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Vertical root fracture in nonendodontically treated teeth
0099-2399/95/2106-0337503.00/0 JOURNALOF ENDODONTICS Copyright © 1995 by The American Association of Endodontists
Printed in U.S.A.
VOL. 21, No, 6, JUNE1995
CASE REPORT Vertical Root Fracture in Nonendodontically Treated Teeth Shue-Fen Yang, DDS, Eric M. Rivera, DDS, MS, and Richard E. Walton, DDS, MS
Vertical root fractures have been reported to occur primarily in endodontically treated teeth due to condensation forces and/or with post placement. This study describes 11 Chinese patients with 12 molars that developed vertical root fractures without endodontic or post procedures. These showed characteristics of a true vertical root fracture as confirmed after extraction. Fractured teeth showed a consistent pattem. The majority were severely attrited mandibular molars in males. All had clinically intact crowns with no or minimal restorations.
The etiology of vertical root fractures has been studied. Reports describe vertical root fractures as occurring in endodontically treated teeth with or without posts. Some of the causes that have been suggested or identified are condensation forces during obturation (1, 3-5), corrosion of posts (6), or wedging during post cementation (7). However, there are no reports in the "Western" literature of spontaneous vertical root fractures, that is fractures without a predisposing endodontic or intracanal restorative procedure. Vertical root fracture in nonendodontically treated teeth is apparently uncommon. In the "Eastern" literature, three studies ( 8 i0) have appeared in Chinese journals. In these studies, the patients and affected teeth showed certain patterns. The majority were in older males. Fractures occurred almost entirely in posterior teeth (primarily molars) with minimal or no restorations. Many of the crowns showed severe attrition. This report discusses 11 Chinese patients with 12 molars that developed vertical root fractures without endodontic or post preparation procedures.
As defined (1, 2), the true vertical root fracture is a longitudinal fracture confined to the root that usually initiates on the internal canal wall and extends outward to the root surface. The fracture may initiate at the apex or midroot and occurs primarily in a facial-lingual plane. This type fracture is different from the cracked tooth, which is an incomplete fracture that runs mesio-distal, is centered occlusally, involved one or more marginal ridges, and extends from the occlusal surface toward the cervical and eventually down the root. It is also different from the split tooth, in which there is a complete fracture due to long-term extension of an incomplete fracture (crack tooth) or sudden occurrence (2).
CASE REPORT Eleven patients were suspected to have vertical root fractures because of widening of the root canal space seen from radiographs (Figs. 1A, 2, and 3A) in 12 nonendodontically treated molars. Oral
FIG 1. (A) Radiograph of left mandibular first molar of patient A. Widening of root canal space of mesialroot was noted. (B) Photograph of extracted left mandibular first molar of patient A. Severe occlusal attrition was noted. Buccal-lingual direction fracture line was demonstrated.
337
338
Yang et al.
Journal of Endodontics
to severe occlusal attrition. Two teeth had small amalgam restorations. Five of the 11 teeth were pulp tested with EPT. Four were responsive, whereas one tooth was unresponsive. Two had associated sinus tracts onto facial gingiva. Patients' subjective complaints varied from no symptoms to thermal sensitivity, pain on mastication, and constant pain. Upon extraction, 11 teeth showed classic characteristics of vertical root fracture (1, 2, 4, 11) (Figs. 1B and 3B). One tooth was not extracted, but had the same radiographic evidence of vertical root fracture (Fig. 2B). Fractures were confined to the roots, extended from canal to root surface, and were oriented in a facio-lingual plane. The fractures were correlated to the radiographically consistent finding of a marked widening of the canal space. Mesial canals of mandibular molars or mesial-buccal canals of maxillary molars (usually indistinct) were involved and were very radiolucent and/or wider; this was the fracture. In addition, some demonstrated a periapical radiolucency with or without root resorption.
DISCUSSION
FIG 2. (A) Radiograph of right mandibular first molar of patient G. Widening of mesial root canal space was noted. (/3) Radiograph of left mandibular first molar of patient G. Severe widening of mesial root canal space was demonstrated.
diagnosis was performed in the Dental Department of Veterans General Hospital-Taipei from 1977 to 1992. The pertinent clinical and radiographic information on the patients and their teeth demonstrated fairly consistent patterns. The specific findings are included in Table 1. All were males (11 of 11), with ages ranging from 56 to 71 yr. None of these teeth had received root canal or prosthodontic treatment. Examination of clinical crowns revealed no crack lines, and all showed moderate
Vertical root fracture resulting from endodontic/post placement procedures is common (3). However, in most parts of the world, spontaneous vertical root fracture (nonroot canal treatment, nonpost-prepared) is likely a rare occurrence. A careful search of the literature over 1-yr period via MEDLINE uncovered no reports of the entity other than when associated with endodontic and/or prosthodontic procedures. Although the search included several thousand journal titles, some world publications are neither included nor are key words always referenced. However, the phenomenon of spontaneous vertical root fracture may be confined to, or much more common in a certain group, that is, in Chinese (8-10); this is further confirmed in our study. The reasons for this are unclear. It is difficult to explain why these particular teeth of Chinese had a tendency to fracture, especially when considering that other races also have attrition due to factors such as grinding or chewing smokeless tobacco. Tooth morphology, root curvature, hereditary predilection, or changes in dentin collagen cross-linking may be important. However, factors normally attributed to certain Chinese populations, such as C-shaped canals or four canals with three roots in mandibular first molars, were not present in any of the teeth in this study. This is a perplexing condition that requires further investigation.
FiG 3. (A) Radiograph of left mandibular first molar of patient H. Widening of mesial root canal space was noted. (B) Photograph of extracted left mandibular first molar of patient H. Occlusal attrition was noted. Buccal-lingual direction fracture line of mesial root was demonstrated.
Nonendodontic Vertical Root Fracture
Vol. 21, No. 6, June 1995
339
TABLE 1. S u m m a r y of clinical and radiographic findings Involved Root
Crown
Sinus
Situation
Tract
Patient
Age
Tooth
A
--
19
Mesial
--
Attrited
--
B
--
30
Mesial
--
Attrited
--
C
--
19
Mesial
--
Attrited
--
D
56
19
Mesial
Attrited
(+)
E
67
30
Mesial
--
--
F
59
15
Mesial-buccal
(+)
Attrited and with buccal class V amalgam filling Attrited
G
65
19
Mesial
(+)
Attrited
m
G
65
19
Mesial
(+)
Attrited
m
H
68
19
Mesial
--
Attrited
I
65
19
Mesial
(-)
Attrited and with distal class II amalgam filling
J
71
19
Mesial
(+)
Attrited
K
62
19
Mesial
--
Attdted
EPT
m
(+)
Radiographic Finding of Involved Root
Other Findings
Widening of root canal space Widening of apical root canal space Widening of root canal space Widening of root canal space and root resorption Widening of root canal space
--
Widening of root canal space and discontinuity of PDL Widening of root canal space Widening of root canal space Widening of root canal space Widening of root canal space and periapical radiolucency Widening of root canal space Widening of apical root canal space and periapical radiolucency
--
-Combined with a midroot resorption
No clinical symptom or deep probing depth
A 10-mm probing depth on mesial buocal area Two sinus tracts: one over buccal side and the another one over ligual side
EPT, e l e c t r o n i c p u l p test results; - - , n o i n f o r m a t i o n available; PDL, p e r i o d o n t a l l i g a m e n t .
In our study, the range in patient population age was from 56 to 71 yr. Lu (8) analyzed 81 patients with 83 root fractures in which 80 tooth crowns were noncarious and without cracks. In that study, the patient's age was from 17 to 80 yr old. Most patients were 41 to 60 yr old; posterior and attrited teeth were most involved. The diet pattern and habits are additional considerations. The Chinese diet pattern is different from the Western diet in some ways (e.g. chewing bones in meat is more common). Occlusal attrition increases with age, which might be diet-related. This was generally found in our patients with nonendodontically treated vertical root fracture. However, definitive conclusions must not be made before further investigations that involve more complete history and clinical records taking. The forces and/or fractures that would make a tooth fracture as shown in this study need to be identified. Although the spontaneous vertical root fracture may be rare, or essentially nonexistent in the majority of patient groups, the phenomenon does occur. This is important in contemporary terms; immigrants from the prevalent occurrence group (Chinese) are relocating throughout the world. Dr. Yang is attending doctor, Department of Restorative Dentistry, Veterans General HospitaI-Taipei, Taiwan, Republic of China, and is an endodontic
resident, Department of Endodontics, University of Iowa, Iowa City, IA. Dr. Rivera is assistant professor and Dr. Walton is professor and chair, Department of Endodontics, University of Iowa, Iowa City, IA. Address requests for reprints to Dr. Eric M. Rivera, Department of Endodontics, the University of Iowa, College of Dentistry, Iowa City, IA 52242.
References 1. Pitts DL, Natkin E. Diagnosis and treatment of vertical root fracture. J Endodon 1983;9:338-46. 2. Walton R. Cracked tooth/vertical root fracture, chap. 28. In: Principles and practice of endodonUcs, 2nd ed. Philadelphia: WB $aunders, 1995 (in press). 3. Morris A. Vertical root fracture. Oral Surg 1990;69:631-5. 4. Meister F, Lommel T, Gerstein H. Diagnosis and possible causes of vertical root fractures. Oral Surg 1980;49:243-53. 5. Dang D, Walton R. Vertical root fracture and root distortion: effect of spreader design. J Endodon 1989;15:294 -301. 6. Rud J, Omnell D. Root fractures due to corrosion: diagnostic aspects. Scand J Dent Res 1970;78:397-403. 7. Oberrnayr G, Walton R. Vertical root fracture and relative deformation during obturation and post-cementation. J Prosthet Dent 1991;66:181-8. 8. Lu H-F. Tooth root fracture--report of 81 cases. Chinese J Stomatol 1980;15:29--31. 9. Cao C-F. Tooth root split. Chinese J Stomatol 1981;16:235-7. 10. Wei P-C, Ju Y-R. Vertical root fracture--case report and clinical evaluation. Chang Gung Med J 1989;12:237-43. 11. Walton R, Michelich R, Smith G- The histopathogenesis of vertical root fractures. J Endodon 1984;10:48-56.
Printed in U.S.A.
VOL. 21, No, 6, JUNE1995
CASE REPORT Vertical Root Fracture in Nonendodontically Treated Teeth Shue-Fen Yang, DDS, Eric M. Rivera, DDS, MS, and Richard E. Walton, DDS, MS
Vertical root fractures have been reported to occur primarily in endodontically treated teeth due to condensation forces and/or with post placement. This study describes 11 Chinese patients with 12 molars that developed vertical root fractures without endodontic or post procedures. These showed characteristics of a true vertical root fracture as confirmed after extraction. Fractured teeth showed a consistent pattem. The majority were severely attrited mandibular molars in males. All had clinically intact crowns with no or minimal restorations.
The etiology of vertical root fractures has been studied. Reports describe vertical root fractures as occurring in endodontically treated teeth with or without posts. Some of the causes that have been suggested or identified are condensation forces during obturation (1, 3-5), corrosion of posts (6), or wedging during post cementation (7). However, there are no reports in the "Western" literature of spontaneous vertical root fractures, that is fractures without a predisposing endodontic or intracanal restorative procedure. Vertical root fracture in nonendodontically treated teeth is apparently uncommon. In the "Eastern" literature, three studies ( 8 i0) have appeared in Chinese journals. In these studies, the patients and affected teeth showed certain patterns. The majority were in older males. Fractures occurred almost entirely in posterior teeth (primarily molars) with minimal or no restorations. Many of the crowns showed severe attrition. This report discusses 11 Chinese patients with 12 molars that developed vertical root fractures without endodontic or post preparation procedures.
As defined (1, 2), the true vertical root fracture is a longitudinal fracture confined to the root that usually initiates on the internal canal wall and extends outward to the root surface. The fracture may initiate at the apex or midroot and occurs primarily in a facial-lingual plane. This type fracture is different from the cracked tooth, which is an incomplete fracture that runs mesio-distal, is centered occlusally, involved one or more marginal ridges, and extends from the occlusal surface toward the cervical and eventually down the root. It is also different from the split tooth, in which there is a complete fracture due to long-term extension of an incomplete fracture (crack tooth) or sudden occurrence (2).
CASE REPORT Eleven patients were suspected to have vertical root fractures because of widening of the root canal space seen from radiographs (Figs. 1A, 2, and 3A) in 12 nonendodontically treated molars. Oral
FIG 1. (A) Radiograph of left mandibular first molar of patient A. Widening of root canal space of mesialroot was noted. (B) Photograph of extracted left mandibular first molar of patient A. Severe occlusal attrition was noted. Buccal-lingual direction fracture line was demonstrated.
337
338
Yang et al.
Journal of Endodontics
to severe occlusal attrition. Two teeth had small amalgam restorations. Five of the 11 teeth were pulp tested with EPT. Four were responsive, whereas one tooth was unresponsive. Two had associated sinus tracts onto facial gingiva. Patients' subjective complaints varied from no symptoms to thermal sensitivity, pain on mastication, and constant pain. Upon extraction, 11 teeth showed classic characteristics of vertical root fracture (1, 2, 4, 11) (Figs. 1B and 3B). One tooth was not extracted, but had the same radiographic evidence of vertical root fracture (Fig. 2B). Fractures were confined to the roots, extended from canal to root surface, and were oriented in a facio-lingual plane. The fractures were correlated to the radiographically consistent finding of a marked widening of the canal space. Mesial canals of mandibular molars or mesial-buccal canals of maxillary molars (usually indistinct) were involved and were very radiolucent and/or wider; this was the fracture. In addition, some demonstrated a periapical radiolucency with or without root resorption.
DISCUSSION
FIG 2. (A) Radiograph of right mandibular first molar of patient G. Widening of mesial root canal space was noted. (/3) Radiograph of left mandibular first molar of patient G. Severe widening of mesial root canal space was demonstrated.
diagnosis was performed in the Dental Department of Veterans General Hospital-Taipei from 1977 to 1992. The pertinent clinical and radiographic information on the patients and their teeth demonstrated fairly consistent patterns. The specific findings are included in Table 1. All were males (11 of 11), with ages ranging from 56 to 71 yr. None of these teeth had received root canal or prosthodontic treatment. Examination of clinical crowns revealed no crack lines, and all showed moderate
Vertical root fracture resulting from endodontic/post placement procedures is common (3). However, in most parts of the world, spontaneous vertical root fracture (nonroot canal treatment, nonpost-prepared) is likely a rare occurrence. A careful search of the literature over 1-yr period via MEDLINE uncovered no reports of the entity other than when associated with endodontic and/or prosthodontic procedures. Although the search included several thousand journal titles, some world publications are neither included nor are key words always referenced. However, the phenomenon of spontaneous vertical root fracture may be confined to, or much more common in a certain group, that is, in Chinese (8-10); this is further confirmed in our study. The reasons for this are unclear. It is difficult to explain why these particular teeth of Chinese had a tendency to fracture, especially when considering that other races also have attrition due to factors such as grinding or chewing smokeless tobacco. Tooth morphology, root curvature, hereditary predilection, or changes in dentin collagen cross-linking may be important. However, factors normally attributed to certain Chinese populations, such as C-shaped canals or four canals with three roots in mandibular first molars, were not present in any of the teeth in this study. This is a perplexing condition that requires further investigation.
FiG 3. (A) Radiograph of left mandibular first molar of patient H. Widening of mesial root canal space was noted. (B) Photograph of extracted left mandibular first molar of patient H. Occlusal attrition was noted. Buccal-lingual direction fracture line of mesial root was demonstrated.
Nonendodontic Vertical Root Fracture
Vol. 21, No. 6, June 1995
339
TABLE 1. S u m m a r y of clinical and radiographic findings Involved Root
Crown
Sinus
Situation
Tract
Patient
Age
Tooth
A
--
19
Mesial
--
Attrited
--
B
--
30
Mesial
--
Attrited
--
C
--
19
Mesial
--
Attrited
--
D
56
19
Mesial
Attrited
(+)
E
67
30
Mesial
--
--
F
59
15
Mesial-buccal
(+)
Attrited and with buccal class V amalgam filling Attrited
G
65
19
Mesial
(+)
Attrited
m
G
65
19
Mesial
(+)
Attrited
m
H
68
19
Mesial
--
Attrited
I
65
19
Mesial
(-)
Attrited and with distal class II amalgam filling
J
71
19
Mesial
(+)
Attrited
K
62
19
Mesial
--
Attdted
EPT
m
(+)
Radiographic Finding of Involved Root
Other Findings
Widening of root canal space Widening of apical root canal space Widening of root canal space Widening of root canal space and root resorption Widening of root canal space
--
Widening of root canal space and discontinuity of PDL Widening of root canal space Widening of root canal space Widening of root canal space Widening of root canal space and periapical radiolucency Widening of root canal space Widening of apical root canal space and periapical radiolucency
--
-Combined with a midroot resorption
No clinical symptom or deep probing depth
A 10-mm probing depth on mesial buocal area Two sinus tracts: one over buccal side and the another one over ligual side
EPT, e l e c t r o n i c p u l p test results; - - , n o i n f o r m a t i o n available; PDL, p e r i o d o n t a l l i g a m e n t .
In our study, the range in patient population age was from 56 to 71 yr. Lu (8) analyzed 81 patients with 83 root fractures in which 80 tooth crowns were noncarious and without cracks. In that study, the patient's age was from 17 to 80 yr old. Most patients were 41 to 60 yr old; posterior and attrited teeth were most involved. The diet pattern and habits are additional considerations. The Chinese diet pattern is different from the Western diet in some ways (e.g. chewing bones in meat is more common). Occlusal attrition increases with age, which might be diet-related. This was generally found in our patients with nonendodontically treated vertical root fracture. However, definitive conclusions must not be made before further investigations that involve more complete history and clinical records taking. The forces and/or fractures that would make a tooth fracture as shown in this study need to be identified. Although the spontaneous vertical root fracture may be rare, or essentially nonexistent in the majority of patient groups, the phenomenon does occur. This is important in contemporary terms; immigrants from the prevalent occurrence group (Chinese) are relocating throughout the world. Dr. Yang is attending doctor, Department of Restorative Dentistry, Veterans General HospitaI-Taipei, Taiwan, Republic of China, and is an endodontic
resident, Department of Endodontics, University of Iowa, Iowa City, IA. Dr. Rivera is assistant professor and Dr. Walton is professor and chair, Department of Endodontics, University of Iowa, Iowa City, IA. Address requests for reprints to Dr. Eric M. Rivera, Department of Endodontics, the University of Iowa, College of Dentistry, Iowa City, IA 52242.
References 1. Pitts DL, Natkin E. Diagnosis and treatment of vertical root fracture. J Endodon 1983;9:338-46. 2. Walton R. Cracked tooth/vertical root fracture, chap. 28. In: Principles and practice of endodonUcs, 2nd ed. Philadelphia: WB $aunders, 1995 (in press). 3. Morris A. Vertical root fracture. Oral Surg 1990;69:631-5. 4. Meister F, Lommel T, Gerstein H. Diagnosis and possible causes of vertical root fractures. Oral Surg 1980;49:243-53. 5. Dang D, Walton R. Vertical root fracture and root distortion: effect of spreader design. J Endodon 1989;15:294 -301. 6. Rud J, Omnell D. Root fractures due to corrosion: diagnostic aspects. Scand J Dent Res 1970;78:397-403. 7. Oberrnayr G, Walton R. Vertical root fracture and relative deformation during obturation and post-cementation. J Prosthet Dent 1991;66:181-8. 8. Lu H-F. Tooth root fracture--report of 81 cases. Chinese J Stomatol 1980;15:29--31. 9. Cao C-F. Tooth root split. Chinese J Stomatol 1981;16:235-7. 10. Wei P-C, Ju Y-R. Vertical root fracture--case report and clinical evaluation. Chang Gung Med J 1989;12:237-43. 11. Walton R, Michelich R, Smith G- The histopathogenesis of vertical root fractures. J Endodon 1984;10:48-56.