VERTICAL ROOT FRACTURE

A longitudinally orientated complete or incomplete fracture initiated in the root at any level generally directed
bucco-lingually. By definition these fractures do not originate from the propagation of fractures on the crown.

Based on position:
Class 1: incomplete supraosseous as one terminating coronal to the alveolar crest not
creating a periodontal defect.
Class 2: Incomplete supraosseous fracture as one terminating at or slightly apical to the
alveolar crest creating a shallow osseous lesion.
Class 3: complete or incomplete intraosseous fracture resulting in the loss of periodontal attachment.

Based on separation of fragments:

1 Complete Fracture: where total separation is visible or fragments can be moved independently.
2 Incomplete Fracture: occur in the absence of visible separation.

Associated with endo treated teeth:

1. Vigorous and injudicious instrumentation of narrow canals.
2. Excess force during obturation, especially during lateral condensation.
3. Wedging effect of endo treated posts.
4. Corrosion and expansion of posts.
5. Pathologic features secondary to periodontics lesion.
6. Abutment teeth with unfavourable forces.
7. Pre-existing microcracks in radicular dentine (40% mx molars and canines have microcracks).

Associated with coronal restorations:

1. Excessive removal of tooth structure during cavity preparation causing weakening of cusps.
2. Delayed expansion of amalgam.
3. Excessive polymerisation shrinkage of composite resins.
4. Improper reproduction of occlusal anatomy causing deflection occlusal contacts.
5. Premature contacts and high occlusal loading.

Extremely variable based on position of fracture, tooth type, time after fracture and periodontal condition.
1. Swelling of the soft tissue and tenderness over the root.
2. Presence of a sinus tract close to attached gingiva, rather than the apical region. (13-35% of cases)
3. Deep, narrow, isolated perio pocket. Occur due to bacteria from oral cavity penetrating fracture. Generally
located on the B or L in the root convexity of tooth.
4. Repeated dislodgement of post/crown.
5. Sharp cracking sound at the time of condensation of GP or cementation of a post.
6. Bleeding during condensation and an apparent lack of resistance within the canal.

Patient history
o Pain or sensitivity adjacent to a given tooth.
o A history of investigations that revealed no cause.
o Often endo retreatment may have been carried out.
o Feeling of pressure.
Probing (localised deep pocket)
PA
CBCT on axial setting if sufficiently large > 0.15mm. AAE and AAOMFR do not recommend the use for dx.
Susceptible Teeth and Locations (can occur in any teeth)
Maxillary and Mandibular Premolars.
M root of mandibular molars.
MB roots of maxillary molars.
Mandibular incisors.

Early Signs
Pain or discomfort on affected side.
Sensitive on chewing dull nature as opposed to a sharp pain of that of cracked cusps or teeth.

Late Signs:
Destruction of alveolar bone.
o J shaped or Halo radiolucency

Signs can vary considerably.

1. Fracture Lines: proliferation of granulation tissue between the separated fragments often results in the
rapid movement away of the fragment away from the root.
2. Double Images: overlapping of fragments (when radiograph not parallel to tooth/fragment) may result in
double images of the external root surface. This effect is sometimes normal for teeth.
3. Space Beside a Root Filling: may appear as vertical space beside the root canal. If root filling is well
condensed but only close contact with one side of the canal, suspect a fracture.
4. Space Beside a Post: space between GP and post.
5. Radiopaque Signs: if occurs during obturation, cement may move into the crack space.
6. Patterns of Bone Loss: occurs in relation to crack location. B-L fracture appearance will be different to M-D.
7. Widening of PDL Space: widening around the whole length of the root.
8. Radiolucent Halo: M-D fractures. Localised periodontal destruction in otherwise healthy mouth.

Crucial - allowing the extraction of the tooth before extensive damage to the alveolar bone can occur. Important
when implants are a consideration for tooth replacement.

Multirooted tooth: hemisection or root resection may save the tooth.

Anterior tooth: prognosis is unfavourable with extraction the treatment of choice.
Prevention: is key. Removal of iatrogenic causes.

Use of CO2 and laser to fuse tooth roots.

Bonding the fractured segments with GIC and replanting the tooth in conjunction with an e-PTFE membrane.
Two stage surgical procedure of bonding with silver GIC placement of bone grafr and guided tissue
regeneration therapy.
Use of 4META/MMA-TBB resin through the root canals to bond fractured teeth.
Use of dual-cured adhesive resin cement is preferred for bonding the fractured fragment, as it had
controlled polymerisation and is easy to apply.
Pathways of the Pulp: Hargreaves, K. M., Berman, L. H., 2016