vertical root fracture

Diagnosing Root Fractures - continued

As mentioned in the last post, in most cases, I prefer to verify a fracture before extraction. This is time consuming and not very profitable, but I believe it is in the patient's best interest.

However, there are some cases where it is reasonable to call a root fractured without seeing the fracture. Here is an example.

This 80 year old patient had this root canal done many years ago. She presented today with redness and swelling/sinus tract on the buccal surface. Examination finds #4 with normal pocket depths, lateral and apical radiolucency & class II mobility.

All of these clinical findings (normal probings, lateral lucency, mobility, sinus tract at the midroot) point to the probability of a root fracture at the level of the post rather than an endodontic abscess or periodontal abscess.

I recommended extraction due to fractured root.

Friday, August 8, 2008

Diagnosing Root Fractures

Diagnosis of a vertical root fracture is very difficult. It sometimes frustrates me to see how quickly some people diagnose a root fracture. I tell my patients that I like to rule everything else out before I make that assumption. I say assumption, because unless you can visualize the root fracture, you are making an assumption.

There are some clinical signs that can be associated with a vertical root fracture, however, they are not 100% diagnostic of a vertical root fracture.

For example, a long narrow periodontal pocket is often associated with a vertical root fracture. The periodontal attachment breaks down along the fracture line, creating this defect. However this same type of narrow periodontal defect can also be caused by an abscess draining through the periodontal ligament.



A j-shaped lesion is often associated with vertical root fractures. However, not all j-shaped lesions are fractured roots.

In this case there were no fractures found. Complete resolution of these lesions is expected.







If visualization of a vertical root fracture is the most accurate way to diagnose a root fracture, how is that to be done?


Visualization of a fracture is best done using a microscope. A microscope with a light source will allow you to see fractures during endodontic treatment.

A microscope will allow you to determine if a crack goes down past the CEJ and into the root
or if it crosses the pulpal floor.

Visualizing a crack running across the pulpal floor of the tooth is (on left) is a 100% accurate diagnosis. This tooth must be extracted.










This is another example of a crack running along the floor of the pulp chamber from the MB root to the Palatal root of a Mx first molar.












In most cases, I prefer to verify a fracture before extraction. This is time consuming and not very profitable, but I believe it is in the patient's best interest. This is also the course I would take if it were my tooth.

Monday, May 19, 2008

Vertical Root Fracture

This 92 year old patient came into our office for evaluation of #7. She reported no pain, but had a sinus tract between #6 & #7. Probing around #7 appeared normal.

The radiograph appeared to show some lateral radiolucency at the level of the post. The post also appeared slightly off angle with the root canal obturation. Despite the lack of narrow probing depths, I suspected a root fracture.

At this point, we decided to verify that fracture by disassembling the restoration. The patient was informed that if the root was fractured, then she we would not be able to save the tooth.



After simultaneous removal of the post and crown, multiple vertical root fractures were identified. A lingual, and distal fracture are seen in this image.

A mesial root fracture is seen in this angle.

Visualizing a fracture is the only certain way to diagnose a root fracture. This procedure is not well reimbursed, if at all. It will certainly require time that could be used for more productive treatment. However, if it was my tooth, I would want to know it is fractured before extracting it.

I suspect that a possible application of the new cone beam dental CT's will help with diagnosis of vertical root fracture.

Tuesday, October 16, 2007

Cracked Tooth

When a crack extends from the occlusal (chewing) surface towards the root, we call it a cracked tooth. These cracks may be very small or very large. The crack often causes damage to the pulp of the tooth. Primary symptom of a cracked tooth is pain upon chewing. This pain may be irregular and sporadic.

The depth and position of the crack determines whether the tooth is restorable. If the crack is in the coronal portion of the tooth, then placing a crown with prevent futher flexing of the tooth as well as prevent bacterial leakage through the crack.

A crack extending down the root surface is also commonly referred to a root fracture. Root fractures can be difficult to diagnose. Often they are associated with a deep, narrow, periodontal defect. However, a draining abscess can also cause a deep narrow pocket, which can easily be confused with a root fracture.


In the picture above, the extracted tooth has been dyed. The periodontal ligament picks up the stain. You can see that in the area of the crack, the pdl has broken down and a deep, narrow periodontal defect has developed on the line of the crack.

A cracked tooth that is not treated will worsen and lead to loss of the tooth. Early diagnosis and treatment are essential in preserving these teeth.

Saturday, September 1, 2007

Horizontal Root Fracture?

This tooth was referred to an oral surgeon for extraction and immediate implant placement on #11. A void between the post and the root canal filling is noted and it appears there may be some widening of the periodontal ligament adjacent to that void. There was purulence noted from the sulcus and the attached gingival tissue was inflammed. The tooth was otherwise asymptomatic. I was asked to do a consultation to confirm the horizontal fracture before the tooth was extracted. As I have mentioned in previous posts, root fractures are very difficult to diagnose.

A second radiograph of the tooth appears normal. No sign of fracture or change in the periodontal ligament from this view. It does appear that there may be some coronal leakage on the distal margin of the crown.

Another radiographic shift reveals that the post preparation was off center slightly with the canal. I explained to the patient and my oral surgeon colleague that the only way to know for sure would be to examine the tooth surgically or by removing the post and examining the tooth internally using the microscope.

When given the option to evaluate the tooth microscopically and potentially retain the natural tooth, the patient elected to disassemble the post & crown and evaluate it. Microscopic examination as well as additional radiographs revealed no sign of horizontal fracture. Endodontic retreatment was completed and a post and core build up was completed. There is plenty of supracrestal bone to get a good ferrule for the new crown.
Proper endodontic consultation allowed this patient to retain his natural tooth, save considerable time and money and be back to complete function in a matter of a few weeks.
The endodontic part of the "multi-disciplinary" approach to implant treatment planning is often lacking. Diagnosis of root fracture rarely can be made by looking at a single film. Endodontic consultation is an important part of implant treatment planning.

Monday, July 30, 2007

Apical Surgery Saves the Bridge

This root canal was orginally done in 1982 and an instrument was separated at the time. Within the next two years, the tooth was treated with an apicoectomy to remove the separated instrument. This was "Old School" endo surgery. No microscope with an amalgam retrofill. Despite this, the tooth was retained (survived) for 25 years. You can tell that the amalgam retrofill came loose and the apical seal was jeopardized. An apical radiolucency is apparent.

We discussed with the patient the possibility of a root fracture, but that the most likely reason for the apical lesion was the lost retrofill. We recommended endodontic microsurgery to retreat the lost retrofill. The patient agreed and procedure was peformed.

A root end fracture was found. At this point, we decided to go ahead and resect the root to see how far the fracture went. (I decided that rather than remove more bone looking for the dislodged amalgam, I would leave it.)

Under the microscope we were able to remove the fractured portion of the root. We went ahead and placed a retrofill with MTA (Mineral Trioxide Aggregate).

Post-operative radiograph following placement of new apical retrofill.

A six month recall on the tooth reveals complete healing of the bone and full function of the tooth. No pain to percussion, normal probings. Despite a small root end fracture, this tooth was treatable with endodontic microsurgery. The endodontic microsurgery option has allow this patient to retain his natural tooth and keep his 3 unit bridge.

Thursday, July 19, 2007

Wow - Nice Healing!

In a previous post I mentioned how a J-shaped lesion is often indicative of vertical root fracture? I also mentioned that thorough endodontic diagnostics must always be completed before condemning a tooth with a vertical root fracture. Here is a perfect example of a huge j-shaped lesion, that is not a vertical root fracture. This patient came in today, and I took a 4.5 yr recall on this tooth. Healing is complete.

Friday, June 29, 2007

Vertical Root Fracture

Vertical root fracture (VRF) can be one of the most challenging parts of endodontic diagnosis. It is often only diagnosed after you have ruled out everything else.

Since treatment of a VRF is extraction, it is important to have an accurate diagnosis. The most certain way to diagnose a vertical root fracture is to see it. This is easily done with a microscope internally. However, that takes significant chair time.

Here are a few tricks that will help you diagnose a VRF.



RADIOGRAPHS:
Look closely at this radiograph. You can see a dark line running parallel to the canal. This dark line will appear if the fracture has caused the root to separate or if you just get lucky with the horizontal angle of your radiograph (just make sure it is not a missed canal).









J-shaped lesions are often indicative of a VRF. **however large, non-fractured, endodontic lesions can also have this appearance

PROBINGS:
Long narrow periodontal probings are often indicative of a VRF. A long, narrow probing develops along the line of a fracture because the pdl cannot attach to the fracture. Looking closely at this image demonstrates the pdl breakdown along the line of the fracture.

**However, a draining sinus tract throught the periodontal ligament can also give you similar probing.**

As you can tell, all of these tips still have some exception to them. Full, accurate diagnosis of VRF sometimes requires a couple of visits to rule out all of the other possibilities. Visualizing the fracture is best done internally with a microscope. However, if you find several of these signs together, you can be fairly confident that you have a VRF.