|Year : 2011 | Volume
| Issue : 2 | Page : 101-104
Vertical root fractures: Review and case report
Mithra N Hegde1, Nidarsh D Hegde2, Chiradeep Haldar1
1 Department of Conservative Dentistry and Endodontics, A.B. Shetty, Memorial Institute of Dental Sciences, Derelakatte, Mangalore, India
2 Department of Oral and Maxillofacial Surgery, A.B. Shetty, Memorial Institute of Dental Sciences, Derelakatte, Mangalore, India
|Date of Web Publication||17-Sep-2011|
Mithra N Hegde
Department of Conservative Dentistry and Endodontics, A.B. Shetty, Memorial Institute of Dental Sciences, Derelakatte, Mangalore
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Vertical root fractures, or VRFs, usually are characterized by an incomplete or complete fracture line that extends through the long axis of the root toward the apex. The cause of VRFs is mainly trauma and iatrogenic reasons. Complete or incomplete VRFs constitute an ongoing problem in dentistry because they are difficult to be diagnosed in the early stages. In most cases, tooth extraction is the only reasonable treatment when the VRF is finally diagnosed. Other options have been put forward such as bonding the two fractured segments and reimplanting the tooth. A similar case has been described here.
Keywords: Extraction, re-implantation, vertical root fracture
|How to cite this article:|
Hegde MN, Hegde ND, Haldar C. Vertical root fractures: Review and case report. J Interdiscip Dentistry 2011;1:101-4
| Introduction|| |
Vertical root fractures, or VRFs, usually are characterized by an incomplete or complete fracture line that extends through the long axis of the root toward the apex. 
Vertical root fractures represent between 2 and 5 percent of crown/root fractures, with the greatest incidence occurring in endodontically treated teeth and in patients older than 40 years of age.  The cause of VRFs is mainly trauma and iatrogenic reasons. Trauma is the most likely cause of VRFs in vital teeth, typically occurring from physical trauma, clenching or bruxism, or occurring in teeth undergoing apexification. Early diagnosis of a VRF usually begins with gathering a comprehensive dental history, listening well to the patient, asking many questions and encouraging the patient to recall when the symptoms first occurred. Complete or incomplete VRFs constitute an ongoing problem in dentistry because they are difficult to be diagnosed in the early stages. In most cases, tooth extraction is the only reasonable treatment when the VRF is finally diagnosed. Early detection in a multirooted tooth allowed timely removal of the broken root and possible retention of the remaining portion of the tooth.
| Etiology|| |
If the tooth is vital, the possible reasons which may cause a VRF include history of trauma to the tooth, presence of a developmental defect within the tooth which can weaken it and also a tooth which is brittle. If the tooth has a large metallic restoration which is stronger than the tooth structure, the restoration will not wear out along with the normal wear of the tooth. This may lead to a wedging effect resulting in a VRF. Other situations which may lead to a VRF include a single tooth in the arch and its resultant overloading and also abutments in which eccentric forces are acting.
In endodontically treated teeth, the reasons for a VRF include the following:
Excessive canal shaping
Excessive canal shaping during endodontic treatment, especially in teeth with curved roots that are narrow in the mesiodistal plane, can lead to development of a VRF. This is why maxillary second premolars, mesiobuccal roots of maxillary molars, mesial roots of mandibular molars and mandibular premolars are most prone to VRFs. In addition, excessive removal of tooth structure contributes to the overall weakening of the tooth, which promotes a higher incidence of VRFs.
Excessive restorative procedures
When preparing a canal to place a dowel, the clinician must ensure that the width and length of the dowel space are appropriate for the anatomy of the canal to avoid weakening the walls by making them too thin. Furthermore, a dowel must be cemented passively avoiding pressure that may wedge the dowel into the canal, because the cement produces hydrostatic pressure in the root canal that may lead to the development of a VRF.  In addition, tapping a dowel or cast intracoronal restoration into place may contribute to the development of VRFs.
Excessive hand pressure
Excessive hand pressure during lateral or vertical compaction of gutta-percha can result in development of a VRF. 
Inappropriate choice of tooth for a bridge abutment
Choosing an inappropriate tooth for a bridge abutment may contribute to the development of a VRF (for example, mandibular incisors with a 1:1 crown/root ratio or the inappropriate use of a tooth to support a cantilever).  Studies by Yang et al, and Felton et al, have focussed on whether post-retained restorations have the potential effect of weakening the root and predisposing the tooth to VRFs. , Some VRFs may begin with an incomplete VRF. Cameron described this initial crack (known as cracked tooth syndrome) as a break or split in the continuity of the root surface without a perceptible separation.
| Diagnosis|| |
The patient initially may complain of a sharp pain during chewing or biting of hard food, as well as occasional pain on consumption of cold food or drinks, because the dentin and sometimes the pulp is affected by the VRF. This is seen more frequently in teeth with large restorations, especially molars, which involve the dentin and sometimes the pulp, thus differing from small enamel fracture lines. By removing the restoration, the clinician can perform a direct visual examination for a crack. The ridges of the mesial and distal margins should be evaluated carefully, since these areas are most predisposed to crack. A comprehensive, detailed dental history typically yields the initial clues suggesting a VRF.
Furthermore, strong coaxial illumination along with good magnification is essential to identify a VRF.
To reproduce the biting and chewing pain described by the patient, the dentist may use rubber wheels, cottonwood sticks or tooth slooth fracture detector to replicate masticatory motion. This test can be performed tooth-by-tooth or cusp-by-cusp. When the patient responds with pain, the dentist should inquire if the pain is similar to his or her chief complaint.
Shining a strong fiberoptic light through the tooth (provided there is no restoration to block light transmission) in a horizontal direction at the gingival sulcus may help the clinician to visualize a crack. If he or she finds a crack in the tooth, the light will be deflected at the crack, reducing its transmission through the tooth, and the fractured segment on the other side of the crack will appear darker.
Periodontal probing test
Careful probing with a thin periodontal probe may reveal a narrow, isolated, periodontal defect in the gingival attachment. In the absence of any other associated periodontal disease, this narrow defect is consistent with an underlying bony dehiscence that is secondary to a VRF. To visually illustrate the problem for the patient, the dentist can expose a radiograph with a Gutta Percha point placed in the defect which helps us to track the exit and the entry point of the fracture line into the periodontal ligament space.
Remove all restorations
There is no substitute for direct visualization, with good illumination (via fiber optics) and magnification (≥΄3.5).
Vitality tests (that is, electrical, thermal or laser Doppler flowmetry  can be helpful in diagnosing a VRF, especially in ostensibly sound teeth. When the patient complains of a sharp, sudden pain, especially while chewing, pulp testing provides valuable diagnostic information. Often, the fracture is incomplete but extends to the pulp, where it eventually causes necrosis. A non vital tooth that is intact or has a minimal restoration is highly suggestive of a VRF.
The use of disclosing dye helps the clinician to visualize a suspected crack after the restoration is removed and the dye is placed in the inner aspect of the cavity.
Although essential, radiographic images do not always reveal a VRF. Unless the X-ray beam is parallel to the fracture line (± 4 degrees), the root fracture will not be revealed. Direct digital radiography helps us to visualize the bone loss or loss in the lamina dura at the point of fracture line on the cementum.
Surgical exploration may be advisable if a VRF is strongly suspected, but cannot be confirmed by other available techniques. (this consists of lifting a full-thickness flap and examining the bone and root directly with high-magnification and illumination.) There is no substitute for direct visualization if the diagnostic and prognostic assessment remains questionable.
The progression of a vertical crown fracture that is in an early stage (that is, it has not reached the pulp chamber or the furcation of a multirooted tooth) may be slowed or arrested by drilling out all evidence of the fracture line and restoring the tooth with a bonded restoration. However, the clinician should advise the patient that the prognosis will remain guarded. When a coronal crack crosses both marginal ridges and produces a split tooth, and when that split extends apically, the prognosis was poor and extraction was often required. Immature pulpless teeth that previously have undergone apexification treatment may have thin walls that might result in a greater potential for development of a VRF. Even with its intrinsic limitations, direct digital radiographic examination is one of the most important methods for accurately diagnosing a VRF. Advantages of direct digital radiographic examination include the fact that it helps in assessment as it is possible to increase and decrease the size and density of the image. When the VRF is at an early stage, it is often possible for the radiographic examination to reveal a thickening of PDL along one side of the root. As the VRF advances, a radiolucent halo of bone loss is observed along one side of the root. As the VRF advances further, the radiolucent halo may surround the entire root. This halo indicates that the root fragments have separated completely, along with the attached PDL; often, there is an associated deep pocket and loss of additional supporting bone.
Though extraction is the treatment of choice, other options have been but forward such as bonding the two fractured segments and reimplanting the tooth. A similar case has been described in the following case report.
| Case Report|| |
A 52-year-old lady, Mrs. Sangeeta, reported to Dental Speciality Clinic with the complaint of pus discharge and discomfort in her upper anterior teeth. She gave a history of root canal treatment in her upper left cental incisor one year previously. On radiographic evaluation, it was noted that the obturation was satisfactory. However, a large periapical lesion was noted with respect to that tooth [Figure 1]. The patient gave a history of bruxism. The tentative diagnosis provided was a non healing radicular cyst and the treatment plan was to do a surgical enucleation of the cyst. A flap was raised and the periapical area of the tooth was examined [Figure 2]. It was noted that the tooth exhibited a vertical root fracture. The fracture line propagated from the cementoenamel junction to the apex of the tooth [Figure 3]. The treatment plan was modified and the tooth was atraumatically extracted using Emdent Upper Anterior Forceps. The two segments were thoroughly cleaned, irrigated and dried. They were then bonded with a cyanoacrylate based adhesive  material, held under pressure for three minutes and any excess adhesive was cleaned from the surface. The tooth was re-implanted into the socket and splinting was done on the lingual surface for a period of two weeks. The patient reported that her symptoms were relieved and the tooth was noted to be firm in the socket. Post operative evaluation after two years showed healed periapical lesion [Figure 4] and functional tooth in the anterior segment.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]