Quality Resource Guide l Diagnosing and Managing the Cracked Tooth Part Two 3rd Edition 3 www.metdental.com 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). 9 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 The time needed for development of VRF is uncertain. 16 It may be years after endodontic treatment, restoration of the tooth, or post placement before evidence of a fracture is clinically detected. Although there are certain findings that are indicative of VRF (dual buccal-lingual sinus tracts, “J” shaped periapical radiolucencies along the root surface (Figure 6), and narrow deep 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.