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Cracked Teeth
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Question #1: Should I routinely check for fractures on an asymptomatic patient?

Answer: Yes, the time to treat fractures is before they become symptomatic. Patient risk factors and the typical location and appearance of fractures should aid in detecting them as early as possible. Remember this is the third most common cause of tooth loss.
Any fracture should be discussed with the patient to help decide if the risk of leaving it untreated is worth it to them.

Question #2: Is bonding as good as placing an orthodontic band on symtomatic teeth?
Answer: No, because a band is circumferential it has resistance to failure from loading. Bonding is indicated for treating asymptomatic teeth. Although bonding may be successful it is more risky since the cusps will only be secured internally rather than circumferentially. Placing one at the first signs of a fractured tooth can often prevent later tooth loss. Successful treatment with a band will more accurately predict the stability of final treatment with a cusp coverage restoration.

Question #3: Is an onlay as good as a full gold crown?

Answer: Usually not since a fracture may extend beyond the bounds of an onlay. Also, many onlay preparations have an intercoronal component which can exert wedging forces during function. A full gold crown with supragingival margins is the safest restoration. A porcelain fused to metal restoration is more difficult since much of the buccal cusp must be removed when the lingual cusps are the most common one to fracture. The more tooth structure removed the higher the risk for later failure.

Question #4: How far down should I explore a fracture at the time of tooth preparation?

Answer: No further than 3 mm from the bone level to avoid a violation of biologic width. At this point the dentist should stop and provisionalize the restoration. Most teeth can be successfully treated without covering all aspects of a fracture with a restoration. Only if treatment above the zone of biologic width is unsuccessful should a flap and bone removal to follow a fracture be attempted .

Question #5: What about the black fracture lines on the gingival floor. Should I leave them or prepare them?

Answer: In an asymtomatic tooth they should be left alone. In a symptomatic tooth they should be covered with a bacteriocidal base (e.g. calcium hydroxide) and allowed to become asymstomatic prior to treatment. Careful evaluation for endodontic therapy should be completed prior to further treatment.

Question #6: Some dentists feel that all fractured teeth require root canal therapy. Do you agree?

Answer: No! Root canal therapy will generally alleviate symptoms but in the long run could lower the prognosis of some teeth since the fractures can be increased during endo therapy. Maintaining tooth vitality, when possible, improves the prognosis for fractured teeth since reparative dentin can aid in recovery.

Question #7: Is it prudent for dentists to warn all of their cracked-tooth patients of the potential for root canals and tooth loss?

Answer: Yes. Not to do so would be negligent on the part of the dentist. It is also important to tell patients the possible consequences of an untreated tooth.

Question #8: Should I routinely recontour nonfunctional cusps, especially in susceptible patients?

Answer: It is wise to do so, especially if one lower molar has fractured and the other has very prominent lingual cusps.

Question #9: What about persistent pain after a fractured tooth has been restored with a full coverage restoration. Is endodontic therapy the next step?

Answer: Endodontics may be necessary, but only when irreversible pulpitis is suspected. Check for periodontal pockets to see if the periodontal ligament is involved. If so endodontics may not help the situation. Generally, if the pain does not improve over time and all other etiologies have been ruled out endodontics may relieve the discomfort. Patients should be advised, however, that tooth loss is still a possibility regardless of the success of endodontic therapy.

Question #10: At what point should extraction be considered preoperatively?

Answer: Only when no other treatment is possible. In this case an implant to replace the tooth should be considered.

Question #11: When should I restore a vertical fracture and when should I extract the tooth?
Answer: When the fractured tooth can function asymptomatically with adequate bony support it should be restored.

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