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. They may begin as a crack, and propagate slowly down into the pulp chamber, and then the root. In my clinical experience, VRF is becoming a more common reason for tooth loss. Previously, the leading cause was caries, however, patients are now far more aware of the impact of their diet on oral health. This, combined with increased use of fluoride has begun to make caries less problematic. As such, vertical root fracture caused by tooth surface loss is likely to be the next tooth loss epidemic – with its incidence increasing in recent years.
Preventing the next tooth loss epidemic
This more frequent occurrence is problematic for a number of reasons. The loss of teeth is expensive should patients choose to replace them with dental implants. Biologically, whilst implants are good, they are not as good as natural teeth as there is no periodontal ligament. Additionally, the loss of alveolar bone associated with tooth loss is devastating for patients’ oral health.
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, through occlusal analysis and mouth guards, for example, 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. Prior to now, we might have anticipated this type of fracture in patients in their 60s and 70s who have had extensive restorative treatment. VRF is also much more common in root filled teeth, and there has been an increase in frequency since COVID. 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.
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.
Radiographically, when assessing a tooth with a suspected fracture, circumferential bone loss is a key indicator. Here, a CBCT scan can be helpful for identifying areas of bone loss, and communicating this with patients in a clear manner. Further to this, the “Tamse Triad” offers clinicians a number of identifying factors during the assessment. These include a sinus close to the gingival margin, a deep and narrow probing defect, and circumferential bone loss. 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 in which the tooth is opened up, and the extent of the fracture is assessed. Using magnification and transillumination is crucial here, to enable the clinician 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 in cases where a full crown is not provided.[ii]
Prevention is better than cure
Cracks and vertical root fractures are an increasing problem, and the likelihood is that they are only going to get worse with time. 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.
