‘‘true’’ VRF is defined as a longitudinally oriented complete or incomplete fracture initiated in the root at any level, usually directed buccolingually American association of endodontics

endodontics‘‘true’’ VRF is defined as a longitudinally oriented complete or incomplete fracture initiated in the root at any level, usually directed buccolingually
American association of

1. VERTICAL ROOT FRACTURE DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS UTTARANCHAL DENTAL AND MEDICAL RESEARCH INSTITUTE Presented by:- Dr. ABDUL KADIR PG 3 RD YEAR

2. Definition A ‘‘true’’ VRF is defined as a longitudinally oriented complete or incomplete fracture initiated in the root at any level, usually directed buccolingually American association of endodontics

3. Split Tooth Originate from crown to root. Direction- Mesiodistal Marked pain on chewing Often root filled Poor- unless crack subsides subgingivally Vertical Root Fracture Originate in root . Direction – Faciolingual . Vague pain mimicking periodontal disease Mostly root filled Poor- root resection in multi rooted teeth

4. Incidence Gher   et al . have reported a low incidence of 2.3%.  Gher ME Jr, Dunlap RM, AndersoLV.Clnical survey of fractured teeth. J Am Dent Assoc 1987;114:174-7.   Highest incidence has been observed in endodontically treated teeth and in patients older than 40 years of age. Premolars are the most susceptible teeth for vertical root fracture followed by molars, incisors and cuspids in descending order.  The most susceptible roots to fracture are maxillary and mandibular premolars, mesial roots of mandibular molars and mandibular incisors.  Cohen . Pathways of pulp , 11 th edition , chp-21, pg no- 800.

5. JOE 2009

6. VRF is rare in vital anterior teeth. VRF in vital teeth occurs more frequently in males due to factors such as stronger masticatory force, increased attrition, habitual chewing of hard food and less pliable supporting bone.  Fracture most commonly occurs in bucco -lingual direction in individual roots of molar teeth. Mesio -distal fractures are less common. In anterior teeth, the fractures are most commonly in a bucco -lingual direction.  Holcomb JQ, Pitts DL, Nicholls JI. Further investigation of spreader loads required to cause vertical root fracture during lateral condensation. J Endod 1987;13:277-84 .         Chan CP, Lin CP, Tseng SC, Jeng JH. Vertical root fracture in endodontically versus nonendodontically treated teeth: A survey of 315 cases in Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radio Endod 1999;87:504-7

7. Testori  et al . reported premolars to have the highest incidence of VRF in endodontically treated teeth; however, Chan  et al . reported first molars to be the teeth most frequently fractured. On the other hand, canines had the lowest incidence. Testori T, Badino M, Castagnola M. Vertical root fractures in endodontically treated teeth: A clinical survey of 36 cases.JEndo1993;19:87-91 .              Chan CP, Lin CP, Tseng SC, Jeng JH. Vertical root fracture in endodontically versus nonendodontically treated teeth: A survey of 315 cases in Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radio Endod 1999;87:504-7

8. Prevalence of vertical root fractures in teeth planned for apical surgery. A retrospective cohort study. M. Maddalone1 , M. Gagliani , C.L. Citterio , A. Pellegatta & M. Del Fabbro . Int Endo . Journal ,2018

9. using a finite elements model, concluded that the lack of bonding between post and canal walls increased the frequency of VRFs, stating that “Tensile stress peaks for the non-bonded models were approximately three times higher than for the bonded or intact models”. Santos AF, Tanaka CB, Lima RG et al. (2009) Vertical root fracture in upper premolars with endodontic posts: finite element analysis. Journal of Endodontics 35, 117-20. Suggested that the improper selection of intra-canal posts or excessive pressure in positioning them could cause fractures in roots Tamse A (1988) Iatrogenic vertical root fractures in endodontically treated teeth. Endodontics and Dental Traumatology 4, 190-6.

10. DIAGNOSIS OF VERTICAL ROOT FRACTURE IS BASED ON:-

11. HISTORY:- History of facial trauma (could result in a VRF if the trauma is directed accordingly. • History of pain, swelling, presence of sinus tract, mobility, or any history of post or restoration dislodgement. • A thorough clinical examination, including age and gender of patient; involved tooth, its location, pulp vitality; history of previous dental treatment (including endodontic and restorative treatments); and type of restoration (with or without post and crown) using glass ionomer cement, resin‑based composite or amalgam Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

12. CLINICAL DIAGNOSTIC TESTS:- Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

13. Prevalence An overall prevalence of 3% to 5% has been reported in retrospective studies.  However, the percentage of extracted teeth with VRF has been reported to be much higher - 10-20%.  Bergman B, Lundquist P, Sjögren U, Sundquist G. Restorative and endodontic results after treatment with cast posts and cores. J Prosthet Dent 1989;61:10-5.           Fuss Z, Lustig J, Tamse A. Prevalence of vertical root fractures in extracted endoodontically treated teeth. Int Endod J 1999;32:283-6.        

14. According to Chan et al.,11- 40% of VRFs occurred in nonendodontically treated teeth of Chinese patients, which may result from excessive, repetitive, and heavy masticatory stress exerted vertically on attrited occlusal surface Chan CP, Lin CP, Tseng SC, Jeng JH. Vertical root fracture in endodontically versus nonendodontically treated teeth: a survey of 315 cases in Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:504e7. It has been reported that VRFs accounted for 8.8 -20% of all extracted root-filled teeth Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factors related to extraction of endodontically treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:

15. Clin Oral Invest DOI 10.1007/s00784-014-1357-4, 2014

16. CLASSIFICATION

17. Leubke RG. Vertical crown-root fractures in posterior teeth. Dent Clin North Am 1984;28:883-94.            Based on separation of fragments Complete fracture Incomplete fracture Relative to position of alveolar crest Intra- osseous fracture supra- osseous fracture LEUBKE’S CLASSIFICATION

18. Pathogenesis Holcomb JQ, Pitts DL, Nicholls JI. Further investigation of spreader loads required to cause vertical root fracture during lateral condensation. J Endod1987:13: 277–284

19. Etiology VRFs have a multifactorial etiology  Predisposing factors Iatrogenic factors Endodontically treated teeth Non Endodontically treated teeth Non Endodontically treated teeth Endodontically treated teeth Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

20. Predisposing factors for endodontically treated teeth:-

21. Excessive cutting during various phase of root canal treatment Increased stress generation with threaded and tapered posts  Increased wedging forces with lateral compaction of gutta-percha accounts for 48% to 84% of cases of VRFs . The development of these stresses initiates crack introduction and propagation, leading to final root fracture. Iatrogenic errors for endodontically treated teeth Yang HS, Lang LA, Molina A, Felton DA. The effects of dowel design and load direction on dowel and core restorations. J Prosthet Dent 2001;85:558-67.         Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with different post systems. J Prosthet Dent 2002;87:431-7.         Tamse A. Iatrogenic vertical root fractures in endodontically treated teeth. Endod Dent Traumatol 1988;4:190-6.        

22. In Non-endodontically treated teeth In non-endodontically treated teeth, fractures might be related to special diet patterns or chewing habits, excessive, repetitive and heavy masticatory stress referred to as “fatigue root fractures” So the physical trauma is the most common cause for tooth/root fracture in vital teeth. Yang SF, Rivera EM, Walton RE. Vertical root fracture in nonendodontically treated teeth. J Endod 1995;21:337-9.        

23. Predisposing factors in vital teeth Loss of tooth material Anatomy of the susceptible teeth Previous dental cracks and alveolar bone support Habits:- Bruxism and clenching Increased stress in compromised teeth. Poor cavity preparation design. Poorly fitting intracoronal restoration. Improper choice of teeth for bridge abutment.

24. Clinical Manifestation Early manifestation- Pain or discomfort on the affected side of tooth. Uncomfortable and sensitive upon chewing. Swelling often occurs and sinus tract may be present. Radiographic findings are unlikely. A deep, narrow and isolated periodontal pocket may be associated with root Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

25. Late manifestation :- Radiographically- J –shaped or halo radiolucency Pocket – Along the fracture, which was initially tight and narrow, may become wider and easier to detect. The segments of root may also separate, resulting in radiograph that clearly reveals an objective root fracture Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

26. Pathognomic for presence of VRF Sinus tract & Narrow , Isolated periodontal probing defect associated with a tooth that has undergone a root canal treatment , with or without post placement According To American Association Of Endodontists

27. Periodontal Pocket Vertical Root Fracture Pocket As a result of bacterial biofilm that initiates at cervical area of tooth. Pockets are typically wider coronally and relative loose. Pocket present at mesial or distal aspects of tooth. Affects group of teeth Develops due to bacterial penetration into fracture. Pockets are deep and with narrow coronal opening. Pocket is often located at buccal or lingual convexity of tooth. Affects single tooth and present in limited area adjacent to affected tooth

28. Deep probing in one position around the circumference of tooth in presence of otherwise normal attachment usually indicates that the tooth is fractured (as opposed with periodontal disease, where the pocketing is generalized around a large part of the tooth). Deep probing in two positions on opposite sides of the infection is almost pathognomonic for the presence of a fracture. Vertical root fractures and their management .Sandhya Anand Khasnis, Krishnamurthy Haridas Kidiyoor , Anand Basavaraj Patil, Smita Basavaraj Kenganal Year  : 2014  |    Volume  : 17  |   Issue  : 2  |   Page  : 103-110

29. Rigid metal periodontal probing may be ineffective in probing VRF. A flexible probe should be used – probe from Premier dental products. As reported by tamse & colleagues typical VRF pocket was observed in 67% of VRF cases. Tamse A. Iatrogenic vertical root fractures in endodontically treated teeth. Endod Dent Traumatol 1988;4:190-6.         Vertical root fractures and their management .Sandhya Anand Khasnis, Krishnamurthy Haridas Kidiyoor , Anand Basavaraj Patil, Smita Basavaraj Kenganal Year  : 2014  |    Volume  : 17  |   Issue  : 2  |   Page  : 103-110

30. Coronally located sinus tract Chronic apical abscess Location- At site of least bone resistance, against apical part of root or in area of junction of attached gingiva and oral mucosa. Vertical root fracture Location- more coronal position as the source is not from a periapical lesion Vertical root fractures and their management .Sandhya Anand Khasnis, Krishnamurthy Haridas Kidiyoor , Anand Basavaraj Patil, Smita Basavaraj Kenganal Year  : 2014  |    Volume  : 17  |   Issue  : 2  |   Page  : 103-110

31. J-shaped or “halo” radiolucency demonstrated the greatest association with VRF (52.2%), Followed by periodontal pocket depth >5 mm( 25.5%) Sinus tract alone- 11.9% Periodontal swelling or abscess- 7.3% Approximately 70% of cases manifested themselves as combinations of at least two of these factors. Teeth having two and three or four of these factors had 3.14 times and 11.64 times higher risks for the presentations of vrfs , respectively (p < 0.001) Journal of the Formosan Medical Asso (2018)

32. Direct visualization Direct visual examination (with good illumination and magnification) of tooth especially the marginal ridges is important. When excess coronal structure is missing, or when a crown has dislodged, fracture may be directly viewed by examining the remaining tooth structure. Fracture is clearly visible when separation of fragments has occurred. A sharp probe may aid in identifying the fracture line where separation has not occurred.

33. Staining Disclosing dyes stain the fracture line and aid the clinician to visualize a suspected crack. Also, cleaning the occlusal surface with a cotton pellet moistened with 70% isopropyl alcohol, washes away the food coloring on the surface, but the food coloring within the fracture line remains and becomes apparent. Pulp testing Pulp vitality tests can be helpful in diagnosing a VRF (especially in sound teeth) as fracture line may extend to the pulp causing inflammation and necrosis. Diagnostic information may be obtained when the patient complains of a sharp, sudden pain, especially while chewing.

34. Bite test: Rubber wheels, cottonwood sticks or aids such as Tooth Slooth may be used to reproduce the biting pain described by the patient. This test is performed tooth‑by‑tooth or cusp‑by‑cusp. Usually the patient feels relaxed on biting and pain starts while releasing the pressure. Transillumination test: Fiberoptic light may be used to visualize a crack. Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

35. Periodontal probing test: Probing with periodontal probe or a no. 25 silver cone may reveal a narrow, isolated, periodontal defect in the gingival attachment. Tracing the sinus tract: Gutta percha, endodontic explorer, etc., may be used to trace the sinus tract back to its origin. Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

36. Radiographic features In early stages of VRF , no radiolucent bone lesions observed In a study of pattern of bone resorption in 110 VRF Cases, Lustig and associates found 72% of patients with either chronic signs and symptoms or acute exacerbations - as greater bone loss compared to patients for whom a VRF diagnosis was made at an early stage. J shaped or halo appearance are associated with high probability of VRF An angular bone resorption of crestal bone along the root on one or both sides , without involvement of periapical area was found in 14% cases

37. Tamse & coworkers reported radiographic appearance of halo and periodontal radiolucencies's in vertically fractured mesial roots of mandibular molars- 37 & 29% respectively. Tamse A (1988) Iatrogenic vertical root fractures in endodontically treated teeth. Endodontics and Dental Traumatology 4, 190-6.

38. Radiolucency in bone along root Substantial destruction of cortical plate of alveolar bone is seen In early stages, bone resorption is limited in buccolingual plane and is usually obscured by superimposition of roots. As the VRF progresses to intermediate stage, radiographs taken at different angulations may detect bone resorption. This feature should be differentiated from split tooth , in which fracture plane is typically mesiodistal. Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

39. A periapical radiograph can detect a fracture line only in 35.7% cases. The reasons for this may be, i . Superimpositions of root canals on fracture line ii. X-ray beam not parallel to the plane of fracture iii. Fracture line present in the fused root superimposed by radiopaque anatomic structures iv. Location of fracture line precludes the use radiograph . Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

40. Cone-Beam computed tomography American association of endodontics recommended use of CBCT for diagnosis of VRF. Unique feature of CBCT is its ability to study the suspected tooth and associated bone in an axial plane. At a voxel size of 0.3mm, the detection of early , unseparated VRFs is not reliable, however small voxel size is used. Smallest voxel size of 0.075mm is available for CBCT device, & CBCT imaging would visualize fracture when the width of fracture is greater than 0.15mm

41. Results showed better sensitivity and specificity of CBCT scans than PRs in the detection of VRFs in unfilled teeth, particularly when a voxel size of 0.2 mm was used. Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

42.   The sensitivity and specificity of VRF diagnosis in assessing gutta-percha filled canals were 32% and 68% The sensitivity and specificity of VRF diagnosis in assessing the empty canals (without gutta-percha ) were 72% and 96% . And concluded that intracanal filling materials such as gutta-percha reduce the diagnostic ability of vertical root fractures. Hence, it is recommended to remove those materials from root canals before imaging to improve the diagnostic potential of CBCT. The Scientific World Journal volume 2018,  Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

43. Endodontic status after healing has occurred Rapid deterioration of endodontic status of a tooth after a long time without symptoms, or reappearance of radiolucencies after healing has previously taken place, is indicative of fracture. Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

44. Laser in diagnosis Kimura  et al .  suggested that root fracture could be diagnosed by DIAGNOdent with methylene blue (MB) dye solution. In a further study, they proposed that the use of detergent allows better penetration of dye thereby enhancing the detection of root fractures.    Kimura Y, Tanabe M, Amano Y, Kinoshita J, Yamada Y, Masuda Y. Basic study of use of laser on detection of vertical root fracture. J Dent 2009;37:909-12 Kimura Y, Tanabe M, Yamazaki N, Amano Y, Kinoshita JI, Yamada Y,  et al . Basic study on diagnosis of root fracture by DIAGNOdent 1. Jap J Cons Dent 2009;52:12-20 .        

45. Exploratory Surgery Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

46. Misdiagnosis of VRF Fuzz Z, Lusting J, Katz A, Tamse A. An evaluation of endodontically treated vertical root fractured teeth: Impact of operative procedures. J Endod 2001;27:46-8.         Chan CP, Lin CP, Tseng SC, Jeng JH. Vertical root fracture in endodontically versus nonendodontically treated teeth: A survey of 315 cases in Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radio Endod 1999 Reported that general practitioners often misdiagnose VRFs . The teeth that were extracted in studies had often been diagnosed as endodontic failures or refractive periodontal pockets, only to realize after extraction that in some of them actual cause was a VRF

47. Management: Single rooted teeth Multirooted teeth Unfavourable prognosis Resecting the root Extraction Root Amputation Hemisection Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113

48. 1) Extraction and replantation after bonding 2) Application of a bio‑resorbable membrane 3) Other treatment options for bonding can be use of:- Composite Resin Mineral Trioxide Aggregate 4) Other alternative attempts Vertical root fractures: An update review Anu Dhawan ,  Sumit Gupta ,  Rakesh Mittal 2014  |   Volume  : 2  |   Issue  : 3  |   Page  : 107-113 various Treatment modalities

49. Chief complaint- 52-year-old lady, complaint of pus discharge and discomfort in her upper anterior teeth. History – RCT in upper 21 one year previously. Radiographically , it was noted that the obturation was satisfactory. However, a large periapical lesion was noted with respect to that tooth . Diagnosis - A non healing radicular cyst Treatment plan - surgical enucleation of the cyst Vertical root fracture- A Case report Hegde MN, Hegde ND, Haldar C. Vertical root fractures: Review and case report. J Interdiscip Dentistry 2011;1:101-4

50. . A flap was raised and the periapical area of the tooth was examined  It was noted that the tooth exhibited a vertical root fracture. The treatment plan modified and the tooth was atraumatically extracted. The two segments were thoroughly cleaned, irrigated and dried. They were then bonded with a cyanoacrylate based adhesive  material, held under pressure for three minutes and any excess adhesive was cleaned from the surface. Cohen S, Burns RC. Pathways of the pulp. 8  th  ed. St Louis: Mosby; 2002.             

51. The tooth was re-implanted into the socket and splinting was done on the lingual surface for a period of two weeks. The patient reported that her symptoms were relieved and the tooth was noted to be firm in the socket. Post operative evaluation after two years showed healed periapical lesion  and functional tooth in the anterior segment.

52. 2) Application of a bio‑resorbable membrane :- Reinforce periodontal healing, by preventing any gingival connective tissue from making contact with the curetted root surfaces during healing and allowing for regeneration of periodontal ligament cells around the teeth has been suggested in few reports.This membrane also prevents the ankylosis after replantation.

53. 3) Other treatment options like use of:- Composite Resin Mineral Trioxide Aggregate Silver Glass Ionomer Cement for bonding the fracture line have also been tried. Calcium hydroxide to promote tissue repair and resolve osseous defects before the roots were restored has also been used. Poor long‑term prognosis has been reported with teeth cemented extra‑orally with cyanoacrylate.

54. Other alternative attempts at treating VRF include: • Bonding the fractured segments with glass ionomer cement and replanting the tooth in conjunction with an e‑PTFE membrane. Trope M, Rosenberg ES. Multidisciplinary approach to the repair of vertically fractured teeth. J Endod 1992;18:460‑3 • Two‑stage surgical procedure of bonding with silver glass ionomer cement, placement of a bone graft material and GTR therapy. Seiden HS. Repair of incomplete vertical root fractures in endodontically treated teeth in vivo trials. J Endod 1996;22:426‑9.

55. Replantation with intentional rotation of a complete vertically fractured root using adhesive resin cement Fidel SR, Sassone L, Alvares GR, Guimarães RP, Fidel RA. Use of glass fiber post and composite resin in restoration of a vertical fractured tooth. Dent Traumatol 2006;22:337‑9. KudouY , Kubota M. Replantation with intentional rotation of a complete verticallyfractured root using adhesive resin cement. Dent Traumatol 2003;19:115^117 Combined technique of glass fiber‑post and composite for aesthetic and functional results

56. Use of dual‑cured adhesive resin cement is preferred for bonding the fractured fragments, as it has a controlled polymerization and is easy to apply Oztürk M, Unal GC. A successful treatment of vertical root fracture: A case report and 4 year follow‑up. Dent Traumatol 2008;24:e56‑60. Use of CO2 and Nd.YAG laser to fuse fractured tooth roots Arakawa S, Cobb CM, Rapley JW, Killoy WJ, Spencer P. Treatment of root fracture by C02 and ND: YAG lasers: An in vitro study. J Endod 2012;22:662‑7.

57. Four cases were presented in which 1 endodontically treated maxillary or mandibular molar had an incomplete vertical root fracture involving 1 of the roots. The tooth underwent a flap elevation procedure to visualize the pattern of bone loss and assess the extent of root fracture. The fracture line was eliminated by resecting the root in a beveled manner, after which root-end preparation and root-end filling were performed by using mineral trioxide aggregate. JOE 2012

58. The osteotomy was covered with an absorbable collagen membrane. Cases were followed up for 8–24 months after surgery. Results : The procedure was shown to be predictable and successful in this series. Root length was preserved, and tooth extraction was avoided. Conclusions: The microsurgical treatment option for multirooted teeth with incomplete vertical root fracture resulted in long-term clinical success

59. Chief Complaint:- Five patients referred to a periodontal practice for management of severe vertical bone loss and suspected VRF were evaluated and found to have vertical fractures located subgingivally , on the root surface and only on one side of the tooth (unilateral). History:- All teeth had previously been treated endodontically, but without resolution of the chronic infection and periodontal pocket associated with the tooth. In all cases, the bony defect was 10 mm or greater and demonstrated bleeding on probing and associated inflammation. Radiographic examination failed to demonstrate the fracture in any of the cases.

60. All teeth failed during this period and required extraction due to recurrent periodontal abscess, increased probing depth, inflammation and patient discomfort

61. Attempts to repair a fracture by filling the crevice with a variety of restorative material have been reported ; however none of these repair is considered as reliable long term solution . Cohen . Pathways of pulp , 11th edition , chp-21, pg no- 800 .

62. Prevention Avoiding or correcting all the etiological factors provides the best prevention. This may include Kishen A. Mechanisms and risk factors for fracture predilection in endodontically treated teeth. Endodontic topics 2006;13:57‑83 .

63. Conclusion:- Cracked tooth syndrome and Vertical root fracture is a common and well-documented entity in the clinical practice. Patients usually present with a wide variety of signs and symptoms, thus making the diagnosis difficult and complicated. Detailed history and thorough clinical examination may help in establishing a correct diagnosis and hence that an appropriate treatment plan can be instituted.

64. Thank you

65. RESULTS: The case series analysis revealed that the time from implant placement to the diagnosis of VRF was between 5 and 28 months (average = 11 months). The majority of cases occurred in female patients who received 2 or more implants. Six of the 7 patients were older than 40 years, with an average age of 54 years . The majority of teeth with VRF were premolar or mandibular molar teeth (6/8 teeth). All fractured teeth had been restored with a crown and had a post present , and the quality of the root canal filling was determined to be adequate. The systematic review revealed that implant-associated VRF has not been investigated or reported in the literature yet.