FRACTURE MECHANICS

QUESTIONS

10 marks

Diagnosis and management of vertical root fracture

Cracked tooth syndrome
Vertical root fractures

Classification of Longitudinal fractures (AAE 2008)

1. Craze lines
2. Fractured cusps
3. Cracked tooth
4. Split teeth, and
5. Vertical root fractures
FRACTURED/CRACKED CUSP

Cohen 11th ed

A cracked cusp is characterized by a crack between a cusp and the rest of the tooth structure, to the
extent of allowing microscopic flexure upon mastication.

• This crack typically does not involve the pulp.

• With time, the crack may propagate, eventually resulting in a fractured cusp

Etiology

- Extensive intracoronal restorations

- Other causes similar to cracked tooth

Clinical Manifestation

Early Manifestation

- Sharp pain upon chewing.

- Cracked cusps are often associated with extensive occlusal restorations, which may
undermine and weaken the cusp and predispose it to initiating or perpetuating a crack from
occlusal forces.
- Nevertheless, cracked cusps may also be present in intact teeth or teeth with smaller
restorations.

Late Manifestation

- With time, a crack may propagate and result in a fractured cusp.

 - If the fracture line occurs coronally to the periodontal ligament the fractured portion will
simply separate from the tooth. However, if the fracture line extends subgingivally, gingival
fibers or the periodontal ligament will often retain the fractured cusp.
- Initially, it may be possible to move the cusp by wedging a sharp explorer into the fracture
line, making the fractured cusp more visible. Often, from continued mastication, a localized
and more acute type of pain may emerge secondary to the movement of the fractured
fragment in the coronal PDL.
- The pulpal pain that is typical at an earlier stage and will typically resolve once a complete
fracture occurs

Diagnosis

- Affected tooth may not be sensitive to percussion

- Normal response to pulp vitality, but with time response may resemble a pulpitis
- A cracked cusp may be diagnosed, to a large extent, on the basis of the patient history.
- Diffuse, protracted pain not associated with caries induced pulpitis creates the suspicion of
tooth infraction or fracture
- To locate the affected tooth, a biting test should be performed using a Tooth Slooth. The
device is composed of a small pyramid with a flattened top that is placed on a selective cusp,
while the wider part of the device is applied to several opposing teeth while the patient
occludes. The application of these forces to a cracked cusp will generate a sharp pain, which
may occur upon pressure or release
- Magnification with loupes or an operating microscope can be helpful when looking for a
crack.
- If the tooth does not have an extensive intracoronal restoration, transillumination may also
assist in revealing the crack line.
- If the tooth has a large restoration, the removal of the restoration may facilitate the effective
use of this diagnostic tool. The light source should be intense but with small dimensions,it is
applied to the tooth at the area of the suspected cusp fracture, with the lights of the dental
unit, microscope, and room extinguished. The light penetrates the tooth structure up to the
crack, leaving the part beyond the crack relatively dark. However, when large intracoronal
restorations are present, this type of examination may be less effective.
- Once the crack propagates, resulting in a fractured cusp, the diagnosis becomes more
straightforward: the fractured cusp will either be missing or moved by wedging an explorer
into the fracture line

Treatment Planning

Cracked Cusp

• Treatment should consist of protecting the affected cusp from occlusal forces, both to prevent
pain while chewing and to prevent the propagation of the crack into a full fracture.
 • A full-coverage crown or onlay is recommended, although bonded composite restorations
have also been proposed.
• If the fracture plane extends apically into the root, the tooth will be potentially nonrestorable.
• Endodontic treatment is indicated only if signs and symptoms of pulpal pathosis are observed.
• In addition, if the removal of the cracked cusp and associated restoration will result in little or
no remaining coronal tooth structure, then elective root canal treatment may be necessary for
prosthetic reasons.
• When such a treatment plan is selected, one should also perform an occlusal reduction of the
tooth as soon as possible to remove the tooth from active occlusion.

Fractured Cusp

• The treatment of a fractured cusp depends on the amount of tooth structure remaining.
• If the missing part is limited in size, then the conservative restoration of a bonded composite
resin may be indicated to cover the exposed dentin.
• In contrast, when a larger fragment has fractured and is either removed or missing, a full
crown or an onlay may be necessary.

CRACKED TOOTH

A cracked tooth exhibits a crack that incompletely separates the tooth crown into two parts

In certain cases, the crack may extend into the root

Etiology

- Extensive intracoronal restoration

- Amalgam pins especially self threading and friction lock pins
- Masticatory forces are the main cause of cracked teeth.
- Thus, the dietary habit of chewing on coarse food and habits such as chewing ice has been
proposed as a contributing factor.
- Unexpected chewing of a hard object (e.g., a cherry pit or an unpopped corn kernel in
popcorn). Bruxism or clenching of the teeth as well as occlusal prematurities
- In certain cases, traumatic injuries, such as a severe upward blow to the mandible can also
cause a tooth crack or fracture.
- The occlusal forces applied by the first molars are as high as 90 kg,which, when fully applied
unexpectedly, may damage the tooth structure.
- However, in most cases, a tooth crack can be attributed to no specific cause other than normal
or excessive masticatory forces.
- Non carious lesions may also lead to weakening of tooth structure

Diagnosis (Ingle, 6th ed)

- Similar to cracked cusp – mainly depends on patient history

- Biting test - Various techniques have been recommended, such as biting on burlew wheels,
rubber wheels, cotton tip applicators, moist cotton rolls, and commercial biting applicators
such as Tooth Slooth and Fracfinder. Patient will complain pain on releasing pressure
- Use of the Tooth Slooth device may or may not provide as clear a result for a symmetrically
cracked tooth, as each of the parts of the tooth may be rather stable.
 - Asking the patient to chew on a cotton roll or on the tip of a cotton-tip applicator placed at a
particular site may reproduce the pain. Nevertheless this method may not indicate whether the
source is a maxillary or mandibular tooth and need further measures to pinpoint the involved
tooth.
- Cold test and EPT – response at lower threshold levels than seen in non-cracked tooth
- Percussion test – may be normal as periodontium is not involved
- Cameron has suggested the use of a thin sharp explorer to probe around the cervical
circumference of teeth suspected of having infractions, particularly in interproximal areas not
readily visible if the tooth crown has a large or full coverage restoration. Both the ‘‘click’’ of
the explorer tip encountering the crack and perhaps the patient’s response can provide a clue.
- Magnification
- Dyes, such as methylene blue or tincture of iodine, which are applied either to the outer
surface of the crown or to the dentin after the removal of an existing intracoronal restoration,
can be helpful for visualizing the crack.
- Transillumination
- Anesthetizing the suspected tooth, followed by asking the patient to chew again on the cotton
roll, may further confirm the diagnosis and finally differentiate the origin as a mandibular or
maxillary tooth.
- In case of pulpitis or necrosis, its difficult to diagnose

Radiographic findings

- No radiographic manifestations are present at these early stages, as the crack is microscopic
and runs in mesiodistal direction which is perpendicular to the x-ray beam.
- If the crack is present in the buccolingual direction, the fracture line ca be clearly visible in
the radiograph
- When pulp necrosis occurs, the radiographic manifestation may be an apical radiolucency,
which is undistinguishable from that of apical periodontitis.

Clinical manifestations

Variable signs and symptoms

With time, the patient may report that he or she used to have a sharp pain and now experiences great
sensitivity to cold stimuli; the patient may even report, at a later stage, that the pain has subsided.

Early manifestation

- Cracked teeth may have extensive restorations with a weakened crown, or they may have
minimal or no restorations.
- Typically run in the mesiodistal direction, often splitting the crown into the buccal and lingual
fragments.
- In the early stages, the tooth may be vital and painful to mastication.
- Sharp pain on mastication. This condition may persist for an extended period of time.
- A unique pain response to chewing experienced by many patients is the pain that occurs when
they release the pressure of biting, variously referred to as ‘‘rebound’’ or ‘‘relief’’ pain
- Pain on cold response also present
- The pain may be localized or referred to any tooth, maxillary or mandibular, on the same side
of the mouth.
- The affected tooth may or may not be sensitive to percussion
 - Pulp testing may be normal

Late Manifestation

- May include pulp involvement and eventually the loss of pulp vitality (mostly when crack
pass through the central fossa) due to bacterial penetration
- The sharp pain upon mastication that is typical of the early stage may disappear once pulp
vitality is lost.
- Moreover, apical periodontitis in an apparently intact molar may be a late manifestation of an
untreated case of a cracked tooth.
- A crack may propagate with time through the pulp chamber and into the root, resulting in a
complete fracture that separates the tooth into two parts, a condition termed split tooth

Mechanism of pain

- Ingle 6th ed
- Brannstrom has proposed that the masticatory pain is due to sudden movement of dentinal
fluid when the fractured tooth portions move independently, activating myelinated A-d fibers
in the pulp and creating a rapid, acute pain response.
- Stimulation of the A-d fibers does not require inflammation of pulp tissue, which explains
why chewing discomfort occurs in the very early stages of infraction and appears to be a
symptom common to all infractions, both cuspal infractions and those involving the pulp.
- Sutton also suggested that the occasional sharp, momentary lancinating masticatory pain was
due to bending and rubbing of dentin along fracture lines
-

Treatment Planning

• Patient should be informed that the prognosis is reduced and sometimes questionable.
• Protecting a tooth from the propagation of a crack and improving comfort while chewing are
the principal goals in the treatment of cracked teeth.
• Both goals can often be immediately achieved by placing an orthodontic band around the
tooth or by placing a provisional crown. These procedures allow the clinician to evaluate the
extent of pulp involvement by checking whether the pulpal symptoms subside in response to
the intervention.
• Protecting the tooth from further splitting forces by the placement of a permanent crown is
essential in these cases.
• Unfortunately, a crown alone is often not sufficient to resolve symptoms, and endodontic
treatment may be considered prior to the placement of the permanent crown, depending on the
pulpal symptoms. A root canal treatment followed by a permanent crown has the benefit of
immediately eliminating the long-lasting, painful symptoms as well as early protection from
occlusal forces that may cause propagation of a cracked tooth to become a split tooth.
• If a crack is found that reaches from the mesial wall, through the floor of the pulp chamber
and into the distal wall, then the prognosis for the tooth is poor, and extraction should be
considered

SPLIT TOOTH

If the crack is allowed to propagate longitudinally, the tooth will eventually fracture into two
fragments, resulting in a split tooth.
Involves both crown and root, extending to proximal surfaces

Clinical manifestation

- Similar to cracked tooth

- When this split occurs, the resulting parts of the tooth may be movable by wedging a sharp
explorer into the fissure.
- Later, more evident movement of the parts may be observed.
- The radiographic presentation at such a late stage may eventually develop into a diffuse
radiolucency surrounding the root.
- At this late stage, narrow isolated deep periodontal pockets may be present. However, such
pockets are typically located mesially or distally and, if adjacent teeth are present, they will be
difficult, if not impossible, to detect.

Diagnosis

Similar to cracked tooth

Wedging of a sharp explorer into the fracture line will provide a clear diagnosis of a split tooth

Treatment planning

• When the tooth is split either through its whole length or diagonally, extraction is typically
the only treatment option.
• However, if the fracture line is such that the split results in large and small segments, and if
the removal of the small fragment preserves enough tooth structure that is restorable, then
retention and restoration of the tooth may be considered

VERTICAL ROOT FRACTURE

A vertical root fracture (VRF) is a longitudinally oriented complete or incomplete fracture initiated in
the root at any level and is usually directed buccolingually and usually initiates at the apex and
propagates coronally– AAE

These types of fractures do not arise from the propagation of a fracture that originated in the crown –
differentiates from split tooth

Etiology

The etiology of VRFs is multifactorial.

It is likely that in the presence of one or an accumulation of more predisposing factors, the repeated
functional or parafunctional occlusal loads may eventually lead, over months or even years, to the
development of a VRF.

Predisposing factors

• Natural ones, such as the anatomy of the root, or

• Iatrogenic ones, such as the excessive forces during root canal instrumentation, excessive
tooth structure removal, or excessive obturation pressure.
Natural Predisposing Factors

Shape of Root Cross Section

• An oval cross section of the root, with a buccolingual diameter being larger than the
mesiodistal diameter. Other roots such as triangular, kidney shaped, ribbon shaped roots are
also affected
• These teeth include the maxillary and mandibular premolars, the mesial roots of the
mandibular molars, and the mandibular incisors.
• Finite element analysis clearly demonstrated strain concentration on the inner side of the
remaining dentin wall at the highest convexity point (i.e., the buccal and lingual sides of the
oval roots)
• this is the reason these roots fracture in a buccolingual direction and not mesiodistally,
although more tooth structure is removed from the mesial and distal aspects at the stage of
canal instrumentation and post space preparation.

Note the strain concentration on the inner side of the highest convexity of the remaining
dentin wall. Red and orange represent areas of higher strains than blue areas

Root curvature and root depressions in the mesial root of mandibular molars and the buccal root of
bifurcated maxillary premolars are anatomical entities that can predispose the roots to fracture and
perforation - ingle

Occlusal Factors

• Excessive occlusal loads or concentration of such loads may be another natural predisposing
factor.
• Load concentrations, such as those caused by occlusal prematurities in maxillary premolars,
and excessive occlusal forces, specifically in the case of mandibular second molars, are
examples.
• In combination with other natural and iatrogenic predisposing factors, excessive occlusal
loads may, over time, lead to VRFs.

Preexisting Microcracks

• Preexisting microcracks may be present in the radicular dentin, likely resulting from repeated
forces of mastication or occlusal parafunction.(parallel or perpendicular to the root canal
space in intact tooth)
• One of the studies have found these microcracks in 40% of intact maxillary incisors and
canines
• During intracanal procedures when dentin is removed, especially in the mesiodistal areas,
such cracks may be exposed (incomplete fractures or infractions), and then later may
propagate in buccal and/or lingual directions (complete fracture).
Iatrogenic Predisposing Factors

Root Canal Treatment

• VRFs mostly appear in endodontically treated teeth

• A common clinical speculation is that an endodontically treated tooth is more brittle and that
the dentin undergoes changes in collagen cross-linking after root canal treatment. However,
this has not been validated. Moisture loss in these teeth, is not a major etiological factor but
rather a predisposing one for fracture - ingle
• Although the physical characteristics of the dentin, as a material, may not be compromised by
endodontic treatment, the radicular dentin, as a structure, may be compromised by the
accumulative or combined effect of several natural or iatrogenic factors associated with the
endodontic treatment and the restoration of endodontically treated teeth. This may be the
reason for the often-reported association of VRF with endodontically treated teeth.

Excessive Root Canal Preparation

• In one study, cracks detected by transillumination were more frequent when the same teeth
were subjected to a gradually increasing endodontic canal preparation. (Wilcox LR. J Endod
1997)
• Enlargement of coronal third in root canal preparation and excessive tooth preparation for
post space leads to less dentinal walls
• To reduce the risk of VRFs, less invasive methods may be considered, such as minimally
invasive endodontic instrumentation

Microcracks Caused by Rotary Instrumentation

• Root canal preparation using nickel-titanium rotary and reciprocating files often results in
microcracks in the remaining radicular dentin.
• A finite element analysis by Kim et al reported that rotary files induce strain on the dentin, as
measured in the surface layers of the root dentin, which likely exceeds the elasticity of the
dentin, causing subsequent microcracks
• Additional stress, by either root obturation with lateral compaction or by retreatment that was
applied to roots that were previously instrumented with rotary files, caused some of the
microcracks to propagate and become through-and-through fractures that were
indistinguishable from VRF

Uneven Thickness of Remaining Dentin

• The instrumentation of root canals often results in uneven thickness of the remaining dentin,
particularly when curved canals are straightened by instrumentation.
• Uneven dentin thickness can also occur upon excessive instrumentation of the mesial roots of
the mandibular molars or first maxillary premolars, which may exhibit a distal or mesial
concavity, respectively, that is not detectable in a common planar, periapical radiograph.
These areas, which have been referred to as “danger zones,” may be characterized by a
decrease in the remaining dentin thickness in which the application of internal strain may
potentially lead to a fracture.
• The anatomic groove that is often found on the palatal side of the buccal root of maxillary
bifurcated premolars is another example of such a hidden danger zone
 • Lingual access, which is commonly used in incisors, may also result in a thinner buccal wall
in the apical area as compared with the lingual wall. This phenomenon may be especially
pronounced when thick, and thus rigid, instruments are used excessively.

The thicknesses of the remaining

buccal and lingual dentin were
similar

The thickness of the remaining

dentin was lower on the buccal side
than on the lingual side (uneven)
due to the lingual access and rigidity
of the instruments used.

Methods of Obturation

• Certain obturation techniques, such as lateral compaction, involve the application of internal
pressure with a spreader, which may cause strains and subsequent propagation of microcracks
into fractures across the full dentin thickness.
• Other obturation methods may create less pressure, such as thermoplasticized gutta-percha,
and may reduce the risk of VRFs

Type of Spreader Used

• The use of a more rigid and thick stainless-steel hand spreader may lead to increased strain in
the radicular dentin (wedging effect) and can result in an increased incidence of root fracture.
• The introduction of more flexible finger spreaders(NiTi spreaders), which have smaller
diameter, may greatly reduce such risks. This allow insertion with less force than stainless-
steel finger spreaders.
• The nickel titanium spreaders also allow a further reduction in the strain induced in the
radicular dentin during obturation compared to traditional stainless-steel finger spreaders

Post Design

• Post space preparation, selection of tapered posts, traumatic seating of the post creating
hydrostatic pressure, and expansion of posts due to corrosion, are additional iatrogenic causes
for VRF - ingle
• Post selection, design, and seating have a significant effect on the strain distribution in the
root.
• Excessively long or thick posts are considered a predisposing factor for VRFs
• The use of posts carries an inherent risk of root fracture, particularly if excessive sound dentin
is removed during preparation.
 • Posts should only be used when essential for core retention and should be avoided whenever a
sufficient coronal tooth structure is available for the secure retention of the crown.

Crown Design

• When considering endodontically treated teeth, crowns with a ferrule margin (i.e., supported
by a sound tooth structure all around and beyond the gingival margins of the core) provide
better strain distribution than similar restorations that are supported by the post and core
alone.
• This design may help to avoid yet another potential predisposing factor for VRFs.

Clinical Manifestations

Susceptible Teeth and VRF Location

- VRF are commonly associated with endodontically treated teeth with or without a post.
- Nevertheless, VRFs can also occur in teeth with no previous root canal treatment.
- The most susceptible sites and tooth groups are the maxillary and mandibular premolars, the
mesial roots of the mandibular molars, the mesiobuccal roots of the maxillary molars, and the
mandibular incisors. However, VRFs may occasionally occur in other teeth and roots as well.
- VRF may progress in the buccolingual direction in these teeth and roots, which are typically
narrow mesiodistally and wide buccolingually. However, VRFs may also propagate
diagonally, thus affecting the mesial or distal aspect of the root.
- VRFs may be initiated at any root level. They may be initiated at the apical part of the root
and propagate coronally. Nevertheless, certain VRFs originate at the coronal, cervical part of
the root and extend apically, and in other cases, a VRF may be initiated as a midroot fracture.
- It is commonly believed that VRFs begin as microcracks at the root canal surface of the
radicular dentin and gradually propagate outward until the full thickness of the radicular
dentin is fractured..

Early Manifestation

- In the early stages of a VRF, there may be pain or discomfort on the affected side of the tooth.
- In particular, the tooth may feel uncomfortable and sensitive upon chewing, although this pain
is often of a dull nature, as opposed to the sharp pain typical of a cracked cusp or tooth with a
vital pulp.
- As the fracture and subsequent infection progresses, swelling often occurs, and a sinus tract
may be present at a location more coronal than a sinus tract associated with a case of chronic
apical abscess
- Other symptoms like tooth mobility, periodontal abscess may also be present
- A deep, narrow, and isolated periodontal pocket may be associated with the root, which often
cannot be explained by, as it is inconsistent with, the surrounding periodontal examination.
This specific type of periodontal defect occurs secondary to the bony dehiscence caused by
the vertical root fracture. It is substantially different from the pockets caused by advanced
periodontitis

Late Manifestation

- A longstanding vertical root fracture is easier to detect.

 - The major destruction of the alveolar bone adjacent to the root has already occurred, allowing
the VRF to be more likely revealed in a periapical radiograph
- In addition, the pocket along 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 segments of the root may
also separate, resulting in a radiograph that clearly reveals an objective root fracture
- Typical bone loss associated with the vertical root fracture involves loss of alveolar bone
buccal to the affected root – Ingle
- Bone resorption pattern seen in VRF – buccal bony dehiscence have been seen in most cases.
In lingual aspect, bone resorbs into a shallow, rounded U-shaped defect because spongeous
bone is much thicker and resorbs away from the root, and only later extends laterally. – Ingle

Diagnosis

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 can occur.
- Early diagnosis is particularly important when implants are a potential part of the future
restorative procedure; when an extraction is performed at an early stage, the uncomplicated
placement of an implant is likely.
- When the tooth is extracted after extensive damage has already occurred, bone regeneration
procedures may be required, adding cost and time to the restoration procedure.
- 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.
- However, the combination of the following two factors makes the early diagnosis difficult:
a. many of the clinical symptoms associated with VRFs mimic apical periodontitis or
periodontal disease, and
b. the narrow and tight pocket associated with early stages of VRF is difficult to detect using
rigid probes. Consequently, a delay in the accurate diagnosis or a misdiagnosis of a VRF
may often occur.

Misdiagnosis of VRFs

- Certain cases of longstanding VRFs are so discernible that no dentist can miss the diagnosis
- However studies have shown that certain teeth that were extracted because of endodontic
failures or refractive periodontal pockets, it was realized only after extraction that in some of
them the actual cause was a VRF

VRF Pockets

- The deep pockets associated with periodontal disease develop as a result of the bacterial
biofilm that initially accumulates at the cervical areas of the tooth and the destructive host
response to these bacteria.
- The pockets associated with VRFs develop due to bacterial penetration into the fracture,
triggering a destructive host response that occurs in the periodontal ligament along the entire
length of the fracture. These bacteria may leak from an infected root canal; however, when
 the VRF extends to the cervically exposed root, the microbes in the fracture may also
originate from the oral cavity.
- In the early stages, the periodontal ligament is affected and destroyed along the longitudinal
opening of the fracture, initially with a limited resorption to the adjacent bone. This permits
the penetration of a periodontal probe.
- The pocket associated with a VRF is typically isolated and present only in a limited area
adjacent to the affected tooth (affects groups of teeth in pdl pockets)
- This pocket is often located at the buccal or lingual convexity of the tooth (mesial or distal in
pdl pockets)

Periodontal pockets are loose and allow

probing at various sites, (common in
proximal sites) whereas VRF pockets are
tight and more common on the buccal
or lingual sides

- In the early stages, the pocket is deep but has a narrow coronal opening (pdl pockets are wider
coronally and relatively loose). The insertion of a probe first requires the detection of the
coronal opening; often, light pressure is necessary for the insertion of the probe. Because the
pocket is narrow, probe insertion may result in the blanching of the surrounding tissue

Periodontal pockets (left) are wide

coronally, whereas VRF pockets
(right) are narrow and deep.

- Rigid metal periodontal probes may be ineffective in probing VRF pockets in the early stages
of a VRF. Given that the pocket is deep, narrow, and tight, the bulge of the tooth’s crown may
prevent the insertion of a metal probe into the pocket. A flexible probe should be used
instead, such as a probe available from Premier Dental Products (Plymouth or a similar
device.
- When a typical VRF pocket is located on the convex flank of the root on the buccal or lingual
side, it is likely that the root has a VRF. In contrast, when such a pocket is located at the
furcation of a molar, the pocket may indicate either a VRF or a sinus tract from an apical
abscess that found a point of least resistance at the furcation area.
- In cases with a furcation pocket, when a VRF diagnosis cannot be conclusively determined, a
positive healing response to the elimination of infection by initiating root canal retreatment
may differentiate between these two types of pathoses.
Coronally Located Sinus Tract

- Sinus tracts that are associated with a VRF pocket are often found in a more coronal position,
as the source is not from a periapical lesion (site of least bone resistance - apical part or jn of
attached gingiva and mucosa)
- if the sinus tract is located at the furcation of a molar, this observation does not necessarily
indicate a VRF, as periapical abscesses from a failing root canal treatment can also drain in
this coronal location.

Radiographic Features

- VRF can be detected radiographically only in 2 instances: a) when there is evidence of

separation of the root segments, usually accompanied by a large radiolucency surrounding the
bone between the roots that is actually inflammatory tissue separating the segments. b) when
a ‘‘hair-like’’ fracture line radiolucency extending longitudinally down the root can be seen -
ingle
- However, in the early stages, radiographic findings are unlikely because (1) the root canal
filling may obstruct the detection of the fracture, and (2) the bone destruction (which still has
limited mesiodistal dimensions) may be obstructed by the superimposed root structure.
- Therefore, two or three periapical radiographs should be exposed from different horizontal
angulations when a fracture is suspected
- In late stages, One of the most typical signs is the J-shaped or halo radiolucency, which is a
combination of periapical and periradicular radiolucency (i.e., bone loss apically and along
the side of the root, extending coronally)
-

Radiolucency in the Bone Along Root

- The type of periradicular radiolucency associated with a vertical root fracture represents a
substantial destruction of the cortical plate of the alveolar bone.
- In the case of a VRF in the buccolingual plane, often the bone resorption is limited at early
stages, and any associated radiolucency may be obscured by the superimposition of the root
- As the bone loss increases, the radiolucency becomes greater than the dimensions of the root,
allowing it to be detected more clearly in the above-mentioned manner.

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 (A, B). At later stages, when major damage has occurred to the
cortical plate (C), the bone defect may be large enough to extend beyond the silhouette of the root
(C, D) and appear as a radiolucent defect along the root
 - As the VRF progresses to an intermediate stage, radiographs taken at different horizontal
angulations may detect bone resorption, whereas a conventional orthoradial radiograph may
not.

A different horizontal angulation

reveals a radiolucent lesion along
the root

Radiograph of Empty Canal

- Because most VRFs are in the buccolingual plane, the radiopaque obturation often obstructs
the view of the hairline radiolucency of the fracture
- When a VRF is suspected, one may initiate root canal retreatment, removing the root
obturation, and taking radiographs at two or three different horizontal angulations.
- The detection of a hairline radiolucency may provide a more definitive diagnosis of a VR

Cone-Beam Computed Tomography in VRF Diagnosis

- Several studies suggested that the detection of early-stage VRFs by a CBCT scan set to an
axial view may be possible. Yet such detection may greatly depend on the resolution of the
machine (i.e., the voxel size).
- At a voxel size of 0.3 mm, the detection of early, unseparated VRFs is not reliable; however,
when smaller voxel sizes were used, the reliability greatly increased.
- Although the detection level of a fracture is thought to be twice the voxel size of CBCT
imaging, there is presently no literature available to support this theory.
- Therefore, given that the smallest voxel size currently available for a CBCT device is about
0.075 mm, CBCT imaging would not be able to visualize a root fracture unless the fracture
width was greater than 0.15 mm.
- It should also be noted that the intracanal presence of gutta-percha or a metal post often
causes artifacts that make it extremely difficult to differentiate a VRF from such artificial
lines.
- Although early VRFs may still be below the detection level of many CBCT machines, the
early destruction of the bone along the suspected fracture may be visible in the cancellous
bone (i.e., with an axial view) at relatively early stages, whereas this early bone destruction
would not be detectable in traditional planar, periapical radiographs; such bone resorption
may help to establish a VRF diagnosis
- With likely increased resolution in the near future, CBCT may become an important
diagnostic tool for the detection of VRFs.
- For the present, neither the most updated Joint Position Statement of the American
Association of Endodontists and American Academy of Oral and Maxillofacial Radiology
 (2010), nor the European Society of Endodontology position statement on the use of CBCT in
endodontics (2014) recommend the use of CBCT for diagnosis of VRF.

Exploratory Surgery

- When clinical and radiographic evaluations are equivocal in detecting a suspected vertical
root fracture, exploratory surgery may be indicated.
- When a full-thickness flap is raised and the granulation tissue is removed, a VRF may often
be directly visualized
- The bone resorption pattern associated with a VRF is mostly seen as a bony dehiscence, with
the greater bone destruction being present on the buccal cortical plate located over the
offending root. In a small percentage of the cases, fenestration can also be seen.
- Furthermore, it has been shown that the longer a VRF-related infection persists, the greater
the resulting periradicular bone destruction.

Treatment Planning

- Prevention is the key to managing vertical root fractures.

- There are many predisposing factors and iatrogenic causes of these fractures, all of which
should be minimized as much as clinically possible.
- Comprehensive clinical, radiographic, and periodontal examination is imperative when
evaluating any tooth that is planned for endodontic treatment or retreatment. A flexible
periodontal probe is mandatory in such examinations.
- 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 possibly compromise the placement of an endosseous implant.
- Thus the measures and means that may allow the dentist to make the diagnosis at early stages
are important.
- 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