Diagnosis and management of teeth with vertical root fractures

Transcription

1 INVITED REVIEW Austrlin Dentl Journl 1999;44:(2):75-87 Dignosis nd mngement of teeth with verticl root frctures Alex J. Moule* Bill Khler Astrct Verticl frctures in teeth cn present difficulties in dignosis. There re, however, mny specific clinicl nd rdiogrphicl signs which, when present, cn lert clinicins to the existence of frcture. In this review, the dignosis of verticl root frctures is discussed in detil, nd exmples re presented of clinicl nd rdiogrphic signs ssocited with these frctured teeth. Tretment lterntives re discussed for oth posterior nd nterior teeth. Key words: Endodontics, dignosis, verticl frctures. (Received for puliction Mrch Accepted Mrch 1999.) Introduction Verticl root frctures hve een descried s l o n gitudinlly oriented frctures of the root, extending from the root cnl to the periodontium. 1 They usully occur in endodonticlly treted teeth, lthough occurrence in non-restored teeth hs een descried. 2-4 The verticl frcture my involve the whole length of the root or only section of it. It my involve only one or oth sides of the root. 5-7 In molr teeth, the frcture is most commonly ucco-lingul in ori e n t tion in individul roots. Mesio-distl frctures re less common. In nterior teeth, the frctures re most commonly in uccolingul direction. 5 Verticl root frctures cn e i n i t i ted from coronl tooth structure (Fig. 1) or t the pex (Fig. 2). Incomplete nd complete root frctures h ve een descri e d. 8, 9 Most ve rticl root frctures re complete. 6 The rdiogrphic nd clinicl signs of ve rticl root frctures were extensively reviewed y Pitts nd Ntkin in A numer of other dignostic reviews hve een pulished. 7,10-13 Numerous cse reports lso pper in the literture descriing single or multiple cses of verticl root frctures If unrecognized, verticl root frctures cn led to frustrtion nd inpproprite endodontic tretment. Dignosis is sometimes difficult s there is often no *Endodontist, Brisne. Generl Prctitioner, To owo o m. single clinicl feture which indictes tht root frcture is present 11 nd signs nd symptoms re often delyed. Indeed, verge time etween root filling nd the ppernce of verticl root frcture hs een estimted to e etween 39 months 23 nd 52.5 months 29 with rnge of three dys to 14 yers. In generl, however, ll verticlly frctured teeth exhiit specific clinicl nd rdiogrphic signs which should lert the prctitioner to the possiility of root frcture eing present. This pper reviews these dignostic fetures, presenting exmples of ech. Tretment lterntives re discussed ut cuses of verticl root frctures re not ddressed. They will e the suject of further review. Clinicl presenttion The clinicl presenttion of verticl root frcture is extemely v rile. The clinicl signs nd symptoms vry ccording to the position of the frcture, tooth type, time fter frcture, the periodontl condition of the tooth nd the rchitecture of the one djcent to the frcture. Teeth with verticl root frctures often present with long history of vrile discomfort or soreness, usully ssocited with locl chronic infection. The pin is usully mild to m o d e r te in intensity. 23 Rrely is severe pin ssocited with these teeth. Verticlly frctured teeth cn lso present with history of pin on iting. Verticl root frctures should e considered if n pprently well root filled tooth does not settle fter the root filling is completed. 16 Where root filled tooth is ssocited with pin on iting nd is lso ccompnied y d tste, verticl root frcture is most likely present. Occsionlly, the ptient cn e wre of shrp crcking sound t the time of c o n d e n s tion of gutt perch, 1, 2, 23 or the cementt i o n of post. 21 Bleeding during condenstion of root filling mteril nd n pprent lck of resistnce within the cnl during condenstion, leding to n lmost unlimited ility to condense gutt perch into the cnl, 11 re lso signs tht verticl root frcture is present. Austrlin Dentl Journl 1999;44:2. 75

2 Fig. 1. Upper centrl incisor s h owing complete crow n - d ow n verticl root frcture. Fig. 2. Mxillry second premolr shows n incomplete ucco-lingul ve rticl root frcture which hs een initited in the pex. Note the V-shped r e s o rp t i ve defect which hs occurred piclly. Fig. 6. Digrmmtic representtion of proing pttern seen in () periodontl disese nd () verticl root frcture. A deep nrrow pocket in one position round the circumference of the tooth nd the presence of otherwise norml ttchment is feture of verticlly frctured teeth. When similr pocketing occurs in two points round the circumference of the tooth, verticl root frcture is inevitly present. Fig. 3. Digrmmtic representtion of the position of soft tissue swelling () in tooth with peripicl scess, nd () in tooth with verticl root frcture. Fig. 7. Mxillry centrl incisor tooth exhiiting deep nrrow pocket on the lil surfce of the tooth with norml ttchment in the interproximl re. The presence of ucco-lingul verticl root frcture ws confirmed y surgery. Fig. 4. A rod-sed swelling over the mesio-uccl root of this mndiulr first molr is typicl of tht ssocited with verticl root frcture. Fig. 5. Doule or multiple sinus trcts re feture of verticlly frctured teeth. Fig. 8. () Mxillry right first premolr with mesio-distl frcture. Deep proing is evident mesilly nd distlly ut ttchment is norml on the uccl nd lingul spect. () Rdiogrph of sme tooth. Note the extensive one loss mesilly nd distlly ut little evidence of one loss piclly. 76 Austrlin Dentl Journl 1999;44:2.

3 Some swelling of soft tissues is usully present. The swelling is usully rod-sed, nd mid-root in position. Plption will often show swelling nd tenderness over the root itself, ut little swelling in the peripicl region (Fig. 3, 4). When sinus trct is present, it my e situted in or close to ttched gingiv rther thn in the picl region. Doule or multiple sinus trcts re common. 1 Where multiple sinus trcts re present one or more of these trcts my e locted some distnce from the involved tooth. The insertion of gutt perch point into ech sinus trct cn ssist with dignosis. An exmple of ve rticlly root frctured tooth exhiiting multiple sinus trcts is shown in Fig. 5. A common feture of verticlly root frctured teeth is the development of deep, nrrow, isolted periodontl pockets. Pocketing is usully situted djcent to the frcture site. When the frcture extends right through the root, proing ptterns my e ilterl. The proing pttern for tooth with verticl root frcture is different from tht seen in teeth with periodontl disese, where the pocketing is firly consistent in depth round lrge prt of the tooth (Fig. 6). Deep proing in one position round the circumference of the tooth in the presence of otherwise norml ttchment usully indictes tht the tooth is frctured (Fig. 7, 8). Deep proing in two positions on opposite sides of the infection is lmost pthognomonic for the presence of frcture. It my e necessry to remove the restortion efore deep pocketing cn e proed in the interproximl region of molr teeth with mesio-distl frctures. 1 A common presenting feture is the dislodgement of post or post crown. A root frcture should e suspected if n pprently well-fitting post or post core ecomes dislodged. A typicl cse is illustrted in Fig. 9. The presence of verticl root frcture should e strongly suspected in teeth where there hs een history of repeted dislodgement of post or post crown. Becuse of prolems with dignosis, it is not uncommon for teeth with verticl root frctures to hve een treted repetedly y s u r g e ry efore the presence of frcture is suspected. When surgery fils for no ovious resons, verticl frcture should e considered possiility efore the peripicl re is re-entered surgiclly. Rdiogrphic signs While the clinicl presenttion of verticl root frcture cn e vrile, rdiogrphic signs re, t times, quite specific. These signs cn v ry considerly from cse to cse, depending on the ngle of the X-ry em in reltion to the plne of frcture, the time fter frcture nd the degree of seprtion of the frgments. Rdiogrphic chnges seen in verticl root frctures re summrized elow. Seprtion of root frgments (Fig ) When seprtion of root frgments occurs, the root frcture is clerly visile. Once seprtion of frgments hs occurred, prolifertion of grnultion tissue 22 often results in the rpid movement of the frgment wy from the remining root, in mny cses until the frgment comes into contct with n djcent tooth. Wide seprtion of frgments cn occur very rpidly, sometimes occurring in mtter of weeks. Frcture lines long the root or root fillings (Fig ) On occsions, direct evidence of frcture cn e seen s verticl rdiolucent line running cross the root or the root filling. Direct evidence of verticl root frcture line is often difficult to visulize. For the frcture to e seen the X-ry em must pss lmost directly down the frcture line. Smll chnges in horizontl ngultion my render the frcture undetectle. A four degree vrition in the h o rizontl ngultion of the film cn preve n t visuliztion of the frcture. 30 Pitts nd Ntkin 1 suggest tht frcture line tht devites from the long xis of the cnl my e rdiogrphiclly more ovious, wheres frcture line running prllel nd djcent to root filling my e less esy to see. While it is sometimes possile to see frcture imges clerly on rdiogrph, cre should e tken when ttempting to identify verticl lines s frcture lines, s ntomicl fetures, pltl grooves, rtefcts nd scrtches cn mimic the ppernce of frcture. Spce eside root filling (Fig. 20) Minor seprtion of frgments cn result in the rdiogrphic ppernce of verticl spce djcent to the root filling mteril in n otherwise welloturted cnl. Verticl root frctures should e suspected if the root filling ppers well condensed ut is in close contct with only one wll of the root cnl. Spce eside post (Fig. 21) In generl, posts re constructed so tht they fit the cnl. When post is present in verticlly root frctured tooth, slight seprtion of the frctured frgments cn result in the ppernce of spce etween the edge of root cnl, which my e coted with cement, nd the post itself. Doule imges (Fig. 22) When seprtion of frgments occurs in direction other thn prllel to the X-ry em, overlpping of frgments my result in doule imges of the externl root surfce. While this effect is sometimes seen in norml teeth, for exmple, in the mesil concvity of mxillry premolr teeth, step-like doule imges on the externl outline of Austrlin Dentl Journl 1999;44:2. 77

4 c Fig. 9. () Clinicl presenttion of ptient with discomfort ssocited with the mxillry right centrl incisor which ws crowned. The ptient hs experienced low grde discomfort, nd n itchy feeling ssocited with this tooth for some months. () Peripicl rdiogrph shows the tooth to e restored with post retined crown. No evidence of root filling is present lthough the lmin dur t the pex ppers intct. There is slight widening of the periodontl ligment spce in the mid-root region. (c) Clinicl photogrph six months fter Fig. 9. The post crown is dislodged nd root frcture is evident on the lil surfce. (d) Dislodged c r own from Fig. 9. Dislodgement of n pprently well-fitting post or post crown is sign tht the root my e frctured. d Fig. 13. Seprtion of the frgments in the mesil root of this mndiulr right molr cn e clerly seen. The mesil frgment hs remined ttched to the lrge restortion. Fig. 14. A frcture line (rrows) cn e seen running prllel to the root cnl nd then exiting distlly in the picl third in this mxillry left centrl incisor tooth. Fig. 10. Seprtion of the frgments is clerly visile in this ve rticlly frctured m x i l l ry left first premolr. Fig. 11. Verticlly frctured mndiulr lterl incisor showing wide seprtion of the frgments. The distl frgment is completely seprte from the tooth nd hs moved distlly to e in contct with the cnine. Grnultion tissue seprtes the gutt perch fill from oth frgments. Fig. 12. Mxillry cnine showing verticl root frcture in the picl portion nd wide seprtion of the frgments. Fig. 15. () A ve rticl frcture (rr ows) rdiogr p h i c l l y superimposed over the root filling is present in this mxillry left centrl incisor tooth. () Clinicl photogrph of tooth from Fig. 15 showing the frcture (rrow). Note the mount of firous tissue which is ttched to this tooth once it hs een extrcted. This is feture of teeth tht re verticlly root frctured. 78 Austrlin Dentl Journl 1999;44:2.

5 Fig. 16. Two peripicl rdiogrphs tken t the sme consulttion showing the effects of ngultion chnges on the visiility of the root frcture on the right mxillry centrl incisor tooth. () The frcture is difficult to see. () The frcture is esy to see (rrow) where the X ry em psses down in the plne of the frcture. Fig. 17. Digrmmtic representtion of the chnges in horizontl ngultion of the X-ry em tht re necessry to detect verticl root frcture (). For etter visuliztion of trnsverse root frcture, the ngultion is chnged verticlly rther thn horizontlly (). Fig. 18. Peripicl rdiogrph of mxillry right centrl incisor with deep pltl groove, the rdiogrphic picture of which mimics verticl root frcture. Austrlin Dentl Journl 1999;44:2. Fig. 19. () Peripicl rdiogrph of filed nterior ridge. A drk line extending from the ottom of the post in the mxillry right centrl incisor to the pex (rrow) gives the ppernce of verticl root frcture eing present. () Clinicl photogrph of the rdiogrph showing mrk (rrow) responsile for the rdiogrphic imge. In interpreting rdiogrphic lines on rdiogrphs considertion must e given for the presence of rtefcts nd scrtches. Fig. 20. Peripicl rdiogrphs of root filled premolr tooth. () At one yer recll, there is no evidence of ny rdiogrphic chnges which re suggestive of prolem. () Two yers lter there is widening of the periodontl ligment spce nd the ppernce of lrge peripicl lesion. The frcture is seen s spce (rrows) which hs developed on the distl side of the root filling due to slight seprtion of the frgments. Fig. 21. Mxillry right first premolr restored with post/crown restortion. A spce is present etween the post nd the root which is covered with lyer of cement. The spce cn e trced pst the post eyond where the frcture line is clerly shown (rrow). 79

6 tooth re often n indiction tht frcture is present. Rdiopque signs (Fig ) Where verticl root frcture is present prior to root filling, or occurs during the root filling procedure, extrusion of cement or root filling mteril cn occur into the frcture site or piclly. When the plne of the frcture is predominntly in ucco-lingul direction, the excess cement mteril cn e seen s more intensely rdiopque line s u p e rimposed over the root filling. 1 In some instnces, this cn give the ppernce of second cnl or n irregulrly oturted root cnl. Where the plne of the frcture is mesio-distl, the cement excess cn sometimes e seen s thin film extending proximlly from the root cnl filling to the root surfce. Where seprtion of the frcture occurs during root filling, extension of root filling mteril through the pex cn result in tngle of ccessory points t the pex ( picl spghetti ). P tterns of one loss Verticl frctures llow the ingress of cteri nd s s o c i ted irritnts which cuse loclized peri o d o n t l destruction nd one loss djcent to the frcture site. 6 The mount of one loss is dependent on the nture of the frcture nd the time the frcture hs een present. Rdiogrphiclly, there re certin specific ptterns of one loss which re found to e ssocited with verticlly frctured teeth. The rdiogrphic ppernce of the one loss is dependent on the extent of destruction, the plne of frcture nd the rchitecture of the one djcent to the frcture. Thus, the ppernce of one destruction seen when the frcture plne is ucco-lingul will e different from tht seen when the plne of the frcture is mesio-distl. Bone destruction ssocited with nterior teeth will e esier to see thn tht ssocited with lower molrs, where chnges re msked y thick uccl plte of one. Widening of periodontl ligment spce (Fig. 26) Wide enlrgement of the periodontl ligment round the whole length of the root is n indiction tht the tooth is verticlly frctured. The rdiogrphic ppernce of one loss is quite different from tht seen in peripicl lesion where picl one loss cn occur ut without destruction of the lmin dur long the root surfce. When the frcture is in ucco-lingul direction nd involves the picl portion, there is loss of one on the uccl nd lingul surfces of the tooth. Rdiogrphiclly, the tooth root cn e seen more clerly (or ppers more in focus ) thn djcent teeth. Widening of the periodontl ligment spce round the whole length of the root is clssic sign tht verticl root frcture is present. Rdiolucent hlos (Fig. 27) When the plne of frcture is t right ngles to the X-ry em, the pttern of one loss ppers wider nd more diffuse thn tht seen in ucco-lingul frctures. Pitts nd Ntkin 1 hve descried this ppernce s hlo-like rdiolucency running round the whole of the tooth. While the width of the diffuse one loss my vry, rdiolucent hlo which runs round the whole of the root surfce is clssic sign of verticl root frcture. Step-like one defects (Fig. 28) When the frcture runs oliquely cross the root, or where the frcture does not extend into the picl p o rtion, chrcteristic step-like one defect develops. 1,31 The width of the one loss cn vry. However, the depth of the step is governed y the picl extent of the frcture. The ppernce of step-like one defect on prticulr tooth is suject to the ngultion of the X-ry em. Additionl r d i o grphic exmintion with the X-ry em ngled 15 degrees to the mesil or distl my provide etter view of the defect. It must e rememered t h t step-like one defects cn mimic simple endodontic lesions resulting from other cuses, for exmple, post perfortions nd verticl grooves. Similr defects cn lso e ssocited with non-vitl teeth tht hve not een root filled ut such defects will include the pex. Step-like one defects re only sign tht frcture my e present. The presence of the frcture needs to e confirmed y other mens. Pitts nd Ntkin 1 hve suggested tht the possiility of frcture is incresed if the pocket extends to the mid-root level rther thn to the pex, s this elimintes picl pthology from considert i o n. Isolted horizontl one loss in posterior teeth (Fig. 29) It is unusul for one tooth in dentition to e severely involved with periodontl disese without involvement of other teeth. When only n isolted tooth shows ilterl horizontl one loss the presence of mesio-distl root frcture should e expected, prticulrly in the presence of pprently successful endodontic therpy, nd where the overll periodontl sitution is stle. Occsionlly, the sme rdiogrphic ppernce cn e seen where there is foreign ody wedged in the periodontium. Unexplined ifurction one loss (Fig. 30, 31) Bone loss in the ifurction region of molrs cn occur in ptients without overt periodontl disese in situtions where there is ingress of cteri through defects in the ifurction, for exmple, perfortions nd other defects in the pulpl floor. Bifurction one loss is lso seen in lower molrs with non-vitl pulps ut this is usully in ssocition with peripicl one loss. Where ifurction one 80 Austrlin Dentl Journl 1999;44:2.

7 Fig. 22. Wide seprtion of the frgments hs occurred in this verticlly frctured mxillry right cnine which is frctured mesiodistlly. Doule imges of the distl root surfce (rrows) re cused y overlpping of the frgments. Fig. 26. Peripicl rdiogrph of mxillry left lterl incisor showing widening of the periodontl ligment spce round the whole of the root. This is clssic sign tht root frcture is present. Fig. 27. Peripicl r d i o grph of mndiulr left first molr showing wide diffuse rdiolucent hlo round oth roots. The tooth ws frctured mesiodistlly. Rdiolucent hlos of this type re clssic sign tht verticl root frcture is present. Fig. 23. () Peripicl rdiogrph of recently root filled mxillry right cnine showing well condensed root filling with n irregulr outline. () Extrcted tooth showing verticlly frctured root. Fig. 24. Pe ripicl rdiogrph of root filled mxillry right first molr which suffered verticl root frcture. A thin film of cement (rr ows) is evident in the uccl root extending from the root filling to the root surfce. c Fig. 25. () Peripicl rdiogrph of root filled mndiulr left lterl incisor showing tngle of ccessory points in the picl portion (rrow). () Extrcted tooth showing the frctured root nd the tngled rry of ccessory points through the pex. Fig. 28. () Peripicl rdiogrph of hemisected lower molr showing good one dpttion to the distl surfce. () A step-like one defect hs developed on the distl in ssocition with verticl frcture in the root. (c) A peripicl rdiogrph tken t slightly different ngle revels tht the step-like one defect finishes t the level of the frcture. Austrlin Dentl Journl 1999;44:2. 81

8 Fig. 29. Isolted horizontl one loss occurring in ssocition with single isolted tooth, in n otherwise periodontlly stle mouth, is n indiction tht verticl root frcture is present. Fig. 32. () Mndiulr right first molr which hs een root filled nd restored with lrge mlgm restortion. Note the diffuse V-shped one loss (rrows) round the mesil root which is clssic sign tht root frcture is present. () Peripicl rdiogrph tken four months lter clerly shows mjor frcture with wide seprtion of frgments. Fig. 30. () Peripicl rdiogrph of mndiulr right first molr tooth showing unexplined one loss in the ifurction region. The lmin dur is intct piclly nd there is norml ttchment uclly nd lingully. () Clinicl photogrph of the tooth showing the mesio-distl frcture running cross the pulp chmer. A verticl frcture should e suspected if there is unexplined one loss in the ifurction region of the molr teeth. Fig. 33. Verticlly frctured second premolr tooth showing V-shped resorptive defect t the pex. The periodontl ligment spce is widened round the whole root. Fig. 31. () Peripicl rdiogrph of verticlly frctured mxillry left first molr shows one loss in the ifurction region of this molr. () In stright on view of the sme tooth, the lesion in the ifurction is msked y the pltl root. There is widening of the periodontl ligment spce round the mesio-uccl root. The lmin dur ppers to e intct round the tooth. This tooth ws frctured mesio-distlly. Fig. 34. Dislodgement of retrofilling mteril is sign tht root frcture my e present. This premolr ws treted surgiclly nd retrofilling mteril ws plced t the pex. () A peripicl rdiogrph tken prior to extrction shows the retrofilling mteril is no longer in plce. () This ptient returned with the mlgm restortion which hd een dislodged through the soft tissues. The existence of verticl root frcture is clerly evident. 82 Austrlin Dentl Journl 1999;44:2.

9 c Fig. 35. A verticl frcture should e suspected if there is rekdown of ony rchitecture which occurs susequent to the complete resolution of n endodontic lesion. () At the time of initil endodontic tretment the mndiulr left centrl incisor (rrows) is ssocited with peripicl lesion. () On review there hs een complete heling. (c) Six ye rs lter lesion hs developed. This tooth is oviously verticlly frctured. Note the resorption long the frcture line. Fig. 39. Where it is importnt to determine the type nd extent of the frcture, full thickness periodontl flp is recommended. Often single verticl incision one tooth distl or mesil to the suspect tooth is ll tht is required to expose sufficient root surfce to visulize the frcture (rrow). Fig. 36. The presence of verticl root frcture is clerly visile on the root fce. The post crown hs een dislodged. Fig. 40. Loss of one nd deposition of soft tissue djcent to the tooth root is usully found in the presence of root frcture. On this occsion, the frcture cn e seen s liner yellowish line in the mid-root region, running verticlly from crown to pex (rrow). Fig. 37. Gentle reflection of soft tissues under locl nesthesi is often ll tht is required to confirm the presence of verticl root frcture. Fig. 38. A tringulr miniflp involving single verticl incision () in the ttched gingiv on the side of the tooth wy from the proing defect or suspected frcture is reltively trumtic wy of exposing the coronl root surfce nd () of confirming the presence of suspected verticl root frcture. Fig. 41. Reflection of full thickness flp revels the full extent nd complexity of the root frcture in this centrl incisor tooth. Flp reflection is recommended to confirm the presence of verticl root frcture. Austrlin Dentl Journl 1999;44:2. 83

10 loss occurs for no pprent reson, nd without ny ovious sign of picl pthosis, the presence of verticl frcture through the ifurction needs to e considered. In mndiulr teeth, ifurction one loss is usully firly esy to see. In mxillry molr teeth, however, it is usully msked y the position of the pltl root. An olique ngle on the rdiogrph is necessry to ring the one loss into view. V-shped diffuse one loss on roots of posterior teeth (Fig. 32) Where the uccl roots of mxillry molrs or the roots of lower molrs re verticlly frctured, the chrcteristic rdiogrphic imge of one loss is diffuse V-shped rdiolucency, widest t the crestl one, nrrowing towrds the pex. 1 The shpe nd diffuse rdiogrphic evidence of the one loss is due to the fct tht much of the one lost is lingul to the uccl plte of one, which to some extent msks its presence. Diffuse one loss of this type, when confined to single root or single tooth in the mouth, is lmost pthognomonic of verticl root frcture. Resorption long the frcture line (Fig. 33) One of the presenting signs of verticl root frcture is resorption long the frcture line. 1,15 This resorption my occur piclly where it cuses V- shped notch in the picl region, or longitudinlly long the whole length of the frcture, giving the ppernce of n irregulr long resorptive defect running long the gutt perch root filling. Disintegrtion of root cnl seler, silver points nd gutt perch in ssocition with extensive resorption of the root hs een reported s eing feture of verticlly root frctured teeth. 15 Dislodgement of retrogrde filling mteril (Fig. 34) Dislodgement of retrogrde filling mteril in ssocition with verticl root frctures hs een d e s c ried previously. 1, 32, 33 Dislodgement of retrogrde root fillings cn occur due to indequte retention. 33 However, for the retrogrde root filling to e displced, some force usully hs to e pplied to move it wy from the root pex. Should retrogrde root filling ecome dislodged, likely cuse is verticl root frcture. In some cses the dislodged r e t r o grde root filling mt e ril cn e expelled through soft tissues. 32 Endodontic filure fter heling hs occurred (Fig. 35) Endodontic filure cn occur mny yers fter the tooth is root filled for lrge numer of resons. 34 Coronl lekge 35 is considered to e one mjor cuse of long-term filure of endodontic procedures. However, when the endodontic sttus of tooth d e t e ri o r tes rpidly fter long time without symptoms, or where rdiolucencies repper fter heling hs previously tken plce, verticl root frcture should e considered s cuse nd further investigtions of the tooth should e undertken with this possiility in mind. Direct visuliztion of the frcture While clinicl nd rdiogrphic signs gi ve resonly ccurte indiction tht root frcture is present, direct oservtion of the frcture is the only sure wy to confirm the presence of the frcture in mny cses. Where sufficient coronl structure hs een lost, or where crown restortion hs ecome dislodged, it my e possile to view the frcture directly y exmining remining tooth structure (Fig. 36). Where seprtion of frgments hs o c c u rred, the frcture spce is clerly evident. Where seprtion hs not occurred, shrp proe cn e used to identify the frcture. Should this not e possile, then gentle retrction of the soft tissues in the region of the suspected frcture line with flt plstic or other instrument (under nesthetic if required) my e sufficient to view the frcture on the root surfce (Fig. 37). Once the soft tissues re displced, the frcture often cn e clerly seen. Loction of the frcture cn e ssisted y pssing s h rp proe lightly over the tooth surfce. A clicking sound cn e herd s the proe is pssed over the frcture line. 1 Where this is not possile, reflection of smll flp is recommended in order to view the root nd confirm the presence of frcture. The simplest wy to do this is with tringulr miniflp. A single verticl incision cn e mde in the ttched gingiv on the side of the tooth wy from the proing defect or suspected position of the root frcture nd round the offending tooth only. This conservt i ve flp usully llows sufficient reflection of soft tissues to confirm the presence of most verticl root frctures (Fig. 38). Where the extent of the root frcture is importnt to determine, or where it is considered tht miniflp will not expose sufficient tooth structure, full thickness periodontl flp cn e used. In generl, verticl root frcture is esy to see once the flp is retrcted, p rticulrly if there is some seprtion of the frgments (Fig. 39). Its presence is lwy s ccompnied y loss of one nd the deposition of soft tissue djcent to the frcture. At the time of surgery, the ppernce of the frcture cn vry. Where the frcture is stined, visuliztion is esy. On mny occsions, however, sutle liner colour chnge (Fig. 40) is ll tht is pprent. Chnge in the ngle of lighting or the position of viewing is sometimes necessry to confirm the presence of the frcture. It is sometimes necessry to remove the soft tissue over the portion of the root eing exmined so the frcture cn e visulized. A fire-optic light is useful dignostic tool, prticulrly where the frcture 84 Austrlin Dentl Journl 1999;44:2.

11 is not stined, or where seprtion of frgments hs not occurred. It is proposed y these uthors tht, where possile, smll flp should e rised routinely to confirm the presence of frcture, r ther thn just to suspect tht one is present (Fig. 41). Tretment lterntives Once the presence of verticl root frcture is confirmed, the decision needs to e mde regrding the future tretment of the tooth. The discomfort ssocited with these frctures is often not cute, nd often ptients hve put up with discomfort for mny yers. Some re reluctnt to hve the tooth r e m oved, nd this is understndle from symptomtic point of view. However, it should e rememered tht while the frcture is present, one loss continues nd should the frctured tooth e left in plce indefinitely, the mount of one loss tht occurs my severely compromise the success of future restortive procedures nd my result in the need for complex periodontl surgery or ri d g e ugmenttion. It is, therefore, recommended tht root frctured teeth e removed s soon s prcticl. A numer of complictions hve een reported where verticl root frctures hve een left in plce for some length of time. 36,37 Tretment of verticlly frctured teeth is difficult nd is dependent on the tooth type s well s on the extent, durtion nd loction of the frcture. The mjority of verticl frctures involve the gingivl sulcus nd result in destruction of the periodontium to the picl extent of the frcture, due to ingress of cteri nd other irritnts, 6 resulting in lveolr one loss in lmost ll teeth. 30 Repir of the periodontium nd the one cnnot occur in the presence of the cteril infection. 1 The im of tretment is therefore to eliminte the frcture or the lekge of cteri long the frcture plne. 1 From tretment plnning point of view, distinction must e mde etween tooth tht is crcked nd tooth t h t is frctured. Where there is seprtion of frgments nd/or rdiogrphic chnges nd/or one loss ssocited with the root defect, ve rticl frcture cn e ssumed to e present nd elimintion of the crck is tretment priority. Where the tooth is crcked or crzed without one loss or ttchment loss the root is crcked. Conservtive mngement of these crcked root filled teeth is sometimes possile. Multirooted teeth cn often e successfully treted y resecting the frctured root, either y root m p u t tion or hemisection. 1, 38 Prognosis for posteri o r teeth is good, provided the frcture cn e removed in its entirety. Studies of root resected teeth hve reported five yer retention rtes of 94 per cent 39 nd ten yer retention rtes of 68 per cent. 40 A series of tretment options for posterior teeth involving hemisection nd root mputtion hs een descried in the literture. 1,7 In generl, prognosis for single rooted teeth is poor nd extrction is often the tretment of choice. However, mny cse reports re descried in the literture where innovtive ttempts to tret nd retin nterior teeth hve een ttempted with vrying success. Clinicins hve either removed the frctured segment or ttempted to ond the root using iocomptile mteril. Cynocrylte hs een used in n ttempt to ond the frgments of nterior teeth. 41 While the treted teeth were comfortle t 16 month followup, long-term prognosis ws considered poor due to deep pocketing nd resorption. An in vitro study 42 ssessing the resistnce to frcture of root segments onded with glss ionomer cement, composite resin, nd cy n o c ry l te concluded tht the ond strengths of composite resin nd cynocrylte were superior to glss ionomer cement. A numer of cse reports pper in the literture suggesting the use of glss ionomer cement in verticlly root frctured teeth. It hs een proposed tht glss ionomer cement my ond round the frcture line, p r e venting propgtion of the frcture. 43 G l s s ionomer nd mlgm condensed into the coronl hlf to two-thirds of the root cnl in teeth with incomplete verticl root frctures hs een reported successful t eight month follow-ups 44 ut long-term follow-ups hve not een recorded in the literture. Clcium hydroxide hs een used to promote tissue repir nd resolve osseous defects efore the roots were restored. Teeth treted with clcium hy d r oxide, then reinforced with glss ionomer cement, hve shown heling t six month follow-up ppointments. 14 Studies using n expnded polytetrfluoroethylene Gore-Tex memrne to estlish new periodontl ttchment fter the frgments hve een onded with glss ionomer cement hve reported differing results; six teeth filed in twelve month period. 45 Only one study hs reported success with this method of tretment. Trope nd Rosenerg 46 extrcted oth segments of mxillry second molr nd protected the periodontl ligment y soking it with Hnks lnced slt solution, while onding the segment with glss ionomer nd susequently replnting the tooth using Gore-Tex memrne to estlish new periodontl ttchment. After six months, they reported reduction in pocket depth from 10 mm to 2-3 mm. A crown ws plced fter one yer s the tooth ws functioning normlly. It cn e concluded from these results tht the use of glss ionomer cement in teeth with incomplete verticl root frctures my e n effective wy of treting the teeth on short-term sis. Long-term follow-ups hve yet to e reported on these teeth nd this tretment cn only e regrded s experimentl. Also, on lnce, the use of Gore-Tex memrne in s s o c i tion with glss ionomer onding of the frgments cn only e regrded s experimentl. It Austrlin Dentl Journl 1999;44:2. 85

12 m y e pprecited tht there is no point in ttempting such tretment in nterior teeth if there is not sufficient coronl tooth structure to llow for n dequte ferrule to hold the coronl tooth structure together. 47 Regenertion of one hs een shown to occur fter surgicl removl of the frctured segment from n nterior tooth, ut long-term follow-up ws shown to e unfvourle due to deep pocketing nd moility. 48 Successful three yer follow-up hs een reported where the frctured frgment ws removed in tooth without periodontl disese nd the remining root filling covered y n mlgm restortion. 49 Though the mjority of verticl root frctures re complete, frcture of only one side my occur. 6 In these instnces, complete removl of the frcture hs een proposed. 1 It hs een suggested tht in instnces where the gingivl sulcus is intct, the root cn e sectioned, mintining long evel nd eliminting the entire frctured segment. A fireoptic light source or the use of dye re vlule ids in ssessing the frcture lines. 31 D e s p i t e considerle loss of root length, provided plque control is dequte nd the entire frcture is eliminted, these teeth with reduced periodontium cn still hve good long-term prognosis. 1,50 Clims hve lso een mde for the successful conservtive tretment of verticl root frctures which originte piclly ut which do not involve the gingivl sulcus. Root extrusion 51 or intentionl replnttion in n extruded nd/or rotted position re possile. It hs lso een suggested tht if the frcture only involves the fcil wll, nd does not involve the gingivl sulcus, the frcture my e eliminted with the p r e p r tion of long mlgm restort i o n. 1, 18, 52 Vertucci 49 treted single tooth with n incomplete ucco-lingul verticl frcture y removl of the uccl segment, covering of the root cnl filling with n mlgm restortion nd treting the remining root surfces with 20 per cent citric cid solution for five minutes. The tooth ws considered functionl with no prole periodontl defects or rdiogrphic evidence of disese t three yer review. The dvntge in these procedures is tht the originl root length is mintined. It my e resonle to expect tht the frcture could still propgte to the lingul wll. The plcement of long uccl restortion my e indicted if resection of the tooth root in coronl dimension would not leve the tooth with dequte root support. Oviously, ny detection of lingul frcture would require evelling of the root s descried erlier. None of the ove procedures would e effective in the long term in the presence of contminted root filling. Thus, if such tretment is considered, re-root filling is indicted wherever possile. A numer of other cse reports discussing tretment lterntives hve een pulished. Tktsu et l. 53 used orthodontic elstics to join the uccl nd pltl segments of verticlly frctured mxillry second molr which were then seled with photocured resin liner to llow the tooth to e endodonticlly treted nd restored with cst crown. The tooth remined in function for more thn three nd hlf yers with reduction in pocket depth. Sini nd Krt z 48 d e m o n s t r t e d regenertion of one nd heling when the detched root segment, root cnl filling nd soft tissues were s u r giclly removed. Howe ver, long-term follow-up w s unfvourle due to deep pocketing nd moility. An in vitro study 54 proved CO 2 nd Nd:YAG lser to e n ineffective wy to fuse frctured tooth roots. Scnning electron microscopy reveled het - i n d u c e d fissures nd crcks, res of cementum rekdown nd seprtion of cementum from underlying dentine. Energy densities required to induce melting were considered excessive nd dmging to pulp tissue. At the present time, there does not seem to e ny justifiction for the use of lser to fuse frctured portions of tooth together. Conclusion Mny of the tretment options reported in this review hve involved extensive procedures on smll numers of teeth, often with poor outcomes. Where successful outcomes hve een climed, the longterm prognosis hs yet to e proven. All cse reports pulished so fr which descrie tretment rt i o n l e, do not include enough teeth to scertin the efficcy of ny procedure. There is room for further clinicl reserch on the tretment of teeth tht re verticlly root frctured. While there is no dout tht, with some posterior teeth, tretment procedures which successfully remove the frctured frgments completely (either y hemisection or root mputtion) cn result in long-term successful result, tretment of nterior teeth cn t est e regrded s experimentl. While it must e cknowledged tht ttempts to tret strtegic teeth in n effort to defer complicted or extensive restructure tretment 1 my e wrrnted, efore ny complex experimentl tretment procedures re considered, the desirility for retention of the tooth root should e crefully weighed up ginst extrction nd replcement with denture, ridge or implnt. Acknowledgements Prticulr thnks must e given to Dr John Myne for use of illustrt i ve mt e rils in this pper. Contriution of cses y Drs Gil Sherer, Ross P rry nd Grhme Brown is lso gr t e f u l l y cknowledged. 86 Austrlin Dentl Journl 1999;44:2.

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