Endodontic Miscellany : 1.

An unusual vertical root fracture

Dua K K* Kundabala M** Bhat KS***

Introduction
Vertical root fractures have been described as longitudinally oriented fractures of the root, extending from the root canal to the periodontium.1 Vertical root fractures represent 2-5 % of crown/root fractures, with the greatest incidence occurring in endodontically treated teeth and in patients older than 40 years of age2. Leubke 3 described two types of root fractures based on the separation of the fragments: Where total separation is visible or fragments can be moved independently. This is defined as a complete fracture. An incomplete fracture is said to occur in the absence of visible separation.

mainly iatrogenic, attributable to dental treatment such as excessive canal shaping, excessive pressure during compaction of gutta percha, 7-8 excessive width and length of a post space in relation to the tooths anatomy or excessive pressure during placement of dowel9-11. The clinical presentation of vertical root fracture is extremely variable. The clinical signs and symptoms vary according to the position of the fracture, tooth type, time elapsed since fracture, periodontal condition of the tooth and the architecture of the bone adjacent to the fracture. Local chronic infection leads to a variable combination of discomfort and soreness, mild to moderate pain, pain on biting, bad taste, swelling of soft tissues, sinus tract and deep, narrow, isolated periodontal pockets.12 Radiographs may reveal the existence of a fracture line, separated root fragments, space beside a root filling, double images of external root surface, bone destruction, widening of periodontal ligament, radiolucent halos which may mimic periodontal disease. The purpose of this paper is to present a case of vertical root fracture in an endodontically treated mandibular second premolar in which the displaced fractured fragment appeared in the radiograph like an additional root which is unusual for a lower premolar.

In addition, Luebke 3 has defined root fractures relative to the position of the alveolar crest. He suggests that intra osseous fractures (i.e., those terminating below the level of the alveolar bone) will result in periodontal problems whereas supra osseous fractures would not. Root fractures may originate at coronal tooth structure or at the apex. The vertical root fracture may involve the whole length of the root or only a section of it and may involve only one or both sides of the root.4-6 The cause of vertical root fractures is
* Post Graduate Student ** Professor, *** Former Dean and Professor Emeritus, Department of Conservative Dentistry and Endodontics, College of Dental Surgery, Manipal Academy of Higher Education Manipal - 576104, India

Case Report
A 45-year-old woman presented to the clinic, complaining of occasional pain on biting and pus exudation of 6 months duration from the lower right posterior region. She gave the history of root canal therapy in the lower right 23

Endodontology, Vol. 16, 2004

Fig. 1. Periapical radiograph showing an appearance of an additional root towards distal. Note acceptable obturation in one canal, complete obliteration in additional root and oblique bone loss on the distal surface of mandibular premolar.

loss around all the maxillary and mandibular teeth and also the right second mandibular premolar appeared to be two-rooted (Fig 1). Intra oral periapical radiograph revealed a tworooted second premolar with one canal acceptably obturated. There was evidence of an unfilled additional root, the canal of which seemed to be calcified. A 1.4 x 1.1 cm radiolucent area was noticed at the apices of both the roots. Oblique bone loss was evident in relation to the distal surface of the tooth, which confirmed the presence of a deep infrabony pocket (Fig 1) Since the prognosis of the tooth was poor for a conservative approach, owing primarily to severe periodontal destruction, the tooth was extracted under local anaesthesia. Examination of the extracted tooth revealed a complete vertical root fracture extending from mesial to distal surface across the pulp chamber and extending up to the apical foramen. It was also seen that it was the smaller buccal fragment, which had got displaced. (Fig 2 and 3)

mandibular second premolar and placement of an amalgam restoration two years back, elsewhere. The tooth was examined clinically and radiographically. Periodontal probing revealed generalized 5-6 mm pockets around all the teeth and an isolated deep pocket 910mm adjacent to the distolingual surface of the involved tooth. The tooth showed a grade II mobility. Clinical examination after removing the amalgam restoration revealed a fracture line, which was visible on the disto buccal angle of the tooth near the gingival margin. Orthopantomogram (OPG) was taken in order to evaluate the general periodontal status and an intraoral periapical radiograph for the involved tooth. OPG revealed generalized bone

Discussion
Vertical root fractures are a diagnostic enigma for the clinician, since often they are symptom-free or may present with mild pain and discomfort. Such fractures have, therefore,

Fig. 2. Separated root fragments after extraction. Note the evidence of granulation tissue in larger fragment and root canal space in smaller buccal fragment.

Fig. 3. approximated fractured fragments revealing a complete vertical root fracture.

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Dua KK et al.

Vertical root fracture...

been confused with periodontal disease since the symptomatology of both conditions at presentation has considerable similarities. Objective evaluation may reveal periodontal breakdown, soft tissue inflammation, swelling, suppuration, fistulas, sinus tracts or presence of periapical radiolucencies. Radiographs too fail to disclose vertical root fracture during the initial stages as the angulation used while taking the radiograph may obscure the fracture line. Even in the later stages, a radiograph may just show bone loss. The vertical fracture may be complete or incomplete, may or may not include the root canal, and may extend from one surface to another. The case under discussion revealed almost all the typical features of vertical root fracture, which have previously been described by Moule and Kahler12. In addition, appearance of an unusual additional root of mandibular first premolar on the radiograph complicated the diagnosis and treatment planning in this case. The fracture line extending mesio-distally was recognized only on clinical examination after removal of amalgam restoration. It was not recognized radiographically due to its orientation, which was mesio distal. The fracture might have occurred during or after endodontic instrumentation. The cause of fracture in this case may be attributable to either overzealous endodontic cavity preparation, excessive lateral and vertical forces of root canal obturation using gutta percha, inadequate post endodontic restoration or excessive occlusal trauma. This unusual feature in the radiograph can only be due to gross displacement of the fractured fragment, which occurred over a period of time. Such a displacement can be due to the formation of granulation tissue between and around the fragments, which must have gradually pushed the fractured segments apart13. The prognosis of a tooth with vertical root fracture, especially in cases of single rooted 25

teeth is usually unfavorable. Because of extensive bone loss and uncertain prognosis, extraction may be the only choice of treatment, as was done in this case.

Conclusion
Vertical root fracture poses a difficult diagnostic challenge. Clinical diagnostic tests include trans-illumination, bite test, dye test etc. Most often radiographs fail to disclose vertical root fractures. Often, a conclusive diagnosis is arrived at only by surgical method. This case throws light on the importance of careful manipulation and tissue handling during endodontic therapy, the importance of appropriate post endodontic restorations and difficulties in diagnosing such cases complicated by possible radiographic misinterpretations.
Acknowledgments The authors acknowledge Dr. Keerthilata M. Pai, Professor of Oral Medicine and Radiology, Dr. K. M. Bhat, Professor of Periodontics and Dr. Arvind Garg for their help and support.

References
1. Pitts DL, Natkin E. Diagnosis and treatment of vertical root fractures. J Endod 1983; 9:338-346. 2. Fuzz Z, Lusting J, Katz A, Tamse A. An evaluation of endodontically treated vertical root fractured teeth: impact of operative procedures. J Endod 2001; 27:46-8. 3. Leubke RG. Vertical crown-root fractures in posterior teeth. Dental Clin North Am 1984; 28:883-894. 4. Holcomb JQ, Pitts DL, Nicholls JI. Further investigation of spreader loads required to cause vertical root fracture during lateral condensation. J Endod 1987; 13:277-284. 5. Walton RE, Michelich RJ, Smith NG. The histopathogenesis of vertical root fractures. J Endod 1984; 10:48-56. 6. Schetritt A, Steffensen B. Diagnosis and management of vertical root fracture. J Can Dent Assoc 1995; 61:607-613. 7. Let Chirakarn V, Palamara JE, Messer HH. Load and strain during lateral condensation and vertical root fracture. J Endod 1999; 25:99-104.

Endodontology, Vol. 16, 2004 8. Silver Thom MB, Joyce TP. Finite element analysis of anterior tooth root stresses developed during endodontic treatment. J Biomech Eng 1999; 121:108-15. 9. Yang HS, Lang LA, Molina A, Felton DA. The effects of dowel design and load direction on dowel and core restorations. J Prosthet Dent 2001; 85:558-67. 10.Felton DA, Webb EL, Kanoy BE, Daugoni J. Threaded endodontic dowels: effect of post design on incidence of root fracture. J Prosthet Dent 1991; 65:179-87. 11. Morando G, Leupold RJ, Meiers JC. Measurement of hydrostatic pressure during simulated post cementation. J. Prosthet Dent 1995, 74:586-90. 12.Alex J Moule, Bill Kahler. Diagnosis and management of teeth with vertical root fractures. Aust Dent J 1999; 44:75-87. 13.Meister F Jr, Lommel TJ, Gerstein H, et al. An additional clinical observation in two cases of vertical root fracture. Oral Surg Oral Med, Oral Pathol 1981; 52:91-96.

2. Mandibular first premolar with three canals

Moayedi S* and Lata DA**

Introduction
Root canal therapy requires a thorough knowledge of root canal morphology to adequately clean and shape the canal system.10 It is generally recognized that the incomplete instrumentation and cleansing of root canals will lead to endodontic failure4,5. Frequently root canals are left untreated because the clinicians fail to identify their presence, particularly in teeth that have anatomical variations or additional root canals (Slowey 1979), before the root canal treatment is performed. Therefore, the clinician should be aware of the configuration of the pulp space of the tooth that is to be treated4,5,11. The internal anatomy of a canal system may demonstrate fins, isthmuses, lateral and accessory canals, or diverse canal shapes. An investigation of the lateral surface of root may separate the canal into the multiple canal systems. Incomplete cleaning and shaping of these areas may leave tissue, bacteria, or necrotic debris in the canal. The presence of these irritants can result in
* Post graduate student ** Professor and Head Deptt. of Conservative Dentistry and Endodontics M.R. Ambedkar Dental College and Hospital Bangalore 560-005, Karnataka, India

persistent periapical inflammation and failure of root canal treatment10. The root canal system of mandibular first premolar can be particularly difficult to clean and shape . Ingle stated that the canal anatomy might account for greater increase in endodontic failure of this tooth. Slowey reported that mandibular premolars are possibly the most difficult teeth to treat endodontically due to wide variation in root canal morphology10. Vertucci described five different types of canal configuration for mandibular first premolar.10,14 Muller reported that root canals in mandibular first premolars were usually quite round and conical, but inclined to be ribbon like in the cervical third of the root. He also reported that if the canal is very wide buccolingually, it can suddenly narrow into bifurcation, making two very small canals10. Ingle described the shape of the canal as ovoid at the cervical level , round or ovoid at the midroot level and round at the apical third2.

Case Report
A 35 year old woman was referred for root canal treatment of her right, first and second permanent mandibular premolars. Her medical history was found to be non- contributory. The patients chief complaint was pain in 26