Periapical lesions and vertical root fractures

Prof.  Dr. Paula Perlea*,  Assist. Prof. Dr. Cristina Coralia Nistor*

*Faculty of Dental Medicine, University of Medicine and Pharmacy Carol Davila Bucharest Romania

For a correct endodontic treatment we need to have an accurate diagnosis for establishing a precise treatment plan. Periapical lesions must be detected radiologically and in some cases using CBCT scanning as early as possible. Long lasting chronical apical periodontitis is causing localized inflammatory apical root resorption with important consequences:  loss of hard tissue, shortening of the root length and enlargement of the apical foramina. Conservative endodontic treatment for chronical apical periodontitis can be performed in a single visit or sometimes it is necessary to apply calcium hydroxide or Ledermix ™ to annihilate dentinoclast action. These conservative methods are not applicable for vertical root fractures (VRF). These are linked also to periapical or lateral radiolucent lesions, but the poor prognosis of teeth with such pathology makes the diagnosis challenging and the condition must be early and very precise detected. The correct diagnosis of the VRF is the result of imagistic means (radiographs and CBCT scan), clinical symptoms (the occlusal pressure sensitivity, sinus tract), direct visualization, the use of complementary exams (transillumination, dental operative microscope), periodontal probing, flap lifting.

Both lesions lead to progressive bone and hard dental tissue loss.

Periapical radiograph, which is currently used, has limitations because of the 2D representation and the overlapping of the anatomical structures. The CBCT is a more accurate imagistic method for showing radiolucent lesions, but it also can be altered by artefacts when used for the diagnosis of VRF.

The presented clinical cases  demonstrates the efficiency of early detecting the loss of hard dental tissue and bone loss in the apical area due to VRF and chronical periradicular inflammation, using radiograph or CBCT scanning. In case of periapical lesions it is mandatory to follow up radiollogically for a time period longer than a year.

Success in endodontic treatment when treating periapical periodontitis has to be predictable by performing rigorous biomechanical treatment, appropriate antibacterial therapy and proper sealing of the endodontic space, sometimes using MTA for an apical barrier.  In case of VRF, the diagnosis has to be very precise, as extraction of a tooth has to be done with responsibility.

Key words: periapical lesions, VRF, CBCT, diagnosis