Can cracked teeth be saved? This is a question I get ALL the time. But, to be honest, I prefer when dentists ask this question compared to when they simply assume that cracked teeth have to be extracted.
Sometimes it gets under my skin when dentists take out teeth because they are “cracked.” But then I have to remember that, during dental school, endodontics is simplified and not usually given enough time. I don’t want to villainize dental schools here! They have a LOT to cover within the curriculum. But, as a result, endo and other specialties often get the short end of the stick. In fact, some dental schools don’t even have an endodontist on their faculty!
So, let’s deepen our understanding today, so we can recommend the best treatment plans for our patients.
I’d like us to start with our definitions, so we’re on the same page. There is a difference between a cracked tooth and a vertical root fracture. One has a chance (the cracked tooth) and the other needs to be extracted (the vertical root fracture).
A lot of dentists equate these two definitions and think they’re the same thing. As a result, they give up on teeth far too early. Don’t believe me? Let’s explore a cracked tooth story with a happy ending.
Can cracked teeth be saved? Here’s proof.
This tooth had normal probings, was tender to percussion, and had no response to cold. So the diagnosis was a Necrotic Pulp and Symptomatic Apical Periodontitis tooth #31.
How do you diagnose a crack? Well, there are a few ways. A diagnosis is when we marry our clinical findings with our radiographic findings.
Radiographically, I don’t see any decay or any obvious way for the bacteria to get into the pulp, yet there is a periapical radiolucency.
So, how did the nerve die? The dental pulp only dies by way of bacteria, so there must be a pathway to the pulp that the bacteria followed. That pathway (or doorway) has to be through a crack that lets those bugs in. And if you think about it, a crack doesn’t have to be that big to let those little buggers in. They are microscopic, so it really doesn’t take much.
We can also look at the person and the tooth clinically to get other clues. This tooth also happens to be the only lower molar in that quadrant. Are you thinking what I am thinking? Why did the patient lose tooth #30? Did they crack that tooth too? Does this patient have a history of cracking their teeth? Could this be a piece of their tooth story? If so, can we prevent this from happening in other teeth moving forward?
This insight may lead you to the etiology of why this is happening.
Let’s take a peek at what this tooth looks like clinically…
Giving this tooth the benefit of the doubt
You can clearly see the crack in this photograph. Plus, it is a lower second molar, and I find that the distal marginal ridge of a mandibular second molar is a very vulnerable area for a crack.
When I see something like this, I want to take my periodontal probe and see if that tissue probes immediately adjacent to that crack. If so, then I know that this could be a draining sinus tract or the tooth could have a vertical root fracture down the distal surface of the root.
See what I just did there? I didn’t make an assumption that this tooth was non-restorable. Instead, I created a differential diagnosis, and a vertical root fracture just happened to be on the differential list.
How am I going to make my final decision? Well, this can only come from accessing the tooth and visualizing the crack internally from the chamber.
This tooth did not probe along that distal root beyond 4mm, so I was going to go for it and try to save the tooth.
But, that means that I have a very specific conversation with the patient. I am always very open and transparent with my patients. They understand that I don’t have a crystal ball, I don’t know if they will make this crack worse over time.
So, I let them know that this tooth may last one month, one year, 10 years, or the rest of their life. I honestly have no idea. But, it is my job as the clinician to provide the patient with all the data, the prognosis, and the possibilities. It is now up to them to make a treatment plan choice. I just have to understand and respect the patient that is sitting before me and their values.
Moving forward with treatment
When I present the treatment plan to a patient in a case like this, they are very well aware that things can change once I am in the tooth. So, I give them two versions of a treatment plan.
One says: the tooth is fine and dandy, and we can save it, so they will be charged the entire root canal amount.
The other says: I found a very big crack that is on the verge of the tooth splitting, and I don’t think it is a good idea for that patient to invest any further in this tooth. That means the patient will need to be sent to an oral surgeon for the extraction.
Luckily for this patient, I felt like his tooth was redeemable. The crack was there, which let bacteria in, and that’s what killed the nerve. But, that crack was contained to the coronal tooth structure and didn’t extend down into the root.
We finished the root canal and the final treatment looked like this…
When I see a crack like this, I make sure that the patient runs (not walks) to their restoring dentist to get that crown started right away. I don’t want them to wait the typical two weeks to get their crown. Instead, I want them at least in the buildup and a temporary crown stat to help protect that tooth from cracking even further.
One year later, he showed up at my office like this…
A tooth fully intact, in function with all their bone grown back.
Can cracked teeth be saved? Here’s the bottom line.
It is amazing what we can do for our patients. But we have to try. We have to have faith in teeth to heal and bone to regrow, and in endodontics to work its magic.
This is why I like to talk about “the technology of belief.” Here’s what I mean by that. You can have every modern-day, amazing tool at your fingertips. And yet, if you don’t believe a tooth can be saved… then it won’t be saved.
We have to upgrade our beliefs about how cracked teeth can be saved, so that we give teeth a chance!
Take my What’s Your Endodontic Know-How Quiz to see what dental beliefs you might need to reexamine!
– Sonia