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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 56-61

Diagnosis of vertical root fractures using cone-beam computed tomography


1 Department of Removable Prosthodontics, The Nippon Dental University School of Life Dentistry, Niigata, Japan
2 Department of Oral and Maxillofacial Radiology, The Nippon Dental University School of Life Dentistry, Niigata, Japan
3 Department of Comprehensive Dental Care, The Nippon Dental University Niigata Hospital, Niigata, Japan
4 Dental Anesthesia and General Health Management, The Nippon Dental University Niigata Hospital, Niigata, Japan

Date of Submission04-Dec-2020
Date of Decision02-Jan-2021
Date of Acceptance12-Jan-2021
Date of Web Publication26-Feb-2021

Correspondence Address:
Fumi Mizuhashi
Department of Removable Prosthodontics, The Nippon Dental University School of Life Dentistry, Niigata, 1-8 Hamaura-Cho, Chuo-Ku, Niigata
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_24_20

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  Abstract 


Background/Aim: The aim of this study was to investigate the occurrence of vertical root fracture using cone-beam computed tomography (CBCT). Methods: We reviewed the CBCT images of 41 patients who were examined and verified vertical root fracture. The characteristics of root fractures (pulpal vitality, existence of injury, kind of tooth, and core construction) that were considered to influence the occurrence of root fracture were investigated. The position of the tooth and the fracture direction were also examined. Diagnostic propriety of root fractures between intraoral radiography and CBCT was examined. Statistical analyses of each characteristic and the fracture direction were performed by Chi-squared test. The position of the tooth and diagnostic propriety were analyzed by cross-tabulation. Results: The number of vertical root fracture was larger at nonvital tooth (P < 0.001) and larger on nontraumatized tooth (P < 0.001). There was not statistically significant difference among metal core, composite resin core, and no core to the occurrence of vertical root fracture. The number of vertical root fracture was largest on the premolar teeth (P = 0.022), and the anterior teeth fracture was larger on the upper teeth (P = 0.003). On the premolar teeth, the frequency of buccolingual fracture was larger than that of mesiodistal fracture (P = 0.033). The vertical root fracture that was diagnosable by CBCT was larger in comparison to that by intraoral radiography (P < 0.001). Conclusions: These results suggested that vertical root fracture easy to occur on nonvital tooth, nontraumatized tooth, and premolar tooth, and diagnosable using CBCT.

Keywords: Cone-beam computed tomography, diagnosis, vertical root fracture


How to cite this article:
Mizuhashi F, Ogura I, Sugawara Y, Oohashi M, Mizuhashi R, Saegusa H. Diagnosis of vertical root fractures using cone-beam computed tomography. J Oral Maxillofac Radiol 2020;8:56-61

How to cite this URL:
Mizuhashi F, Ogura I, Sugawara Y, Oohashi M, Mizuhashi R, Saegusa H. Diagnosis of vertical root fractures using cone-beam computed tomography. J Oral Maxillofac Radiol [serial online] 2020 [cited 2021 Apr 17];8:56-61. Available from: https://www.joomr.org/text.asp?2020/8/3/56/310382




  Introduction Top


Percentage of the dental patients with caries and periodontal disease has been decreased because of the development of the preventive dentistry, and the cause of tooth loss changed from caries or periodontal disease to root fractures.[1] Root fractures could be occurred by the cause from endodontics, prosthetics, and trauma and so on. Enlargement of the root canal during the endodontic treatment can reduce fracture resistance by forming the microcracks,[2] and the pressure of root canal obturation causes the extension of the microcracks.[3] The preparation of the post after the endodontic treatment cause thinning of the root canal wall and reducing fracture resistance.[4] Concerning the influence of the post material to the root fracture, it is reported that the postmaterial affected the fracture resistance of endodontically treated teeth.[5],[6]

The root fractures are broadly classified as vertical and horizontal root fractures.[7] Vertical root fracture occurs along the tooth axis and most of the fracture extends from the apex of root to the coronal part and from the internal wall of root canal to the root surface.[8] The vertical root fracture is reported to occur in endodontically treated teeth,[9] and the incidence of vertical root fracture in endodontically treated teeth is shown between 3.7% and 30.8%.[8] Another study reported that the vertical root fracture in nonendodontically treated teeth is not uncommon in the Chinese population, and the incidence of vertical root fracture in nonendodontically treated teeth is shown over 40%.[10],[11] Concerning the kind of the tooth, vertical root fracture is more prevalent in premolars and mesial root of mandibular molars.[12],[13] Root fracture teeth often lead a deep osseous defect around the fracture site.[14] Thus, the cases of tooth loss caused by root fracture are increasing and a timely and definite diagnosis is important to avoid progressive alveolar bone loss.[15]

Concerning the diagnosis of root fracture, specific clinical signs or symptoms and radiographic features have been performed.[16] However, the clinical signs or symptoms of root fracture are often unclear.[17] For the diagnosis of root fracture by the radiographic features, periapical radiography has been used; however, periapical radiography is of limited use for the detection of fractures due to the compression of three-dimensional anatomy into a two-dimensional image, anatomical noise, and geometric distortion.[18] On the other hand, cone-beam computed tomography (CBCT) provides a three-dimensional image viewing and has been widely used for the diagnosis or treatment planning.[19] CBCT has been reported to have higher accuracy than periapical radiography in the detection of root fracture[20] and shown its usefulness for the diagnosis of root fractures.[17],[21],[22]

It is important to prevent and treat root fracture to increase the life span of teeth. In order to that, we should know about the occurrence of the root fracture and the diagnostic method of the root fracture. The aim of this study was to investigate the occurrence of vertical root fracture using CBCT.


  Methods Top


This retrospective study was approved by the ethics committee of our institution. We reviewed the CBCT images of 41 patients (17 male, 24 female; range age: 16–86 years, mean age: 62.0 ± 15.9 years) who were examined by CBCT for the diagnosis of root fracture and verified the vertical root fracture after extraction in our university hospital from January 2017 to October 2019. All patients were performed CBCT after intraoral radiography. The images were independently evaluated by two dentists and any discrepancies were resolved by consensus.

Intraoral radiographs were acquired with an intraoral machine (HELIODENT Plus; Sirona Dental Systems, Tokyo, Japan) using the dental protocol at our hospital: tube voltage, 70 kV and tube current, 7 mA. CBCT imaging was performed with a CBCT unit (FineCube; Yoshida, Tokyo, Japan). The CBCT parameters were as follows: tube voltage, 90 kV; tube current, 4 mA; field of view, 81 mm × 81 mm; and rotation time, 16.8 s. The protocol was set at a thickness of 0.144 mm, resulting in axial, cross-sectional, and parasagittal multiplanar reformation images and three-dimensional images.[23]

The characteristics of root fractures were investigated. Four factors (pulpal vitality, existence of injury, kind of tooth, and core construction) that were considered to influence the occurrence of root fracture were investigated. About pulpal vitality, the number of vital tooth and nonvital tooth was counted. Trauma experience was sorted out the tooth with a history of trauma (traumatized tooth) from the tooth without a history of trauma (nontraumatized tooth), and the number of each tooth was counted. Concerning to core construction, the number of metal core, composite resin core, and no core were counted. Kind of tooth was classified into anterior teeth, premolar teeth, and molar teeth, and the number of each tooth was counted.

Position of the tooth was also classified to upper teeth and lower teeth, and the number of each tooth on anterior teeth, premolar teeth, and molar teeth was counted. Fracture direction was classified to buccolingual and mesiodistal root fractures, and the number of each tooth on anterior teeth, premolar teeth, and molar teeth was counted. Diagnostic propriety of root fractures between intraoral radiography and CBCT was also examined. The frequency of root fracture tooth diagnosable and impossibility of diagnosis were counted for each radiography technique (intraoral radiography and CBCT).

Statistical analyses of each characteristic of root fractures and the fracture direction were performed by Chi-squared test. Position of vertical root fracture tooth and diagnostic propriety of vertical root fractures were analyzed by cross-tabulation. When statistically significance was found by cross-tabulation, a residual analysis was performed. Statistical analysis was performed using statistical analysis software (SPSS 17.0, SPSS JAPAN, Tokyo, Japan), and differences of α < 0.05 were considered significant.


  Results Top


[Table 1] shows the characteristics of vertical root fractures. The result indicated that the occurrence of root fracture was different by pulpal vitality (χ2[1] = 23.44, P < 0.001), and the number of vertical root fracture was larger at nonvital tooth in comparison with vital tooth. On the frequency of vertical root fracture by trauma experience, the number of nontraumatized tooth was larger in comparison with traumatized tooth (χ2[1] = 37.10, P < 0.001). Concerning core construction, there was no statistically significant difference among metal core, composite resin core, and no core to the occurrence of vertical root fracture (χ2[2] = 0.17, P = 0.920). The number of vertical root fracture was different by the kind of tooth, and the number of the premolar teeth was largest (χ2[2] = 7.66, P = 0.022).
Table 1: Characteristics of vertical root fractures in this study

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[Table 2] shows the position of vertical root fracture tooth with upper and lower teeth. The number of vertical root fracture was different between the upper and lower teeth (χ2[2] = 11.57, P = 0.003, V = 0.53), and the number of vertical root fracture on the anterior teeth was larger at the upper teeth. Although there were not statistically significant differences, the number of vertical root fractures on the premolar and the molar teeth tended to be larger at the lower teeth.
Table 2: Position of vertical root fracture tooth

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[Table 3] shows the fracture direction of the vertical root fracture. The frequency of buccolingual fracture and mesiodistal fracture was not different at the anterior teeth (χ2[1] = 0.00, P = 1.000) and the molar teeth (χ2[1] = 0.11, P = 0.739). On the premolar teeth, the frequency of buccolingual fracture was larger than that of mesiodistal fracture (χ2[1] = 4.55, P = 0.033).
Table 3: Fracture direction of vertical root fractures

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[Figure 1] shows the intraoral radiography image [Figure 1]a and CBCT image [Figure 1]b of one subject in this study that vertical root fracture (mesiodistal fracture) could not be diagnosed by intraoral radiography image but diagnosable by CBCT image. [Figure 2] shows the intraoral radiography image [Figure 2]a and CBCT image [Figure 2]b of one subject in this study that vertical root fracture (buccolingual fracture) was diagnosable by intraoral radiography and CBCT images. [Table 4] shows the diagnostic ability of vertical root fractures. The result indicated that the number of the vertical root fracture that was diagnosable by CBCT was larger in comparison to that by intraoral radiography (χ2[1] = 45.22, P < 0.001, V = 0.74).
Figure 1: Intraoral radiography and cone-beam computed tomography images that vertical root fracture (mesiodistal fracture) could not be diagnosed by intraoral radiography image but diagnosable by cone-beam computed tomography image. (a) Intraoral radiography image. (b) cone-beam computed tomography image. Arrow indicates the part of root fracture. A. Axial image. B. Cross-sectional multiplanar reformation (MPR) image. C. Parasagittal MPR image

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Figure 2: Intraoral radiography and cone-beam computed tomography images that vertical root fracture (buccolingual fracture) was diagnosable by intraoral radiography and cone-beam computed tomography images. (a) Intraoral radiography image. Arrow indicates the part of root fracture. (b) Cone-beam computed tomography image. Arrow indicates the part of root fracture. A. Axial image. B. Cross-sectional multiplanar reformation (MPR) image. C. Parasagittal MPR image

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Table 4: Diagnostic ability of vertical root fractures

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  Discussion Top


The tooth loss caused by root fracture has been increasing instead of caries or periodontal disease.[1] This study investigated the occurrence of the vertical root fracture and the diagnostic method of the vertical root fracture.

Characteristics of vertical root fractures were investigated. Concerning pulpal vitality, the result showed that the occurrence of vertical root fracture was statistically significantly larger at nonvital tooth in comparison with vital tooth. This result was consistent with the results of the previous reports.[24],[25] The reason of this result could be considered that the nonvital tooth was undergone the overzealous root canal preparation and the excessive forces applied during compaction of root filling materials.[26] The frequency of vertical root fracture was larger on nontraumatized tooth in comparison with traumatized tooth. Horizontal root fractures are the most common type of traumatic injuries.[7] The result of this study would support the following recommendations to the frequency of vertical root fracture that is larger on nontraumatized tooth, and traumatized tooth tends to be horizontal root fractures.[7]

Concerning core construction, there was no statistically significant difference among metal core, composite resin core, and no core for the occurrence of vertical root fracture. This result was inconsistent to the previous reports[27],[28],[29] that showed that metal core easily be subject to fracture compared to the core with a lower modulus of elasticity such as fiber post. In contrast, the other study showed that the use of fiber posts resulted in higher stress on root structures compared with metal posts, primarily when the bonding between the fiber posts and the root canal surface failed.[30] Thus, there are no unified views concerning fracture resistance by core materials. In the limit of this study, it was indicated that core construction would not influence the occurrence of vertical root fracture.

The number of vertical root fracture was largest at premolar teeth. The result of additional investigation that analyzed the difference between the upper teeth and lower teeth indicated that all vertical root fractures on the anterior teeth were the upper teeth. On the other hand, the number of vertical root fracture on the premolar and the molar teeth tended to be larger at the lower teeth. Previous reports mentioned that vertical root fracture was more prevalent in premolars and mesial roots of mandibular molars.[12],[13] The result of this study was consistent with these reports.[12],[13] Premolar is the teeth of flat and thin roots with smaller mesiodistal diameter and an oval diameter in a buccolingual direction.[31] On the nonvital tooth, not only the excessive forces during compaction of root filling[26] but also some etiologic forces such as excessive masticatory forces and parafunctional habits[32] were applied. Therefore, the number of vertical root fracture would be largest on the premolar teeth.

Concerning the frequency of vertical root fracture between the buccolingual and mesiodistal fractures, the number of buccolingual fracture was significantly larger on the premolar teeth. The reason of this result would be caused by the anatomy of the premolar tooth. The root of the premolar tooth is flat and thin, and the mesiodistal diameter is small with an oval diameter in a buccolingual direction.[31]Therefore, the premolar tooth would be suffered excessive forth to the buccolingual direction.

The diagnostic propriety of vertical root fractures was statistically significantly different between intraoral radiography and CBCT, and the diagnostic ability by CBCT was significantly greater than that by intraoral radiography. Only two cases were impossibility of diagnosis by CBCT because of metal artifacts. CBCT can provide a better visualization of fracture line through multiplanar reconstructed images (axial, coronal, and sagittal planes). Intraoral radiography is two-dimensional radiograph; therefore, overlap of adjacent structures causes limits of the visualization of fracture line.[8] In the limit of this study, vertical root fracture could be detected by intraoral radiography only for the root fracture that the root was separated clearly. On the other hand, CBCT could detect vertical root fracture even if the root was not separated and the fracture line was not recognized by intraoral radiography. These results supported the previous study which indicated that CBCT was significantly more accurate than periapical radiography for the detection of vertical root fractures.[17]

In the limit of this study, it was suggested that vertical root fracture would be easier to occur on nonvital tooth, nontraumatized tooth, and premolar tooth. On premolar tooth, the fracture direction tended to be buccolingual direction. CBCT showed high diagnostic ability in comparison to intraoral radiography. In the case that vertical root fracture was doubtful, it was suggested to check the characteristics of root fractures and use CBCT for the diagnosis of root fracture.


  Conclusions Top


This study investigated the occurrence of vertical root fractures using CBCT. The results suggested that vertical root fracture would be easier to occur on nonvital tooth, nontraumatized tooth, and premolar tooth, and the radiography of the first choice to diagnose the vertical root fracture was CBCT.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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