Tag Archives: broken tooth

Beware of the Cracks!

Imagine the following scenario:

A busy day in practice! A patient comes in with tooth #2-6 (upper left first maxillary molar) being extremely sensitive to cold (a.k.a. a “hot tooth”).  You notice a very old, large amalgam filling on the tooth which had been done over 2o years ago.  No recent restorative changes in the area  is reported by the patient.  Breathing in air, blowing air on this tooth with an air-water syringe or applying ice to the tooth sends the patient through the roof.  All other teeth in this quadrant are responding normally to cold test. Quickly and confidently, a pulpal diagnosis is reached (irreversible pulpitis), endodontic treatment is recommended, and the need for a full coverage crown is also emphasized after root canal treatment. Simple, right?

cracked tooth, split tooth

pre-op radiograph


Well, not so fast!

  • unless you stopped and thought about the reasons why the tooth became sensitive to begin with (i.e. thinking about the etiology for pulpitis and the possible pathways to the pulp),
  • unless you thoroughly examined the tooth clinically and looked for signs of cracks, leakage, caries, periodontal disease, parafunctional habits, etc.,
  • unless you grabbed a perio probe and actually noticed a 6-7mm probing defect on the distal aspect of the tooth,
  • unless you noticed on the pre-op radiograph a questionable area with respect to the quality of the crestal bone between teeth #2-6 and #2-7,
  • unless you removed the obscuring filling and gave yourself an adequate view of what lies beneath during the treatment (as opposed to those who still love to brag about their super conservative access and their beautiful final result through a tiny 2x2mm hole),

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You may miss a more serious issue with this innocent-looking tooth in need of JUST a root canal and a crown,  you may lose the opportunity to properly inform your patient of possible outcomes of your treatment and you may end up performing unnecessary treatments for a tooth with no hope.

Just imagine the final conversation with the patient after a quick exploratory/pulpectomy procedure:

Me –  “Ms. Black, unfortunately your tooth cannot be saved as I had suspected and warned you before we started the root canal procedure today.”

Ms. Black – “I am amazed Dr. E! [with a smile]  You knew exactly what was wrong with my tooth. You called it.”

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A Hopeless Case?

“In traumatic dental injuries, not only it is important to know when to treat a case (endodontically-speaking); it is equally important to know when not to treat it.” – Martin Trope

Before considering extraction of a tooth with root fracture, no matter how bad it looks on the x-ray, the following treatment approach must be considered in order to give the tooth another chance:

1) reduction: repositioning the tooth back into the socket,

2) fixation: stabilizing the tooth with a flexible splint for four weeks (if the fracture is in the middle or apical third area), or for four months (if the fracture is in the cervical third area),

3) relief of occlusion: to minimize further damage to the PDL and the protective layer of the root, and

4) recall: monitoring clinically and radiographically in 6-8 weeks, 4 months, 6 months, 1 year and yearly for 5 years.

After three months of follow-up, endodontic treatment of only the coronal segment should be considered if the tooth continues to be unresponsive to vitality testing, appears discoloured, and/or develops periapical pathosis (radiolucency) around the fracture line.

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The tooth above has remained asymptomatic and functional 2 years after the endodontic treatment and 3 years after sustaining a traumatic injury. I always remind myself of what Ian Linde would say when considering all options for cases that appear hopeless on the radiograph: “Implants should replace missing teeth not teeth.”

(Resource: The Dental Trauma Guide: your interactive tool to evidenced based trauma treatment.)