VERTICAL ROOT FRACTURE :

A CHALLENGE IN DIAGNOSIS

SONA ANNS KURIA

1st Year MDS
Dept. of Endodontics
 CONTENTS

 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

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
VRFs are typically detected in the bucco-lingual plane of
the tooth, and less commonly in the mesio-distal Plane.

(von Arx & Bosshardt, 2017)

 LEUBKE’S CLASSIFICATION

Based on separation of fragments

• Complete fracture
• Incomplete fracture

Relative to position of alveolar crest

• Infra- osseous fracture
• Supra- osseous fracture

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

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)

• .
 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.
1999 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).

 PREDISPOSING FACTORS
Natural
 Shape of root cross section
 Occlusal factors
 Preexisting microcracks
Iatrogenic
 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
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.
 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.
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

 Mild pain or dull discomfort on the affected

side of tooth

 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

• As a result of bacterial • Develops due to bacterial

biofilm penetration into fracture.
• Pockets are typically • Pockets are deep and
wider coronally and with narrow coronal
relative loose. opening.
• Pocket present at mesial • Pocket is often located at
buccal or lingual
or distal aspects of tooth. convexity of tooth.
• Affects group of • Affects single tooth
teeth
• Rigid metal periodontal probing is ineffective in
probing VRF and a flexible probe should be used

• 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.
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

• Direct visual examination (with good

illumination and magnification) of tooth
especially the marginal ridges is important.

• Fracture is clearly visible when separation of fragments has occurred.

• A sharp probe may aid in identifying the fracture line where separation has n
occurred.
 DYE TEST

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.
 VITALITY TESTS

Vitality tests for individual teeth are usually positive.

Signs of hypersensitivity to cold thermal stimuli due to the presence of pulpal

inflammation; a feature that may help to confirm a diagnosis of cracked tooth

syndrome.

Teeth affected by the condition may be seldom tender on apical percussion.

 BITE
TEST

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.
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.
 TRANS ILLUMINATION TEST

Transillumination is an important aid in diagnosing the cracks, whether it

is an incomplete crack (as in cracked tooth syndrome) or a complete
vertical root fracture
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
PERIODONTAL PROBING TEST

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
 RADIOGRAPHIC FEATURES

Early stage VRF

• No obvious change +/− subtle crestal bone loss
• Thickening of the periodontal ligament along axial
root wall(s)

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 still has limited mesiodistal dimensions) may be
obstructed by the superimposed root structure.
Bone Resorption
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.
 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
Other radiographic features include:

Existence of a fracture line;

Separated root fragments;
Space beside a root filling;
Double images of external root surface;
Separation of root fragments
Vertical bone loss.

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,

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.[
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).

A meta-analysis evaluating data assessing the radiographic detection of root

fractures concluded that CBCT provided much higher diagnostic accuracy for the
detection of VRFs when compared to PRs
(Salineiro et al., 2017)

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).

Minimal beam hardening and scatter

associated with fiber post retained
tooth compared to cast gold in sagital
and axial CBCT views.

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

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.
 RECENT ADVANCES

Novel hybrid nano-ceramic materials such as ,

 Cerasmart (GC Corporation, Tokyo, Japan),

 Lava Ultimate(3 M ESPE, USA)
 Enamic (Vita Zahnfabrik, Bad Säckingen, Germany)

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.
 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

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 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.

Clinical and Radiographic Characteristics of Vertical Root Fractures in Endodontically and

Nonendodontically Treated Teeth,Wan-Chuen Liao, et al,JOE1999
Thank you