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<< Back to 2002 Case List

May 2002 Vertical Root Fracture in Apparently Successful Case

Fig. 1

In August of 2000 a female 31 year old patient presented with evidence of deep amalgam restoration in tooth #16. (Fig.1)The tooth was slightly percussion sensitive and not responding to pulp tests. A diagnosis of necrosis was made and endodontic treatment was performed. (Fig.2) The referral had asked me to make a post space in the palatal canal in order to retain a core.

Fig. 2

Soon after the endodontic treatment was completed the tooth was restored. The patient was subsequently seen in May of 2002 at which time she was complaining of palatal swelling at the gingival crest, sinus tract, percussive sensitivity and soreness to occlusion. A gutta percha cone was placed in the sinus tract to trace it to its source. (Fig. 3) I also noted that periodontal probing showed a localized area of apparent loss of attachment on the mesio-palatal side of the tooth. Probing depth in this area was 10 mm. The pocketing corresponded to an area of radiolucency on the mesial side of the tooth.

Fig. 3

Periapically, the case tooked fine. However, I was disappointed in the clinical result. Having done thousands of molar endodontic treatments, I was aware of the low failure rate of endodontic treatment of the palatal root. Compared to other maxillary molar roots, this was usually one of the easiest canals to treat. Clinical endododntic failure in this root was rare.

My attention was also drawn to the post. Although I strongly recommend PASSIVELY fitting posts, sometimes my recommendations are not followed. In this case, I feared that the screw post that had been placed was more "Active" than the root dentin could tolerate. I suspected a fracture. if that was the case, the prognosis was poor. We agreed that extraction was the treatment of choice and the tooth was removed by the referral. He was kind enough to send it to me for further examination, though he told me he could not see a fracture in the palatal root.

With slight magnification the problem became apparent.

Fig. 4 and 5 - Palatal View of Fracture
(Fig. 5 stained with Methylene Blue stain) Fracture is obvious.
Interestingly, it is at the exact level of the post.

Solution
With the increase in bond strength of restorative materials, the need for post placement has become reduced. Still, old habits die hard and there are still clinicians who insist on placing posts in teeth that I would rather they leave as is. Should posts be necessary, they must always be PASSIVELY placed in the prepared canal space with minimal insertion force, proper venting and care. Use of "Active" posts with deep threads should be avoided at all costs. Failure to adhere to this rule can result in catastrophic fracture of the root dentin that will result in loss of the tooth. This is especially frustrating in the case of the endodontically treated and restored tooth where success seems to have been obtained in the short term. Needless to say, the patient was not pleased with the result.