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22 I I case report _ root fractures The following surgical protocol is helpful during the process: 1.Local anaesthesia using a solution of 2% articaine with 0.1% epinephrine and a full-thickness muco- periosteal flap for better visualisation; 2.Circumferential dissection of the supra-alveolar fibres; 3.Gentle extraction of the tooth with minimum damage to the periodontium and immersion in saline solution; and 4.Curettage of the socket walls adjacent to the fracture region and irrigation with saline solution for the removal of inflamed tissue. For the treatment of VRFs, the following steps are recommended: 1.The root-filling material and granulation tissue are removed with a sharp scalpel through the entire root. During this process, in order to prevent dehy- dration, tooth fragments should be kept in gauze moistened with saline. 2.The sealant should be applied in small amounts to avoid covering the periodontal ligament on the root-canal dentine, which is dried prior to sealing. 3.The self-etching, dual-cured adhesive resin cement shouldbecuredfor20secondsforpropersettingof thematerial.Inaddition,thiswillhelptoreducethe working time extra-orally. 4.After fragment attachment, the root surfaces may be treated with tetracycline for 30 seconds to enhance periodontal ligament cell attachment.27 5.Inthefinalstep,thereconstructedtoothisreplanted in its original position.4,8,24 After the surgical procedure, patients are pre- scribed a chlorhexidine-digluconate mouth rinse and 500mg amoxicillin (3 tablets) plus 550mg naproxen (2 tablets) daily for one week. Following intentional replantation, clinical examinations should be per- formed in intervals to evaluate tooth mobility and sensitivity to percussion. The percussion tone can be compared with healthy adjacent teeth. Clinicalsuccessisdefinedbyalackofsensitivityto percussion, percussion tone that does not differ from thehealthyadjacentteeth,andmobilitywithinnormal limits at six months. Failure is defined as clinical con- ditionsthatdonotmeettherequirementsforsuccess and/or increased discomfort of the patient. Incasesinwhichthetoothhasbeentreatedextra- orally, healthy cementum on the root surface and periodontal membrane vitality are important factors in preventing ankylosis.4,28 Solutions such as citric acid, tetracycline and EDTA have been advocated for root-surfacemodificationtoproduceasurfacethatis conducive to cellular adhesion and growth.29 A 30- second application of tetracycline has been reported to remove the smear layer, leaving clean and open tubules.27 During evaluation of the CBCT images for VRFs, as previously reported by Hassan et al., axial slices have proven to be more accurate than coronal and sagittal slices (Fig. 1b).30 Thus, it is important to pay attention to axial plane images in particular. Sagittal planeimagesareusefulfordeterminingtheextentand direction of each fracture line (Fig. 1c). _Conclusion 1.EarlyandaccuratediagnosisofaVRFisimportantin preventing bone destruction. CBCT imaging allows the clinician to accurately detect these problems and inform the patient about alternative treatment modalities. 2.Bonding the separated fragments of VRFs extra- orally followed by intentional replantation of the reconstructed tooth is an innovative method that provides an alternative to tooth extraction, espe- cially for anterior teeth. 3.Scanner units with higher resolutions are advisable foruseindetectingVRFsandinthefollow-upperiod for better evaluation during the recovery phase._ Editorial note: A complete list of references is available fromthepublisher. roots1_2011 ӗDr Senem Yigit Özer graduated from Selçuk Uni- versity’s Dental Faculty in Konya,Turkey,in 1997.She completed her PhD in 2004 at the Department of Endo- dontics at Ege University in lzmir,Turkey,and worked at the Dental Hospital of the Ministry of Health in Diyarbakir,Turkey,between 2005 and 2008. Thereafter,she began working at the Department of Operative Dentistry and Endodontics at Dicle University in Diyarbakir,and still serves there as Assistant Professor.Her research interests are root-canal instruments,root-canal obturation materials,survival analysis of endodontic treatment outcomes,diagnosis and treatment ofVRFs,and use of CBCT in endodontics.Dr Özer can be reached at senemygt@hotmail.com. _about the author roots .