When a VRF is diagnosed in single roots of a multirooted tooth, the most straightforward option is to surgically remove the fractured root only. More than 100 years ago, Farrar [58] described a surgical technique that included root resection with a filling of the remaining part with an ordinary filling material, such as amalgam. Farrar proposed resection at various levels, even leaving a short root stamp in the gingival tissue [58].

In some cases, a portion of the crown can be resected together with the involved root. In other cases, a tooth can be extruded orthodontically for easier management of the remaining tooth structure [7].

Root amputation may be recommended for maxillary molars with one fractured root (Fig. 7.1). Depending on the level of the fracture line and periodontal status of the patient, the resection can be performed at different levels of the root, and the most coronal part of the root can be retained following a root-end management and retrograde filling. A careful presurgical evaluation should be performed to exclude the possibility of fused roots rendering the amputation impossible. For fractured fused roots, a proper technique was described by Matusow [59] as “root stripping.” He presented a case of a second mandibular moral that served as a bridge abutment with fused medial root with VRF. The fused root was surgically “stripped,” leaving the distal root segment intact. This technique may be attempted for management of maxillary premolars with fractured buccal root where apically positioned furcation prevents a conventional root resection. For mandibular molars, while a root amputation is sometimes performed, hemisection and extraction of the fractured root or root resection is a more reliable option.

The actual treatment for the VRF may be divided into two main categories: a treatment modality that includes extraction and replantation of the involved root or tooth following extraoral repair of the fracture; and repair of the fracture using flap elevation procedure while the tooth remains attached in the periodontium.

Extraction of the fractured tooth, cementation of the root fracture, and replantation as an attempt to preserve VRF teeth was reported in several case reports and in a case series [14–16].

Hayashi Kinomoto et al. [16] reported on treatments of 26 vertically fractured roots using replantation and reconstruction with dentin-bonded resin. They found that 18 cases were functional and retained, with 6 fully successful, after 4–76 months. They found that teeth with longitudinal fractures extending more than 2/3 from the cervical portion toward the apex and posterior teeth showed significantly lower success rates [16].

Arikan et al. [14] presented a successful treatment after 18 months follow-up of a central incisor with complete VRF that was extracted and root segment bonded and replanted. Kawai et al. [15] attempted a modification of this approach by replanting two VRF teeth with resin-bonded segments at 180° rotation into the original socket in order to bring the fracture line under healthy bony coverage and sound periodontal ligaments on the tooth surface face the destroyed boneless area. Hadrossek et al. [55] treated a central incisor by filling the fracture line and the retrograde preparation with a calcium silicate cement (Biodentine).

Another case of bonding the fracture line with adhesive resin cement was reported by Moradi Majd Akhtari et al. [60]: vertically fractured maxillary incisor was extracted, the fracture line was treated with adhesive resin cement, and the tooth was replanted. After 12 months, the tooth was asymptomatic [60].

In addition to doubtful prognosis of the fracture repair, the main disadvantage of this treatment modality is the risk of complications related to the extraction, such as inability to extract the tooth in one piece, lack of periodontal healing or bone resorption following replantation, and root resorption due to the damaged PDL. Therefore, the contraindications for tooth extraction and replantation are teeth which probably cannot be extracted and repositioned due to a complicated root anatomy, teeth with severe periodontitis, teeth without adjacent teeth, a noncompliant patient, and patients with critical general medical conditions [55].

Several attempts to treat VRF by a flap procedure to gain access to the fracture line and enable its management were described. Selden [61] reported on a conservative treatment of six teeth with incomplete VRF using silver glass ionomer cement with bone graft, but all cases presented in that study failed in the long term [61].

Modern endodontics presents a possibility to treat fractured teeth by employing magnification and illumination devices that allow better visualization of the surgical field, thus increasing the accuracy of the treatment.

MTA was proposed as a sealing material to repair VRF [21], by preparing a groove along the entire vertical fracture, placing MTA in the groove and covering it with a absorbable membrane. Floratos et al. prepared the fracture line using a rotary or ultrasonic instrument with ensuing sealing of the defect with MTA and coverage with absorbable collagen membrane or calcium sulfate using microsurgical techniques and the microscope-assisted regenerative procedures [13].

Taschieri et al. [4] reported on 10 maxillary anterior teeth with incomplete VRF treated by a modern surgical endodontic technique (Fig. 7.2). Strict inclusion criteria were applied—teeth with probing depths of more than 4 mm or cases with halo-like periradicular radiolucency or interproximal angular radiolucency on one side of the root were excluded from that study. Following flap elevation, a groove following the fracture line was prepared using ultrasonic devices and sealed with MTA, and then filling of the bone defect with calcium sulfate. At 12 months follow-up, all cases were successful. After 33 months from seven patients available for follow-up, five cases remained healed [4].

Dederich et al. [62] in a case report of a mandibular premolar sealed a hairline vertical fracture associated with a vertical bone defect using a CO₂ laser with subsequent placement of collagen matrix barrier over the defect. After 12 months, no evidence of inflammation was detected; however, gingival recession was present [62].

Floratos and Kratchman [13] treated four cases in which endodontically treated maxillary or mandibular molars had an incomplete VRF involving one of the roots. Unlike in the study by Taschieri et al. [4], in this study, a similar technique was used successfully in anterior teeth with vertical fracture lines deriving from the apical part of the root. The fracture line was eliminated by resecting the root in a beveled manner, after which root-end preparation and root-end filling were performed by using MTA. The osteotomy was covered with an absorbable collagen membrane. After 8–24 months, cases demonstrated clinical success [13].

The flap procedure may have several disadvantages: a possible scar may form in the esthetic area of the gingiva, an additional osteotomy may be needed which generates extra loss of healthy bone structure, and a gingival recession may be expected. Therefore, in some cases this procedure is not indicated because of esthetic considerations [55].