VRF as an Endodontic Periodontal Lesion

The focus of this chapter will be on the diagnosis of vertical root fractures and the difficulties to achieve the accurate diagnosis and in timely manner. The AAE has stated in 2008 that, there are three very typical signs and symptoms for VR diagnosis of which when occurring together can be considered-pathognomonic, there are quite few difficulties nevertheless. They are: (1) the fact that not all the VRF cases manifest themselves as with the “athognomonic combination, " (2) the signs, symptoms, and radiographic manifestations are mimicking either periodontal disease or poor outcome of endodontic treatment, (3) no correlation can be found as to the location and extent of the root fracture and the signs, symptoms, and radiographic features, and (4) vertical root fracture in endodontically treated teeth is not clinically evident until infection occurs in the fracture site with ensuing emergence of signs and symptoms. A brief description of the nomenclature of chronic, longitudinal type of tooth fractures which is based on the initiation and propagation of the fracture will be presented. This part will be followed by a short summary of the complex etiology of these fractures thus making the prevention of such fractures very difficult. The pathogenesis of the vertical root fracture is the most important factor leading to the endodontic-periodontal involvement in these cases. When a longitudinal-bucco-lingual fracture occurs in the root, tissue remnants and bacteria tend to leave the root, formulate a biofilm, and reach the periodontal ligament. This is causing an inflammatory process in the soft tissue which increases as the fracture parts tend to separate as a result of the continuous occlusal pressure. At the same time, the cortical bone facing the fracture is resorbing quickly and a dehiscence in most of the cases follows. The bacteria which are dominant in these cases are mostly gram positive. Most of the time, the tooth or root that is involved with a vertical root fracture should be extracted, thus stopping the inflammatory process and the bone loss. However, management of the involved tooth is possible in some cases that can be achieved via surgical endodontics. A complete root amputation can be done in a multi-rooted tooth, or a procedure to shave some of the root eliminating the fracture, thus shortening one root but keeping the tooth with satisfactory function and esthetics.