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.
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).
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.