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27 September 2023

What are the risk factors, signs and symptoms of vertical root fractures

Lara Figini

A vertical root fracture (VRF) is defined as a longitudinal fracture along the axis of the root, which may appear as incomplete (involving only part of the root) or complete (extending from one side to the opposite side of the root) .

In advanced stages a VRF may develop as a visible separation of the 2 parts of the root. Without a doubt, VRF is one of the most frustrating events that can occur in dentistry as it usually involves the extraction of the root or affected tooth.

Several studies have reported that VRF is a multifactorial phenomenon and it could be helpful to identify and understand risk factors early (such as loss of coronal tooth substance, pre-existing cracks, changes in the biomechanical properties of dentin and age-related microstructural changes). , root anatomy, tooth position and parafunctions) as well as concomitant risk factors (excessive removal of dentin during root canal preparation and inappropriate insertion of posts, exposure to overly aggressive endodontic disinfectants) associated with the etiology of such fractures.

VRF usually occurs in endodontically treated (ETT) teeth; it has occasionally been observed in vital teeth.

Materials and methods

In a recent systematic review, published in the Journal of Endodontics, the authors identified specific clinical signs or symptoms and potential risk factors associated with the presence of a vertical root fracture (VRF) in endodontically treated teeth (ETT).

Electronic databases (Medline via PubMed, Embase via Ovid, Scopus, and Web of Science) were used by 2 reviewers in October 2022 to track clinical trials in which potential risk factors associated with a VRF were evaluated.

Risk of bias was assessed using the Newcastle-Ottawa scale. Odds ratio (OR) meta-analyses were performed separately for different signs or symptoms and risk factors.


Fourteen studies were included in the final meta-analyses, reporting data on 2877 teeth (489 with VRF and 2388 without VRF). The presence of fistulous tracts (OR = 4.87; 95% confidence interval [CI], 1.58-15.0), the greater depth of periodontal probing (OR = 13.24; 95% CI, 5.44 -32.22), swelling/abscess (OR = 2.86; 95% CI, 1.74-4.70) and pain on percussion (OR = 1.76; 95% CI, 1.18-2 ,61) were significantly associated with the presence of VRF. None of the risk factors evaluated (gender, tooth type, tooth position, presence of posts, indirect restorations and apical extension of the root canal filling) were significantly associated with the presence of a VRF.


From the data of this review, which must be confirmed in other similar studies and reviews, it can be concluded that there are mainly four clinical manifestations identified as the most significant signs or symptoms of a vertical root fracture (VRF) in endodontically treated teeth (ETT ): fistulous tract, greater probing depth, swelling/abscess and pain on percussion.

None of the risk factors evaluated were significantly associated with vertical root fracture (VRF).

Risk factors for and clinical presentations indicative of vertical root fracture in endodontically treated teeth: a systematic review and meta-analysis. 

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