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An unusual vertical fracture of the root
CLINICAL ARTICLES
An unusual vertical fracture of the root P. C. Makkes, DDS, PhD, and T. lZolmer, DDS, Amsterdam, The Netherlands
Fractures of the root are described as fractures involving dentin, cementum, and the pulp. A c c o r d i n g to Andreasen, ~ fractures of the root are u n c o m m o n a m o n g d e n t a l injuries and comprise 1~ to 7~7~ of injuries that affect p e r m a n e n t teeth, t:ractures of the root usually occur in the region of the m a x i l l a r y central incisors and most c o m m o n l y occur in persons 1l to 20 years old.' Usually, the fracture surface forms an oblique angle with the l o n g i t u d i n a l axis of the tooth. Vertical fractures of the root are those in which the fracture line is more or less parallel to the long axis of the root?' This report describes an unusual kind of vertical fracture of the root. CASE REPORT A 33-year-old w o m a n asked a dentist to replace two acrylic crowns on the maxillary central incisors for esthetic reasons. She had been involved in a car a c c i d e n t when she was 10 years old, a n d e n d o d o n t i c treatment was done on both teeth at that time. In 1972, the two acrylic crowns were made. As a r e p l a c e m e n t for the acrylic crowns, dowels with crown extensions a n d porcelain jacket crowns were m a d e in 1975 for both teeth. T w o years later, in O c t o b e r 1977, the p a t i e n t h a d a painful swelling in the p a l a t a l region of the right central incisor. An extensive p e r i o d o n t a l pocket with a d e p t h of 10 to 11 m m could be measured on the mesial a n d lingual aspects of the right central
Fig l-Radiograph two.),ears after replacement of aco'lic crowns. Notice depth of pocket illustrated by gutta-percha cone placed in pocket. Fracture line visible near arrow.
incisor (Fig 1). No o t h e r pockets could be measured in the region of the maxillaD" and m a n d i b u l a r incisors a n d canines. T w o m o n t h s later, the right central incisor was extracted, a n d a t e m p o r a r y bridge was c e m e n t e d in place. T h e extracted root showed an irregular surface with a steplike ledge along the m a i n part of the p a l a t a l aspect of the tooth (Fig 2). T h e apical foramen was wide, a n d the formation of the root a p p e a r e d stunted. F o u r months later, when the patient returned for the p r e p a r a t i o n
Fig 2-Top, extracted root shows irregular surface. Notice steplike ledge (arrow). Bottom, peel-like root.fragment, approximately 10 • ,5 • 1.5ram.
of the p e r m a n e n t restoration, she c o m p l a i n e d a b o u t a c o n t i n u i n g tenderness of the labial and p a l a t a l mueosa at the site of extraction. A sinus tract on top of the alveolar ridge was discovered, a n d a radiog r a p h was taken. W h i l e the sinus tract was being probed, a h a r d ohiect was felt. A thin, peel-like fragment of the root, firmly a t t a c h e d to the alveolar bone with fibrous tissue (Fig 3), was removed surgically. T h e frag315
IOURNAL OF ENDODONTICS
VOL 5, NO 10, OCTOBER 1979
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m e n t was composed of d e n t i n a n d c e m e n t u m (Fig 4). After the fragment was removed, healing of the w o u n d proceeded u n d i s t u r b e d .
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DISCUSSION T h e formation of the root seemed to match the stage of d e v e l o p m e n t of the patient's tooth at the time the accident occurred. T h e fracture described can be classified as u n u s u a l because the pulp was not involved, a n d only a relatively thin b u t large strip of d e n t i n and c e m e n t u m was fractured vertically from the body of the root. A possible e x p l a n a t i o n for the development of the deep pocket after so m a n y years is that the most coronal margin of the fracture was situated apically to the epithelial a t t a c h m e n t of the tooth. It seems likely that, after the p r e p a r a t i o n and placement of the dowel a n d new jacket crown, the epithelial attachm e n t moved apically just enough to reach the coronal part of the fracture line. As a result, microorganisms from the gingival crevice invaded the fissure, and a chronic abscess associated with vertical loss of bone a n d an extensive and deep periodontal pocket developed. As described by different authors, :-'~ vertical loss of bone a n d a periodontal pocket to the apical extent of a fracture line a p p e a r to be the result of a vertical fracture of the root which c o m m u n i cates with the oral cavity. T h e case described suggests that, when an extensive a n d deep period o n t a l pocket is found in a m o u t h otherwise relatively free of periodontal disease, the clinician should be aware of the possibility of a fracture of the root.
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Ftir 4-Photomicrograph of part of root flagmerit and adjacent inflamed periodontal tissue (orzlq mag X 80).
Dr. Makkes is assistant professor, department of cariology, endodontology, and pedodontology, and Dr. Folmer is assistant professor, department of periodontology, University of Amsterdam, Dental School, Louwesweg 1, 1066 AE Amsterdam, The Netherlands. Requests for reprints should be sent to Dr. Makkes.
Fz~q 3--Top, radiograph four months after extraction with gutta-percha cone placed in sinus tract. Notice root fragment between arrows. Bottom, rai~ed flap. Notice root fragment between arrows.
SUMMARY T w e n t y - t h r e e years after injury to the maxillary central incisors, an u n u s u a l vertical fracture of the root of one of these teeth caused a diagnostic problem. A deep a n d extensive periodontal pocket mesial a n d lingual to the right central incisor developed in a relatively short time. O n l y after surgical intervention a n d histologic observation could the correct diagnosis be made.
References
1. Andreasen,J.O. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 78:329342, 1970. 2. Andreasen, J.O. Traumatic injuries of the teeth, ed 1. Copenhagen, Munksgaard, 1972, pp 111-140. 3. Linahurg, R.G., and Marshall, F.J. The diagnosis and treatment of vertical root fractures: report of a case. JADA 86:679-683, 1973. 4. Ingle, J.l., and others. Diagnosis and treatment of traumatic injuries and their ~quelae. In Ingle, J.I., and Beveridge, I';E. (eds.). Endodontics,ed 2. Philadelphia. l.ea & Febiger, 1976, pp 685-741. 5. Polson, A.M. Periodontal destruction associated with vertical root fracture: report of four cases. J Periodontol 48(1):27-32, 1977. 6. Lommel, T.J., and others. Alveolar bone loss associated with vertical root fractures. Report of six cases. Oral Surg 45(6):909-919, 1978.
An unusual vertical fracture of the root P. C. Makkes, DDS, PhD, and T. lZolmer, DDS, Amsterdam, The Netherlands
Fractures of the root are described as fractures involving dentin, cementum, and the pulp. A c c o r d i n g to Andreasen, ~ fractures of the root are u n c o m m o n a m o n g d e n t a l injuries and comprise 1~ to 7~7~ of injuries that affect p e r m a n e n t teeth, t:ractures of the root usually occur in the region of the m a x i l l a r y central incisors and most c o m m o n l y occur in persons 1l to 20 years old.' Usually, the fracture surface forms an oblique angle with the l o n g i t u d i n a l axis of the tooth. Vertical fractures of the root are those in which the fracture line is more or less parallel to the long axis of the root?' This report describes an unusual kind of vertical fracture of the root. CASE REPORT A 33-year-old w o m a n asked a dentist to replace two acrylic crowns on the maxillary central incisors for esthetic reasons. She had been involved in a car a c c i d e n t when she was 10 years old, a n d e n d o d o n t i c treatment was done on both teeth at that time. In 1972, the two acrylic crowns were made. As a r e p l a c e m e n t for the acrylic crowns, dowels with crown extensions a n d porcelain jacket crowns were m a d e in 1975 for both teeth. T w o years later, in O c t o b e r 1977, the p a t i e n t h a d a painful swelling in the p a l a t a l region of the right central incisor. An extensive p e r i o d o n t a l pocket with a d e p t h of 10 to 11 m m could be measured on the mesial a n d lingual aspects of the right central
Fig l-Radiograph two.),ears after replacement of aco'lic crowns. Notice depth of pocket illustrated by gutta-percha cone placed in pocket. Fracture line visible near arrow.
incisor (Fig 1). No o t h e r pockets could be measured in the region of the maxillaD" and m a n d i b u l a r incisors a n d canines. T w o m o n t h s later, the right central incisor was extracted, a n d a t e m p o r a r y bridge was c e m e n t e d in place. T h e extracted root showed an irregular surface with a steplike ledge along the m a i n part of the p a l a t a l aspect of the tooth (Fig 2). T h e apical foramen was wide, a n d the formation of the root a p p e a r e d stunted. F o u r months later, when the patient returned for the p r e p a r a t i o n
Fig 2-Top, extracted root shows irregular surface. Notice steplike ledge (arrow). Bottom, peel-like root.fragment, approximately 10 • ,5 • 1.5ram.
of the p e r m a n e n t restoration, she c o m p l a i n e d a b o u t a c o n t i n u i n g tenderness of the labial and p a l a t a l mueosa at the site of extraction. A sinus tract on top of the alveolar ridge was discovered, a n d a radiog r a p h was taken. W h i l e the sinus tract was being probed, a h a r d ohiect was felt. A thin, peel-like fragment of the root, firmly a t t a c h e d to the alveolar bone with fibrous tissue (Fig 3), was removed surgically. T h e frag315
IOURNAL OF ENDODONTICS
VOL 5, NO 10, OCTOBER 1979
r '
(
m e n t was composed of d e n t i n a n d c e m e n t u m (Fig 4). After the fragment was removed, healing of the w o u n d proceeded u n d i s t u r b e d .
,:
s rib
'P
j
r ! I
DISCUSSION T h e formation of the root seemed to match the stage of d e v e l o p m e n t of the patient's tooth at the time the accident occurred. T h e fracture described can be classified as u n u s u a l because the pulp was not involved, a n d only a relatively thin b u t large strip of d e n t i n and c e m e n t u m was fractured vertically from the body of the root. A possible e x p l a n a t i o n for the development of the deep pocket after so m a n y years is that the most coronal margin of the fracture was situated apically to the epithelial a t t a c h m e n t of the tooth. It seems likely that, after the p r e p a r a t i o n and placement of the dowel a n d new jacket crown, the epithelial attachm e n t moved apically just enough to reach the coronal part of the fracture line. As a result, microorganisms from the gingival crevice invaded the fissure, and a chronic abscess associated with vertical loss of bone a n d an extensive and deep periodontal pocket developed. As described by different authors, :-'~ vertical loss of bone a n d a periodontal pocket to the apical extent of a fracture line a p p e a r to be the result of a vertical fracture of the root which c o m m u n i cates with the oral cavity. T h e case described suggests that, when an extensive a n d deep period o n t a l pocket is found in a m o u t h otherwise relatively free of periodontal disease, the clinician should be aware of the possibility of a fracture of the root.
316
'&
i
9
I
x
!
q
? 4",',"
:"
Ftir 4-Photomicrograph of part of root flagmerit and adjacent inflamed periodontal tissue (orzlq mag X 80).
Dr. Makkes is assistant professor, department of cariology, endodontology, and pedodontology, and Dr. Folmer is assistant professor, department of periodontology, University of Amsterdam, Dental School, Louwesweg 1, 1066 AE Amsterdam, The Netherlands. Requests for reprints should be sent to Dr. Makkes.
Fz~q 3--Top, radiograph four months after extraction with gutta-percha cone placed in sinus tract. Notice root fragment between arrows. Bottom, rai~ed flap. Notice root fragment between arrows.
SUMMARY T w e n t y - t h r e e years after injury to the maxillary central incisors, an u n u s u a l vertical fracture of the root of one of these teeth caused a diagnostic problem. A deep a n d extensive periodontal pocket mesial a n d lingual to the right central incisor developed in a relatively short time. O n l y after surgical intervention a n d histologic observation could the correct diagnosis be made.
References
1. Andreasen,J.O. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 78:329342, 1970. 2. Andreasen, J.O. Traumatic injuries of the teeth, ed 1. Copenhagen, Munksgaard, 1972, pp 111-140. 3. Linahurg, R.G., and Marshall, F.J. The diagnosis and treatment of vertical root fractures: report of a case. JADA 86:679-683, 1973. 4. Ingle, J.l., and others. Diagnosis and treatment of traumatic injuries and their ~quelae. In Ingle, J.I., and Beveridge, I';E. (eds.). Endodontics,ed 2. Philadelphia. l.ea & Febiger, 1976, pp 685-741. 5. Polson, A.M. Periodontal destruction associated with vertical root fracture: report of four cases. J Periodontol 48(1):27-32, 1977. 6. Lommel, T.J., and others. Alveolar bone loss associated with vertical root fractures. Report of six cases. Oral Surg 45(6):909-919, 1978.