Vertical root fracture: Factors related to identification

doi:10.1016/j.adaj.2016.11.014

The Journal of the American Dental Association

Volume 148, Issue 2, February 2017, Pages 100-105

https://doi.org/10.1016/j.adaj.2016.11.014 Get rights and content

Abstract

Background

Vertical root fracture (VRF) requires root removal. Diagnostics for proper identification are critical. The author conducted a study to relate subjective, objective, and radiographic findings for VRF identification. They noted visual changes of root and overlying bone patterns after flap reflection.

Methods

The author examined a case series of roots with suspected VRF after flap reflection and root or root-end removal; 42 roots were identified with a fracture. Before reflection, the author obtained diagnostic and periapical radiographic data that included symptoms, soft-tissue changes, percussion, mobility, probing patterns, and radiographic findings. After flap reflection, the author evaluated bony changes and root surfaces. VRF was visually confirmed after tooth or root removal.

Results

Signs and symptoms diagnostic of VRF were inconsistent. All patients had endodontic therapy, many with posts, and for all patients, the pain was none to mild. In addition, the author found a history or presence of swelling (77%) or sinus tract (31%), that probing patterns differed (narrow-rectangular 66%), and that there was no defect in some patients (21%). Radiographic patterns varied from no change to extensive bone loss, and mobility ranged from none (55%) to slight or moderate (45%). Flap reflection revealed a “punched-out” bony lesion with granulomatous tissue (100%), and patterns were fenestration (21%) or dehiscence (79%). A fracture was visible on roots or resected root ends.

Conclusions

The author found no consistent signs, symptoms, or radiographic changes of VRF. Flap reflection was found to be predictably useful; fractured roots had bony defects filled with granulomatous tissue.

Practical Implications

VRF may be suspected from clinical findings; however, flap reflection is usually required for identification. Characteristic bony pattern and root visualization reveals the fracture, although root-end resection and examination is occasionally required.

Section snippets

Methods

The study was approved by the institutional review board of the Medical College of Georgia School of Dentistry, Augusta, GA. I assured the board and the patients that no unnecessary procedure would be performed when gathering the data. All patients gave consent to participate, and I guaranteed that their identities would be confidential. They further gave consent that the teeth could be used in a companion histologic evaluation.¹

The process of selection was as follows. I subjected all patients

Results

All VRFs had received endodontic therapy; many also contained a post. Overall, the only definitive mode of identifying a VRF required flap reflection and visualization of bone and root. All fractured roots had an overlying, facial, “punched-out” bony lesion, filled with granulomatous, inflammatory tissue (Figure 1, Figure 2, Figure 3). I was not as readily able to see all the fracture lines on root surfaces; the balance of fracture lines were seen after root-end resection.

My findings from other

Discussion

The most important conclusion from my case series study was that the usual noninvasive (without flap reflection) diagnostic findings, tests, and periapical radiographs—alone or in combination—were not reliable indicators of a VRF. Only direct visualization of bone and root after flap reflection gave proof. The bony defect was a consistent finding, although with variation, as shown in Figure 4. Because these findings are of a case series, the findings are not necessarily indicative of what would

Conclusions

In this case series, I investigated 42 teeth with demonstrated VRF. The aim of the study was to relate subjective and objective probing and radiographic findings to the identification of the VRF. Also determined after flap reflection were visual changes (fracture lines) on the roots, and changes of the overlying alveolar bone. The most important findings were that there were no significant, consistent signs, symptoms, probing patterns, or radiographic changes that were conclusively diagnostic.

Dr. Walton is a professor emeritus, Department of Endodontics, College of Dentistry, University of Iowa, Iowa City, 801 Newton Rd., IA 52242.

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Cited by (39)

Radiographic Criteria for Differential Diagnosis Between Vertical Root Fracture and Apical Periodontitis in Single-Rooted Endodontically Treated Premolars Using Cone-Beam Computed Tomography
2024, Journal of Endodontics
This study explores the differences between the patterns of bone defects associated with vertical root fracture (VRF) and apical periodontitis (AP) in single-rooted endodontically treated premolars (SRETPs) based on cone-beam computed tomography (CBCT) data.
Eighty-four SRETPs were extracted and categorized into the VRF and AP groups. On preoperative CBCT images, the location of bone defects according to the root thirds in buccolingual and mesiodistal directions across the study groups were compared.
The majority of bone defects in the VRF group were longitudinal and combined, involving more than one root thirds in buccolingual and mesiodistal directions simultaneously. A uniform approach to comparing bone defects using the sites of periradicular area with bone loss as a comparison unit was developed. In the VRF group, bone loss sites in the middle and coronal thirds were detected more often and were located mainly buccolingually compared with the AP group (P < .001).
Bone defects in the middle or middle and coronal root thirds in the buccolingual direction may be potential radiographic signs useful in differentiating between VRF and AP in SRETPs. The introduction of the uniform approach to assessment of bone loss patterns will give practitioners a single simple tool and improve the quality of endodontic treatment.
Comparison of Dentin Microstructure and Its Correlation to the Direction of Fracture Line in Mandibular Molars of Young and Older Individuals: In Vitro Study
2023, Journal of Endodontics
The aim of the study was to assess the presence and extent of sclerotic dentin and to study its impact on the direction of fracture lines in extracted mandibular first molars of young (20–44 years) and older age groups (45 and older).
Extracted permanent mandibular first molars were collected along with the related demographic details. A total of 40 teeth were included in this study, 20 each from young age group (YA group) (20–44 years) and older age group (OA group) (45–70 years). All molars were decoronated, and the sectioned mesial roots were embedded in acrylic blocks. They were subjected to vertical force in a universal testing machine. Fractured roots were then examined under the stereomicroscope at ×8 magnification to determine the direction and pattern of the fracture line. The roots were then sectioned and evaluated at ×10 and ×20 magnification to assess the dentin microstructure and its correlation with the direction of the fracture line. Statistical analysis was done by using χ² test (P < .05).
A greater incidence and degree of sclerotic dentin were found in the OA group as compared with the YA group, which was statistically significant. The sclerotic dentin was distributed predominantly mesiodistally and the fracture line propagated buccolingually in both young and older groups, which was statistically significant (P < .05).
The presence of sclerotic dentin mesiodistally may impede crack propagation in this direction for both young and older age groups, causing the fracture line to extend buccolingually in coronal third of the root.
Risk Factors for and Clinical Presentations Indicative of Vertical Root Fracture in Endodontically Treated Teeth: A Systematic Review and Meta-analysis
2023, Journal of Endodontics
The aim of this study was to identify specific clinical signs or symptoms and potential risk factors which are most likely associated with the presence of a vertical root fracture (VRF) in endodontically treated teeth (ETT).
Electronic databases (MEDLINE via PubMed, EMBASE via Ovid, Scopus, and Web of Science) were searched by 2 reviewers in October 2022 for clinical studies, in which at least either the clinical presentation or potential risk factors associated with a VRF were assessed. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of odds ratios (ORs) were performed separately for several signs or symptoms and risk factors.
Fourteen sources reporting on 2877 teeth (489 with VRF and 2388 without VRF) were included in the meta-analyses. Regarding the clinical presentation, the presence of sinus tracts (OR = 4.87; 95% confidence interval [CI], 1.58–15.0), increased periodontal probing depths (OR = 13.24; 95% CI, 5.44–32.22), swelling/abscess (OR = 2.86; 95% CI, 1.74–4.70), and tenderness to percussion (OR = 1.76; 95% CI, 1.18–2.61) were significantly associated with the presence of a VRF (P_adj. value < .05). None of the assessed risk factors (sex, type of teeth, tooth location, posts, indirect restoration, and apical extension of the root canal filling) were found to be significantly associated with the presence of a VRF (P_adj. value > .05).
Four clinical presentations were identified to be the most significant signs or symptoms for a VRF in ETT: presence of sinus tracts, increased probing depths, swelling/abscess, and tenderness to percussion. None of the assessed risk factors pointed out to be significantly associated with a VRF. Registration: CRD42022354108 (PROSPERO).
Sensitivity and Specificity of MRI versus CBCT to Detect Vertical Root Fractures Using MicroCT as a Reference Standard
2023, Journal of Endodontics
Vertical root fracture (VRF) in root-canal–treated teeth frequently results in tooth loss, partly because VRFs are difficult to diagnose and when detected the fracture is often beyond the point of preservation with surgical intervention. Nonionizing magnetic resonance imaging (MRI) has demonstrated the ability to detect small VRFs, but it is unknown how its diagnostic capabilities compare with the current imaging standard for VRF detection, cone-beam computed tomography (CBCT). This investigation aimed to compare the sensitivity and specificity between MRI and CBCT for detecting VRF, using micro-computed tomography (microCT) as a reference.
A total of 120 extracted human tooth roots were root canal treated using common techniques, and VRFs were mechanically induced in a proportion. Samples were imaged using MRI, CBCT, and microCT. Axial MRI and CBCT images were examined by 3 board-certified endodontists, who evaluated VRF status (yes/no) and gave a confidence assessment for that decision, from which a receiver operating characteristic curve was generated. Intra- and inter-rater reliability were calculated, sensitivity and specificity, and area under the curve.
Intra-rater reliability was 0.29–0.48 for MRI and 0.30–0.44 for CBCT. Inter-rater reliability for MRI was 0.37 and for CBCT 0.49. Sensitivity was 0.66 (95% confidence interval [CI], 0.53–0.78) and 0.58 (95% CI, 0.45–0.70), and specificity 0.72 (95% CI, 0.58–0.83) and 0.87 (95% CI, 0.75–0.95) for MRI and CBCT, respectively. Area under the curve was 0.74 (95% CI, 0.65–0.83) for MRI and 0.75 (95% CI, 0.66–0.84) for CBCT.
There was no significant difference in sensitivity or specificity between MRI and CBCT in detecting VRF, despite the early-stage development of MRI.
Survival analysis of root-resected molars from 1 to 13.4 years: A retrospective cohort study
2023, Journal of Prosthetic Dentistry
While root resective therapy may extend the longevity of a molar, data on patient selection and outcomes of root resection are scarce.
The purpose of this retrospective cohort study was to analyze the survival of root-resected molars and investigate factors affecting the decision and outcomes of the therapy.
Patient- and tooth-related data from participants who had received root resection between 1999 and 2022 were collected. Cox regression was used to build predictive models for time-to-tooth loss based on predictors—initial diagnoses (carious, endodontic, periodontal, or endodontic-periodontal lesions), the presence of a complete-coverage crown, and the location of the tooth in the arch (P<.001).
Of 60 teeth, all from different participants, 31 molars were resected because of endodontic lesions. The failure rate was 35% with 21 teeth extracted. At 5 years, the survival probability was 0.58, considering all predictors. The survival of molars resected because of carious or endodontic lesions was significantly lower than those because of periodontal or endodontic-periodontal lesions (P<.05). The hazard ratio for tooth loss in the resected teeth was 15.6, 95% confidence interval (CI) (3.7 to 83.2) without complete-coverage crowns and 8.6, 95% CI (2.2 to 43.2) at the most posterior location.
Root resection provided to manage a localized periodontal lesion had the highest prognosis. The absence of a crown and the location as the most posterior tooth in the arch were associated with poor survival following resection.
Minimal Detectable Width of Tooth Fractures Using Magnetic Resonance Imaging and Method to Measure
2022, Journal of Endodontics
Vertical root fracture (VRF) in root canal–treated (RCT) teeth is a common cause of pain, bone resorption, and tooth loss. VRF is also difficult to diagnose and measure. Magnetic resonance imaging (MRI) has the potential to identify VRF due to beneficial partial volume averaging, without using ionizing radiation. This investigation aimed to describe the narrowest VRFs detectable based on MRI, using micro-computed tomography (microCT) as the reference standard and proposes a method using profile integrals to measure the widths of small VRFs.
VRFs were induced in 62 RCT tooth root samples. All samples were imaged in a phantom using MRI and reference imaging was obtained using microCT. The stacks of 3-dimensional axial MRIs were assessed by 3 board-certified endodontists. Evaluators determined the most coronal slice within the stack that was discernible as the extent of the VRF. This slice was measured on correlated microCT sections to determine the minimum VRF width (μm) detectable using a profile integral-based method to measure small fractures and negate the effects of the point spread function.
Using profile integrals to measure VRF width was repeatable and resulted in estimates that were on average 1 μm smaller than known reference widths. Adjusted median VRF width detected using MRI was 45 μm (first quartile: 26 μm, third quartile: 64 μm).
Using profile integrals is a valid way to estimate small VRF width. The MRI approach demonstrated ability to repeatedly detect VRFs as small as 26 μm.

View all citing articles on Scopus

Dr. Walton is a professor emeritus, Department of Endodontics, College of Dentistry, University of Iowa, Iowa City, 801 Newton Rd., IA 52242.

: Disclosure. Dr. Walton did not report any disclosures.

: Robert J. Michelich, DDS, MS, Tucker, GA, and G. Norman Smith, DMD, Savannah, GA, participated in performing the clinical procedures, analysis of findings, and assessment of data.

View full text

Original ContributionsVertical Root FractureVertical root fracture: Factors related to identification

Abstract

Background

Methods

Results

Conclusions

Practical Implications

Section snippets

Methods

Results

Discussion

Conclusions

J Endod

J Endod

J Endod

J Prosthet Dent

J Endod

J Endod

J Endod

J Endod

J Endod

Dent Clin North Am

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol

J Endod

J Endod

J Endod

Original Contributions
Vertical Root Fracture
Vertical root fracture: Factors related to identification