asynch lect: cracked teeth and VRF

trend of cracked teeth

increasing

abfraction

v-shaped loss of hard tooth structure cause by biomechanical loading forces from flexure and/or chemical degradation of enamel and/or dentin at same location distance from the actual point of laoding

infraction is also referred to as

craze line

infraction

a crack of the enamel without loss of tooth structure

are infractions commonly encountered

yes

cracked tooth

a thin surface disruption of enamel and dentin, and possibly cementum , of unknown depth or extension

fracture

a spilt of break in bone, cartilage, or tooth structure.

fracture in tooth structure

disruption of the enamel and/or dentin and/or cementum that is assumed to be of greater depth than a crack

• of unknown depth or extension

• visible or not

• is visible clinically or radiographically

• separated or unseparated segments

root fracture

a fx that exists or extends into the root; to include dentin, cementum, and possible pulpal space, which may progress to or from enamel

2 types of longitudinal fractures

• vertical root fracture

• split root

vertical root fracture

fx in root whereby the fx segments are incompletely separated; may/may not occur BL or MD

vertical root fx may cause __________ or __________

isolated periodontal defects; sinus tract

t or f: vertical root fx may be radiographically evident

t

split root

continuation of a crack or vertical root fracture whereby the fx segments are completely separated longitudinally; can occur B/L or M/D

cracked teeth and VRF can be caused by

occlusal forces and dental procedures

cracked teeth/VRF can provide pathways for bacterial penetration in the ______

pulp

cracked teeth/VRF ________ over time

expand

cracked teeth/VRF may occur due to the reduction in ___________ w age

fracture resistance of the root

is there pain w cracked teeth/VRF

possible

is it easy or difficult to dx/tx plan cracked teeth/VRF

difficult

what are some diagnostic aids that can be used to help find/dx cracked teeth/VRF

• CC and HPI

• EOE, IOE

• pulp vitality

• percussion

• palpation

• periodontal probing

• bite test

• radiographs

• transillumination

• restoration removal

• staining

• wedging worse

• surgical exploration

what kind of questions can you ask pt when hearing about their CC and HPI

• exacerbating and relieving factors

• hx of cracked teeth or VRF

• parafunctional habits

• TMJ pain

• do they wear a NG

what signs would be seen in IOE and EOE in suspicion of cracked teeth/VRF

• enlarged jaw muscles

• attrition/abfraction/recession

• wear facets

• fractured cusps

• numerous full coverage restorations

• stained cracks

what sensibility tests can be used for determinign correct pulpal and periapical dx

• percussion

• palpation

• cold test

• EPT

• probing depths

• mobility

what type of probe is more accurate in determining a pocket that is more associated w a crack

plastic- more flexible and accuate compared to standard metal probe

what can be used to conduct a bite test

tooth slooth

goal of using a tooth slooth

attempt to replicate pts chief complaint

how to use tooth slooth

1. place instrument on each cusp and instruct pt to “bite slightly, squeeze tightly, and open quickly”

2. test several teeth

watch for pts response on bite and release

classic symptoms of cracked teeth

pain on biting

if you are doing the bite test on a pt and the pt doesn’t respond negatively, does this mean you can rule out a tooth fracture

no

principle theory of transillumination

transmitting a beam of light penetrating through tooth structure until it meets a space (in this case, a fracture) that reflects the light beam from the crack plane

how likely is it that you will be able to dx a crack from a radiograph

usually can’t see radiographically unless the crack is rlly big

what to evaluate in periapial radiographs

• continuity or lamina dura and uniformity of PDL space

• quality and extent of existing endodontics and restorative tx

• take multiple angled radiographs

what radiographs are helpful to use a dx aids

periapical radiographs

can CBCT be used to detect fractures

can aid in fx detection, but the width of unseparated fracture is typically undetectable <75 microns

what can CBCT be used for as a diagnostic aid

evaluating bone loss along fracture line

cracked teeth are incomplete fractures initiating from…

the crown extending subgingivally

cracked teeth are usualyl directed ______ (M-D/B-L)

M-D (crossing 1 or both marginal ridges)

signs and symptoms vary based on ________, but as soon as these signs and symptoms start to develop, this can be referred to as __________

extent of crack; cracked tooth syndrome

signs and symptoms associated w cracked tooth syndrome

sharp pain on biting and increased cold sensitivity

prevalence of cracked teeth

mand 2nd molars > mand 1 molars > max 1st molars > max 2nd molars

how to reach diagnosis of cracked tooth

• hx of cracked teeth or parafunctional habits

• transillumination

• microscopic evaluations

• staining w methylene blue

• tooth slooth

• periodontal probing → apical extension

• radiographs

• orthodontic band or diagnostic provisional

_________ may be the only way to replicate the pts chief complaint

tooth slooth

how do orthodontic band or diagnostic provisional help in dx of a crack

orthodontic band, or prep tooth for a crown and put a provisional on for a few months → both options should stabilize the crack → prevent further propagation → see if pulpal response has changed at all

tx planning a cracked tooth is dependent on

location and extent of crack

performing rct tx on cracked tooth is dependent on ______ and _______ dx

pulpal; periapical dx

in a study that evaluated cracked teeth w reversible pulpitis receiving crowns, what was found in pts needed RCT vs pts not needing one

• 20% required RCT within 6 mo of crown delivery

• 80% did NOT require RCT over the next 6 yrs

do all teeth with cracks need RCT tx

NO

study done on endodontic prognosis of cracked teeth:

5 yr survival rate of 92%,

but when there was extension of crack to the pulpal floor there was a ___% survival

when there was no pulpal floor extension, there was a __% survival

• 88% (reduced)

• 99%

study done on endodontic prognosis of cracked teeth:

2 yr survival rate 90%

teeth w probing depth of >6 mm had a ___% survival rate

teeth w probing depth of <6 mm had a ___% survival rate

• 74%

• 96.8%

study done on endodontic prognosis of cracked teeth:

had a 1-yr survival rate of 82%

they found the most significant indicators of tx success were _________, ___________, and __________

distal marginal ridge crack, deep probing depths, and periapical dx

vertical root fractures are usually directed ________ (B-L/M-D)

B-L or M-D

vertical root fractures happen most commonly to _________ teeth

endodontically treated (esp if RCT involved excessive removal of dentin or large obturations or post placement)

roots that are ____________________ are most susceptible to vertical root fractures

curved and narrow M-D or w developmental depressions

vertical root fractures _______ (can/can’t) be radiographically evident

can (J-shaped RL)

teeth in the mouth most susceptible to vertical root fractures are…

MB lower molars or B root of max premolars

periodontal probings indicative of VRF

narrow, isolated deep probing w plastic probe (may need to numb is pt is hurting while probing)

signs in radiograph inicative of VRF

• PA: halo or J-shaped PARL

• CBCT

surgical exploration to aid in dx of VRF

• staining

• transillumination

way to prevent VRF while performing rct

• preserve pericervical dentin during access

• enhanced irrigation and conservative cleaning and shaping/obturation

• fiber post use → make endo teeth more resistant to fx vs metal tapered post

if pt has parafunctional habits, what is a preventative method against VRF

occlusal guard

when placing posts during a RCT, the post should fit ___ in the existing canal

passively

proper _______ and emphasis on ___________ in cracked teeth and VRF are essential

dx; early detection