracted elsewise. Hence, the described treatment may contribute to change
the clinical practice of VRF in future.

41. Novel hybrid nano-ceramic materials such as ,
 Cerasmart (GC Corporation, Tokyo, Japan),
 Lava Ultimate(3 M ESPE, USA)
 Enamic (Vita Zahnfabrik, Bad Säckingen, Germany)
RECENT ADVANCES
These may be used in the fabrication of a post-endodontic restoration.
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.

42. • 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.
CONCLUSION

43. Reference
Cohen’s Pathway of the Pulp,12th edition
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 tomographyfor 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.
Clinical and Radiographic Characteristics of Vertical Root Fractures in Endodontically and
Nonendodontically Treated Teeth,Wan-Chuen Liao, et al,JOE1999
Ehsan Hekmatian, Mitra Karbasi kheir, Hossein Fathollahzade, Mahnaz Sheikhi, "Detection of Vertical
Root Fractures Using Cone-Beam Computed Tomography in the Presence and Absence of Gutta-
Percha", The Scientific World Journal, vol. 2018, Article ID 1920946, 5 pages, 2018.
https://doi.org/10.1155/2018/1920946

44. Thank you