Excessive root dentin removal during endodontic treatment and use of posts are the predominant risk factors for root fractures. Common clinical findings associate with root fractured teeth have been discussed in a previous post (It is ‘Game Over’!)
Vertical root fractures are usually detected through careful probing around a tooth but sometimes all you need is air-water syringe.
We have all come across an endodontically-treated tooth with vertical root fracture (VRF). What gives the VRF away is the pattern of bone loss (more bone loss occlusally than apically) and the clinical attachment loss on the buccal or lingual aspects of a specific root. It is also associated with posts inside the canals or use of large size GGs or large-tapered orifice shapers and as a result, weakening of the coronal portion of the canals. Other important findings include: good looking root canals, lack of PA lesions, presence of J-shaped lesion, periodontal probing defect on the buccal or lingual aspects of the root, sinus tract tracing back to the level of fracture and not all the way to the apex.
As soon as vertical root fracture is diagnosed, the prognosis is assumed to be hopeless and extraction and implant become the top choice in the view of the majority of us, dentists. I used to agree with the above statement and never cared for herodontics to save these teeth until I came across quite a few cases with long-term follow-ups that have made me think twice about this.
If I had seen this patient, I would have thought there is no way hemisection would work in this case. To be honest, I may have not even thought about this option in this day and age of implant dentistry. I would have thought to myself that the distal root is very narrow mesiodistally to begin with and has a metal post in it. The distal root would have been the next root to go in my opinion. After all, this is a major chewing tooth with relatively heavy occlusion. A 10-year follow-up of this case shows an absolutely beautiful restorative work with a lone standing root that is still an integral part of this bridge.
I am sure there are so many examples of works like this that have worked out and some that did not stand the test of time. But, I truly believe that every natural tooth deserves a change to survive for as long as possible. Implant is a great option to replace a missing tooth, not a tooth.
