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The Preservation of Teeth with Root-Originated Fractures

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The Preservation of Teeth with Root-Originated Fractures Rosen et al. Evidence-Based Endodontics (2018) 3:2 Evidence-Based Endodontics https://doi.org/10.1186/s41121-018-0016-7 REVIEW Open Access The preservation of teeth with root- originated fractures Eyal Rosen1*, Ilan Beitlitum2 and Igor Tsesis1 Abstract Traditionally, when a root-originated fracture (ROF) was diagnosed in an endodontically treated tooth, the tooth was scheduled for extraction. However, modern endodontics offers new treatment options to manage and maintain certain ROF teeth. The decision of whether to extract a ROF tooth and substitute it with a dental implant, or to implement a more conservative management approach by attempting an additional endodontic treatment aimed to preserve the natural tooth, is complicated and multifactorial. The management alternatives of ROF teeth range from a traditional root amputation in multi-rooted teeth to modern endodontic surgical modalities that may enable the preservation of a fractured tooth. This required decision-making process includes prosthetic, periodontal, esthetic, endodontic, and patient value concerns. Keywords: Root-originated fracture, Vertical root fracture, Treatment, Decision-making Introduction complication is associated with a procedural error, and Root-originated fractures (ROFs), traditionally termed some complications may occur even when all proce- “vertical root fractures,” were defined as “a complete or dures were performed adequately (Tsesis et al. 2015; incomplete fracture initiated from the root at any level, Hofer et al. 2000;Angelos2009). Since ROFs appear in usually directed buccolingually” (Rivera and Walton teeth with either poor or good quality RCTs, ROFs 2008), largely based on its anatomical appearances must be considered as a potential complication, not ne- (Tsesis et al. 2015). cessarily a direct result of a practitioner procedural Since almost all ROFs have a history of root canal error (Tsesis et al. 2015). Therefore, this extended def- treatments (RCTs) (Tsesis et al. 2015; Cuoghi et al. 2010; inition better elucidates both clinical and medico-legal Tsesis et al. 2010a; Garcia-Guerrero et al. 2017; Rosen et aspects of ROFs (Tsesis et al. 2015;Tsesisetal.2010a; al. 2016), it seems clear that there must be an Rosen et al. 2012). association between RCTs and the occurrence of ROFs ROFs are fairly common (Yoshino et al. 2015), with a (Cuoghi et al. 2010; Tsesis et al. 2010a). Thus, based on reported prevalence of 11% up to more than 30% of ex- the nature of these fractures, a new extended definition tracted endodontically treated teeth (Tsesis et al. 2010a; was recently suggested as following: “a complication of Rosen et al. 2012). In a recent study, Yoshino et al. 2015 root canal treatment, characterized by a complete or in- evaluated the prevalence of ROFs as the main reason for complete fracture initiated from the root at any level, the extraction of the permanent teeth. They evaluated a usually directed buccolingually” (Tsesis et al. 2015). total of 736 teeth from 24 different clinics that were ex- It is fundamental to understand that this extended tracted from 626 patients during a 6-month period. Of definition of ROFs as a complication of RCTs does not these teeth, a total of 233 teeth were extracted as a result imply that ROFs necessarily occur as a direct result of a of ROFs (31.7%). practitioner’s procedural error (Hofer et al. 2000). While Anatomically, ROFs frequently develop laterally a procedural error can lead to complications, not every from the root canal wall to the outer root surface (Taschieri et al. 2010). An incomplete fracture extends only on one side of the root surface, while a complete * Correspondence: [email protected] 1Department of Endodontology, The Maurice and Gabriela Goldschleger fracture develops in both directions of the root canal School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Rosen et al. Evidence-Based Endodontics (2018) 3:2 Page 2 of 7 and includes two root surfaces (Taschieri et al. 2010; Floratos and Kratchman 2012). Consequently, extrac- Walton et al. 1984;Tamse2006), occasionally leading tion was normally indicated (Tsesis et al. 2015; to splitting of the root to segments (Tsesis et al. 2015; Taschieri et al. 2010;Tamse2006). Taschieri et al. 2010). The decision whether to attempt retaining a compro- A timely mannered diagnosis and proper management mised endodontically treated tooth by additional treat- are critical in preventing alveolar bone loss, which may ments or to extract the fractured tooth and substitute it impair the future reconstructive procedures, should im- with an implant-supported restoration has been debated plant therapy be the treatment of choice (Tsesis et al. extensively for many years (Abboud et al. 2013; Avila et 2015; Tsesis et al. 2010a; Taschieri et al. 2010; Tamse al. 2009; Bashutski and Wang 2007; Iqbal and Kim 2007; 2006; PradeepKumar et al. 2016). However, the clinical Iqbal and Kim 2008; Nemcovsky and Rosen 2017). How- and radiographic diagnosis of ROFs is complicated and ever, in recent years, it has become evident that im- challenging for the practitioner (Tsesis et al. 2010a; plants may be more prone to complications and Corbella et al. 2014) and, in certain cases, is only pos- requiremorepostoperative maintenance than the sible by a direct observation of the suspected site fol- natural tooth, and it seems that the pendulum may lowing flap elevation during surgical endodontic swing back towards endodontics and tooth preserva- treatment (Tsesis et al. 2015;Walton2017)(Fig.1). tion (Nemcovsky and Rosen 2017). Traditionally, teeth with ROFs were considered to have In the context of ROF teeth, in recent years, new re- a hopeless prognosis (Tsesis et al. 2010a; Taschieri et al. ports suggested promising treatment alternatives aimed 2010; Floratos and Kratchman 2012). Efforts to treat to preserve ROF teeth (Tsesis et al. 2010a; Taschieri et ROFs in different ways, such as by a replantation pro- al. 2010; Floratos and Kratchman 2012; Taschieri et al. cedure with bonding of the fractured segments, have 2016) which were traditionally condemned to extraction been reported (Tsesis et al. 2010a; Taschieri et al. 2010; (Tsesis et al. 2015; Tsesis et al. 2010a; Taschieri et al. Floratos and Kratchman 2012; Arikan et al. 2008; Kawai 2010; Floratos and Kratchman 2012; Tsesis et al. 2006; and Masaka 2002; Hayashi et al. 2004). However, most Fabbro et al. 2009; Plotino et al. 2007). These unique of these treatment attempts were found to be unpredict- treatment attempts are in their preliminary stages of able and are not recommended as routine treatment al- development and are based mostly on case reports ternatives (Tsesis et al. 2010a; Taschieri et al. 2010; (Tsesis et al. 2010a; Taschieri et al. 2010;Floratosand Kratchman 2012). Still, it seems that modern endodon- tics offers technical means such as magnification and il- lumination devices (Tsesis et al. 2015; Fabbro et al. 2009; Kim and Baek 2004), and the use of modern ma- terials such as bioceramic cements (Torabinejad and Chivian 1999) for the repair of ROFs (Tsesis et al. 2010a; Taschieri et al. 2010; Floratos and Kratchman 2012), that with proper case selection, may allow the treatment and preservation of some ROF teeth (Tsesis et al. 2015; Taschieri et al. 2016). This manuscript will review the modern treatment op- tions for the preservation of ROF roots. Review The importance of case selection Modern endodontics provides a variety of treatment op- tions that allow the preservation of compromised teeth (Tsesis et al. 2010b). Yet, ROFs still pose a complicated diagnostic and treatment challenge for practitioners and are a common trigger of tooth loss (Tsesis et al. 2010a; Kishen 2006). With the development of modern end- odontic treatment options, new dilemmas emerged (Tsesis et al. 2015; Tsesis et al. 2010b). A common dilemma is the decision whether to preserve Fig. 1 Diagnosis of ROF in an upper anterior tooth by a direct a compromised tooth with ROF or to extract the fractured observation of the suspected site following flap elevation during a tooth or root and substitute it with a dental implant surgical endodontic treatment (Tsesis et al. 2010a; Tsesis et al. 2010b). Traditionally, it Rosen et al. Evidence-Based Endodontics (2018) 3:2 Page 3 of 7 was believed that a fast decision to extract the tooth or in modern dentistry, osseointegration of implants is rootmaybeessentialbecausetheensuinginflamma- readily achievable with high long-term survival rates tion in the surrounding periodontal tissues would lead (Abboud et al. 2013; Bashutski and Wang 2007; Butler to periodontal breakdown followed by the develop- and Kinzer 2012; Wheeler 2007), dental implant success ment of significant osseous destruction (Tsesis et al. should be judged also by esthetic outcomes, and esthetic 2010a;Waltonetal.1984;Tsesisetal.2010b). As a re- predictability may be difficult to attain. Furthermore, sult, a future restoration with dental implants in the when implant failure happens in the esthetic zone, it area may be compromised (Tsesis et al. 2015;Tsesiset may be difficult to be corrected entirely (Tsesis et al. al. 2010a;Tamse2006;Tsesisetal.2010b). However, 2015; Abboud et al. 2013; Bashutski and Wang 2007; each case should be judged objectively as some data Butler and Kinzer 2012; Wheelers 2007). (Eichelsbacher et al. 2009)revealedthatwithadequate Nevertheless, periodontal esthetic complications, such case selection, proper management of teeth affected by as the development of gingival recession and alveolar root-originated fractures has no detrimental impact on bone loss, may happen as a result of the surgical proce- periodontal health over a time.
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