Vertical root fracture in a root-filled molar — ORE Part 1 MCQ

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HardRestorative DentistryVertical root fracture in a root-filled molarORE Part 1

A 56-year-old patient has discomfort on biting on a root-filled lower first molar restored with a post-retained core and crown. There is a narrow isolated 9 mm periodontal pocket on the distal root, a J-shaped radiolucency on the periapical radiograph and slight mobility. Adjacent teeth are normal. What is the most likely diagnosis?

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Correct answer: A — Vertical root fracture

The diagnosis is vertical root fracture (VRF). The clinical and radiographic constellation is pathognomonic: a root-filled tooth presenting with a J-shaped ('halo') radiolucency, an isolated deep narrow periodontal pocket, occlusal discomfort, and mobility. The J-shaped radiolucency has the strongest statistical association with VRF. In up to 67% of root-filled teeth with VRF, clinical signs include pain on biting, deep localized periodontal pocket, and possible fistulation. Acute reversible pulpitis is impossible in an already root-treated tooth. Localised gingivitis does not explain J-shaped radiolucency or tooth mobility. Dentine hypersensitivity is incompatible with the radiographic findings and localized periodontal pocket. Necrotising ulcerative gingivitis presents with painful necrotic ulceration of interdental papillae, not isolated pocketing.

Reference: PradeepKumar AR et al. The association between clinical diagnostic factors and the prevalence of vertical root fracture in endodontic surgery. J Endod. 2018. https://pubmed.ncbi.nlm.nih.gov/30193836/ + Liao WC et al. Vertical Root Fracture in Non-Endodontically and Endodontically Treated Teeth: Current Understanding and Future Challenge. J Pers Med. 2021;11(12):1375. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8707645/