A short presentation dealing with the Enigma of vertical root fractures & their management

1. VERTICAL ROOT FRACTURES – AN
UPDATE REVIEW
JOURNAL OF
RESTORATIVE
DENTISTRY
By Dr.Mettina
IInd MDS
Conservative dentistry
& Endodontics

2. INTRODUCTION
• Vertical root fractures are the most common cause of tooth loss.
• Multifactorial etiology.
• Show elusive clinical signs- difficult to detect.
• In this review, the etiology, diagnosis, prevention & management of root fractures is discussed.

3. DEFINITION
• “A true vertical root fracture is defined as a complete or incomplete fracture initiated from the
root at any level, usually directed buccolingually.” It starts from an internal dentinal crack,
develops over time due to masticatory forces & occlusal loads.

4. CLASSIFICATION- LUEBKE’S
Based on fragment
separation
Complete
fracture
Incomplete
fracture
Position of
alveolar crest
Intra osseous
fractures
Supra osseous
fractures

5. PREDISPOSITION
Teeth with flat/thin
roots (mesio-distal
diameter)
Oval bucco-lingual
diameter Premolars,
mandibular incisors
Mesiobuccal roots of
maxillary molars
Mesial roots of
mandibular molars

6. ETIOLOGY
Root
anatomy
Moisture
loss/cracks
Change in
architecture
of tooth
Biochemical
properties of
root dentin
Loss of
healthy tooth
substance
ENDODONTICALLY
TREATED TEETH

7. ETIOLOGY
Iatrogenic
causes
Excessive
cutting
Threaded
/tapered
posts
Wedging
forces–lateral
compaction
Non-RCT
treated teeth
Chewing
habits
Tight cusp
fossa
relations
Poor fit of
intracoronal
restoration

8. PATHOGENESIS
As the vertical root fracture progresses to the
periodontal ligament, soft tissue growth into
the fracture space increases the separation of
the root segments.
On communication with the oral cavity
through the gingival sulcus, bacteria obtain
access to the fracture area, inflammation is
induced in the periodontal ligament.
Along the fracture line , periodontal ligament
disintegrates, followed by bone loss.
The bone loss is progressive in the thin
buccal bone plate.

9. CLINICAL SIGNS & SYMPTOMS
Swelling
Sinus tract
Periodontal pocket

10. DIAGNOSIS
Diagnosis of VRF is based on
• History
• Clinical diagnostic tests
• Radiographic examination
• Endodontic status after healing has occurred
• Lasers

11. HISTORY
• History of trauma
• History of pain, swelling, presence of sinus tract, mobility, restoration dislodgement
• A thorough clinical examination is to be done
• Age, gender, history of previous dental treatment etc is to be obtained.

12. CLINICAL DIAGNOSTIC TESTS
Direct visualization - a probe can be used
Staining
Pulp testing
Bite test
Transillumination test
Tracing the sinus tract

14. RADIOGRAPHIC EXAMINATION
• Radiolucent fracture lines
• Radiolucent line along GP/post.
• Double images
Radiolucent signs
• Extrusion of filling into fracture space
• Dislodgement of retrograde filling
Radiopaque signs

16. PATTERN OF BONE LOSS
• Widening of periodontal ligament space.
• Radiolucent Halos
• Step like bone defects
• Unilateral horizontal bone loss
• Unexplained furcation bone loss
• V shaped diffuse bone loss

17. OTHER CONSIDERATIONS
• Radiologic signs – unreliable & non- specific.
• Only detectable at late stages as a sequelae of Chronic inflammation.
• Mesiodistally oriented fractures – not visualised.
• 90% of teeth exhibited Bone dehiscence
• 10% - Fenestration
• Computed tomography- is more reliable as the plane of axial segments is perpendicular to fracture
line.
• CBCT

18. DIAGNOSIS
• Endodontic status after healing has occurred- sudden deterioration of previously
asymptomatic RCT treated tooth.
• LASER in diagnosis- DIAGNOdent with methylene blue.
• Surgical exploration- gentle soft tissue retraction

19. PREVENTION
• Avoid excessive cutting of Dentin during
preparation.
• Overpreparation of canal for Dowel/ choice
of ill-fitting Dowel.
• Nightguards to be used in patients with
bruxism.
• Early reinforcement by castings with cusp
coverage.
• Internal splinting with adhesive ceramic
restorations
• Fiber reinforced resin based composite posts
with same modulus of elasticity as dentin.

20. MANAGEMENT
• In Multi- rooted teeth with vertical root fracture, resecting the root/ Hemisection can save the
tooth.
• Single rooted teeth with VRF- Poor prognosis
• Extraction & replantation after bonding-
• Atraumatic extraction
Bonding of fragments
180 degree rotation
Replantation

21. MANAGEMENT
• Application of Bio- resorbable membrane to reinforce periodontal healing- prevents ankylosis.
• Use of composite resin, MTA, silver glass ionomer cement to bond the fracture line.
• Calcium hydroxide to promote tissue repair & resolve osseous defect.
• Bonding the tooth with silver GIC , placement of bone graft material and GTR therapy.
• Combined technique of Glass fiber post and composite.

22. MANAGEMENT
• Use of 4-META/MMA-TBB resin through the root canals to
bond the segments.
• Use of dual cured adhesive resin cement.
• Use of orthodontic elastics to bond the buccal & palatal
segments followed by the use of photocured resin liner.
• Fitting of orthodontic bands before endodontic treatment to
prevent fracture.
• Use of CO2 & Nd: YAG laser to fuse the tooth fragments.

23. DISCUSSION
• CBCT is valuable in the diagnosis of root fracture.
• The necessity of a post in endodontically treated teeth should be
carefully evauated.
-Posts not needed in Maxillary incisors with only access cavities.
-For posterior teeth with sufficient tooth structure remaining posts
are not needed.
-Post and core may prevent coronal fractures in thin tooth structures.
-Threaded posts cause highest strain, use should be restricted.

24. DISCUSSION
• Complete coverage restorations are needed in posterior RCT Treated teeth.
• More flexible & less tapered finger spreaders are safer.
• Smear layer should be removed in case of fiber posts.
• Resin based sealers like AH 26 can be used to strengthen the root canal.
• Over flared root canals can be reinforced by MTA.

25. CASE REPORT

26. CONCLUSION
• Vertical root fractures are an enigma & further research is needed to find more effective
methods for management of Vertical root fractures.