VERTICAL ROOT FRACTURE: This case was referred to us because a j-shaped periapical lesion was noted on routine radiographic assessment of tooth #18 by the patient’s general dentist. The patient denied history of pain or swelling. Tooth #18 is an abutment of a three unit FPD with intact margins, was sensitive to percussion, and tested within normal limits to palpation and periodontal probing. In absence of direct visualization of a crack or fracture, there was no definitive evidence of vertical root fracture. However, the possibility of vertical root fracture could not be ruled out as a possible etiology.
As the patient was motivated to save the tooth at all costs, selective retreatment of the distal root with long-term (8 week) calcium hydroxide application was recommended. If upon re-evaluation at the 8 weeks, sensitivity to percussion and size of the periapical lesion improved, vertical root fracture could be more confidently ruled out, and endodontic retreatment could be completed.
At the 8 week evaluation appointment, three important findings were noted:
1. Temporary restoration was intact
2. Periapical lesion persisted
3. Calcium hydroxide was completely washed out of the canal
These three factors demonstrate that there must be a communication or fracture within the root canal system. Consequently the patient was advised that the tooth is non-restorable and recommended for extraction.
TAKE HOME MESSAGE: The presence of a j-shape lesion was likely consistent with vertical root fracture. However, this is NOT ALWAYS the case. If a patient is motivated to save the tooth, the tooth can be deconstructed and medicated for further evaluation. The key to diagnosis in this case was comparing quality pre-op, immediately after calcium hydroxide application, and 8 month post calcium hydroxide application radiographs.