vertical root fracture and it's management .....
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Impossible is just a word used by people who are unwilling to change things. Impossible is an opinion, not a fact, and is a challenge rather than a declaration. Impossible is only temporary and represents potential and opportunity. Impossible means nothing.
vertical root fracture and it's management .....
- 1. “Impossible is just a big word thrown around by small men who find it easier to live in the world they’ve been given than to explore the power they have to change it. Impossible is not a fact. It’s an opinion. Impossible is not a declaration. It’s a dare. Impossible is potential. Impossible is temporary. Impossible is nothing.” Good Morning MUHAMMAD ALI 1
- 2. VERTICAL ROOT FRACTURE & IT’S MANAGMENT 2
- 3. •Introduction •Epidemiology •Predisposing Factors •Aetiology •Classification •Clinical presentation •Radiographic findings •Treatment modalitlies •Refernces •Conclusion 3
- 4. • ‘‘A vertical root fracture is a longitudinally oriented fracture of the root that originates from the apex and propagates to the coronal part.’’ American association of endodontics 4
- 5. Prevalence of Vertical Root Fracture • 2% and 5% with the greatest incidence occurring in teeth during or after endodontic therapy and in patients older than 45 years of age and more in males. • Maxilla is more affected than mandible especially premolars and molars. • Roots that are wide facio lingually but thinner mesio-distally tend to fracture more often 5
- 6. The prevalence of vertical root fractures, in endodontically treated teeth, is 11-20%. J Endod 1992;18:460-3.6
- 7. Predisposing Factors Loss of tooth structure due to caries or restoration. Excessive biomechanical preparation Overzealous widening for post-placement Exposure to occlusal forces beyond normal level Increased stress that exceeds the distributing capacity of the periodontal ligament (PDL) Moisture loss in pulpless teeth Previous cracks in dentin due to pressure during obturation International Journal of Contemporary Dental and Medical Reviews (2015) 7
- 8. Aetiology 1. Endodontic treatment • Over prepared access • excess canal shaping – excess dentin removal 2. Placement of post, pins • Tapered and threaded posts generally produce the highest root fracture incidence, followed by tapered and parallel posts • Fractures with tapered posts occur at the coronal-third of the root and, with parallel posts, occur at the apical-third of the root. 3. Parafunctional habits- bruxism clenching 4. Restorative treatment • extensively restored teeth. 5. Pathologic fracture – resorption induced 8
- 9. Ismail Davut Capar et al concluded that Root canal instrumentation with the Ni-Ti rotary system, different obturation techniques, and retreatment of different filling techniques can create fractures or cracks Int Endod J 42:208, 2009. Shemesh et al. compared lateral compaction and non-compaction filling with standard 0.2-tapered cones and reported that the total number of cracks after lateral compaction was higher than after non- compaction filling. Shemesh et al. documented that retreatment procedures increase crack formation because of further preparation and more manipulations. J Endod 2011;37:63–6. Dental Traumatology 2015; 31: 302–307 9
- 10. Classification The basis of separation of the fragments Complete On the basis of relative position of fracture to the alveolar crest Incomplete Supraosseous Intraosseous Vertical root fractures (VRFs) 10
- 11. Complete fracture • When total separation is visible or fragments can be moved independently. Incomplete fracture • When there is an absence of visible separation and segments can easily be separated by an instrument. Supraosseous fracture • This terminates above the bone, and does not create a periodontal defect. Intraosseous fracture • This involves the supporting bone, creating a periodontal defect. 11
- 12. Classification of fatigue root fracture by Chin- Jyh Yeh- • Vertical fractures: the fracture line is parallel to the long axis of the root, and located only in the root. • Oblique fractures: the fracture line follows an angle in relation to the long axis of the root • Horizontal fractures: the fracture line is perpendicular to the long axis of the root • Laminar fractures: a piece of root fragment, not involving the root canal. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-797 12
- 13. •Illumination •Radiographs •Periodontal Probing •Staining •Surgical Exploration •The Bite Test •Direct Visual Examination •Observation Under The Dental Microscope 13
- 14. Position Of The Fracture Tooth Type Time Elapsed After Fracture The Periodontal Condition Architecture Of Bone Adjacent To The Fracture Clinical Presentation History of variable discomfort or soreness, mild to moderate pain especially on biting. Vertical root fracture must be suspected if a root filled tooth presents with pain on biting and is also accompanied by a bad taste International Journal of Contemporary Dental and Medical Reviews (2015) 14
- 15. Maxillary and mandibular premolars, The mesial roots of the mandibular molars The mesiobuccal roots of the maxillary molars The mandibular incisors COHEN 11TH EDITION 15
- 16. Early Manifestation Microcracks at the root canal Gradually propagate outward Pain or discomfort on the affected side of the tooth. Sensitive upon chewing, Pain is often of a dull nature, COHEN 11TH EDITION 16
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- 18. Endodontic failure in teeth, which had previous healing may also point to the presence of a vertical root fracture Vertical root fractures can lead to International Journal of Contemporary Dental and Medical Reviews (2015) 18
- 19. Late Manifestation Major destruction of the alveolar bone adjacent to the root J-shaped or halo radiolucency, Pocket along the fracture, which was initially tight and narrow, may become wider and easier to detect. COHEN 11TH EDITION A sinus tract and a narrow, isolated periodontal probing defect associated with a tooth that has undergone a root canal treatment, with or without post placement, can be considered Pathognomonic for the presence of a VRF. American Association of Endodontists 2008 19
- 20. ???? Two factors makes the early diagnosis difficult: (1) Many of the clinical symptoms associated with VRFs mimic apical periodontitis or periodontal disease (2) The narrow and tight pocket associated with early stages of VRF is difficult to detect using rigid probes 20
- 21. Diagnosis VRF Pockets COHEN 11TH EDITION 21
- 22. Coronally Located Sinus TractDiagnosis COHEN 11TH EDITION 22
- 23. Radiographic FeaturesDiagnosis COHEN 11TH EDITION 23
- 24. Radiographic signs • Separation of root fragments • Fracture lines along the root or root fillings • Space beside a root filling • Space beside a post • Double images • Radiopaque signs Patterns of bone loss • Widening of periodontal ligament space • Radiolucent halos • Step-like bone defects • Isolated horizontal bone loss in posterior teeth • Unexplained bifurcation bone loss • V-shaped diffuse bone loss on roots of posterior teeth Australian Dental Journal 1999;44:2. 24
- 25. Separation of root fragments Fracture lines along the root or root fillings Australian Dental Journal 1999;44:2. 25 Space beside a root filling
- 26. Space beside a post Double images Radiopaque signs Australian Dental Journal 1999;44:2. 26
- 27. Widening of periodontal ligament space Radiolucent halos Step-like bone defects Australian Dental Journal 1999;44:2. 27
- 28. Isolated horizontal bone loss in posterior teeth Unexplained bifurcation bone loss 28
- 29. Radiolucency in the Bone Along RootDiagnosis 29
- 30. Radiograph of Empty CanalDiagnosis 30
- 31. Cone-Beam Computed Tomography in VRF Diagnosis Diagnosis S. Patel et al concluded that periapical radiographs and CBCT were not accurate in detecting the presence and absence of simulated VRF. International Endodontic Journal, 46, 1140–1152, 2013 Smaller radiation dose compared to traditional medical spiral CT imaging CBCT imaging would not be able to visualize a root fracture unless the fracture width was greater than 0.15 mm. With likely increased resolution in the near future, CBCT may become an important diagnostic tool for the detection of VRFs. COHEN 11TH EDITION 31
- 32. • A variety of approaches have been attempted and used to treat the VRF, including- • Bonding using glass ionomer cement and composite resin. • Bonding using wires. • Bonding using adhesive resin cement. • Bonding using adhesive resin cement and rotational replantation. • Fusing the fragments using Co2 and Nd: YAG laser. • Hemisection and root amputation. • Extraction. The aim of treatment is therefore to eliminate the fracture or the leakage of bacteria along the fracture plane Australian Dental Journal 1999;44:2. 32
- 33. • Multirooted teeth can often be successfully treated by resecting the fractured root, either by root amputation or hemisection J Periodontol 1981;52:719-722. Langer B et al reported that the retention rate of root resected teeth is 94% in five years. Australian Dental Journal 1999;44:2. •Prognosis for single rooted teeth is poor and extraction is often the treatment of choice 33
- 34. Endod Dent Traumatol 1993;9:101-105. An in vitro study assessing the resistance to fracture of root segments bonded with glass ionomer cement, composite resin, and cyanoacrylate concluded that the bond strengths of composite resin and cyanoacrylate were superior to glass ionomer cement Quintessence Int 1991;22:707-709. Calcium hydroxide has been used to promote tissue repair and resolve osseous defects before the roots were restored. Teeth treated with calcium hydroxide, then ‘reinforced’ with glass ionomer cement, have shown healing at six month follow-up appointment 34
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- 36. • Trope and Rosenberg extracted both segments of a maxillary second molar and soaked in Hanks balanced salt solution, while bonding the segment with glass ionomer and subsequently replanting the tooth using Gore-Tex membrane to establish a new periodontal attachment. • After six months, they reported a reduction in pocket depth from 10 mm to 2-3 mm. A crown was placed after one year as the tooth was functioning normally Australian Dental Journal 1999;44:2. 36
- 37. 4-methacryloxy etheyl trimellitate anhydride (META)/ methyl methacrylate (MMA) tri- n- butyl borane (TBB): 4-META/MMA TBB. The advantages associated with the use of 4-META/MMA TBB is low toxicity and biocompatibility for PDL cells. The cement interferes only slightly with cell attachment and proliferation. There is decreased level of inflammatory and replacement resorption. Dual cure resin cements: These cements have high bond strength, good marginal integrity, acceptable biocompatibility and short polymerization time… International Journal of Contemporary Dental and Medical Reviews (2015), 37
- 38. Mineral trioxide aggregate (MTA): MTA is a calciumsilicate based root repair material and has many applications in endodontics. Taschieri et al. in 2010 used MTA to repair incomplete vertical root fractures. A vertical groove was placed next to the fracture line and restored with MTA after ultrasonic cleaning. A resorbable membrane was placed next to the MTA to inhibit epithelial down growth. All 10 cases showed good results on 1 year follow up. International Journal of Contemporary Dental and Medical Reviews (2015), 38
- 39. • Takatsu et al. used orthodontic elastics to join the buccal and palatal segments of a vertically fractured maxillary second molar which were then sealed with a photocured resin liner to allow the tooth to be endodontically treated and restored with a cast crown. • The tooth remained in function for more than three and a half years with a reduction in pocket depth. Australian Dental Journal 1999;44:2. 39
- 40. • Sinai and Kratz demonstrated regeneration of bone and healing when the detached root segment, root canal filling and soft tissues were surgically removed. • An in vitro study54 proved CO2 and Nd:YAG laser to be an ineffective way to fuse fractured tooth roots. Australian Dental Journal 1999;44:2. 40
- 41. Replantation of root filled teeth with vertical root fracture reconstructed with resin bonding has emerged.The long-term prognosis of resin bonded and replanted teeth were determined by Hayashi et al. in 2004 in a 18 month follow-up study, which gave good results. The prognosis of replantation therapy depends on: • Atraumatic extraction of the fragments • Extra-oral time of <15 min as given by Pohl et al. • Disinfection using short- term calcium hydroxide dressing • Systemic tetracycline administration. International Journal of Contemporary Dental and Medical Reviews (2015), 41
- 42. Prevention • Avoid excessive removal of intraradicular dentin • Treatment and restorative procedures that require minimal dentin preparation should be selected • Condensation of obturation materials should be carefully controlled • Adequate ferrule that effectively resist functional forces and enhances fracture strength of post core restored endodontically treated tooth should be prepared Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-79742
- 43. • More flexible and less tapered finger pluggers or spreaders are preferred. • Any post used should be as small as possible, have a passive fit, and not grip or lock the root internally with threads • Cementation should be done carefully and slowly; an escape vent for the cement is probably helpful Prevention Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-79743
- 44. • VRF can be detected early by listening to the patient’s chief complaints, carefully examining radiographs and performing a thorough clinical examination. • VRF associated with root canal treated teeth is one of the most difficult problems to diagnose and treat. Early detection has two fold advantages –It prevents unnecessary frustration and inappropriate endodontic treatment and prevents extensive damage to the supporting tissues. • Before any complex experimental treatment procedures are considered, the desirability for retention of the tooth root should be carefully weighed against extraction and replacement with a denture, bridge or implant 44
- 45. • COHEN 11TH EDITION • Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 791-797 • International Journal of Contemporary Dental and Medical Reviews (2015), • Australian Dental Journal 1999;44:2. • J Periodontol 1981;52:719-722. • International Endodontic Journal, 46, 1140–1152, 2013 • American Association of Endodontists 2008 • Dental Traumatology 2015; 31: 302–307 • Int Endod J 42:208, 2009. 45
- 46. Thank you 46