C L I N I C A L P R A C T I C E ABSTRACT

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Background. Early


detection and manage-

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COVER STORY ment of vertical root frac- A D A

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tures, or VRFs, remain a

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Vertical root fractures vexing issue that has A ING ED 1

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caused needless suffering for TICLE

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Clinical and radiographic patients as well as for dentists.

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The authors present techniques A to U
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diagnosis dentist in recognizing VRFs.
Methods. During a five-year period, the
ICLE

authors examined 36 patients who had

STEPHEN COHEN, D.D.S., M.A.; LUCIA BLANCO, VRFs. Absent control subjects and a larger
D.D.S.; LOUIS BERMAN, D.D.S. number of patients, the authors did not
design this investigation for statistical
analysis. They diagnosed VRFs through
ertical root fractures, or VRFs, usually are dental histories and clinical and radio-

V characterized by an incomplete or complete graphic examinations.

fracture line that extends through the long
axis of the root toward the apex1 (Figure 1).
Vertical root fractures represent between 2
and 5 percent of crown/root fractures, with the greatest
incidence occurring in endodontically treated teeth and
in patients older than 40 years of age.2
The cause of VRFs mainly is iatrogenic, resulting
from dental treatment excesses (for example, excessive
canal shaping, excessive pressure during compaction of
gutta-percha,3,4 excessive width and
Vertical root length of a post space in relation to the
fractures can tooths anatomy and morphology, or
excessive pressure during placement of
be detected
the dowel). 5-7
early by Trauma is the most likely cause of
listening to the VRFs in vital teeth, typically occurring
patients chief from physical trauma, clenching or
8(pp1,30)
complaints, bruxism, or occurring in teeth
undergoing apexification. 9
Early diag-
carefully
nosis of a VRF usually begins with gath-
examining
ering a comprehensive dental history,
radiographs listening well to the patient, asking
and performing many questions and encouraging the
a thorough patient to recall when the symptoms
8(pp1,30)
clinical first occurred.
examination. The purpose of this study was to show
clinicians how to identify the most
prominent clinical and radiographic
findings that might indicate a VRF, and how to differen-
tially diagnose the VRF from recurrent endodontic or
periodontal disease.
SUBJECTS, MATERIALS AND METHODS
During a five-year period (1996 to 2001) we conducted
an examination of 36 patients (25 women and 11 men)
Results. The study revealed VRFs in
36 teeth, two of which were vital and 34 of
which were nonvital (that is, endodontically
treated). The 34 VRFs resulted from exces-
sive operative procedures performed in the
root canal after endodontic therapy. Thirty-
one of these 34 VRFs were caused by poorly
designed dowels (too long, too wide or both)
or inappropriate selection of the tooth as a
bridge abutment; two VRFs were caused by
a restoration that exerted lateral pressure
on the axial walls of the preparation; and
one VRF was caused by overzealous
endodontic forces. The VRFs in the two
vital teeth were in men who had a history of
bruxism or clenching.
Conclusions and Clinical
Implications. VRFs can be detected
early by listening to the patients chief com-
plaints, carefully examining periapical and
bitewing radiographs and performing a
thorough clinical examination.
with 36 teeth having VRFs. The mean
age of patients was 52 years, with a
range from 40 to 65 years. We observed
VRFs in 34 endodontically treated teeth
that had been restored with dowel
cores; two of these teeth had been
restored with glass ionomer cement and
resin-based composite. We observed
VRFs in two vital teeth; the dental his-
tory of these patients revealed that they
had destructive parafunctional habits

434 JADA, Vol. 134, April 2003

Copyright 2003 American Dental Association. All rights reserved.
 C L I N I C A L P R A C T I C E

Figure 1. Radiograph from a 52-year-old man showing a

vertical root fracture in a second maxillary premolar
serving as a bridge abutment. Note the periradicular,
radiolucent halo along the mesial aspect (arrows).

(that is, clenching or bruxing). Absent control

subjects and a larger number of patients, we did
not design this investigation for statistical
analysis.
We made the diagnosis of VRFs through the
patients dental history and clinical and radio-
graphic examination findings. A thorough clinical
examination was performed, which included the Figure 2. A no. 25 gutta-percha cone placed into the sinus
following: age of patient; pulp vitality; type of tract of a 45-year-old woman. Note that the cone follows
the periodontal ligament, which strongly suggests a ver-
restoration (with or without post and crown) tical root fracture.
using glass ionomer cement, resin-based com-
posite or amalgam; degree of pain, if any; pres-
ence or absence of swelling; presence or absence nosis between a VRF and periapical or peri-
of sinus tract; depth and extent of any peri- odontal pathology (Figure 2).
odontal defects; degree of mobility When extraction was indicated,
(within normal limits, mild, mod- we macroscopically examined the
The 34 vertical
erate or severe); and any history of roots to determine the type of VRF
post or restoration dislodgement or root fractures in (that is, incomplete or complete).
oral trauma. the nonvital teeth
In addition, we noted radio- RESULTS
resulted from
graphic findings, which included excessive operative We observed VRFs in 36 teeth, two
the following: thickening of the procedures performed of which were vital; the other 34
periodontal ligament, or PDL; peri- were nonvital (endodontically
in the root canal after
radicular halo radiolucency; loss treated). The 34 VRFs in the non-
of attachment apparatus seen as a endodontic therapy. vital teeth resulted from excessive
deep, narrow, isolated periodontal operative procedures performed in
pocket; and a separation (or not) of the root canal after endodontic
the root fragments. therapy. Thirty-one (91 percent) of these 34 VRFs
We noticed that when swelling and a sinus were due to poorly designed dowels (too long, too
tract were observed, a no. 25 gutta-percha cone wide or both) or the inappropriate selection of the
placed into the sinus tract may have run parallel tooth as a bridge abutment; two VRFs (6 percent)
to the PDL, often only tracing to the middle of were due to a restoration that exerted lateral
the root as opposed to the apex. In such cases, pressure on the axial walls of the preparation;
one might reasonably suspect a VRF, thus and one VRF (3 percent) was due to overzealous
enabling the clinician to make a differential diag- endodontic forces. The VRFs in the two vital

JADA, Vol. 134, April 2003 435

Copyright 2003 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
Figure 3. A. Radiograph of a second mandibular premolar serving as a bridge abutment in a 49-year-old woman. Note
the periradicular halo surrounding the root. B. Separated root fragments after extraction.
Figure 4. Radiograph from a 42-year-old woman with a
vertical root fracture in a maxillary lateral incisor. Note
the excessive canal shaping and large dowel. Radiograph
shows the presence of a radiolucent halo on the distal
aspect of the root, with bone loss (arrow).
436 JADA, Vol. 134, April 2003
Copyright 2003 American Dental Association. All rights reserved.
teeth were in men who had a history of bruxism
or clenching.
In this investigation, we found VRFs in the fol-
lowing locations:
d12 maxillary premolars (33.3 percent) (nine of
which were bridge abutments);
d11 mandibular premolars (30.6 percent) (eight
of which were bridge abutments);
dnine mesial roots of mandibular molars
(25 percent);
dtwo maxillary lateral incisors (5.6 percent);
dtwo maxillary canines (5.6 percent).
In the 36 teeth we examined, it appeared that
when premolars were used as bridge abutments,
a surprising number of these abutments sus-
tained a VRF. We believe this may be because
these roots have a narrow mesiodistal dimension.
When the dowel in a restored tooth (whether cast
or preformed) becomes dislodged more than once
(and the post and crown are well-designed), this
strongly suggests the likelihood of a VRF (Figures
3 through 5).
The clinical examinations and discussions with
patients revealed that the most common signs
and symptoms associated with endodontically
treated teeth with VRFs were pain, swelling and
the presence of a sinus tract or a deep, narrow,
isolated periodontal pocket along one surface of
the tooth. The most common radiographic find-
ings were thickening of the PDL (Figure 6, page
438); deep, localized, vertical bone loss; and local-
ized periradicular bone loss (that is, the halo
effect). If the demineralized area of bone loss (the
halo) completely surrounds the root, this typically
indicates that the root fragments are completely
separated and a VRF has developed (Figure 3).

We found VRFs in vital teeth of two patients
who complained of occasional pain when drinking
a cold liquid in teeth with no restorations (or with
shallow restorations), pain with lateral percus-
sion and occasional pain while chewing.
DISCUSSION
Complete or incomplete VRFs constitute an on-
going problem in dentistry because they are diffi-
cult to diagnose in the early stages. In most cases,
tooth extraction is the only reasonable treatment
when the VRF is finally diagnosed. (Early detec-
tion in a multirooted tooth might allow timely
Copyright 2003 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
Figure 5. A. Preoperative radiograph from a 52-year-old
woman who had complained of pain and swelling. Note
the dowel, periapical radiolucency and loss of attachment
apparatus. B. After removal of the dowel, the vertical
root fracture with separated root fragments was visible.
C. Radiograph after the dowel was removed.
removal of the broken root and possible retention
of the remaining portion of the tooth.) Commonly,
patients complain that ever since they bit down
on something hard (such as a popcorn kernel,
cherry pit or piece of bone), they felt a jolt of pain,
and may state that since then, the tooth just
never felt right. In the early stage, patients may
notice a mild discomfort when biting or
chewing,8(pp1,30) or pain with lateral percussion. In
the more advanced stage, patients commonly
have noticeable gingival swelling, moderate pain
(with or without a sinus tract) or both. In these
cases, the prognosis is unfavorable and tooth
extraction clearly is indicated.1-8(pp1,30)9,10
Etiology. Factors in the development of VRFs
may include one or more of the following:
Excessive canal shaping. Excessive canal
shaping during endodontic treatment, especially
in teeth with curved roots that are narrow in the
mesiodistal plane (that is, the danger zone) can
JADA, Vol. 134, April 2003 437
C L I N I C A L P R A C T I C E

ment. Choosing an inappropriate tooth for a

Figure 6. Radiograph from a 51-year-old woman who had
complained of pain while chewing. Note the thickening of
the periodontal ligament along the distal aspect of the
root (arrow).
lead to development of a VRF.11 This is why max-
illary second premolars, mesiobuccal roots of
maxillary molars, mesial roots of
mandibular molars and mandibular
premolars are most prone to VRFs. A comprehensive,
In our patients, we found that VRFs detailed dental
were present less frequently in history typically yields searching for a crack.
maxillary lateral incisors and max-
the initial clues
illary canines1-8(pp1,30),9,10 (Figures 3
through 5). In addition, excessive suggesting
removal of tooth structure con- root fracture.
tributes to the overall weakening of
the tooth, which promotes a higher
incidence of VRFs.
Excessive hand pressure. Excessive hand pres-
sure during lateral or vertical compaction of
gutta-percha can result in development of a
VRF.3,4
Excessive restorative procedures. When
preparing a canal to place a dowel, the clinician
must ensure that the width and length of the
dowel space are appropriate for the anatomy of
the canal to avoid weakening the walls by making
them too thin. Furthermore, a dowel must be
cemented passively (that is, avoiding pressure
that may wedge the dowel into the canal, thus
splitting the root), because the cement produces
hydrostatic pressure in the root canal that may
lead to the development of a VRF.7 In addition,
tapping a dowel or cast intracoronal restoration
into place may contribute to the development of
VRFs.
Inappropriate choice of tooth for a bridge abut-
bridge abutment may contribute to the develop-
ment of a VRF (for example, mandibular incisors
with a 1:1 crown/root ratio or the inappropriate
use of a tooth to support a cantilever).5,6,12,13
Several studies4-6 have been conducted
regarding whether post-retained restorations
have the potential effect of weakening the root
and predisposing the tooth to VRFs.6
Some VRFs may begin with an incomplete
VRF. Cameron14 described this initial crack
(known as cracked tooth syndrome) as a break or
split in the continuity of the root surface without
a perceptible separation.
Diagnosis. The patient initially may complain
of a sharp pain during chewing or biting of hard
food, as well as occasional pain on consumption of
cold food or drinks, because the dentin (and some-
times the pulp) is affected by the VRF.8(pp1,30) This
is seen more frequently in teeth with large resto-
rations, especially molars,15,16 which involve the
dentin (and sometimes the pulp), thus differing
from small enamel fracture
lines.8(pp1,30) By removing the restora-
tion, the clinician can perform a
direct visual examination while
15-17
The ridges
of the mesial and distal margins
should be evaluated carefully, since
a vertical these areas are most predisposed to
crack.
A comprehensive, detailed dental
history typically yields the initial
clues suggesting a VRF.9 Further-
more, strong coaxial illumination along with good
magnification are essential to identify a VRF.
With this foundation, clinicians can conduct the
following tests.8(pp1,30)15-17
Bite test. To reproduce the biting and chewing
pain described by the patient, the dentist may use
rubber wheels, cottonwood sticks or some other
elements (such as Tooth Slooth fracture detector,
Professional Results, Laguna Niguel, Calif.) to
replicate masticatory motion. This test can be
performed tooth-by-tooth or cusp-by-cusp. When
the patient responds with pain, the dentist should
inquire if the pain is similar to his or her chief
complaint.
Transillumination test. Shining a strong fiber-
optic light through the tooth (providing there is no
restoration to block light transmission) in a hori-
zontal direction at the gingival sulcus may help
the clinician visualize a crack. If he or she finds a

438 JADA, Vol. 134, April 2003

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Figure 7. The presence of a vertical root fracture some-
times can be observed using transillumination. As this
figure illustrates, the part of the tooth closest to the light
source will transmit light, but the root fracture will
inhibit most of the light from reaching the part of the
tooth beyond the root fracture.
crack in the tooth, the light will be deflected at the
crack, reducing its transmission through the
tooth, and the fractured segment on the other side
of the crack will appear darker (Figure 7).
Periodontal probing test. Careful probing with a
thin periodontal probe or a no. 25 silver cone may
reveal a narrow, isolated, periodontal defect in the
gingival attachment. In the absence of any other
associated periodontal disease, this narrow defect
is consistent with an underlying bony dehiscence
that is secondary to a VRF. To visually illustrate
the problem for the patient, the dentist can expose
a radiograph with the periodontal probe or a
silver cone placed in the defect. This enhanced
documentation also may be helpful if any ques-
tions later arise regarding the diagnosis of a VRF
(Figures 8 and 9).
Remove all restorations. There is no substitute
for direct visualization, with good illumination
(via fiber optics) and magnification ( 3.5).
Pulp testing. Vitality tests (that is, electrical,
thermal or laser Doppler flowmetry8(pp1,30)) can
be helpful in diagnosing a VRF, especially in
ostensibly sound teeth. When the patient com-
plains of a sharp, sudden pain, especially while
chewing, pulp testing provides valuable diagnostic
information.8(pp431-6) Often, the fracture is incom-
plete but extends to the pulp, where it eventually
causes necrosis. A nonvital tooth that is intact or
has a minimal restoration is highly suggestive of a
VRF (Figure 10).
Staining. The use of disclosing dye (for
Copyright 2003 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
Figure 8. As this figure illustrates, when probing a ver-
tical root fracture, or VRF, the dentist typically finds a
deep, narrow, isolated periodontal pocket over the bony
dehiscence that was created secondary to the VRF.
example, a blue or green vegetable dye) helps the
clinician visualize a suspected crack.
Radiographic examination. Although essential,
radiographic images do not always reveal a VRF.
Unless the X-ray beam is parallel to the fracture
line ( 4 degrees), the root fracture will not be
revealed.18
Surgical exploration. Surgical exploration may
be advisable if a VRF is strongly suspected, but
cannot be confirmed by other available tech-
niques. (This consists of lifting a full-thickness
flap and examining the bone and root directly
with high-magnification and illumination.) There
is no substitute for direct visualization if the diag-
nostic and prognostic assessment remains
questionable.
Prognostic assessment. From our experience,
the progression of a vertical crown fracture that is
in an early stage (that is, it has not reached the
pulp chamber or the furcation of a multirooted
tooth) may be slowed or arrested by drilling out
all evidence of the fracture line and restoring the
tooth with a bonded restoration.19,20 However, the
clinician should advise the patient that the prog-
nosis will remain guarded.
When a coronal crack crosses both marginal
ridges and produces a split tooth,15 and when that
split extends apically into the root, the prognosis
is poor and extraction often is required. Imma-
ture, pulpless teeth that previously have under-
gone apexification treatment may have thin walls
that might result in a greater potential for devel-
JADA, Vol. 134, April 2003 439
C L I N I C A L P R A C T I C E
Figure 9. A. Radiograph of a nonvital mandibular pre-
molar with a cast inlay. B. A narrow, isolated, deep peri-
odontal pocket found on probing. C. On extraction, a
fracture was observed (arrows).
opment of a VRF.9
Even with its intrinsic limitations, the radio-
graphic examination is one of the most important
methods for accurately diagnosing a VRF.8(pp1,30)
When the VRF is at an early stage, it often is
440 JADA, Vol. 134, April 2003
Copyright 2003 American Dental Association. All rights reserved.
Figure 10. A. Radiograph of a nonvital mandibular second
molar with a minimal restoration. B. After the tooth was
sectioned, a fracture was seen extending into the pulp
(arrows).
possible for the radiographic examination to
reveal a thickening of PDL along one side of the
root (Figure 6). As the VRF advances, a radiolu-
cent halo of bone loss is observed along one side of
the root. As the VRF advances further, the radio-
lucent halo may surround the entire root. This
halo indicates that the root fragments have sepa-
rated completely, along with the attached PDL;
often, there is an associated deep pocket and loss
of additional supporting bone8(pp1,30),21,22
(Figures 3, 8 and 9).
In our patients, we noticed that when swelling
and a sinus tract were observed, a no. 25 gutta-
percha cone placed into the sinus tract may follow
(that is, run parallel to) the PDL. When observed,
one may reasonably suspect a VRF, thus pro-
viding a technique to differentiate between a VRF
and periapical or periodontal pathology (Figure 2).
VRFs sometimes may be misinterpreted as being
recurrent endodontic or periodontal disease if the
clinician is not alert to the possibility of a VRF.

The clinician should be aware that when a
deep, narrow, isolated periodontal pocket is asso-
ciated with the affected tooth, a VRF is the most
likely cause. However, when periodontal disease is
present, there are several deep and wide peri-
odontal pockets usually affecting several teeth
(Figure 8).
Clinicians should suspect a VRF when a dowel
dislodges more than one time. Some authors have
suggested that the tooth with a VRF should be
extracted; the root fragments should then be
repaired via bonding with an adhesive resin
cement; and the tooth should then be
replanted.23,24 However, we could find no long-term
follow-up studies in the literature to substantiate
this approach. Therefore, in the presence of a
VRF, extraction is still the treatment of choice.
If a VRF develops in a multirooted tooth with a
healthy attachment apparatus, the dentist might
consider root resection, thus allowing a portion of
the tooth to be preserved.11-14 In the single-rooted
tooth, however, extraction is the only treatment
option at this time.
For patients who brux or clench, nightguards
afford some protection to minimize the risk of
VRFs.
CONCLUSION
VRFs present a challenge to the clinician in that
the diagnosis often is difficult, and is based on
some subjective parameters. It is important to
recognize the sometimes subtle findings to prop-
erly inform patients, so that they have a better
understanding of their prognosis and the poten-
tial for successful treatment.
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