The name of our game is to save as many teeth as possible, right? But can a cracked tooth be saved? When it comes to a cracked tooth, how do we know when you should persevere and when to extract it?
To answer this question we’ll travel back to 2009.
Can a Cracked Tooth Be Saved? Let’s Dig In…
As an endodontist, I see cracked teeth multiple times a day (in fact I’m pretty sure most teeth have a crack somewhere). So I didn’t think much of it when in 2009 a referred patient came to me with a mandibular second molar, that was cracked on the distal marginal ridge. Nothing new or noteworthy there.
But what’s important here is not just the condition of the tooth when the patient came in, but how we decided as a team (the patient and I) to approach treatment.
The Diagnosis
Due to pain levels, the tooth had been opened by the referring dentist. Here’s what I discovered:
- All probings were normal (about a 4mm depth on the distal).
- No probing alongside the crack.
- The tooth did not respond to cold, and it was slightly tender to percussion.
So I diagnosed tooth #31 as Previously Initiated and Symptomatic Apical Periodontitis.
Would you have diagnosed the same?
But here’s the real question I had to ask myself, and I’d love for you to think through: Can this cracked tooth be saved? How would you have approached treatment here?
A faint crack was traveling vertically from the distal marginal ridge, a common crack that can become a bacteria doorway. And that, my friends, means those bugs are headed STRAIGHT for the pulp, not to mention super painful symptoms. Not good.
Yet, there was no probing alongside the crack (one of the main criteria I look for when deciding whether to save or extract).
So, you know me. I wanted to save this tooth!
I had a totally candid conversation with the patient about what his options were and what the likelihood of success was, and he was in agreement. He wanted to save his tooth just as much as I did!
Here is the immediate postoperative radiograph. Just FYI, this case was done early in my career, so I wasn’t placing an orifice barrier at the time like I do now. It’s amazing how we evolve as clinicians right?
Fast Forward 2 Years …
… and the tooth is doing great!
I was so happy to see the tooth recovering at his recall. But, in actuality, the story doesn’t end there.
Get ready for the plot twist!
When the patient came back in 2020, the crack had progressed. Darn it.
He now had a deep probing on the distal and pain while biting. The diagnosis this time?
Tooth #31 was a Previously Treated and Symptomatic Apical Periodontitis.
The CBCT scans showed bone loss, suggestive of a vertical root fracture in between the cortical plate and the root surface.
Sadly, the time had come to extract the tooth.
Again, you can see more bone loss in the sagittal image here.
Learning When to Extract, and When Not to
Fortunately, most cracked teeth cases don’t transition into a vertical root fracture or split tooth. Yet, there are many lessons to take from this over-a-decade-long tale.
Most importantly, an upfront discussion with the patient helps them make the most empowered decision for themself. That means they can take charge of their own dental health with a clear picture of what the outcomes might be.
This patient opted to invest in treatment on his tooth, knowing he may still lose it eventually. But that doesn’t mean that every patient would have done the same thing.
The outcome of this case is unfortunate, but impressive. I mean, 11 years is a long time to have put off an extraction, and I think treatment exceeded the patient’s expectations! Plus, an implant today is way better than an implant 11 years ago, so I still stand by my decision.
Can a cracked tooth be saved? I’d say yes, even if it is just for an extra decade. That’s some quality tooth time!
What are other treatment options for a cracked tooth?
If your patient has a cracked tooth, there are a number of modification options to explore to diagnose and plan treatment. Here’s what I’d recommend:
- Change instrumentation to a smaller taper. And more irrigation to clean the tooth. Try to conserve as much dentin as possible.
- Make sure the patient gets their tooth crowned as soon as possible (they shouldn’t wait the typical 2 weeks.). Crowns can prevent future extractions. .
- Obturate the canal with the crack in it with MTA. I have done that with several cases, and those teeth are still in the patient’s mouth!
- Take the tooth out of occlusion. To make sure the patient does not bang it too hard while they are waiting to get their crown.
- Look at other areas of the mouth. These things tend to happen in pairs, especially with the same tooth on the other side. So look around; perhaps you can prevent the same scenario from happening to another tooth.
- Recommend a nightguard, especially for patients who are frequent cracked-tooth- offenders.
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– Sonia
Rarely would a person keep a car for 11 years. I think it was great that the tooth lasted that long.
We really need to educate our patients better. They want us to guarantee a tooth that they have practically destroyed to last for 50 more years.
I love doing implants, but most patients can tell a difference when a 2 or 3 rooted molar is replaced by a single rooted implant. Most get used to it, but the shape is different.
Thanks Sam for always reading my blogs!!
Best,
Sonia
I have a tooth I would like to save. do you know any dentist in the east coast, CT, NJ,NY area that is more interested in saving teeth.?
Please check out the resources page on the website to find someone I trust near you. Thanks.
-Sonia
Hi Sonia,
I have a tooth I would like to save. do you know any dentist in the east coast, CT, NJ,NY area that is more interested in saving teeth.?
Thanks for the info! I see cracks all the time now during the pandemic. It’s almost epidemic here, and I have struggled with how to treat. I try to encourage occlusal guards as I think there is a lot of clenching and grinding going on. So many times this seems to occur from occlusal amalgams on the molars.
Erin,
Yes, those amalgams are such culprits. Sometimes crowning these teeth prevent seeing the endodontist!
-Sonia
Hi sonia
Thank you very much for your thoughts,efforts and sharing your cases.
I am endodontist and periodontist , practicing for 32 years
I would do the same thing and will do the same thing as you did.
Implants have improved but the way they are placed have not improved. Because more people who are not trained are placing them. Crack tooth syndrome has alway been a nightmare. And it is alway hard to deal with. Specifically when first molars gone.
I rather discuss furthermore over phone if you like
Thanks again for sharing your thoughts
Mehrdad,
I am glad that you agree. All things dentistry need more time in educating and it takes a ton of practice. That is why I am trying to lead in that direction. Thanks for your comment.
Best,
Sonia
Thanks
This is a great read and a reminder.
Thank you!
I would say 11 years is a success story! For me it depends on the front end risk tolerance of the patient, like you said. Some are willing, some are not willing to under go the treatment and investment to save the tooth.
After I’ve gathered all data and made an assessment, I make sure that the entire treatment process from RCT to crown is accepted and that the patient realizes that the entire treatment is the only hope for long term success. I also gauge their expectations and make sure they are realistic.
Putting the ball in the patients court to decide based on solid information keeps it a win, win.
I so agree with you Matt!
Best,
Sonia
Hello Dr Chopra, how are you?
Your case re the cracked second mandibular molar is an exemplary treatment modality on a VRF. A return after 11 years is indeed a success.
Thanks for always reading Michael!
Best,
Sonia
Hi Sonia!
Thanks for sharing the case with detailed evaluation. It really is great learning to see how such cases are managed with experts.
Thanks Khalida!
Hi Sonia ,
I do 99.9% endo in my office as GP and really enjoy reading ur blog and learning to refine myself ….thank you for such support
Thanks for reading!
Great case and reminder. 11 years is definitely a success. Would you also recommend keeping that tooth out of occlusion once a crown is placed too?
Dr. Trivedi,
No, I wouldn’t. I think it would just supererupt anyway.
-Sonia
I think the use of MTA for filling the canal with the crack is brilliant! Thank you for this insight! As always a big fan of yours!
Lisa,
Thanks for always reading.
-Sonia
Great case.
Can you tell why you use MTA in the canal that has the crack?
Cheers
Filipe,
I used MTA because if anything is going to seal a crack, that would be the material to do it.
-Sonia
Your diligence in assessment pays off here. That is a large component in the treatment. Combine that with good clinical treatment and you get the clinical success that you achieved. Also, I love to see that you keep learning as you grow and materials and techniques improve with time. Bully for you.
William,
Thank you so much.
-Sonia
I wish you had been my Dentist. I had a cracked 1st pre-molar and my dentist we t straight to extraction. He never even asked if that’s what I wanted.
He told me an implant or pallet would fill the gap but because he broke my tooth off at gum line neither of these are now possible.
I feel terribly and his botched attempt was traumatic
Paul
Paul,
I can totally empathize with your situation as it has happened to me too. I am happy this blog is creating some awareness for you so if (hopefully not) it ever happens again, you are better prepared with some endo knowledge.
-Sonia