Cracked Teeth and Vertical Root Fractures

What is the incidence of cracked teeth and vertical root fractures?

Studies show that the prevalence of cracked teeth and vertical root fractures increased greatly after the pandemic

What might you see in an aging population where people are generally living longer and keeping their natural teeth?

Cracked teeth and vertical root fractures

Define abfraction

A V-shaped loss of hard tooth structure caused by biomechanical loading forces from flexure and/or chemical degradation of enamel and/or dentin at some location distant from the actual point of loading

Define infraction (craze line)

A crack of the enamel without loss of tooth structure, commonly seen

What is a cracked tooth?

A thin surface disruption of enamel and dentin, and possible cementum, of unknown depth or extension

What is a fracture

A split or break in the bone, cartilage or tooth structure. When involving tooth structure, it is a disruption of the enamel and/or dentin and/or cementum that is assumed to be of greater depth than a crakc, of unknown depth or extension, visible or not visible clinically or radiographically, and with separated or unseparated segments

What is a root fracture?

A fracture that exists or extends into the root, to include dentin, cementum, and possible pulpal space, which may progress to or from the enamel

Two examples of longitudinal fracture

1. Vertical Root Fracture

2. Split Root

What is a vertical root fracture?

A fracture in the root whereby the fractured segments are incompletely separated; it may occur buccl-lingually or mesial-distally; it may cause an isolated periodontal defect(s) or sinus tract; it may be radiographically evident

What is a split root?

A continuation of a crack or vertical root fracture whereby the fractured segments are completely separated longitudinally; it may occur buccal-lingually or mesial-distally

What are cracked teeth and vertical root fractures caused by?

Occlusal forces and dental procedures

Cracked teeth and vertical root fractures may expand over time and be a possible source of pain. What might happen to the pulp if the fracture is not taken care of?

It may provide pathways for bacteria to penetrate into the pulp

What are some correlations between age and cracked teeth + vertical root fractures?

May occur due to reduction in fracture resistance of the root with age

What are some diagnostic aids to help determine VRF and cracked teeth?

1. CC and HPI

2. EOE, IOE

3. Pulp vitality

4. Percussion

5. Palpation

6. Periodontal probing

7. Bite test

8. Radiographs

9. Transillumination

10. Restoration removal

11. Staining

12. Wedging force

13. Surgical exploration

What are some questions to ask during CC and HPI?

1. Exacerbating and relieving factors?

2. History of cracked teeth or vertical root fractures

3. Parafunctional habits

4. TMJ pain

5. Do they have nightguard?

What are some characteristics to look for during IOE AND EOE?

1. Enlarged jaw muscles

2. Attrition/abfraction/recession

3. Wear facets

4. Fractured cusps

5. Numerous full coverage restorations

6. Stained cracks

Correct pulpal and periapical diagnoses are imperative. What are some diagnostic tools to use

1. Percussion

2. Palpation

3. Cold test

4. EPT

5. Probing depths

6. Mobility

How does a tooth slooth work?

Attempts to replicate the patient’s chief complaint by placing the instrument on the cusp or fossa and telling them to bite. Watch the patient for their response on bite and release

How does transillumination work?

Light and dark areas are separated by a fracture line. This can be applied to

• Marginal ridges

• Floor of cavity prep

• Pulpal floor following an access

• Proximal surfaces

• During surgical flap reflection

How can you use PA radiographs to check for cracks or VRF?

1. Continuity of lamina dura and uniformity of PDL space

2. Quality and extent of existing endodontic and restorative treatment

3. Take multiple angled radiographs

How can you use CBCT to check for cracks or VRF?

1. Width of an unseparated fracture is typically undetectable

2. Evaluating bone loss along the fracture line

Signs and symptoms of a cracked tooth vary based on the extent of the crack. What is “cracked tooth syndrome”?

Sharp pain on biting and increased cold sensitivity

What is the prevalence of cracked teeth?

Mandibular 2nd molar > Mandibular 1st molar > Maxillary 1st molar > Maxillary 2nd molar

A vertical root fracture occurs in the root whereby the segments are incompletely separated. What can it cause?

Isolated periodontal defect(s) or sinus tract

What kinds of roots are most susceptible to VRF?

Roots that are curved and narrow M-D or with developmental depressions

What are some radiographic characteristics that may indicate a VRF?

“Halo” or “J-shaped”

What is the treatment for a VRF?

1. Extraction

2. Hemisection or root amputation