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.

Time for an Implant

This patient was referred to my office today to finish the RCT on #5. I was obviously a little concerned about the restorability of the tooth. Since she traveled quite far, and her referring dentist had sent her, I went ahead and opened it up to take a peek.





This is what I found. (not surprising)

We discussed the options:

OPTION #1

1. RCT $800

2. Build-up $250

3. Crown Lengthening $700

4. Crown $800

Total $2550 with guarded/poor prognosis



OPTION #2

1. Extract $200

2. Implant $1800

3. Crown $1000

TOTAL $3000 with excellent prognosis

OPTION #3

1. Extract $200

2. Bridge $2400

TOTAL $2600 with excellent prognosis

It is obvious that an implant or bridge will have a better long term prognosis than trying to save this tooth with endodontic therapy, perio therapy & restorative therapy. This is a situation where I made a recommendation for extraction. Since #4 has a nice crown and #6 is a virgin tooth, if it were me, I would personally go with the implant option.

In my practice, I always try to give my patients the same treatment that I would want for myself or my family. I think we owe it to our patients to give them all of the options.

Catching a baseball with your teeth

This youngster tried to catch a baseball with his teeth. Tooth #9 was partially avulsed. Luckily his neighbor is a dental hygenist and knew to re-implant the tooth immediately. They called the general dentist and were at his office within 30 minutes of the accident. I got the call from the doctor to review the guidelines for treatment. As you can see, this is an immature root. Here are the guidelines for treatment of a tooth like this.

ON SITE TX:

• Immediately rinse/gently remove foreign objects. If unable to replant tooth at site of injury then use a transport media to get to dentist - milk, saline or saliva.


• If the tooth is not reimplanted, and a transport media is not used, the emergency treatment by the doctor must be done within 1 hour. (If the tooth is dry for greater than an hour, reimplantation by the dentist is generally not indicated)

AT DR'S OFFICE:

• Clean off affected area (water, saline or chlorhexidine) - don't extract tooth if it has been re-implanted.


• If the tooth is out of the mouth, prepare it for reimplantation by: cleaning with saline, soak in 1mg/20ml doxycycline, remove coagulum from socket with saline, reposition the socket wall if fractured, gently replant the tooth with finger pressure.


• Take radiograph to verify position


• Flexible splint (fishing line, mild steel wire)


• Antibiotic Rx: Doxycyline 2x/day for 7 days or Penicillin 4x/day for 7 days


• Tetnus booster

7-10 DAYS LATER:

• Remove splint


• Begin to monitor for re-vascularization (thermal testing baselines)

3-6 MONTHS:

• Continue to monitor - avoid endodontic treatment unless obvious signs of non-healing are present (pain, swelling, increasing radiolucency). It may take 3 months for the tooth to respond to thermal testing again.


• If endodontic treatment is necessary, follow guidelines for Apexification.

For more information regarding treatment of traumatic injuries: click here

Don't pull that tooth yet!

This patient came into our office complaining of pain on tooth #3. She reported that she had the RCT done within the last year, but it had never felt better. I'm sure that if she had walked into see an implant dentist, he would have pulled this tooth out faster than you can say "nobel biocare"! Fact of the matter, if we don't offer endodontic microsurgery in a case like this, we are doing our patients a real disservice.

After reviewing the apicoectomy and retrofill procedure, the patient wanted to try and save the tooth with an endodontic surgery. We resected the root, removed the extruded gutta percha, and placed an MTA retrofill.
















At the 3 month re-evaluation, complete apical healing of the osteotomy site is evident. The tooth is fully functional and asymptomatic.

For more case examples of endodontic surgery, including video of an apicoectomy - click here

Preventing Rotary File Separation

Anyone using rotary files will occasionally have a file separation. Here are a few tips to prevent rotary file separation.

1. Always create a glide path for the rotary file to follow. I like to use a #10 and #15 hand file
to length.
2. Ensure straight line access to prevent coronal stress on the rotary instrument.
3. Use a light touch with your rotary file. Don’t force them to cut.
4. Use a touch-retract motion. Don’t lean on the file.
5. Don’t rush the instrumentation. You know when you are doing that!
6. Watch for signs of any problems. Listen for clicking. Examine your files continuously. If you
see any signs of fatigue, chuck the file.
7. Replace your files sooner.
8. Practice - operator skill is a major factor in preventing separation.


For an extensive review on the prevention and management rotary file separation see:
Journal of Endodontics, Nov. 2006, 32:11, pp 1031-1043.