Quality Resource Guide l Diagnosing and Managing the Cracked Tooth Part Two 3rd Edition 5 www.metdental.com In a laboratory study using MRI to evaluate induced vertical root fractures in endodontically treated teeth. The study confirmed that MRI is a valid technique for identifying the presence of vertical root fractures. The evaluators were able to consistently detect vertical root fractures as small as 26 microns. 26 Misdiagnosis of teeth with VRF can complicate or delay eventual definitive treatment. Because of overlapping signs and symptoms of VRF with other dental conditions, a careful and methodical approach to diagnosis must be used to reduce errors. Early identification of VRF has many benefits, including preservation of alveolar bone, which is important for any subsequent prosthetic replacement of the fractured tooth. 19 Treatment Options Treatment for a tooth with VRF is usually extraction, or possibly root amputation in some selected multirooted cases. Outcomes following root amputation, especially in mandibular molars, are uncertain. 27,28 However, Langer 29 following up on his earlier original report, 24 noted that, in contrast to mandibular molars, resection of a single root in a maxillary molar resulted in a rather good long-term prognosis. Many clinicians have confirmed that observation. Retaining a maxillary molar for as long as possible - absent risk of continuing bone loss – appears to be a prudent treatment recommendation. 30 Prior to the introduction of dental implants, the primary aim of VRF management was to repair the fracture or replace the tooth with a fixed or removable prosthesis. 31 Current treatment options to consider include the following: • Bonding the vertical fracture extraorally followed by replantation of the tooth 32 The prognosis of teeth treated by bonding of the VRF segments has been shown to initially have a high success rate (88.5% at 12 months) but it progressively drops over time (59% at 60 months). 33 A prospective case series of re-bonded teeth with VRF, placing mineral trioxide aggregate (MTA) into the fractures, noted clinical and radiographic success at twelve months. 34 • Root amputation Root amputation or hemisection in mandibular teeth with VRF have not been favorably reported in the literature, 27,28 but clinical experience has demonstrated some positive outcomes in maxillary multirooted molars (Figure 8). • Autotransplantation of teeth 35 Donor teeth for this procedure would ideally be non-functioning teeth located elsewhere in the mouth. The donor teeth must have adequate periodontal ligament support and root forms that either fit to the recipient site or the socket can be modified to receive the donor teeth (Figure 9). Autotransplantation - (a) Radiograph of tooth #7 in a 50-year old male who complained of a sore and loose tooth. Root canal treatment, post and core and a crown had been completed many years earlier. (b) CBCT image shows the fractured root (arrow). (c) Clinical photo after extraction of #7. (d) Photo showing tooth #12 in a crowded alignment; the patient agreed to have it transplanted to the #7 site. (e) Radiograph taken immediately after transplanta- tion. Root canal treatment was completed 4 weeks later. (f) Photo taken 1-month post- surgery showing soft tissue healing. (g,h) Photo and radiograph taken 3 years and 10 months after transplantation. Case Courtesy: Dr. Mitsuhiro Tsukiboshi, Aichi, Japan Figure 9 c b a d e f h g