Vertical root fracture

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

AIM

This study aimed to identify clinical and radiographic characteristics of teeth with longitudinal fractures to assist in the diagnosis and differentiation between cracked teeth and teeth with vertical root fracture (VRF).

METHODS

Ninety-five patients (95 teeth) diagnosed with a longitudinal fracture (only cracked teeth or VRF) through clinical visualization of the fracture line were included in this study. Clinical and radiographic data were collected from the patients' record to identify the characteristics associated with each condition. Fifty-four patients (54 teeth) had full radiographic [periapical radiograph (PA) and cone-beam computed tomography scan (CBCT)] and clinical findings (probing depths and clinical images of the fracture line). PA and CBCT images were evaluated by two independent examiners to identify the different patterns of bone loss associated with these teeth (no defect, angular defect, J-shaped defect, combined defect). Cohen Kappa analysis was used to compare the results between the two examiners and between the findings of the PA and the CBCT. Pearson's chi-square analysis, fisher exact test, and Adjusted Bonferroni post Hoc testing were used to establish an association between the type and extension of the longitudinal fracture with the probing depth, the CBCT pattern of bony defects, and the presence/absence of the buccal plate. Also, to compare the clinical and radiographic characteristics of cracked teeth and teeth with VRF (P<0.05).

RESULTS

CBCT images had 4.4 times the odds of detecting bony defects suggestive of longitudinal fractures compared to PA. Teeth with VRF were more associated with indirect restorations, deep probing (>6mm), absence of the cortical plate and a J-shaped defect on the CBCT (P<0.05). Cracked teeth, on the other hand, were associated with direct restorations, shallow probing (<6mm), intact cortical plate, and the presence of an angular defect on the CBCT (P<0.001). There was a significant correlation between a radicular extension of the fracture line and deep probing, as well as J-shaped defects (P<0.05).

CONCLUSION

Patterns of bone loss on the CBCT can likely differentiate between cracked teeth and teeth with VRF. The presence of an angular defect may suggest the presence of a crack in the tooth prior to intervention. J-shaped defects, deep probing (>6mm), and loss of the cortical plate are likely suggestive of VRF.

Vertical Root Fracture in Non-Endodontically and Endodontically Treated Teeth: Current Understanding and Future Challenge

A vertical root fracture (VRF) is a complex complication that usually leads to tooth extraction. The aim of this article is to review the prevalence, demography, distribution, diagnostic methods, etiology and predisposing factors, clinical features, radiographic characteristics and treatment strategies of VRFs in non-endodontically treated teeth (VRFNETT) and endodontically treated teeth (VRFETT). Search terms for each subject related to VRFNETT and VRFETT were entered into MEDLINE, PubMed and Google Scholar. Systematic reviews, retrospective cohort studies, demographic research, clinical studies, case reports and case series were reviewed. Most of the VRFs were found in patients older than 40 years old. Older populations were discovered in the non-endodontically treated VRF group when compared to the endodontically treated VRF group. Male patients were found at a greater prevalence than females in the non-endodontically treated VRF group. The initial occurrence of a VRF may accompany radiolucent lines within the root canal, unusual space between the canal wall and intracanal material, a widening of the PDL space along the periradicular surfaces, angular bony destruction, step-like bone defects, V-shaped diffuse bone defects, or root resorptions corresponding to the fracture line before the clear separation of the fractured fragment. The indicative clinical and radiographic signs of VRF included a coronally positioned sinus tract, deep-narrow periodontal defects, the displacement of a fractured fragment, periradicular radiolucent halos and the widening of the root canal space. Interestingly, VRFNETT are more often observed in the Chinese population. Some patients with multiple VRFs were observed, suggesting possible predisposing factors in genetics and tooth development. The management of a VRF usually involves a multidisciplinary approach. The common distribution and features of VRFNETT and VRFETT were elucidated to facilitate recognition and diagnosis. Besides extraction, variable therapeutic schemes, such as the repair of the VRF, root amputation and others reported in earlier literature, are available. A long-term prognosis study of the various therapeutic strategies is needed.

Differentiating spontaneous vertical root fracture in endodontically treated tooth

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.

Disappearance of Intracanal Medication: A Preliminary Clinical Finding from Retrospective Review of Teeth with Vertical Root Fracture

Objective:

The purpose of this article was to report the finding of the disappearance of intracanal medication as a supporting evidence of vertical root fracture (VRF) through non-surgical intervention.

Methods:

A retrospective review of the dental records of patients seen by an endodontist in a private endodontic office from September 2013 to September 2016 was conducted by the same endodontist. Cases that met the inclusion and exclusion criteria were assigned as the subjects of this study, and data were extracted from their clinical and radiographic records. Patient’s demographic features, pre-operative signs and symptoms, details of rendered clinical procedures, follow-up visits, clinical and radiographic findings were recorded. Seventeen teeth for which non-surgical exploratory re-treatment was initiated were included in this study. Calcium hydroxide-based intracanal medication was placed for 2-4 weeks. Obturation of the root canals was performed if the tooth showed improvement of clinical signs and symptoms. If not, a cone-beam computed tomography (CBCT) scan was proposed to the patient to rule out VRF.

Results:

After the non-surgical re-treatment was initiated, 13 teeth showed improvement of clinical symptoms and the re-treatment was therefore completed. The remaining 4 teeth presented with unresolved clinical presentations (deep pocket, presence of sinus tract and/or tender to percussion and palpation). Four teeth showed partial disappearance of intracanal medication where VRF was confirmed using CBCT in 3 teeth and with a conventional periapical (PA) radiograph in 1 tooth.

Conclusion:

The disappearance of intracanal medication during non-surgical intervention was often associated with VRF. Thus, this feature may serve as an aid in diagnosing VRF.

Replacement of vertically root-fractured endodontically treated teeth with immediate implants in conjunction with a synthetic bone cement

PURPOSE

The purpose of this prospective study was to evaluate the clinical outcome of implants immediately placed into fresh extraction sockets for the replacement of endodontically treated teeth with signs of vertical root fracture.

MATERIAL

Sixteen partially edentulous patients, with 1 tooth scheduled for extraction and showing clinical signs and symptoms and/or radiological evidence of vertical root fracture, were included in the study. Sixteen transmucosal implants were installed immediately after extraction and careful debridement. The gap between the implant surface and the socket walls was filled using synthetic bone grafting cement. Prosthetic phase occurred 3 to 4 months after surgery. Implant success and survival and radiographic bone loss were evaluated after 1 year of function. Patient satisfaction for mastication function, phonetics, and aesthetics was also assessed by means of a questionnaire.

RESULTS

No implant failure occurred. The overall implant success and survival was 100% at 1 year. The mean follow-up was 13.5 months. All prostheses were successful. Periimplant bone loss after 1 year averaged 0.48 ± 0.20 mm. All patients reported full satisfaction for mastication function, phonetics, and aesthetics.

CONCLUSIONS

The use of a synthetic bone grafting cement in combination with immediate implant placement procedure can be considered a safe, effective, and predictable treatment option for the rehabilitation of fresh postextraction sockets.

A proposal for classification of tooth fractures based on treatment need

Accuracy in defining a disease makes it easier to study and understand. Similarly, with injuries to the teeth, a comprehensive classification is an aid to correct diagnosis and treatment planning. A thorough review of various classifications of tooth fractures shows that, despite an emphasis on traumatic dental injuries, a consensus needs to be arrived at, especially among clinicians and general/family dentists. The ideal classification would be applicable to both primary and permanent dentition, based on tooth fractures in both the horizontal and vertical planes, encompassing all possible sites, easy to comprehend, communicable amongst health professionals and clinically relevant. With recent improvements in conservative techniques, it is now clinically possible to preserve natural teeth even if they have been horizontally or vertically fractured, and thus an in-depth understanding and knowledge of tooth fractures, together with a simplified classification, is now more than ever essential.

An inexpensive device for transillumination

Patients with cracked-tooth syndrome often present with a chief complaint of vague pains while eating that they cannot localize, making the diagnosis difficult. Frequently practitioners are unable to discover the cause of their symptoms, so treatment is delayed, which can result in apical propagation of the crack, leading to unrestorable vertical root fracture. Transillumination is a valuable aid to diagnosis, but suitable diagnostic lights are difficult to obtain, most being cumbersome and expensive. A portable inspection/bore light that serves as an ideal device for transillumination is available for approximately $10.

Diagnosis and management of teeth with vertical root fractures

Vertical fractures in teeth can present difficulties in diagnosis. There are, however, many specific clinical and radiographical signs which, when present, can alert clinicians to the existence of a fracture. In this review, the diagnosis of vertical root fractures is discussed in detail, and examples are presented of clinical and radiographic signs associated with these fractured teeth. Treatment alternatives are discussed for both posterior and anterior teeth.

Vertical root fracture in nonendodontically treated teeth--a clinical report of 64 cases in Chinese patients

Vertical root fractures (VRFs) in teeth without endodontic treatment are uncommon. A clinical study was done on 64 cases of VRFs in 61 Chinese patients to define better the clinical characteristics, diagnostic signs, and possible causes. Results showed that fractures occurred most often in first molars of patients between 40 and 69 yr of age, and the incidence was two times higher in males than in females. Flat roots with smaller mesiodistal diameters were more prone to fracture. The majority (79%) of patients had intact dentition with less than four teeth missing. Fractured teeth were frequently attrited with no restorations. VRFs may result from excessive or repetitive masticatory force due to damaging chewing habits exerted on flat roots of smaller mesiodistal diameter. Nonendodontic VRFs seem to occur more frequently than earlier believed and may represent an underdiagnosed clinical entity deserving of our attention.

Patterns of periodontal destruction associated with incomplete root fractures

OBJECTIVES

To clarify the differential radiographic diagnostics of teeth with incomplete root fracture.

METHODS

Information on 88 teeth with either a vertical root fracture without displacement of the fractured fragments (n = 22), a vertical periodontal defect (n = 22), a periodontal-endodontic lesion (n = 22) or an endodontic-periapical lesion (n = 22) was collected retrospectively from the patients' records.

RESULTS

Significant differences in the mean probing pocket depths were found between each of the four groups of lesions. Teeth with root fractures demonstrated smaller mean probing pocket depths than those with either periodontal or periodontal-endodontic lesions. Radiographic bone loss was significantly greater in teeth with periodontal and periodontal-endodontic lesions when compared with those with fractures. In teeth with vertical root fractures, there was no correlation between the probing depth and the radiographic bone loss (r = 0.01). The correlation coefficient between the greatest probing depth and alveolar bone loss was r = -0.16 in the fractured teeth, with higher values for the other three groups of lesions. 86.4% of the teeth with fractures had a complete root canal filling. Posts were present in 22.7% of the fractured teeth and in 13% of those with an endodontic periapical lesion. 91% of the teeth with vertical fractures were crowned or fixed-bridge abutments. Only 5% of the fractured teeth had no evidence of periapical bone changes.

CONCLUSIONS

Incomplete root fractures mainly involve teeth which have undergone successful endodontic treatment. An isolated pocket on one aspect of a suspected tooth is reliably diagnostic for a root fracture.

Vertical root fracture and root distortion: effect of spreader design

The incidence of vertical root fractures and the amount of root distortion created during lateral condensation of gutta-percha with either D11 spreaders or B-finger pluggers were evaluated in vitro. Fifty-five extracted human, single-rooted teeth were instrumented using the step-back flare technique. Ten teeth served as positive controls (obturation to the point of fracture) and five teeth as negative controls (prepared but not obturated). Strain gauges were attached to the root surfaces. In the experimental group, 20 teeth were obturated using a D11 spreader and 20 with a B-finger plugger. Recordings were made of root distortion (expansion) created during obturation. Then, after sectioning the teeth, root surfaces of obturated samples were examined for fractures under the scanning electron microscope. Only the more tapered spreader, the D11, produced vertical root fractures, although very few in number. Also, the D11 spreader caused greater root distortion than did the B-finger plugger.

Preserving the maxillary anterior alveolar ridge contour using hydroxylapatite

Although this procedure is not necessarily indicated for all patients, it is an alternative to subsequent soft tissue, osseous, or synthetic grafting procedures. The combination of extraction, hydroxylapatite graft, and acid-etched replacement is an alternative treatment that reduces patient treatment time.

Resolution of fused vertical molar root bridge abutment fracture: report of case

Vertical root fractures involving apparently successful endodontic treatment with gutta-percha may be caused by hairline root fractures that existed before root canal therapy was performed. A root stripping technique was used to restore a strategically located tooth in a 70-year-old patient. Bruxism with occlusal trauma is proposed as a significant cause of hairline vertical root fractures. The commonly held view that these fractures arise from root canal condensation techniques appears more circumstantial than factual.