diagnosis and management of teeth with vertical root fractures

$: Diagnosis and management of teeth with vertical root fractures$
AbstractVertical fractures in teeth can present difficulties indiagnosis. There are, however, many specific clinicaland radiographical signs which, when present, canalert clinicians to the existence of a fracture. In thisreview, the diagnosis of vertical root fractures isdiscussed in detail, and examples are presented ofclinical and radiographic signs associated withthese fractured teeth. Treatment alternatives arediscussed for both posterior and anterior teeth.

Key words: Endodontics, diagnosis, vertical fractures.

(Received for publication March 1999. Accepted March1999.)

Introduction

Vertical root fractures have been described asl o n gitudinally oriented fractures of the root,extending from the root canal to the periodontium.1

They usually occur in endodontically treated teeth,although occurrence in non-restored teeth has beendescribed.2-4 The vertical fracture may involve thewhole length of the root or only a section of it. Itmay involve only one or both sides of the root.5-7 Inmolar teeth, the fracture is most commonly bucco-lingual in ori e n t ation in individual roots.Mesio-distal fractures are less common. In anteriorteeth, the fractures are most commonly in a bucco-lingual direction.5 Vertical root fractures can bei n i t i ated from coronal tooth structure (Fig. 1) or at theapex (Fig. 2). Incomplete and complete root fracturesh ave been descri b e d .8 , 9 Most ve rtical root fractures arecomplete.6 The radiographic and clinical signs ofve rtical root fractures were extensively reviewed by Pittsand Natkin in 1983.1 A number of other diagnosticreviews have been published.7,10-13 Numerous casereports also appear in the literature describing singleor multiple cases of vertical root fractures.14-28

If unrecognized, vertical root fractures can lead tofrustration and inappropriate endodontic treatment.Diagnosis is sometimes difficult as there is often no

Diagnosis and management of teeth with vertical root fractures

Alex J. Moule*Bill Kahler†

single clinical feature which indicates that rootfracture is present11 and signs and symptoms areoften delayed. Indeed, average time between rootfilling and the appearance of a vertical root fracturehas been estimated to be between 39 months23 and52.5 months29 with a range of three days to 14 years.In general, however, all vertically fractured teethexhibit specific clinical and radiographic signs whichshould alert the practitioner to the possibility of aroot fracture being present. This paper reviews thesediagnostic features, presenting examples of each.Treatment alternatives are discussed but causes ofvertical root fractures are not addressed. They willbe the subject of a further review.

Clinical presentation

The clinical presentation of a vertical root fractureis extemely va riable. The clinical signs and symptomsvary according to the position of the fracture, toothtype, time after fracture, the periodontal conditionof the tooth and the architecture of the boneadjacent to the fracture. Teeth with vertical rootfractures often present with a long history of variablediscomfort or soreness, usually associated with localchronic infection. The pain is usually mild tom o d e r ate in intensity.2 3 Rarely is severe painassociated with these teeth. Vertically fractured teethcan also present with a history of pain on biting.

Vertical root fractures should be considered if anapparently well root filled tooth does not settle afterthe root filling is completed.16 Where a root filledtooth is associated with ‘pain on biting’ and is alsoaccompanied by a ‘bad taste’, a vertical root fractureis most likely present. Occasionally, the patient canbe aware of a sharp cracking sound at the time ofc o n d e n s ation of gutta percha,1 , 2 , 2 3 or the cementat i o nof a post.21 Bleeding during condensation of a rootfilling material and an apparent lack of resistancewithin the canal during condensation, leading to analmost unlimited ability to condense gutta perchainto the canal,11 are also signs that a vertical rootfracture is present.

Australian Dental Journal 1999;44:2. 75

*Endodontist, Brisbane.†General Practitioner, To owo o m b a .

INVITED REVIEWAustralian Dental Journal 1999;44:(2):75-87

76 Australian Dental Journal 1999;44:2.

Fig. 1. – Upper central incisors h owing complete crow n - d ow n

vertical root fracture.

Fig. 2. – Maxillary secondpremolar shows an incompletebucco-lingual ve rtical rootfracture which has been initiatedin the apex. Note the V-shapedr e s o rp t i ve defect which has

occurred apically.

Fig. 3. – Diagrammatic representation of the position of soft tissueswelling (a) in a tooth with a periapical abscess, and (b) in a tooth

with a vertical root fracture.

Fig. 4. – A broad-based swelling over the mesio-buccal root of thismandibular first molar is typical of that associated with a vertical root

fracture.

Fig. 5. – Double or multiple sinus tracts are a feature of verticallyfractured teeth.

Fig. 6. – Diagrammatic representation of a probing pattern seen in(a) periodontal disease and (b) vertical root fracture. A deep narrowpocket in one position around the circumference of the tooth and thepresence of otherwise normal attachment is a feature of verticallyfractured teeth. When similar pocketing occurs in two points aroundthe circumference of the tooth, a vertical root fracture is inevitably

present.

Fig. 7. – Maxillary central incisor tooth exhibiting a deep narrowpocket on the labial surface of the tooth with normal attachment inthe interproximal area. The presence of a bucco-lingual vertical root

fracture was confirmed by surgery.

Fig. 8. – (a) Maxillary right first premolar with a mesio-distalfracture. Deep probing is evident mesially and distally but attach-ment is normal on the buccal and lingual aspect. (b) Radiograph ofsame tooth. Note the extensive bone loss mesially and distally but

little evidence of bone loss apically.

a b

a b

a

b

Some swelling of soft tissues is usually present.The swelling is usually broad-based, and mid-root inposition. Palpation will often show swelling andtenderness over the root itself, but little swelling inthe periapical region (Fig. 3, 4). When a sinus tractis present, it may be situated in or close to attachedgingiva rather than in the apical region. Double ormultiple sinus tracts are common.1 Where multiplesinus tracts are present one or more of these tractsmay be located some distance from the involvedtooth. The insertion of a gutta percha point intoeach sinus tract can assist with diagnosis. Anexample of a ve rtically root fractured toothexhibiting multiple sinus tracts is shown in Fig. 5.

A common feature of vertically root fracturedteeth is the development of deep, narrow, isolatedperiodontal pockets. Pocketing is usually situatedadjacent to the fracture site. When the fractureextends right through the root, probing patterns maybe bilateral. The probing pattern for a tooth with avertical root fracture is different from that seen inteeth with periodontal disease, where the pocketingis fairly consistent in depth around a large part of thetooth (Fig. 6). Deep probing in one position aroundthe circumference of the tooth in the presence ofotherwise normal attachment usually indicates thatthe tooth is fractured (Fig. 7, 8). Deep probing intwo positions on opposite sides of the infection isalmost pathognomonic for the presence of a fracture.It may be necessary to remove the restoration beforedeep pocketing can be probed in the interproximalregion of molar teeth with mesio-distal fractures.1

A common presenting feature is the dislodgementof a post or post crown. A root fracture should besuspected if an apparently well-fitting post or postcore becomes dislodged. A typical case is illustratedin Fig. 9. The presence of a vertical root fractureshould be strongly suspected in teeth where therehas been a history of repeated dislodgement of a postor post crown. Because of problems with diagnosis,it is not uncommon for teeth with vertical rootfractures to have been treated repeatedly by s u r g e rybefore the presence of a fracture is suspected. Whensurgery fails for no obvious reasons, a verticalfracture should be considered a possibility before theperiapical area is re-entered surgically.

Radiographic signs

While the clinical presentation of a vertical rootfracture can be variable, radiographic signs are, attimes, quite specific. These signs can va ryconsiderably from case to case, depending on theangle of the X-ray beam in relation to the plane offracture, the time after fracture and the degree ofseparation of the fragments. Radiographic changesseen in vertical root fractures are summarized below.

Separation of root fragments (Fig. 10-13)When separation of root fragments occurs, the

root fracture is clearly visible. Once separation offragments has occurred, proliferation of granulationtissue22 often results in the rapid movement of thefragment away from the remaining root, in manycases until the fragment comes into contact with anadjacent tooth. Wide separation of fragments canoccur very rapidly, sometimes occurring in a matterof weeks.

Fracture lines along the root or root fillings(Fig. 14-19)

On occasions, direct evidence of a fracture can beseen as a vertical radiolucent line running across theroot or the root filling. Direct evidence of a verticalroot fracture line is often difficult to visualize. Forthe fracture to be seen the X-ray beam must passalmost directly down the fracture line. Smallchanges in horizontal angulation may render thefracture undetectable. A four degree variation in theh o rizontal angulation of the film can preve n tvisualization of the fracture.30 Pitts and Natkin1

suggest that a fracture line that deviates from thelong axis of the canal may be radiographically moreobvious, whereas a fracture line running parallel andadjacent to a root filling may be less easy to see.While it is sometimes possible to see fracture imagesclearly on a radiograph, care should be taken whenattempting to identify vertical lines as fracture lines,as anatomical features, palatal grooves, artefacts andscratches can mimic the appearance of a fracture.

Space beside a root filling (Fig. 20)

Minor separation of fragments can result in theradiographic appearance of a vertical space adjacentto the root filling material in an otherwise well-obturated canal. Vertical root fractures should besuspected if the root filling appears well condensedbut is in close contact with only one wall of the rootcanal.

Space beside a post (Fig. 21)

In general, posts are constructed so that they fitthe canal. When a post is present in a vertically rootfractured tooth, slight separation of the fracturedfragments can result in the appearance of a spacebetween the edge of a root canal, which may becoated with cement, and the post itself.

Double images (Fig. 22)When separation of fragments occurs in a

direction other than parallel to the X-ray beam,overlapping of fragments may result in doubleimages of the external root surface. While this effectis sometimes seen in normal teeth, for example, inthe mesial concavity of maxillary premolar teeth,step-like double images on the external outline of a



Fig. 9. – (a) Clinical presentation of a patientwith discomfort associated with the maxillaryright central incisor which was crowned. Thepatient has experienced a low grade discomfort,and an itchy feeling associated with this tooth forsome months. (b) Periapical radiograph showsthe tooth to be restored with a post retainedcrown. No evidence of root filling is presentalthough the lamina dura at the apex appearsintact. There is slight widening of the periodontalligament space in the mid-root region. (c)Clinical photograph six months after Fig. 9a.The post crown is dislodged and a root fractureis evident on the labial surface. (d) Dislodgedc r own from Fig. 9a. Dislodgement of anapparently well-fitting post or post crown is a

sign that the root may be fractured.

Fig. 10. – Separation of thefragments is clearly visible inthis ve rtically fracturedm a x i l l a ry left first premolar.

Fig. 11. – Vertically fractured mandibular lateralincisor showing wide separation of the fragments.The distal fragment is completely separate fromthe tooth and has moved distally to be in contactwith the canine. Granulation tissue separates the

gutta percha fill from both fragments.

Fig. 12. – Maxillary canine showing a vertical rootfracture in the apical portion and wide separation

of the fragments.

Fig. 13. – Separation of the fragments in the mesial rootof this mandibular right molar can be clearly seen. Themesial fragment has remained attached to the large

restoration.

Fig. 14. – A fracture line (arrows) can be seen runningparallel to the root canal and then exiting distally in the

apical third in this maxillary left central incisor tooth.

Fig. 15. – (a) A ve rtical fracture (arr ows) radiogr a p h i c a l l ysuperimposed over the root filling is present in thismaxillary left central incisor tooth. (b) Clinical photo-graph of a tooth from Fig. 15a showing the fracture(arrow). Note the amount of fibrous tissue which isattached to this tooth once it has been extracted. This is

a feature of teeth that are vertically root fractured.

a

b

d

c

a b


Fig. 16. – Two periapical radiographs taken at the same consultationshowing the effects of angulation changes on the visibility of the rootfracture on the right maxillary central incisor tooth. (a) The fractureis difficult to see. (b) The fracture is easy to see (arrow) where the X

ray beam passes down in the plane of the fracture.

Fig. 19. – (a) Periapical radiograph of a failed anterior bridge. Adark line extending from the bottom of the post in the maxillary rightcentral incisor to the apex (arrow) gives the appearance of a verticalroot fracture being present. (b) Clinical photograph of the radio-graph showing a mark (arrow) responsible for the radiographicimage. In interpreting radiographic lines on radiogr a p h sconsideration must be given for the presence of artefacts and

scratches.

Fig. 20. – Periapical radiographs of a root filled premolar tooth. (a) At one year recall, there is no evidence of any radiographicchanges which are suggestive of a problem. (b) Two years later thereis widening of the periodontal ligament space and the appearance ofa large periapical lesion. The fracture is seen as a space (arrows)which has developed on the distal side of the root filling due to slight

separation of the fragments.

Fig. 21. – Maxillary right first premolar restored with a post/crownrestoration. A space is present between the post and the root whichis covered with a layer of cement. The space can be traced past the

post beyond where the fracture line is clearly shown (arrow).

Fig. 17. – Diagrammatic representation of the changes in horizontalangulation of the X-ray beam that are necessary to detect a verticalroot fracture (a). For better visualization of a transverse root fracture,

the angulation is changed vertically rather than horizontally (b).

Fig. 18. – Periapical radiograph of maxillary right central incisorwith a deep palatal groove, the radiographic picture of which mimics

a vertical root fracture.

a b

a b

a ba b

tooth are often an indication that a fracture ispresent.

Radiopaque signs (Fig. 23-25)Where a vertical root fracture is present prior to

root filling, or occurs during the root fillingprocedure, extrusion of cement or root fillingmaterial can occur into the fracture site or apically.When the plane of the fracture is predominantly in abucco-lingual direction, the excess cement materialcan be seen as a more intensely radiopaque lines u p e rimposed over the root filling.1 In someinstances, this can give the appearance of a secondcanal or an irregularly obturated root canal. Wherethe plane of the fracture is mesio-distal, the cementexcess can sometimes be seen as a thin filmextending proximally from the root canal filling tothe root surface. Where separation of the fractureoccurs during root filling, extension of root fillingmaterial through the apex can result in a tangle ofaccessory points at the apex (‘apical spaghetti’).

Pa tterns of bone loss

Vertical fractures allow the ingress of bacteria anda s s o c i ated irritants which cause localized peri o d o n t a ldestruction and bone loss adjacent to the fracturesite.6 The amount of bone loss is dependent on thenature of the fracture and the time the fracture hasbeen present. Radiographically, there are certainspecific patterns of bone loss which are found to beassociated with vertically fractured teeth. The radio-graphic appearance of the bone loss is dependent onthe extent of destruction, the plane of fracture andthe architecture of the bone adjacent to the fracture.Thus, the appearance of bone destruction seenwhen the fracture plane is bucco-lingual will bedifferent from that seen when the plane of thefracture is mesio-distal. Bone destruction associatedwith anterior teeth will be easier to see than thatassociated with lower molars, where changes aremasked by a thick buccal plate of bone.

Widening of periodontal ligament space (Fig. 26)

Wide enlargement of the periodontal ligamentaround the whole length of the root is an indicationthat the tooth is vertically fractured. The radio-graphic appearance of bone loss is quite differentfrom that seen in a periapical lesion where apicalbone loss can occur but without destruction of thelamina dura along the root surface. When thefracture is in a bucco-lingual direction and involvesthe apical portion, there is loss of bone on the buccaland lingual surfaces of the tooth. Radiographically,the tooth root can be seen more clearly (or appearsmore ‘in focus’) than adjacent teeth. Widening ofthe periodontal ligament space around the wholelength of the root is a classic sign that a vertical rootfracture is present.

Radiolucent halos (Fig. 27)When the plane of fracture is at right angles to the

X-ray beam, the pattern of bone loss appears widerand more diffuse than that seen in bucco-lingualfractures. Pitts and Natkin1 have described thisappearance as a ‘halo-like’ radiolucency runningaround the whole of the tooth. While the width ofthe diffuse bone loss may vary, a radiolucent halowhich runs around the whole of the root surface is aclassic sign of a vertical root fracture.

Step-like bone defects (Fig. 28)When the fracture runs obliquely across the root,

or where the fracture does not extend into the apicalp o rtion, a characteristic step-like bone defectdevelops.1,31 The width of the bone loss can vary.However, the depth of the step is governed by theapical extent of the fracture. The appearance of astep-like bone defect on a particular tooth is subjectto the angulation of the X-ray beam. Additionalr a d i o graphic examination with the X-ray beamangled 15 degrees to the mesial or distal may providea better view of the defect. It must be rememberedt h at step-like bone defects can mimic simpleendodontic lesions resulting from other causes, forexample, post perforations and vertical grooves.Similar defects can also be associated with non-vitalteeth that have not been root filled but such defectswill include the apex. Step-like bone defects are onlya sign that a fracture may be present. The presenceof the fracture needs to be confirmed by othermeans. Pitts and Natkin1 have suggested that thepossibility of a fracture is increased if the pocketextends to the mid-root level rather than to the apex,as this eliminates apical pathology from considerat i o n .

Isolated horizontal bone loss in posteriorteeth (Fig. 29)

It is unusual for one tooth in a dentition to beseverely involved with periodontal disease withoutinvolvement of other teeth. When only an isolatedtooth shows bilateral horizontal bone loss thepresence of a mesio-distal root fracture should beexpected, particularly in the presence of apparentlysuccessful endodontic therapy, and where the overallperiodontal situation is stable. Occasionally, thesame radiographic appearance can be seen wherethere is a foreign body wedged in the periodontium.

Unexplained bifurcation bone loss (Fig. 30, 31)

Bone loss in the bifurcation region of molars canoccur in patients without overt periodontal diseasein situations where there is ingress of bacteri athrough defects in the bifurcation, for example,perforations and other defects in the pulpal floor.Bifurcation bone loss is also seen in lower molarswith non-vital pulps but this is usually in associationwith periapical bone loss. Where bifurcation bone



Fig. 22. – Wide separation of thefragments has occurred in thisvertically fractured maxillary rightcanine which is fractured mesio-distally. Double images of the distalroot surface (arrows) are caused by

overlapping of the fragments.

Fig. 26. – Periapical radiograph ofmaxillary left lateral incisor showingwidening of the periodontal ligamentspace around the whole of the root.This is a classic sign that a root

fracture is present.

Fig. 27. – Periapicalr a d i o graph ofmandibular left firstmolar showing awide diffuse radio-lucent ‘halo’ aroundboth roots. The toothwas fractured mesio-distally. Radiolucenthalos of this type area classic sign that avertical root fracture

is present.

Fig. 24. – Pe riapical radio-graph of a root filled maxillaryright first molar which suffereda vertical root fracture. A thinfilm of cement (arr ows) isevident in the buccal rootextending from the root filling

to the root surface.

Fig. 23. – (a) Periapical radiograph of a recently root filled maxillaryright canine showing a well condensed root filling with an irregular

outline. (b) Extracted tooth showing vertically fractured root.

Fig. 25. – (a) Periapical radiograph of root filled mandibular leftlateral incisor showing a tangle of accessory points in the apicalportion (arrow). (b) Extracted tooth showing the fractured root and

the tangled array of accessory points through the apex.

Fig. 28. – (a) Periapical radiograph of hemisected lower molarshowing good bone adaptation to the distal surface. (b) A step-likebone defect has developed on the distal in association with a verticalfracture in the root. (c) A periapical radiograph taken at a slightlydifferent angle reveals that the step-like bone defect finishes at the

level of the fracture.

a b

a b

a

b c


Fig. 29. – Isolated horizontal bone loss occurring inassociation with a single isolated tooth, in an other-wise periodontally stable mouth, is an indication

that a vertical root fracture is present.

Fig. 30. – (a) Periapical radiograph of mandibular right first molar tooth showingunexplained bone loss in the bifurcation region. The lamina dura is intact apicallyand there is normal attachment bucally and lingually. (b) Clinical photograph of thetooth showing the mesio-distal fracture running across the pulp chamber. A verticalfracture should be suspected if there is unexplained bone loss in the bifurcation

region of the molar teeth.

Fig. 31. – (a) Periapical radiograph of vertically fractured maxillary left first molarshows bone loss in the bifurcation region of this molar. (b) In a straight on view of thesame tooth, the lesion in the bifurcation is masked by the palatal root. There iswidening of the periodontal ligament space around the mesio-buccal root. The laminadura appears to be intact around the tooth. This tooth was fractured mesio-distally.

Fig. 32. – (a) Mandibular right first molar which has been root filled and restored with alarge amalgam restoration. Note the diffuse V-shaped bone loss (arrows) around themesial root which is a classic sign that a root fracture is present. (b) Periapical radiographtaken four months later clearly shows a major fracture with wide separation of fragments.

Fig. 33. – Vertically fractured second premolar toothshowing a V-shaped resorptive defect at the apex. Theperiodontal ligament space is widened around the

whole root.

Fig. 34. – Dislodgement of a retrofilling material is asign that a root fracture may be present. This premolarwas treated surgically and a retrofilling material wasplaced at the apex. (a) A periapical radiograph takenprior to extraction shows the retrofilling material is nolonger in place. (b) This patient returned with theamalgam restoration which had been dislodged throughthe soft tissues. The existence of a vertical root fracture

is clearly evident.

a b

a b

a b

a b


Fig. 35. – A vertical fracture should be suspected if there is breakdown of bonyarchitecture which occurs subsequent to the complete resolution of an endodonticlesion. (a) At the time of initial endodontic treatment the mandibular left central incisor(arrows) is associated with a periapical lesion. (b) On review there has been completehealing. (c) Six ye a rs later a lesion has developed. This tooth is obviously

vertically fractured. Note the resorption along the fracture line.

Fig. 36. – The presence ofa vertical root fracture isclearly visible on the rootface. The post crown has

been dislodged.

Fig. 37. – Gentle reflection of soft tissues under local anaesthesia isoften all that is required to confirm the presence of a vertical root

fracture.

Fig. 38. – A triangular ‘miniflap’ involving a single vertical incision (a) in the attachedgingiva on the side of the tooth away from the probing defect or suspected fracture is arelatively atraumatic way of exposing the coronal root surface and (b) of confirming the

presence of a suspected vertical root fracture.

Fig. 39. – Where it is important to determine the typeand extent of the fracture, a full thickness periodontalflap is recommended. Often a single vertical incisionone tooth distal or mesial to the suspect tooth is all thatis required to expose sufficient root surface to visualize

the fracture (arrow).

Fig. 41. – Reflection of a full thickness flap revealsthe full extent and complexity of the root fracture inthis central incisor tooth. Flap reflection isrecommended to confirm the presence of a vertical

root fracture.

Fig. 40. – Loss of bone and deposition of soft tissue adjacent to thetooth root is usually found in the presence of a root fracture. Onthis occasion, the fracture can be seen as a linear yellowish line inthe mid-root region, running vertically from crown to apex (arrow).

a b c


loss occurs for no apparent reason, and without anyobvious sign of apical pathosis, the presence of avertical fracture through the bifurcation needs to beconsidered. In mandibular teeth, bifurcation boneloss is usually fairly easy to see. In maxillary molarteeth, however, it is usually masked by the positionof the palatal root. An oblique angle on theradiograph is necessary to bring the bone loss intoview.

V-shaped diffuse bone loss on roots ofposterior teeth (Fig. 32)

Where the buccal roots of maxillary molars or theroots of lower molars are vertically fractured, thecharacteristic radiographic image of bone loss is adiffuse V-shaped radiolucency, widest at the crestalbone, narrowing towards the apex.1 The shape anddiffuse radiographic evidence of the bone loss is dueto the fact that much of the bone lost is lingual to thebuccal plate of bone, which to some extent masks itspresence. Diffuse bone loss of this type, whenconfined to a single root or a single tooth in themouth, is almost pathognomonic of a vertical rootfracture.

Resorption along the fracture line (Fig. 33)

One of the presenting signs of a vertical rootfracture is resorption along the fracture line.1,15 Thisresorption may occur apically where it causes a V-shaped notch in the apical region, or longitudinallyalong the whole length of the fracture, giving theappearance of an irregular long resorptive defectrunning along the gutta percha root filling.Disintegration of root canal sealer, silver points andgutta percha in association with extensive resorptionof the root has been reported as being a feature ofvertically root fractured teeth.15

Dislodgement of retrograde filling material(Fig. 34)

Dislodgement of retrograde filling material inassociation with vertical root fractures has beend e s c ribed previously.1 , 3 2 , 3 3 Dislodgement of retro-grade root fillings can occur due to inadequateretention.33 However, for the retrograde root fillingto be displaced, some force usually has to be appliedto move it away from the root apex. Should a retro-grade root filling become dislodged, a likely cause isa vertical root fracture. In some cases the dislodgedr e t r o grade root filling mat e rial can be expelledthrough soft tissues.32

Endodontic failure after healing has occurred(Fig. 35)

Endodontic failure can occur many years after thetooth is root filled for a large number of reasons.34

Coronal leakage35 is considered to be one majorcause of long-term failure of endodontic procedures.However, when the endodontic status of a tooth

d e t e ri o r ates rapidly after a long time withoutsymptoms, or where radiolucencies reappear afterhealing has previously taken place, a vertical rootfracture should be considered as a cause and furtherinvestigations of the tooth should be undertakenwith this possibility in mind.

Direct visualization of the fracture

While clinical and radiographic signs gi ve areasonably accurate indication that a root fracture ispresent, direct observation of the fracture is the onlysure way to confirm the presence of the fracture inmany cases. Where sufficient coronal structure hasbeen lost, or where a crown restoration has becomedislodged, it may be possible to view the fracturedirectly by examining remaining tooth structure(Fig. 36). Where separation of fragments haso c c u rred, the fracture space is clearly evident.Where separation has not occurred, a sharp probecan be used to identify the fracture. Should this notbe possible, then gentle retraction of the soft tissuesin the region of the suspected fracture line with a flatplastic or other instrument (under anaesthetic ifrequired) may be sufficient to view the fracture onthe root surface (Fig. 37). Once the soft tissues aredisplaced, the fracture often can be clearly seen.Location of the fracture can be assisted by passing as h a rp probe lightly over the tooth surface. A‘clicking’ sound can be heard as the probe is passedover the fracture line.1 Where this is not possible,reflection of a small flap is recommended in order toview the root and confirm the presence of a fracture.The simplest way to do this is with a triangular‘miniflap’. A single vertical incision can be made inthe attached gingiva on the side of the tooth awayfrom the probing defect or suspected position of theroot fracture and around the offending tooth only.This conservat i ve flap usually allows sufficientreflection of soft tissues to confirm the presence ofmost vertical root fractures (Fig. 38). Where theextent of the root fracture is important to determine,or where it is considered that a miniflap will notexpose sufficient tooth structure, a full thicknessperiodontal flap can be used. In general, a verticalroot fracture is easy to see once the flap is retracted,p a rticularly if there is some separation of thefragments (Fig. 39). Its presence is alway saccompanied by loss of bone and the deposition ofsoft tissue adjacent to the fracture. At the time ofsurgery, the appearance of the fracture can vary.Where the fracture is stained, visualization is easy.On many occasions, however, subtle linear colourchange (Fig. 40) is all that is apparent. Change inthe angle of lighting or the position of viewing issometimes necessary to confirm the presence of thefracture. It is sometimes necessary to remove the softtissue over the portion of the root being examined sothe fracture can be visualized. A fibre-optic light is auseful diagnostic tool, particularly where the fracture


is not stained, or where separation of fragments hasnot occurred. It is proposed by these authors that,where possible, a small flap should be raisedroutinely to confirm the presence of a fracture,r ather than just to suspect that one is present (Fig. 41).

Treatment alternatives

Once the presence of a vertical root fracture isconfirmed, the decision needs to be made regardingthe future treatment of the tooth. The discomfortassociated with these fractures is often not acute,and often patients have put up with discomfort formany years. Some are reluctant to have the toothr e m oved, and this is understandable from asymptomatic point of view. However, it should beremembered that while the fracture is present, boneloss continues and should the fractured tooth be leftin place indefinitely, the amount of bone loss thatoccurs may severely compromise the success offuture restorative procedures and may result in theneed for complex periodontal surgery or ri d g eaugmentation. It is, therefore, recommended thatroot fractured teeth be removed as soon as practical.A number of complications have been reportedwhere vertical root fractures have been left in placefor some length of time.36,37

Treatment of vertically fractured teeth is difficultand is dependent on the tooth type as well as on theextent, duration and location of the fracture. Themajority of vertical fractures involve the gingivalsulcus and result in destruction of the periodontiumto the apical extent of the fracture, due to ingress ofbacteria and other irritants,6 resulting in alveolarbone loss in almost all teeth.3 0 Repair of theperiodontium and the bone cannot occur in thepresence of the bacterial infection.1 The aim of treat-ment is therefore to eliminate the fracture or theleakage of bacteria along the fracture plane.1 From atreatment planning point of view, a distinction mustbe made between a tooth that is cracked and a tootht h at is fractured. Where there is separation offragments and/or radiographic changes and/or boneloss associated with the root defect, a ve rtical fracturecan be assumed to be present and elimination of thecrack is a treatment priority. Where the tooth iscracked or crazed without bone loss or attachmentloss the root is cracked. Conservative managementof these cracked root filled teeth is sometimespossible.

Multirooted teeth can often be successfullytreated by resecting the fractured root, either by roota m p u t ation or hemisection.1 , 3 8 Prognosis for posteri o rteeth is good, provided the fracture can be removedin its entirety. Studies of root resected teeth havereported five year retention rates of 94 per cent39 andten year retention rates of 68 per cent.40 A series oftreatment options for posterior teeth involving hemi-section and root amputation has been described inthe literature.1,7

In general, prognosis for single rooted teeth ispoor and extraction is often the treatment of choice.However, many case reports are described in theliterature where innovative attempts to treat andretain anterior teeth have been attempted withvarying success. Clinicians have either removed thefractured segment or attempted to bond the rootusing a biocompatible material.

Cyanoacrylate has been used in an attempt tobond the fragments of anterior teeth.41 While thetreated teeth were comfortable at a 16 month follow-up, long-term prognosis was considered poor due todeep pocketing and resorption. An in vitro study42

assessing the resistance to fracture of root segmentsbonded with glass ionomer cement, composite resin,and cya n o a c ry l ate concluded that the bondstrengths of composite resin and cyanoacrylate weresuperior to glass ionomer cement. A number of casereports appear in the literature suggesting the use ofglass ionomer cement in vertically root fracturedteeth. It has been proposed that glass ionomercement may bond around the fracture line,p r e venting propagation of the fracture.4 3 G l a s sionomer and amalgam condensed into the coronalhalf to two-thirds of the root canal in teeth withincomplete vertical root fractures has been reportedsuccessful at eight month follow-ups44 but long-termfollow-ups have not been recorded in the literature.

Calcium hydroxide has been used to promotetissue repair and resolve osseous defects before theroots were restored. Teeth treated with calciumhy d r oxide, then ‘reinforced’ with glass ionomercement, have shown healing at six month follow-upappointments.14 Studies using an expanded poly-tetrafluoroethylene Gore-Tex membrane to establisha new periodontal attachment after the fragmentshave been bonded with glass ionomer cement havereported differing results; six teeth failed in a twelvemonth period.45 Only one study has reported successwith this method of treatment. Trope andRosenberg46 extracted both segments of a maxillarysecond molar and protected the periodontal ligamentby soaking it with Hanks balanced salt solution,while bonding the segment with glass ionomer andsubsequently replanting the tooth using Gore-Texmembrane to establish a new periodontal attach-ment. After six months, they reported a reduction inpocket depth from 10 mm to 2-3 mm. A crown wasplaced after one year as the tooth was functioningnormally.

It can be concluded from these results that the useof glass ionomer cement in teeth with incompletevertical root fractures may be an effective way oftreating the teeth on a short-term basis. Long-termfollow-ups have yet to be reported on these teeth andthis treatment can only be regarded as experimental.Also, on balance, the use of Gore-Tex membrane ina s s o c i ation with glass ionomer bonding of thefragments can only be regarded as experimental. It


m ay be appreciated that there is no point inattempting such treatment in anterior teeth if thereis not sufficient coronal tooth structure to allow foran adequate ferrule to hold the coronal toothstructure together.47

Regeneration of bone has been shown to occurafter surgical removal of the fractured segment froman anterior tooth, but long-term follow-up wasshown to be unfavourable due to deep pocketing andmobility.48 Successful three year follow-up has beenreported where the fractured fragment was removedin a tooth without periodontal disease and theremaining root filling covered by an amalgamrestoration.49

Though the majority of vertical root fractures arecomplete, fracture of only one side may occur.6 Inthese instances, complete removal of the fracture hasbeen proposed.1 It has been suggested that ininstances where the gingival sulcus is intact, the rootcan be sectioned, maintaining a long bevel andeliminating the entire fractured segment. A fibre-optic light source or the use of a dye are valuableaids in assessing the fracture lines.3 1 D e s p i t econsiderable loss of root length, provided plaquecontrol is adequate and the entire fracture iseliminated, these teeth with a reduced periodontiumcan still have a good long-term prognosis.1,50 Claimshave also been made for the successful conservativetreatment of vertical root fractures which originateapically but which do not involve the gingival sulcus.Root extrusion51 or intentional replantation in anextruded and/or rotated position are possible. It hasalso been suggested that if the fracture only involvesthe facial wall, and does not involve the gingivalsulcus, the fracture may be eliminated with thep r e p a r ation of a long amalgam restorat i o n .1 , 1 8 , 5 2

Vertucci49 treated a single tooth with an incompletebucco-lingual vertical fracture by removal of thebuccal segment, covering of the root canal fillingwith an amalgam restoration and treating theremaining root surfaces with 20 per cent citric acidsolution for five minutes. The tooth was consideredfunctional with no probable periodontal defects orradiographic evidence of disease at a three yearreview. The advantage in these procedures is that theoriginal root length is maintained. It may be reason-able to expect that the fracture could still propagateto the lingual wall. The placement of a long buccalrestoration may be indicated if resection of the toothroot in a coronal dimension would not leave thetooth with adequate root support. Obviously, anydetection of a lingual fracture would require bevel-ling of the root as described earlier. None of theabove procedures would be effective in the long termin the presence of a contaminated root filling. Thus,if such treatment is considered, re-root filling isindicated wherever possible.

A number of other case reports discussing treat-ment alternatives have been published. Takatsu etal.53 used orthodontic elastics to join the buccal andpalatal segments of a vertically fractured maxillarysecond molar which were then sealed with a photocured resin liner to allow the tooth to beendodontically treated and restored with a castcrown. The tooth remained in function for morethan three and a half years with a reduction inpocket depth. Sinai and Krat z4 8 d e m o n s t r at e dregeneration of bone and healing when the detachedroot segment, root canal filling and soft tissues weres u r gically removed. Howe ver, long-term follow-up wa sunfavourable due to deep pocketing and mobility.

An in vitro study54 proved CO2 and Nd:YAG laserto be an ineffective way to fuse fractured tooth roots.Scanning electron microscopy revealed heat - i n d u c e dfissures and cracks, areas of cementum breakdownand separation of cementum from underlyingdentine. Energy densities required to induce meltingwere considered excessive and damaging to pulptissue. At the present time, there does not seem to beany justification for the use of a laser to fusefractured portions of tooth together.

Conclusion

Many of the treatment options reported in thisreview have involved extensive procedures on smallnumbers of teeth, often with poor outcomes. Wheresuccessful outcomes have been claimed, the long-term prognosis has yet to be proven. All case reportspublished so far which describe a treatment rat i o n a l e ,do not include enough teeth to ascertain the efficacyof any procedure. There is room for further clinicalresearch on the treatment of teeth that are verticallyroot fractured. While there is no doubt that, withsome posterior teeth, treatment procedures whichsuccessfully remove the fractured fragmentscompletely (either by hemisection or rootamputation) can result in a long-term successfulresult, treatment of anterior teeth can at best beregarded as experimental. While it must beacknowledged that attempts to treat strategic teethin an effort to defer complicated or extensiverestructure treatment1 may be warranted, before anycomplex experimental treatment procedures areconsidered, the desirability for retention of the toothroot should be carefully weighed up againstextraction and replacement with a denture, bridge orimplant.

Acknowledgements

Particular thanks must be given to Dr John Maynefor use of illustrat i ve mat e rials in this paper.Contribution of cases by Drs Gil Shearer, RossPa rry and Grahame Brown is also gr at e f u l l yacknowledged.


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Address for correspondence/reprints:Brisbane Endodontic Research Group,

C/- Alex Moule,225 Wickham Terrace,

Brisbane, Queensland 4000.

diagnosis and management of teeth with vertical root fractures

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