Quality Resource Guide
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Diagnosing and Managing the Cracked Tooth Part Two 2nd Edition
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The clinical presentation of VRF may occur some
period of time after the initiation of the fracture.
The undetected fracture allows ingrowth of bacteria
resulting in bony and soft tissue pathosis that often
manifest as a periodontal pocket (
Figure 3
).
Vertical root fractures usually start in the apical
region of a root, where endodontic files may have
created micro fractures during canal preparation
(
Figure 4
);
13,14
however, recent evidence questions
the role of canal preparation.
7
It is not known
how extensive a fracture needs to be to create
symptoms.
Teeth most susceptible to VRF are
those with narrow mesial-distal diameters relative
to wider buccal-lingual diameters.
This root
configuration is found in teeth with oval, ribbon
shaped and kidney shaped roots (mandibular
anterior teeth, maxillary and mandibular premolars,
mesial roots of mandibular molars and buccal roots
of maxillary molars).
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Symptoms
Vertical root fractures allow fluid and bacterial
ingress, leading to inflammation and surrounding
bone loss. A tooth with VRF often creates varying
degrees of biting discomfort, swelling, tenderness
to percussion and palpation, and purulent drainage
through the sulcus or a gingival sinus tract.
4
Other
symptoms that are associated with VRF include
deep periodontal probing defects, periodontal-type
abscess formation, periapical radiolucencies, and
tooth mobility. Symptoms of VRF are variable from
patient to patient, and tooth to tooth. Often the
signs and symptoms are difficult to interpret and
may overlap with many other dental conditions such
as periodontal disease and/or failed endodontic
treatment. It should be noted that the degree of pain
experienced by patients with VRF is often remarkably
mild, resulting in delay in seeking treatment that can
lead to extensive bone loss (
Figure 5
).
Diagnosis
Detection of VRF usually begins with the patient
reporting symptoms such as: pain (which is
generally described as “soreness”); soft tissue
swelling; or presence of a sinus tract. A VRF
may also be detected incidentally by observation
of radiographic changes of the lamina dura and
periodontal ligament space around the root and its
apex. A combination of a sinus tract located near
the free gingival margin, combined with a deep and
somewhat narrow periodontal pocket, is an indicator
of a possible VRF.
Clinical examination can be aided
by the use of stains and transillumination.
Staining
the canal space with a dye such as methylene blue
allows the dye to preferentially flow into the fracture
line where it may be visualized, especially with
magnification. Transillumination directed into an
endodontic access cavity and down the root canal
may allow visualization of VRF.
4,15
Figure 4
Vertical root fractures typically originate in
the apical area and progress toward the
crown.
Figure 3
(a) An apparent periodontal pocket in the furcation area was caused by a VRF (arrow) -
clinically shown in (b) - fracture appears to originate in the cervical region of the root.
Figure 5
(a) Five years following root canal treatment of tooth #31, a lesion (arrow) was noted in the
furcation - the patient had minimal symptoms and preferred to postpone any corrective treatment.
(b) Two years later a large bony lesion surrounded the mesial root, yet the patient had noticed
only minor soreness in the region.