Objective

At the end of this case, the reader should be familiar with the diagnosis of vertical root fracture (VRF). The reader should also know the aetiology and treatment options available for VRF.

Introduction

A 62‐year‐old man presented to his general dental practitioner with intermittent dull ache associated with his previously root‐treated lower right first molar (LR6). He was then referred to an endodontic specialist for further management of the LR6.

Chief Complaint

The patient complained of occasional episodes of dull pain on the LR6 for the last few weeks. The patient had the LR6 root canal treated and restored with a metal ceramic crown over 15 years ago by an endodontist and had been asymptomatic until now.

The patient was managing his symptoms with over‐the‐counter analgesics. However, the patient still experienced mild discomfort on biting on the tooth.

Medical History

Unremarkable.

Dental History

The patient was a regular dental attender for routine check‐ups with his general dentist and twice‐a‐year maintenance appointments with his dental hygienist.

Clinical and Radiographic Examination

Extraoral examination was unremarkable. Intraoral examination revealed a moderately restored and well‐maintained dentition with good levels of oral hygiene.

The LR6 was restored with a well‐adapted metal ceramic crown. The LR6 was tender to percussion but not tender on palpation. The periodontal probing depths and mobility of the LR6 were within normal range. No swelling or sinus tract was associated with the LR6. There were no signs of endodontic or periodontal disease associated with the adjacent teeth or opposing teeth. Occlusal assessment revealed there was group function in lateral excursions.

A periapical radiograph (PR; Figure 1.7.1) was taken to investigate the LR6. What did the radiograph reveal about the LR6?

• Normal horizontal bone levels.
• Crown with well‐adapted margins.
• Existing root canal filling had several voids at the canal entrance level.
• The mesial root fillings were approximately 2–3 mm short from the radiographic apex while the distal root fillings appeared to be well condensed and to length.
• A periapical radiolucency was associated with the mesial and distal roots of the LR6.

A small field‐of‐view cone beam computed tomography (CBCT) scan was taken to explore other causes, such as untreated root canal(s). The sagittal CBCT (Figure 1.7.2a) revealed similar findings to the PR with a well‐defined periapical radiolucency on the LR6. However, in the coronal and axial slices (Figure 1.7.2b–d), periradicular radiolucencies were detected on the buccal aspect of the mesial root and lingual aspect of the distal root. These periradicular radiolucencies were separate to and not continuous with the periapical radiolucency.