[pkleemann]

Last week I saw a patient who complaint hypersensitivity towards cold temperature in the upper left jaw. Her first molar showed recurrent decay under a leaking amalgam filling due to a fracture and high contact on the isthmus. Pulp testing with cold was positive and there were no symptoms while patient was chewing.
After the removal of the old restoration a sagittal crack on the cavity floor was exposed.
I just placed a bonded inlay, eliminated the high contact and informed the patient about the fracture line which may cause further problems in future. As I am not sure what is the best way to manage such a situation I wonder if there are any recommendations to handle these cases. Is it obligate to prep a full coverage restoration or even do the root canal therapy? Please share your experience with similar cases.

 kleemann__1_von_3_.jpg (111.8K)
Number of downloads: 23
 kleemann__2_von_3_.jpg (101.24K)
Number of downloads: 37
 kleemann__2_von_6_.jpg (163.28K)
Number of downloads: 38
 kleemann__5_von_6_.jpg (166.73K)
Number of downloads: 29
 kleemann__2_von_2__2.jpg (98.24K)
Number of downloads: 38

[DChung]

Hi,

I am pretty pesimistic about such teeth. With those patients I stop once I find the crack (I tell them their tooth is split) and suggest that if they're particularly keen to keep the tooth I can continue as planned and restore it (inlay or overlay I am happy with) or we can extract the tooth. My advice to them is that there is little chance that a root canal would work longer term due to the split and that if we proceed with restoring the tooth then the chances are only 50/50 that it won't play up. My bottom line to them is that it would be better to extract it.

I always find it one of the hardest conditions to know how to treat. I feel an extraction is the only thing I can do predictably. I always imagine restoring the tooth will lead to root canal, which will lead to a chronic infection, which will lead to antibiotics to help, which will lead to more antibioitcs, then extraction with little bone left in the area to place an implant.

I'm interested to hear what other dentists might have to say.

Regards

Damian

[cerecsurg]

Hi Paul-
indeed what Damian wrote is what I would say too.BUT:
endodontists (specialists with microscope) would not do an endo on cracked teeth.But the documented case shows vitality,absence of serious problems(?) no discoloration and no movement of the fragments(!)I would teach the patient about the problems, do what you would have done:adhesive(!)closing of the cavity(better a cerec crown!!)for reasons of static and stability!!and wait,test and see.When the situation is deteriorating,you have the best conditions for an endo through the crown!There is no better "sealing" than a cerec crown anyway!
happy christmas Frank

[Alessandro Devigus]

Dear colleagues

You find many articles discussing the problem of cracked teeth which seems very common in molars ... attached a recent article describing how to diagnose and treat such teeth ... and extraction is not the first choice in any case

have a peaceful Christmas time and a successful 2010
Alessandro

 cracked_tooth.pdf (461.94K)
Number of downloads: 45

[robendicott]

i too get worried about these sorts of cracks, especially when it goes all the way from one side to the other. I inform the patient of the doubtful prognosis and place a long term provisional crown or CEREC to try to keep the tooth together.

I have had patients in this situation who still have the tooth 2/3 years later, still sensitive but bearing up.

Good post though, cracks are a nightmare!

With best wishes

Rob

www.practiceinabox.co.uk

[drvedberani]

Good case and well restored,
would be interesting to see if the tooth actually turns into an endo or not
in my expereice with cracked teeth, i give it a complete chance with a glass ionomer restn ( Fuji 9) and a molar band
post op review in 3/12
if tooth still vital co2 positive
go ahad and give full coverage
or else endo with doubtful prognosis
i am BIG on informed consent and thus would give patients reading material on CTS and this article i have atttached

worse case scenario is exo

but atleast by trying the temporization and then assesign in 3/12 you have a better chance of 5-10 year survival.

this article also has a good flow chart for management



http://www.cda-adc.c...issue-8/470.pdf

my real question here is "IS a cerec onlay better than full coverage restoration?

[DRPPERD]

I would vote for a complete coverage onlay and a bonded over floor!

Also ZERO occlusal contacts – The patient needs to know that this is iffy at best!

Don’t bother with endo –Waste of $$

Let the patient know to start saving up for an implant!

[pkleemann]

so far so good.
yesterday I saw the patient again and she told me that the symptoms were gone immediately after treatment.
there was a positive reaction on cold testing on the buccal and lingual surface.
of course I am still not sure about this case but there may be a positive influence due to sealing the dentine with dba (in this case-syntac) and occlusal adjustment.
if there are any news concerning this tooth I will give you further information.

@drpperd: I share your opinion that in case of pulpitis a rct won't be an option for this tooth. implant or bridge would surely be the safer therapy.