Dentaltown January 2025 - 37

as pain on release may be useful. Identifi cation of
vertical probing defects or a cervical sinus tract may
be indicative. A diff use J-shaped lesion on a periapical
radiograph may also be helpful. Th e use of CBCT may
also reveal patterns of bone loss associated with a
cracked tooth.
Risk factors for VRF include loss of tooth structure,
the presence of posts-especially large, active or
tapered posts-bruxism and clenching.
A combination of these fi ndings could build a
strong circumstantial case for a vertical root fracture,
but none of these fi ndings, even in combination,
is necessarily pathognomonic. Direct observation
CASE SERIES
1
CASE
A J-shaped lesion
As dentists, we can become
desensitized to how important
each tooth is to a patient and
how impactful we can be in saving one.
Th is patient's dentist told her that #30 had
a vertical root fracture and she needed to
have it extracted and replaced with a dental
implant. No other treatment options
were given. She came independently for a
second opinion and said how devastating
it would be for her to lose a tooth.
Tooth #30 had a diagnosis of previous
root canal treatment with symptomatic
apical periodontitis. Th e mesial root had
a classic J-shaped radiographic lesion and
a narrow probing defect from the buccal
furcation to the root apex. No crack
could be seen on what little root surface
was visible. Th e likelihood of VRF, or the
possibility of a failing root canal with a
chronic apical abscess, were discussed.
Th e latter could be treatable. Th e plan was
to attempt re-treatment after internal
inspection for a possible VRF.
of a VRF-through staining and microscopy of the
fl oor of the pulp chamber and canals, visualization
of the exposed outer surface of a root by retracting
the gingiva or through surgical exposure-is the only
defi nitive way of proving that a VRF exists.
Diagnoses of VRFs are sometimes applied to teeth
that, in fact, do not have a VRF. We suggest that a
tooth should not be assigned a VRF diagnosis unless
the circumstantial evidence is overwhelming and the
crack is directly visualized or otherwise proven.
Th is article describes a case series where patients
presented for second opinions after being given diagnoses
of VRF and recommendations for extraction.
After the buildup and root-fi lling material
were removed, a microscope was used
to confi rm that no cracks were present
in the pulp chamber or the coronal third
of the canals. Th is tooth was treated in
multiple visits using calcium hydroxide,
an antimicrobial intracanal medicament,
and to confi rm healing. Th e root canal
system was cleaned, calcium hydroxide
was placed, and a double-layered longterm
provisional restoration made of
Cavit and bonded composite were placed
to seal the access preparation.
Th e patient returned in three months,
when resolution of symptoms, healing of
the deep probing defect and bone regeneration
were confi rmed. Th e tooth was
obturated, and a foundational restoration
was placed before the rubber dam was
removed. Fourteen years of follow-up
confi rmed long-term periradicular health.
Th e amount of appreciation and gratitude
that this patient expressed reminds us
that each individual tooth demands our
best eff orts.
JANUARY 2025 | 37 | DENTALTOWN.COM
Fig. 1: Preoperative PA.
Fig. 2: Postoperative PA.
Fig. 3: Recall PA.
Fig. 4: Recall CBCT.
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