Impossible is just a word used by people who are unwilling to change things. Impossible is an opinion, not a fact, and is a challenge rather than a declaration. Impossible is only temporary and represents potential and opportunity. Impossible means nothing.

1. “Impossible is just a big word thrown around by small men who
find it easier to live in the world they’ve been given than to
explore the power they have to change it. Impossible is not a
fact. It’s an opinion. Impossible is not a declaration. It’s a dare.
Impossible is potential. Impossible is temporary.
Impossible is nothing.”
Good Morning
MUHAMMAD ALI
1

2. VERTICAL ROOT FRACTURE & IT’S
MANAGMENT
2

3. •Introduction
•Epidemiology
•Predisposing Factors
•Aetiology
•Classification
•Clinical presentation
•Radiographic findings
•Treatment modalitlies
•Refernces
•Conclusion
3

4. • ‘‘A vertical root fracture is a longitudinally
oriented fracture of the root that originates
from the apex and propagates to the coronal
part.’’
American association of endodontics 4

5. Prevalence of Vertical Root Fracture
• 2% and 5% with the greatest incidence occurring in teeth
during or after endodontic therapy and in patients older than
45 years of age and more in males.
• Maxilla is more affected than mandible especially premolars
and molars.
• Roots that are wide facio lingually but thinner mesio-distally
tend to fracture more often
5

6. The prevalence of vertical root fractures, in endodontically treated
teeth, is 11-20%.
J Endod 1992;18:460-3.6

7. Predisposing Factors
Loss of tooth structure due to caries or restoration.
Excessive biomechanical preparation
Overzealous widening for post-placement
Exposure to occlusal forces beyond normal level
Increased stress that exceeds the distributing capacity of the
periodontal ligament (PDL)
Moisture loss in pulpless teeth
Previous cracks in dentin due to pressure during obturation
International Journal of Contemporary Dental and Medical Reviews (2015)
7

8. Aetiology
1. Endodontic treatment
• Over prepared access
• excess canal shaping – excess dentin removal
2. Placement of post, pins
• Tapered and threaded posts generally produce the highest root
fracture incidence, followed by tapered and parallel posts
• Fractures with tapered posts occur at the coronal-third of the
root and, with parallel posts, occur at the apical-third of the
root.
3. Parafunctional habits- bruxism clenching
4. Restorative treatment
• extensively restored teeth.
5. Pathologic fracture – resorption induced
8

9. Ismail Davut Capar et al concluded that Root canal instrumentation
with the Ni-Ti rotary system, different obturation techniques, and
retreatment of different filling techniques can create fractures or cracks
Int Endod J 42:208, 2009.
Shemesh et al. compared lateral compaction and non-compaction
filling with standard 0.2-tapered cones and reported that the total
number of cracks after lateral compaction was higher than after non-
compaction filling.
Shemesh et al. documented that retreatment procedures increase crack
formation because of further preparation and more manipulations.
J Endod 2011;37:63–6.
Dental Traumatology 2015; 31: 302–307
9

10. Classification
The basis of separation
of the fragments
Complete
On the basis of relative
position of fracture to the
alveolar crest
Incomplete Supraosseous Intraosseous
Vertical root fractures
(VRFs)
10

11. Complete fracture
• When total separation is visible or fragments can be moved
independently.
Incomplete fracture
• When there is an absence of visible separation and segments can
easily be separated by an instrument.
Supraosseous fracture
• This terminates above the bone, and does not create a periodontal
defect.
Intraosseous fracture
• This involves the supporting bone, creating a periodontal defect.
11

12. Classification of fatigue root fracture by
Chin- Jyh Yeh-
• Vertical fractures: the fracture line is parallel to the long axis
of the root, and located only in the root.
• Oblique fractures: the fracture line follows an angle in
relation to the long axis of the root
• Horizontal fractures: the fracture line is perpendicular to the
long axis of the root
• Laminar fractures: a piece of root fragment, not involving
the root canal.
Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-797
12

13. •Illumination
•Radiographs
•Periodontal Probing
•Staining
•Surgical Exploration
•The Bite Test
•Direct Visual
Examination
•Observation Under The
Dental Microscope
13

14. Position Of The Fracture
Tooth Type
Time Elapsed After Fracture
The Periodontal Condition Architecture Of
Bone Adjacent To The Fracture
Clinical Presentation
History of variable discomfort or soreness, mild to moderate pain
especially on biting.
Vertical root fracture must be suspected if a root filled tooth
presents with pain on biting and is also accompanied by a bad
taste
International Journal of Contemporary Dental and Medical Reviews (2015)
14

15. Maxillary and mandibular premolars,
The mesial roots of the mandibular molars
The mesiobuccal roots of the maxillary molars
The mandibular incisors
COHEN 11TH EDITION
15

16. Early Manifestation
Microcracks at the root canal Gradually propagate outward
Pain or discomfort on the affected side of the tooth.
Sensitive upon chewing,
Pain is often of a dull nature,
COHEN 11TH EDITION
16

17. 17

18. Endodontic failure in teeth, which had previous healing may also
point to the presence of a vertical root fracture
Vertical root fractures can lead to
International Journal of Contemporary Dental and Medical Reviews (2015)
18

19. Late Manifestation
Major destruction of the alveolar bone adjacent to the root
J-shaped or halo radiolucency,
Pocket along the fracture, which was initially tight and narrow, may
become wider and easier to detect.
COHEN 11TH EDITION
A sinus tract and a narrow, isolated periodontal probing defect associated
with a tooth that has undergone a root canal treatment, with or without
post placement, can be considered Pathognomonic for the presence of a
VRF.
American Association of Endodontists 2008
19

20. ????
Two factors makes the early diagnosis difficult:
(1) Many of the clinical symptoms associated with VRFs mimic
apical periodontitis or periodontal disease
(2) The narrow and tight pocket associated with early stages of VRF
is difficult to detect using rigid probes
20

21. Diagnosis VRF Pockets
COHEN 11TH EDITION
21

22. Coronally Located Sinus TractDiagnosis
COHEN 11TH EDITION
22

23. Radiographic FeaturesDiagnosis
COHEN 11TH EDITION
23

24. Radiographic signs
• Separation of root fragments
• Fracture lines along the root
or root fillings
• Space beside a root filling
• Space beside a post
• Double images
• Radiopaque signs
Patterns of bone loss
• Widening of periodontal
ligament space
• Radiolucent halos
• Step-like bone defects
• Isolated horizontal bone loss in
posterior teeth
• Unexplained bifurcation bone
loss
• V-shaped diffuse bone loss on
roots of posterior teeth
Australian Dental Journal 1999;44:2.
24

25. Separation of root fragments Fracture lines along the root or root fillings
Australian Dental Journal 1999;44:2.
25
Space beside a root filling

26. Space beside a post Double images
Radiopaque signs Australian Dental Journal 1999;44:2.
26

27. Widening of periodontal
ligament space Radiolucent halos
Step-like bone defects
Australian Dental Journal 1999;44:2.
27

28. Isolated horizontal bone loss in
posterior teeth
Unexplained bifurcation bone loss
28

29. Radiolucency in the Bone Along RootDiagnosis
29

30. Radiograph of Empty CanalDiagnosis
30

31. Cone-Beam Computed
Tomography in VRF Diagnosis
Diagnosis
S. Patel et al concluded that periapical radiographs and CBCT were
not accurate in detecting the presence and absence of simulated VRF.
International Endodontic Journal, 46, 1140–1152, 2013
Smaller radiation dose compared to traditional medical spiral CT imaging
CBCT imaging would not be able to visualize a root fracture unless the
fracture width was greater than 0.15 mm.
With likely increased resolution in the near future, CBCT may become an
important diagnostic tool for the detection of VRFs.
COHEN 11TH EDITION
31

32. • A variety of approaches have been attempted and used to treat the
VRF, including-
• Bonding using glass ionomer cement and composite resin.
• Bonding using wires.
• Bonding using adhesive resin cement.
• Bonding using adhesive resin cement and rotational
replantation.
• Fusing the fragments using Co2 and Nd: YAG laser.
• Hemisection and root amputation.
• Extraction.
The aim of treatment is therefore to eliminate the
fracture or the leakage of bacteria along the
fracture plane
Australian Dental Journal 1999;44:2.
32

33. • Multirooted teeth can often be successfully treated by
resecting the fractured root, either by root amputation or
hemisection
J Periodontol 1981;52:719-722.
Langer B et al reported that the retention rate of root resected
teeth is 94% in five years.
Australian Dental Journal 1999;44:2.
•Prognosis for single rooted teeth is poor and extraction is often the
treatment of choice
33

34. Endod Dent Traumatol 1993;9:101-105.
An in vitro study assessing the resistance to fracture of root segments
bonded with glass ionomer cement, composite resin, and cyanoacrylate
concluded that the bond strengths of composite resin and cyanoacrylate
were superior to glass ionomer cement
Quintessence Int 1991;22:707-709.
Calcium hydroxide has been used to promote tissue repair and resolve
osseous defects before the roots were restored. Teeth treated with
calcium hydroxide, then ‘reinforced’ with glass ionomer cement, have
shown healing at six month follow-up appointment
34

35. 35

36. • Trope and Rosenberg extracted both segments of a maxillary
second molar and soaked in Hanks balanced salt solution,
while bonding the segment with glass ionomer and
subsequently replanting the tooth using Gore-Tex membrane to
establish a new periodontal attachment.
• After six months, they reported a reduction in pocket depth
from 10 mm to 2-3 mm. A crown was placed after one year as
the tooth was functioning normally
Australian Dental Journal 1999;44:2.
36

37. 4-methacryloxy etheyl trimellitate anhydride (META)/ methyl
methacrylate (MMA) tri- n- butyl borane (TBB): 4-META/MMA
TBB.
The advantages associated with the use of 4-META/MMA TBB is
low toxicity and biocompatibility for PDL cells.
The cement interferes only slightly with cell attachment and
proliferation. There is decreased level of inflammatory and
replacement resorption.
Dual cure resin cements: These cements have high bond strength,
good marginal integrity, acceptable biocompatibility and short
polymerization time…
International Journal of Contemporary Dental and Medical Reviews (2015),
37

38. Mineral trioxide aggregate (MTA): MTA is a calciumsilicate based
root repair material and has many applications in endodontics.
Taschieri et al. in 2010 used MTA to repair incomplete vertical root
fractures. A vertical groove was placed next to the fracture line and
restored with MTA after ultrasonic
cleaning.
A resorbable membrane was placed next to the MTA to inhibit
epithelial down growth. All 10 cases showed good results on 1 year
follow up.
International Journal of Contemporary Dental and Medical Reviews (2015),
38

39. • Takatsu et al. used orthodontic elastics to join the buccal and
palatal segments of a vertically fractured maxillary second
molar which were then sealed with a photocured resin liner to
allow the tooth to be endodontically treated and restored with a
cast crown.
• The tooth remained in function for more than three and a half
years with a reduction in pocket depth.
Australian Dental Journal 1999;44:2.
39

40. • Sinai and Kratz demonstrated regeneration of bone and
healing when the detached root segment, root canal filling and
soft tissues were surgically removed.
• An in vitro study54 proved CO2 and Nd:YAG laser to be an
ineffective way to fuse fractured tooth roots.
Australian Dental Journal 1999;44:2.
40

41. Replantation of root filled teeth with vertical root fracture
reconstructed with resin bonding has emerged.The long-term
prognosis of resin bonded and replanted teeth were determined by
Hayashi et al. in 2004 in a 18 month follow-up study, which gave
good results.
The prognosis of replantation therapy depends on:
• Atraumatic extraction of the fragments
• Extra-oral time of <15 min as given by Pohl et al.
• Disinfection using short- term calcium hydroxide dressing
• Systemic tetracycline administration.
International Journal of Contemporary Dental and Medical Reviews (2015),
41

42. Prevention
• Avoid excessive removal of intraradicular dentin
• Treatment and restorative procedures that require minimal
dentin preparation should be selected
• Condensation of obturation materials should be carefully
controlled
• Adequate ferrule that effectively resist functional forces and
enhances fracture strength of post core restored endodontically
treated tooth should be prepared
Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-79742

43. • More flexible and less tapered finger pluggers or spreaders are
preferred.
• Any post used should be as small as possible, have a passive
fit, and not grip or lock the root internally with threads
• Cementation should be done carefully and slowly; an escape
vent for the cement is probably helpful
Prevention
Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-79743

44. • VRF can be detected early by listening to the patient’s chief
complaints, carefully examining radiographs and performing a
thorough clinical examination.
• VRF associated with root canal treated teeth is one of the most
difficult problems to diagnose and treat. Early detection has two
fold advantages –It prevents unnecessary frustration and
inappropriate endodontic treatment and prevents extensive
damage to the supporting tissues.
• Before any complex experimental treatment procedures are
considered, the desirability for retention of the tooth root should
be carefully weighed against extraction and replacement with a
denture, bridge or implant
44

45. • COHEN 11TH EDITION
• Indian Journal of Basic and Applied Medical Research; June
2016: Vol.-5, Issue- 3, P. 791-797
• International Journal of Contemporary Dental and Medical
Reviews (2015),
• Australian Dental Journal 1999;44:2.
• J Periodontol 1981;52:719-722.
• International Endodontic Journal, 46, 1140–1152, 2013
• American Association of Endodontists 2008
• Dental Traumatology 2015; 31: 302–307
• Int Endod J 42:208, 2009. 45

46. Thank you
46