ORIGINAL CONTRIBUTIONS
Vertical root fracture
Factors related to identification
Richard E. Walton, DMD, MS
A
vertical root fracture (VRF) is a common
and often devastating event. When
identified, the treatment plan is
straightforward: extraction of a single-
rooted tooth, or at least root amputation or hemi-
section of a molar. As a result of a VRF, processes
begin near the root. In a histologic study, Walton
and colleagues1 showed that the fracture spaces
contained a combination of irritants: bacteria,
necrotic debris, sealer, and degraded inflammatory
cells. Root surfaces consistently demonstrated an
inflammatory lesion adjacent to the fracture.
By definition, according to the American As-
sociation of Endodontists’ Glossary of Endodontic
Terms, the VRF is an incomplete fracture in the
root that may occur buccolingually or mesiodis-
tally; it may cause periodontal defect(s) or sinus
tracts, and may be radiographically evident.2 It is
also described as being confined to the root and
complete or incomplete.3 The VRF is invariably
associated with endodontic therapy and often with
apical surgery.4 Frequently a post is present,5,6
which can generate significant wedging forces.7 The
lateral wedging forces of gutta-percha compaction
during obturation8,9 and post placement10 are the
initiators of stresses and strains that could result in
fracture. The VRF is more prevalent in roots with
a cross-section that is narrower mesiodistally, that
is, in deep oval, flattened, or hour-glass–shaped
roots.11
Obviously, accurate identification of a VRF is
critical12; treatment is tooth extraction or root
Copyright ª 2017 American Dental Association. All rights
reserved.
100 JADA 148(2) http://jada.ada.org February 2017
ABSTRACT
Background. Vertical root fracture (VRF) requires root
removal. Diagnostics for proper identification are critical. The
author conducted a study to relate subjective, objective, and
radiographic findings for VRF identification. They noted visual
changes of root and overlying bone patterns after flap reflection.
Methods. The author examined a case series of roots with
suspected VRF after flap reflection and root or root-end removal;
42 roots were identified with a fracture. Before reflection, the
author obtained diagnostic and periapical radiographic data that
included symptoms, soft-tissue changes, percussion, mobility,
probing patterns, and radiographic findings. After flap reflection,
the author evaluated bony changes and root surfaces. VRF was
visually confirmed after tooth or root removal.
Results. Signs and symptoms diagnostic of VRF were incon-
sistent. All patients had endodontic therapy, many with posts, and
for all patients, the pain was none to mild. In addition, the author
found a history or presence of swelling (77%) or sinus tract (31%),
that probing patterns differed (narrow-rectangular 66%), and that
there was no defect in some patients (21%). Radiographic patterns
varied from no change to extensive bone loss, and mobility ranged
from none (55%) to slight or moderate (45%). Flap reflection
revealed a “punched-out” bony lesion with granulomatous tissue
(100%), and patterns were fenestration (21%) or dehiscence
(79%). A fracture was visible on roots or resected root ends.
Conclusions. The author found no consistent signs, symptoms,
or radiographic changes of VRF. Flap reflection was found to be
predictably useful; fractured roots had bony defects filled with
granulomatous tissue.
Practical Implications. VRF may be suspected from clinical
findings; however, flap reflection is usually required for identifi-
cation. Characteristic bony pattern and root visualization reveals
the fracture, although root-end resection and examination is
occasionally required.
Key Words. Diagnosis; tooth; fracture; endodontics.
JADA 2017:148(2):100-105
http://dx.doi.org/10.1016/j.adaj.2016.11.014
 ORIGINAL CONTRIBUTIONS
removal. Clinical findings suggest 1 of 3 entities: VRF,
periodontal lesion, or failed endodontic therapy. How
to diagnose, differentiate, and treatment plan depends
on identification.13 Lacking is sound evidence-based
research on how to predictably identify these fractures.
A systematic review14 concluded that there was not
substantive evidence in the literature that tested the
accuracy of clinical and radiographic findings as to
diagnosis and identification. The available information is
incomplete and at lower levels of evidence (that is, case
reports and case series).3,4,15-17
With a suspected VRF, these diagnostic approaches
have been proposed18:
- signs and symptoms: possibly, VRF fractures result in
pain with occlusal or lateral forces;
- periodontal probing patterns: it has been suggested
19
that the longitudinal fracture commonly results in nar-
row, deep probing defects on the facial or lingual aspect;
- radiographic findings: the VRF is longitudinal and,
therefore, tends to generate certain patterns of resorp-
tion (Commonly, the resorptive bony defect shows an
apical-to-lateral pattern, the so-called “J-shaped” lesion;
the resorption extends around the apex and extends
along the lateral surface of the root. Other resorptive
patterns have been reported,20,21 but it is unknown if
these patterns are consistent and thus aid diagnosis);
- treatment history: this includes whether a tooth has
had endodontic treatment and the subsequent restora-
tion (post or no post)22;
- surgical exploration: flap reflection to expose the area
of inflammation and visualization of the fracture line
on the root surface.23,24
To date, there have been no complete or compre-
hensive studies or reports on these diagnostic modalities
used for VRF. Unknown is whether any combination
of these findings will consistently and predictably iden-
tify the presence of a VRF. Important questions include:
Are there any definitive indicators from noninvasive
diagnostic findings that will predictably identify the
VRF?, and How may the clinician confidently decide to
remove the tooth or root? The aim of this study was
to determine the relative incidences and frequency of
diagnostic findings in teeth in which a VRF was identi-
fied (visualized after extraction or root-end resection).
METHODS
The study was approved by the institutional review board
of the Medical College of Georgia School of Dentistry,
Augusta, GA. I assured the board and the patients that
no unnecessary procedure would be performed when
gathering the data. All patients gave consent to partici-
pate, and I guaranteed that their identities would be
confidential. They further gave consent that the teeth
could be used in a companion histologic evaluation.1
The process of selection was as follows. I subjected all
patients in whom a VRF was suspected because of a
combination of clinical findings15,18 to further compre-
hensive diagnostic evaluation using these criteria:
- signs and symptoms, including presence, levels, and
initiators (percussion and palpation) of pain;
- periodontal probing to determine depths, patterns,
and shape of probing defects;
- mobility, whether none, slight, or moderate;
- soft-tissue changes, such as swelling or sinus tract;
- periapical radiographic findings including presence
and patterns of radiolucencies;
- history of treatment to the tooth.
In each patient (except when there was a clear sepa-
ration of fractured root segments radiographically),
I reflected a flap to expose the overlying bone and root
surface. I identified bony defects, if present, and
attempted to see the presence of a fracture line on the
root surface (the criterion standard of diagnosis). I
removed overlying inflammatory tissue from the defect
and root surfaces, without magnification. If I saw a
fracture, the diagnosis was definitive. If I did not see a
definitive fracture, I applied dyes or resected a root end
and examined the surfaces under a dissecting microscope
for a fracture.
I included 42 multi- and single-rooted teeth, all from
different patients, in my sample. In these teeth, I
analyzed the diagnostic data relative to incidence. I
further determined whether any 1 or any combination of
noninvasive findings or tests could definitively identify a
VRF, before flap reflection. I extracted those roots in
which VRF was identified visually. I further verified the
fracture by examining the root under a dissecting
microscope. I recorded the data and reported it
descriptively as percentages of each pattern of findings
and test results.
RESULTS
All VRFs had received endodontic therapy; many also
contained a post. Overall, the only definitive mode of
identifying a VRF required flap reflection and visuali-
zation of bone and root. All fractured roots had an
overlying, facial, “punched-out” bony lesion, filled with
granulomatous, inflammatory tissue (Figures 1-3). I was
not as readily able to see all the fracture lines on root
surfaces; the balance of fracture lines were seen after
root-end resection.
My findings from other tests were either negative or
variable and inconsistent:
- pain: none to mild (100%);
- swelling: none (23%), present or history (77%);
- sinus tract: none (69%), present or history (31%);
- probing patterns: no defects (21%), narrow-
rectangular (66%), other (13%);
ABBREVIATION KEY. CBCT: Cone-beam computed
tomography. VRF: Vertical root fracture.
JADA 148(2) http://jada.ada.org February 2017 101
 ORIGINAL CONTRIBUTIONS

Figure 2. After removal of the inflammatory tissue, a through-and-

through defect is identified by using an endodontic explorer.
Figure 1. After flap reflection, a double defect is evident. A fenestration
(top arrow) and a lesion on the cervical margin (lower arrow) both
contain inflammatory tissue, separated by a bony bridge.

- mobility: none (55%), slight-moderate (45%);

- radiographic changes:
n none (21%);
n present: apical only (21%), crestal only (11%),
apical-lateral-coronal (45%), apical-lateral (23%);
n visible root fracture (17%);
- flap reflection: “punched-out” bony lesion (100%)

(Figure 4), dehiscence (79%), and fenestration (21%).

DISCUSSION
The most important conclusion from my case series
study was that the usual noninvasive (without flap
reflection) diagnostic findings, tests, and periapical
radiographs—alone or in combination—were not reliable
indicators of a VRF. Only direct visualization of bone
and root after flap reflection gave proof. The bony defect
was a consistent finding, although with variation, as
shown in Figure 4. Because these findings are of a case
series, the findings are not necessarily indicative of what
would occur in other groups. Therefore, the reported
percentages are of this sample and might not represent a
specific target population.
Importantly, the reported percentage of incidences
of different diagnostic findings was not the essential Figure 3. After extraction, the vertical fracture line is visible on the facial
outcome. More relevant were the generalities of the aspect (arrows).
diagnostic tests and findings—that is, which noninvasive
findings were suggestive of VRF. As important were

102 JADA 148(2) http://jada.ada.org February 2017

 ORIGINAL CONTRIBUTIONS

the negatives (lack of important findings); there were a

substantial number of patients that had no probing de-
fects, and others with no notable radiographic changes.
Interestingly and of importance was that pain was mild
or not present, either as reported by the patient or as
noted on percussion and palpation. The bottom line
was that absence of symptoms, lack of radiographic
changes, or normal probing depths alone or in combi-
nation did not rule out the presence of a VRF.
Often, a clinician will be suspicious that there is a
fracture because of a combination of certain findings:
radiographs, periodontal probings, mobility, sinus tract,
and treatment history. In 2008, guidelines from the
American Association of Endodontics18 stated that this
combination of diagnostic tests and findings in a tooth
that had received endodontic therapy (with or without a
post) is often pathognomonic for a VRF. This patho-
gnomonic combination, however, may not be present;
the result may be a mistake in diagnosis and treatment.15
My findings showed that when a VRF is strongly sus-
pected, a flap must be reflected. The finding of a bony
“punched-out” defect was definitive.
After I had removed granulomatous tissue, a frac-
ture line was not always visible on the root surface. A
clinical operating microscope was not available but likely
would have proved useful. However, at the time of
some of these flap reflections, and to date, microscopes
were not widely used by general practitioners. Indeed,
many fracture lines were not visible as they were located
Figure 4. Root and bone resorption patterns vary. The “punched-out”
on line angles and tucked behind bony margins. It is defect may extend to part of the root length (A) or to the apex (B) or be a
unknown, but likely, that more fractures would be visible fenestration (C). In a cross-section view, the fracture line is facial-lingual
with magnification and a direct light source. By exam- and extends to both surfaces (usually) or to 1 surface. The bony defect
is filled with inflammatory tissue (D). This is contrasted to a normal, knife-
ining the bony resorption pattern, observing the presence edged opening, which is a common anatomic finding (E). VRF: Vertical
of inflammatory tissue, and occasionally viewing the root fracture. Reproduced with permission of the publisher from
resected root end, no errors appeared to be made; all Torabinejad and colleagues.25

removed roots or root segments exhibited the VRF.

If a fracture was not visible—and knowing these
cases may have been the results of failed endodontic
therapy, nonendodontic pathosis, or a periodontal
lesion26—the apical one-third of the root was resected. The
surface of the root-end segment was examined under a
benchtop dissecting microscope. Often the fracture line
was then observed. If not, the assumption was failed
endodontic therapy, and a root-end restoration was
placed. Even then, it was possible that a fracture was pre-
sent but did not extend to the apical one-third of the root27
and, therefore, was not visible. The patient was informed
of this possibility and that the prognosis was guarded.
A frequent finding, although not in all patients, was a
finding or history of a periodontal-like abscess with a
probing defect and localized swelling. With this in mind,
suspicion arose and a flap was reflected. In many cases, it
proved to be a VRF; others were a true periodontal
abscess.
Radiographic findings were interesting. Indeed, most
showed the J-shaped lesion, as described by Tamse.28 I
termed this “apical-coronal-lateral.” Many other images
showed other configurations. Importantly, in several im-
ages (21%), there were no radiographic changes or there
were lesions that exhibited the classic “hanging-drop”
shape, thereby suggesting failed endodontic treatment.3
The bottom line was that radiographs were unreliable
and at best, suggestive.26,27 Radiographs were a definitive
indicator in those patients (17%) showing separated
fractured segments. Flap reflection was, therefore, not
needed, unless necessary for surgical removal.
Other methods, such as cone-beam computed to-
mography (CBCT), have been studied as tools to identify
VRF. Some have shown promise,29,30 but most studies31,32
demonstrate that CBCT is unreliable. The principal
problem with CBCT is interference by obturating
materials, particularly, by posts; the result would be
distortion or artifacts masking a fracture line. Benchtop
techniques,33,34 in which fractures were artificially
generated by wedges, likely differed greatly from in situ
occurrence. From meta-analyses and systematic reviews,

JADA 148(2) http://jada.ada.org February 2017 103

 ORIGINAL CONTRIBUTIONS
the conclusion as to CBCT’s utility as a diagnostic tool
for VRF is that it is not sufficiently reliable to recom-
mend its use.35,36 This may change with different capa-
bilities in future CBCT technology. CBCT is useful,
however, to show associated bony pathosis.37
I found many cases of teeth that were suggestive of
VRF that proved to not be VRF. Most of these were
treated as failed endodontic therapy with root-end sur-
gery. Others were periodontal lesions and were managed
accordingly. Possibly, some fractures did not extend to
the facial aspect, as shown in a histologic study.1 If the
fracture were only at the lingual aspect, there may have
been no visible bony destruction on the facial aspect.
After flap reflection, the consistent finding of a bony
defect was indicative of a VRF; the defect was in the form
of either a fenestration or dehiscence filled with granu-
lomatous tissue. This was also an indicator in another
cohort study.38
My observation that all VRF roots had a history of
endodontic treatment, many with a post, is consistent
with the findings reported in the literature. Studies that
examined the stresses and strains with obturation8,9,39
and post placement6,40 have shown that these wedging
forces can exceed the elastic limits of dentin.
CONCLUSIONS
In this case series, I investigated 42 teeth with demon-
strated VRF. The aim of the study was to relate subjective
and objective probing and radiographic findings to the
identification of the VRF. Also determined after flap
reflection were visual changes (fracture lines) on the
roots, and changes of the overlying alveolar bone. The
most important findings were that there were no sig-
nificant, consistent signs, symptoms, probing patterns, or
radiographic changes that were conclusively diagnostic.
Only flap reflection was definitive for identification; all
fractured roots had overlying bony defects filled with
granulomatous tissue. Examination of the roots or
resected root-ends revealed the fracture line. n
Dr. Walton is a professor emeritus, Department of Endodontics, College
of Dentistry, University of Iowa, Iowa City, 801 Newton Rd., IA 52242,
e-mail Richard-walton@uiowa.edu. Address correspondence to Dr. Walton.
Disclosure. Dr. Walton did not report any disclosures.
Robert J. Michelich, DDS, MS, Tucker, GA, and G. Norman Smith, DMD,
Savannah, GA, participated in performing the clinical procedures, analysis
of findings, and assessment of data.
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