Vertical root fracture (VRF) is a leading cause of tooth loss, especially in endodontically treated teeth.[i] Different to cracks, which may just be coronal, VRFs extend through the pulp to the roots.
In my clinical experience, VRF is becoming a more common reason for tooth loss.
Preventing the next tooth loss epidemic
This more frequent occurrence is problematic for a number of reasons.
As such, a preventative approach to VRF and tooth surface loss is essential. Tooth structure loss often leads to occlusal changes which, in turn, increases the risk of wear. In time, this increases the likelihood of cracks, VRFs, and the need for extraction and subsequentially implant supported restorations.
By preventing tooth structure loss and wear in the first place the patient’s risk of tooth loss is reduced significantly over time.
It’s important to note that patients presenting with VRF are younger than we would previously have expected too – with many in their 40s. Women and older patients do appear to be more at risk, and VRFs are more likely to be seen in mandibular molars and maxillary pre-molars. VRF is also much more common in root filled teeth, and there has been an increase in frequency since COVID.
Diagnosing vertical root fractures
There are numerous factors which may increase the risk of VRF but, ultimately, the two key areas are the structural integrity of the tooth, and the occlusion.
The “Tamse Triad” offers clinicians a number of identifying factors during the assessment. These include:
If these are present, VRF is highly-likely, and the prognosis is usually extraction.
Communication with patients is important too, as this will allow you to more accurately assess the clinical situation. If they have minimal restorations, and are experiencing spontaneous pain, query whether this may be linked to a particular event, such as biting down on hard food, as this will help to indicate the likelihood of fracture.
How should clinicians manage these cases?
In order to recommend the most appropriate course of treatment, it is wise to undertake a restorability assessment. This involves opening the tooth and assessing the extent of the fracture. Using magnification and transillumination is crucial here. This will allow you to see whether the fracture has extended into the root canal system.
In many cases, once the fracture has extended to the roots, the tooth is not salvageable, and extraction is recommended. This is because bone loss is still likely following root canal treatment, which could compromise the options available for restoration using dental implants down the line.
However, in cases where a cracked tooth is restorable, a full coverage crown is recommended to reduce the risk of VRF going forward. The risk of tooth loss is six times higher when full crown is not provided.[ii]
Prevention is better than cure
Treatment options are limited for VRF, as such prevention is better than cure in many cases. This means that clinicians should incorporate occlusal analysis and tooth wear assessments into their workflows as part of their preventative strategies going forward.
Author: Alyn Morgan (Immediate Past-president of the British Endodontic Society and CEO of Mimetrik)
[i] Lee, Kwangsoon, et al. “Prevalence of and factors associated with vertical root fracture in a Japanese population: an observational study on teeth with isolated periodontal probing depth.” Journal of Endodontics 49.12 (2023): 1617-1624.
[ii] Aquilino, Steven A., and Daniel J. Caplan. “Relationship between crown placement and the survival of endodontically treated teeth.” The Journal of prosthetic dentistry 87.3 (2002): 256-263.