A typical vertical root fracture in an endodontically treated, restored maxillary premolar
VRF is regarded as a clinical condition, in which several predisposing factors, such as the root anatomical structure, together with operative procedures, such as root canal treatment and dowel placement, contribute to the development of a fracture in the root [1, 4–12]. However, only after an unknown period of time, when the root canal and the fracture area becomes infected, an associated pathology may develop [1, 4–12].
Therefore, a VRF without infection, defined as a “histological VRF”, is not clinically evident, until infection of the fracture occurs with ensuing emergence of clinical signs and symptoms [1, 4, 12]. At that stage, the VRF may be defined as a “clinical VRF”. The prevalence of “clinical VRFs” as evaluated in extracted endodontically treated teeth was reported to range from 11 to 20 % [6, 7]. However, the prevalence of “histological VRFs” in endodontically treated teeth is yet unknown and is probably significantly larger than the prevalence of the clinically evident “clinical VRFs”.
Imaging techniques, which are an essential landmark in the dental daily practice, may only be helpful sometimes for the definitive VRF diagnosis and are still incapable to demonstrate the incipient fracture [1, 4, 5].
It became acceptable and common to use cone beam computed tomography (CBCT) for the diagnosis of VRF , assuming that CBCT is clinically effective for this purpose and that it possesses superior efficacy over conventional periapical (PA) radiography. Nevertheless, recent published data raises a concern regarding the efficacy of CBCT and its alleged superiority over conventional PA radiography for the detection of VRF [13–15].
New reports suggest that actually there is no difference between the diagnostic accuracy of either imaging modalities and that both modalities have significant limitations [13, 15]. In addition, the presence of intracanal radiopaque materials adversely affects the diagnostic efficacy of CBCT; thus, CBCT is not beneficial for the diagnosis of VRF when metal dowels are present . Therefore, there is a great concern regarding CBCT potential benefit to the patient compared to its potential radiation risks [16–23] and regarding its clinical effectiveness for the diagnosis of VRFs [13–15, 24, 25].
Adding to the clinical complexity of this root-originated fracture is the fact that when a VRF is finally diagnosed, often years after the fracture was initiated and after the root and the tooth are fully treated and restored, it not only requires in some cases invasive diagnostic procedures such as exploratory flap procedure but is already late in most cases to save the tooth or root [1, 4, 5]. However, over the years, there had been attempts to save some of these teeth by either extracting the fractured root in a multirooted teeth or by attempts to treat the fractured root itself [26–32]. Although extraction of the fractured tooth or root is still usually the treatment of choice, modern endodontic techniques combined with an appropriate case selection seems to be able to allow the preservation of some VRF teeth [26–32].
When extraction of the root or the tooth following VRF diagnosis becomes inevitable, the dentist faces many times an additional dilemma, since the bony socket of the extracted tooth or root is infected and much of the tooth supporting bone was resorbed due to the infection facing the infected fracture [5, 31, 33–35]. This clinical challenge is especially evident when the buccal bony plate which is originally very thin is resorbed, and if not diagnosed and treated earlier, the interproximal bone resorbs as well [5, 31, 33–35]. The clinician is now facing a challenge of when and how to treat the infected socket, an issue that nowadays the profession has some new treatment modalities to treat [5, 31, 33–35].
VRFs are sometimes diagnosed years after endodontic and prosthetic procedures have been completed [36, 37], and many times, extraction of the VRF tooth or root becomes inevitable . This late diagnosis may also contribute to significant supporting alveolar bone loss, thus complicating the postextraction socket management and the future restoration . Endodontic medicolegal claims are common among malpractice claims in dentistry [38, 39], and this combined diagnostic and treatment challenge of VRFs may expose the practitioner also to potential medicolegal risks .
It is for the first time that a book is dedicated to this complex clinical condition, presenting the wasn’t updated scientific information on VRF’S in dentistry. Many figures and illustrations accordingly this text to enables an efficient reading and learning of the various issues of VRFs. In this way the book will be beneficial to all dental beneficial to all dental professionals who want to learn more on the topic students, practicing dentist specialists and researches.
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