Cracked and fractured teeth. Nomenclature. Cracks. Craze lines. Dilemmas in treatment planning: cracks and fractures

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1 Dilemmas in treatment planning: cracks and fractures Cracked and fractured teeth Nomenclature Etiology Diagnosis Treatment options Prognosis Marga Ree DDS, MSc, September 21, 2018 Toronto Crown And Bridge Study Group, Toronto Cracked Tooth Syndrome? The term cracked tooth syndrome is misleading as cracked teeth may present with a variety of symptoms that don t form a distinct and reliable pattern Symptoms will vary in teeth that have healthy pulps, inflamed or necrotic pulps, and in teeth that have been root treated Longitudinal tooth fractures Nomenclature 5 types of longitudinal fractures Craze lines: involve only enamel Fractured cusp Cracked tooth Split tooth Begin at the occlusal surface and extend apically, affecting enamel, dentin (and pulp) Vertical root fracture: begins in the root Craze lines Most adult teeth have craze lines In posterior teeth: common on marginal ridges and along buccal and lingual surfaces Involve only enamel, asymptomatic Sometimes of esthetic concern when present in a front tooth Can be distinguished from a crack by transillumination Cracks Cracked tooth: a thin surface disruption of enamel and dentin, and possibly cementum, of unknown depth or extension Glossary of Endodontic Terms AAE 2015 Usually caused by parafunctional habits, trauma or weakened tooth structure Usually mesial to distal 1

2 Longitudinal fractures extending from a defective amalgam restoration over the mesial marginal ridge and down the mid-facial surface Lubisich et al. J Esthet Restor Dent Craze lines versus cracks Facial aspect demonstrating incomplete tooth fracture extending vertically from the occlusal surface approximately 2/3 the distance to the CEJ before proceeding in a mesial direction Lubisich et al. J Esthet Restor Dent Jun;22(3): Prevalence Averaging the results of these 12 studies: 48% of cracked teeth are mandibular molars, 28% maxillary molars 16% maxillary premolars 6% mandibular premolars Approx. 2% other teeth Etiology: multifactorial Natural predisposing features Lingual inclination of the lingual cusps of mandibular molars Steep cusp/fossa of maxillary premolars Bruxism, clenching, extensive attrition, and abrasion Age Iatrogenic causes Cavity design Use of rotary instruments Thermal expansion and contraction of restorative materials Diagnosis of cracks Historically: symptom based localized pain during chewing or biting unexplained sensitivity to cold pain on release of pressure Clinical examination Magnification Transillumination: disruption in light transmission Bite test with tooth slooth Pulp tests Staining with methylene blue Transillumination What about radiographic examination? Extremely rare to visualize a crack on a radiograph Sometimes a vertical root fracture can be visualized on a radiograph Radiographs may help to evaluate pulpal and periodontal health 2

3 Fractured cusp Treatment: Removal of affected cusp Direct or indirect adhesive onlay or full crown Endo if crack affects pulp chamber or has resulted in irreversible pulpitis Cracked tooth Removal of the fracture line only in the area of the cavity floor that would include the initiation of an ideal endodontic access opening is helpful in determing the apical extent of the crack and whether the pulp is involved Removal of the fracture line on the proximal external surface of the tooth below the CEJ is usually not indicated Treatment for symptomatic cracked teeth with reversible pulpitis Study n Follow -up Krell & Rivera 2007 Abbot & Leow 2009 Opdam teeth 100 teeth Treatment Treatment outcome % of teeth needing RCT 6 yrs Full coverage restoration (crown) 5 yrs Sedative lining and interim restoration 41 teeth 7 yrs Bonded restoration with or without cuspal overlay All teeth were retained 21 No extractions 20 No extractions Annual rest. failure rate without cuspal cov. 6% No rest. failures with cuspal coverage 7 Teeth with known cracks year recall Courtesy of Dr. Rick Schwartz J Endod Apr;42(4): Difficult decision 175 teeth were identified as having cracks 88 were treated with RCT, 40 were extracted and 47 were only restored Survival rate of 88 RT teeth: 90 % after 2 years The lower second molar was the most frequently (25%) affected tooth Survival rate of RT teeth with probing depths > 6 mm: 74% Survival rate of RT teeth with probing depths < 6 mm: 97% Decision points Probing depths > 6 mm? Parafunctional habits, occlusal load? Tooth type, fused roots? Tooth location? Patient expectations? 3

4 50-year old female was referred for endo after persistent complaints in 26 Deep probing depths of > 6 mm are significantly associated with reduced survival after RCT, Kang et al Crack progression Crack versus fracture Fractured tooth: disruption of enamel and/or dentin and/or cementum of unknown depth or extension Glossary of Endodontic Terms AAE 2015 Assumed to be of greater depth than a crack May be visible/not visible clinically or radiographically May exhibit separated/unseparated segments Vertical root fracture 52-yr old male, 15 extremely painful on biting, pocket 6 mm at the mesial aspect of 15 A fracture in the root in whereby the fractured segments are incompletely separated Glossary of Endodontic Terms AAE 2015 May occur in bucco-lingual or mesio-distal direction May cause an isolated periodontal defect(s) or sinus tract May be visible in a radiograph 4

5 Patient referred for CBCT for diagnosis Root fractures and failure of RCT Was the fracture already present before initiating the RCT? Was the fracture caused by performing the RCT? Did the fracture occur after RCT? Root fractures and failure of RCT Was the fracture already present before initiating the RCT? What was the reason for starting rct in the first place? Try to obtain historical radiographs Fracture necrosis Pulp necrosis, in the absence of restorations, caries, or luxation injuries, is likely caused by a longitudinal fracture extending from the occlusal surface and into the pulp Berman and Kuttler 2010 Root fractures and failure of RCT Was the fracture initiated during RCT? Excessive obturation forces? Excessive removal of tooth sturucture? Crack initiation by rotary instruments? Adorno et al Does size matter? Root fractures and failure of RCT Did the fracture occur after finishing RCT? Post preparation and post placement Occlusal forces PLUS weakened tooth structure Teeth with TEC access showed lower fracture strength than the ones prepared with CEC or NEC Ultraconservative ninja endodontic cavity access did not increase the fracture strength of teeth compared with the ones prepared with CEC. 5

6 Signs and symptoms of a vertical root fracture A lateral radiolucency or a combination of a lateral and a periapical radiolucency: halo-lesion or J-shaped lesion Signs and symptoms of a vertical root fracture Sinus tract, often close to the gingival margin (< 4mm) Sometimes a double sinus tract Signs and symptoms of a vertical root fracture Deep and narrow (solitary) pocket Pain or abscess

7 Summary Cracked teeth are unpredictable over long-term but not all cracked tooth are poor teeth to save Make a decision based on risk factors Probing depths > 6 mm? Parafunctional habits, occlusal load? Tooth type, fused roots? Tooth location? Patient expectations? When the pulp of a tooth with minimal or no restoration becomes necrotic, think of a longitudinal fracture. These types of teeth may have a poor prognosis after endodontic treatment Dilemmas in treatment planning: retreatment versus implant placement Marga Ree DDS, MSc, September 21, 2018 Toronto Crown And Bridge Study Group, Toronto Lateral radiolucency Patient presents with swelling and pain in LRQ Percussion and palpation Diagnosis? Therapy? Management planning of root-filled teeth with persisting or new apical periodontitis The first and most important: diagnosis of the presenting disease process Determine the cause(s) of the disease(s) Dental history: when was the previous treatment done, who did it, signs and symptoms Clinical and radiographic examination Restorative prognosis Estimate of the prognosis and treatment recommendation Microbial causes Intraradicular infections Persistent infection in the root canal Re-infection of the root canal Extraradicular infection Actinomycosis Other extraradicular microbes Extraradicular viruses Int Endod J Apr;39(4): Non-microbial causes True cysts Cholesterol crystals Foreign bodies Root canal filling materials Scar tissue healing 7

8 53-year old male presents with swelling What are the keys to longevity for ETT? Assess the amount of remaining sound tooth structure All existing restorations should be removed whenever possible to determine restorative prognosis Coronal and radicular dentin should be preserved throughout the procedure ETT should be restored immediately, under good isolation with restorations that are strong and well sealed Patient wanted to have her crowns replaced Restorative prognosis: the key to longevity Preserve dentin! Keep your access opening small 8

9 JOE 2017 JOE 2018 Teeth with TEC access showed lower fracture strength than the ones prepared with CEC, TREC or NEC Impact of contracted endodontic cavities on fracture resistance of endodontically treated teeth: a systematic review of in vitro studies Silva EJNL, Rover G, Belladonna FG, De-Deus G, da Silveira Teixeira C, da Silva Fidalgo TK Clin Oral Investig Jan;22(1): The influenceof accesscavitydesign onfractureresistanceremainslimitedandcontroversial Management options for root-canal treated teeth with persistent apical periodontitis Review and reassess Non-surgical retreatment Peri-apical surgery Combination of retreatment and surgery Intentional replantation Extraction and no further treatment replacement of extracted tooth by a bridge placement of an implant auto-transplantation What is the best treatment option? Scientific evidence For teeth requiring endodontic treatment, what are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations? A systematic review Evaluation of the literature on the survival of both modalities after restoration with crowns 55 studies related to single-tooth implants and 13 studies related to restored root canal treated teeth were included The median follow-up period for implant studies was 5 years and 7.8 years for restored root canal treated teeth The reported survival rates at the last follow-up exams were 96% for implants and 94% for endodontically treated teeth no difference Iqbal & Kim Int J Oral Maxillofac Implants 2007;22: J Endod May;43(5): Among comparative studies, no important differences between both treatments were observed until at least 8 years later The endodontic treatment and the implant placement are both valid and complementary options for planning oral rehabilitation There is a lack of randomized clinical studies comparing both types of therapeutic options What is the best treatment option? Clinical and patient circumstances Clinical circumstances Quality of root canal treatment Quality of coronal restoration Amount of remaining sound tooth structure Location tooth Patient circumstances Age Medical history: bleeding disorders, biphosphonates Finances 9

10 Main indication for an implant in our endodontic practice 55-year old woman Lack of sound coronal and radicular dentin Probing depths 8 mm at the lingual aspect Sinus tract at the lingual aspect of 36 Motivation of patient Decision points Restorability amount of sound coronal and radicular tooth structure presence of an adequate ferrule Resolution of symptoms Overall restorative treatment plan Multiple visit approach! Single versus multiple visit endo Our body of literature doesn t tell us if single or multiple visit endo is more successful More important is predictability Multiple visit endo allows us to assess the effects of our treatment before completion Never obturate a symptomatic tooth Multiple visit endo allows us to assess: Did the patient become asymptomatic? Did the sinus tract heal? Did the swelling resolve? Did the pockets reduce? In a few situations, it pays to delay obturation until there is evidence the bony lesion is healing It allows us to weed out the failing cases before starting restorative/prosthetic follow-up treatment Treatment plan? 40-yr old male presents with sinus tract at the buccal aspect of 11 Patient doesn t find the look of his front teeth disturbing Patient understands poor to guarded prognosis 10

11 Papers on artefacts in CBCT Lack of knowledge and understanding of artefacts may introduce diagnostic errors, and inappropriate treatment recommendations Schulze et al 2011 Small-volume CBCT scanning showed high accuracy in detecting horizontal root fracture without a metallic post. However, the presence of a metallic post significantly reduced the specificity and sensitivity of this examination Costa et al Eur J Radiol Measurements were performed on 14 devices The effective dose for different CBCT devices showed a 20-fold range A distinction is needed between small-, medium-, and largefield CBCT scanners, since the dose received is strongly related to field size What is the best treatment option? Experience and judgement clinician Effective dose for small FOV units (Kodak D, Morita Accuitomo 170): µsv Intra-oral radiograph: 3-6 µsv, Pano: µsv Int Endod J Jul;50(7): Full rehabilitation in 51-year old female High levels of stress and frustration in relation to RCT were reported by the GDPs. RCT was regarded as complex and was often performed with an overall sense of lack of control The more distal the placement of a tooth in the mouth, the more difficult the practitioners found it to reach and negotiate the root canal system Referring dentist asks retreatment of 16, 25 and 26, plus 6 max. front teeth 11

12 What is the best treatment option? Esthetic failures in implant dentistry are known to outnumber mechanical failures, especially in the anterior dentition Goodacre et al Patient preferences Natural tooth preservation versus extraction and implant placement: patient preferences and analysis of the willingness to pay Perforation in the critical zone, 70 yr-old male Patients tend to prefer a conservative approach for the treatment of a tooth with poor prognosis and are willing to pay an additional fee to receive their treatment choice Br Dent J Mar 24;222(6): Factors influencing the decision process: preservation versus extraction The overall restorative treatment plan Presence of adequate ferrule Remaining coronal and radicular tooth structure Age of the patient Will failure hinder future treatment? Periodontal status Psychological expectations Biotype & smile line of patient Location of tooth: posterior/esthetic zone Operator skill 12

13 Summary In general, the majority of root-filled teeth with AP should be retreated, provided that the tooth is restorable with sufficient remaining tooth structure It is often the restorative prognosis and not the endodontic prognosis per se that becomes the critical decision making determinant of whether a tooth is preserved or replaced Restored endodontically treated teeth and single-tooth implant restorations have similar survival rates Both options should be seen as complementing each other, not as competing 13