A radiograph shows a vertical root fracture of tooth #28 (lower left first premolar) at the alveolar bone level with evidence of bone loss. What is the recommended treatment?

A vertical root fracture (VRF) at or below the alveolar bone level has a hopeless prognosis. VRFs cannot be reliably repaired and are associated with a characteristic 'J-shaped' periodontal defect radiographically, bone loss along the fracture line, sinus tract formation, and localized deep probing. Neither endodontic treatment, crown placement, nor retreatment can salvage a tooth with a VRF at the bone level. Extraction is the definitive treatment, followed by healing and consideration of implant or bridge replacement. Occasionally, single-rooted teeth with a cervical VRF amenable to root resection may be treated by hemisection, but fractures at the bone level are not salvageable.