Diagnosing Vertical Root Fractures Early

Vague symptoms around a root-canal-treated tooth, almost normal radiographs, and failure of standard treatment often mislead clinicians into repeating endodontic procedures.  

Yet, the real culprit may be an early vertical root fracture (VRF) that mimics ongoing endodontic pathology. Delayed diagnosis leads to significant bone loss with limited treatment options. So, early detection is your only leverage. 

Prevalence Snapshot 

Studies have shown that 93 to 97% of VRFs occur in previously root-filled teeth. Depending on diagnostic criteria, its prevalence varies from 4% to 32%¹. 

First, Don’t Miss These Clinical Red Flags¹ 

• Multiple sinus tracts near the gingival margin 

• Repeated post or crown dislodgement 

• Pain or biting or mastication 

• Bleeding during obturation 

• Isolated deep periodontal pockets 

• J-shaped or halo-like radiolucency on radiographs 

Pro Tip: Don’t just rely on one red flag after surgery. It can mislead the diagnosis. A structured checklist during postoperative evaluation helps you identify these red flags early, before they become serious.  

Diagnostic Protocols: What Works Best? 

For an accurate diagnosis of VRF, a well-structured and multi-technique approach is essential: 

Clinical Technique² 

• Transillumination: Fiber-optic light helps to identify the crack line, particularly in anterior teeth. 

• Bite Test: Use cotton rolls, rubber wheels, commercial biting devices, and cotton tip applicators to assess pain in pressure. 

• Pulp Testing: Helps to figure out pulpal disease and distinguish it from endodontic failure. 

• Periodontal Probing: Watch out for narrow, deep pockets near a root surface, usually isolated and sudden. 

• Staining: To visualize suspected cracks, use methylene blue. 

• Bone Resorption Pattern: VRF often presents with oblong resorption that extends laterally and apically into interproximal areas. 

• Direct Visualization:  To identify root-level fractures, remove restorations, and inspect under magnification (>3.5×) with strong illumination. Exploratory surgery may be required for confirmation 

Pro Tip: Examine cast-restored RFTs for signs of radiolucency near the post base. These may indicate a hidden VRF.  

Radiographic Interventions ² 

• Periapical radiograph (PRs) may show: 

• No pathology in early stages 

• Frank separation of the root fragments 

• Mild periradicular bone loss 

• Lateral root surface radiolucency in cast-restored teeth 

• Classic J-shaped radiographic lesion 

• Crestal bone loss starting at the CEJ and extending apically 

• Cone Beam CT (CBCT) 

• To detect periradicular bone loss patterns that may indicate VRFs, CBCT provides enhanced sensitivity 

• The CBCT scan may fail to detect a vertical root fracture, especially if segments are not widely displaced 

Pro Tip: The study has shown that 66% of the VRFs were diagnosed between 2 to 5 years post root canal treatment. So long-term follow-up is crucial³. 

Clinical Insight: CBCT can be useful for assessing subtle bone changes, but it should be interpreted cautiously. It may support your clinical judgement, but don’t solely rely on it. 

Management Planning: What’s Next After Diagnosis? 

The tooth type and the extent of the fracture will decide the management strategy¹: 

• Single-Rooted Teeth: Generally, require extraction 

• Multi-Rooted Teeth: May be treated with hemisection or root amputation 

• Replantation With Resin Bonding: Suitable in some cases with minimal extraoral time and proper disinfection 

Clinical Insight: Proceed with replantation only when aseptic conditions and rapid insertion can be maintained. 

Final Takeaway 

If post-endodontics symptoms persist, always rule out VRF. You can consider CBCT when conventional imaging doesn’t give you clear result 

For cracked teeth, a timely crown placement can improve treatment outcomes and survival rate 

Reference 

1. Patel S, Bhuva B, Bose R. Present status and future directions: vertical root fractures in root filled teeth. International Endodontic Journal. 2022 May;55:804-26. 

2. Dhanalakshmi D, Sivaraj S. Vertical Root Fracture and its Management: A Review. Int J Sci Dev Res. 2024 Feb;9(2):107–110. Available from: https://ijsdr.org/papers/IJSDR2402017.pdf 

3. García-Guerrero C, Mendoza-Beltrán W, Roldan-Roldan M, Villa-Machado P, Restrepo-Restrepo F. Vertical root fractures: a time-dependent clinical condition. A case-control study in two colombian populations. Journal of Clinical and Experimental Dentistry. 2021 Nov 1;13(11):e1104.