Tag Archives: cracked tooth

Cover It Up!

Heavy bite, specially with less than ideal occlusion or cusp-fossa relationship, can result in cracks and fractures in teeth.  Here is an example of a case with heavy occlusal pressure concentrated on the lingual inclinations of the buccal and lingual cusps of tooth #2-4.  Two mesial enamel cracks are evident in this case.

cracked tooth

 

Lets imagine the following scenario if we do nothing for this asymptomatic tooth:

With time, the cracks propagate and involve the pulp chamber. Based on the position of the existing restoration, a tooth split may result no matter how innocent (don’t blame the amalgam fillings). Clinical symptoms (pulpitis) appear.  Root canal is done and the initial sensitivity symptoms do resolve. A crown is then fabricated for a possibly deeply cracked tooth. The biting tenderness however persists post-endodontic treatment.  If the patient is lucky not to go through further unnecessary treatments (i.e. retreatment, apical surgery, etc.), the tooth will eventually be replaced with an implant. And, this is one of the reasons why root canals get their poor reputation. “Root canals don’t work”, “every root canaled tooth fractures”, or the most insulting to my profession that I have ever heard: “root canaled tooth is an eventual space maintainer for an implant.”

So, lets contemplate the above scenario and think about prevention and saving teeth instead.


Office website: vanendo ,  FaceBook page: @endospecialists


it’s vital…with no fillings…but it hurts!

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Radiographs can be so deceiving! This radiograph of the first quadrant looks so calm, so unassuming…everything looks normal. What you didn’t see was the patient attached to this radiograph – having extreme, radiating pain. When everything looks fine on the radiograph, and we have a quadrant full of unrestored or minimally restored teeth, my spidey sense tells me to pick up a probe, and also a transilluminating device. In this particular case, there were no isolated deep probing depths (often suspicious of a root fracture), but transillumination revealed a cracked tooth. The pain can likely be ascribed to the process of “fracture necrosis” – eventual necrosis caused by a significant crack from the outside of the tooth to the pulp. A crack is just one of five types of fractures, which also include craze lines, cuspal fractures, root fractures, and a split tooth. Each are managed a little differently, depending on the presentation.

In this case, we performed a pulpectomy, and used the microscope to look into the crown. It did not appear that the mesial-distal crack extended past the CEJ. The patient had a temporary crown placed that week – and the tooth became comfortable over the ensuing weeks. This is often a nice way for us to ensure the tooth will be comfortable under a crown – an orthodontic band often serves the same purpose. The endodontic therapy was then completed. Even despite the good restorative work that was eventually completed, a tooth with a crack always has a long term guarded prognosis.

Teeth with cracks and fractures can be difficult to detect, visualize, diagnose, and treat. The prognosis of teeth with cracks and fractures also comes with uncertainty and risk. Furthermore, the symptoms of teeth presents with cracks and fractures run the gamut from mild biting sensitivity to severe and radiating pain. However, a few visual aids, like a transillumination light, magnification, and the trusty old periodontal probe can help us to diagnose and manage such cases.


Office website: vanendo ,  FaceBook page: @endospecialists


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.”


Office website: vanendo ,  FaceBook page: @endospecialists


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