What do you do when a tooth is cracked? Cracked teeth are not only hard to diagnose but can also really put a wrinkle in your treatment plan. The uncertainty is hard to deal with for both the doctor and the patient.
As providers, we always want to give our patients treatment that will last, but cracked teeth are unpredictable and don’t give us that assurance. Additionally, we can’t really know what kind of parafunctional habits our patients have that could make a cracked tooth worse.
As an endodontist, I deal with cracked teeth every day (and usually multiple times a day). If you ask me, I would say that most teeth that I treat have a crack in them somewhere. If I took out all the teeth that had a crack in them, I wouldn’t have much work to do. But I would say the skill comes in knowing when to treat and when not to treat. Today, I am going to share with you a case that I treated in 2009 and that now, 11 years later, needs to be extracted.
Knowing Your Criteria When a Tooth is Cracked
I try to save as many teeth as I can, and I hope you do, too. But this case brings up a very important topic and discussion. When a tooth is cracked, what are your criteria for deciding when to save the tooth and when to extract it? (Let me know in the comments below. I really do want to know!)
I often see this kind of case in my practice. The mandibular second molar is notorious for cracking, especially on the distal marginal ridge, and that is exactly what happened here. The tooth was opened up by the referring dentist due to his level of pain prior to the referral to my practice. All probings were normal (maybe about a 4mm depth on the distal), it did not respond to cold, and it was slightly tender to percussion. I diagnosed tooth #31 as Previously Initiated and Symptomatic Apical Periodontitis.
Upon access, I could see the crack travelling down vertically from the distal marginal ridge. It was very faint, but a crack nonetheless. These are the kinds of cracks that I see all the time. They become doorways to let bacteria in to infect the pulp and cause havoc and symptoms.
One of my criteria for saving or extracting when a tooth is cracked is this: is there any probing alongside the crack? If there is no probing, then I shoot for saving the tooth.
Realistic Expectations When a Tooth is Cracked
After a long discussion with the patient, we decided to complete treatment on this tooth. He was completely aware that this tooth may not last him the rest of his life. We discussed the options, and he decided to go for it, thinking that even a few more years of having his tooth was better than not having it.
Two years later, he came back for a recall visit, and his tooth was doing great!
But 11 years later (in 2020), he came back, and the crack had progressed even more. (Which sometimes happens when a tooth is cracked.You just never know if it’s going to take a turn for the worse.) He now had a deep probing on the distal and pain while biting. The diagnosis this time? Previously Treated and Symptomatic Apical Periodontitis #31.
This is what the tooth looked like on the CBCT. Notice that you can see the bone loss in between the cortical plate and the root surface. The pattern of bone loss is very suggestive of a vertical root fracture. Plus, I know the history of this patient.
Again, you can see more bone loss in the sagittal image here.
Fortunately, most of my cracked teeth cases don’t transition into a vertical root fracture or split tooth like this one. But when a tooth is cracked, it is so important to have the discussion about the possibilities of what could happen with the tooth prior to any treatment. I am a firm believer in setting my patient’s expectations and giving them enough information so that they can feel like they can make an informed decision about their care.
There are some people who really don’t want to invest in their teeth if there is even a 1% chance that it will have to be extracted down the line. It’s imperative to have conversations like these and to be completely transparent with your patient.
Other Modifications When a Tooth is Cracked
Here are some modifications that I may make in my treatment in cases of cracked teeth:
- One thing I have learned is to change my instrumentation to a smaller taper and more irrigation to clean the tooth. I no longer instrument teeth with such a large taper. You will notice that over time my preps have gotten smaller. Try to conserve as much dentin as possible.
- Also, I make sure that the patient gets their tooth crowned as soon as possible. I don’t typically wait the typical 2 weeks. Instead, I call the referring dentist and try to help facilitate an appointment as soon as possible.
- Sometimes, I even 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!
- I 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.
- Often, I recommend the patient looks at other areas of the mouth (ie amalgams) to make sure the same scenario won’t pop up again on another tooth. Things like to happen in pairs, especially with the same tooth on the other side (so check the other second molar!). I also inform them on how crowns can be preventative for future root canals.
- Additionally, I will recommend a nightguard to my patients who are frequent offenders of cracking their teeth.
Evaluating the Outcome
The outcome of this case is unfortunate, but it also is quite impressive, all at the same time. I mean, 11 years is a long time to have put off the extraction, and it definitely exceeded the patient’s expectations. If you think about it, an implant today is way better than an implant 11 years ago, so I still think it was the right decision.
Tell me what you think — I would love to hear your thoughts! Would you have done it differently? Did this blog change the way you look at things?