1.6
Cracked Tooth with Radicular Extension
Suhaila S. Shariff and Matthew C. Davis
Objectives
At the end of this case, the reader should be able to diagnose and prognose cracked teeth with cracks that extend onto the root surface. The reader should also understand treatment and post‐treatment protocols that are likely to impact the treatment outcome.
Introduction
A 57‐year‐old male presented to the endodontist with pain on mastication and constant throbbing in the lower left quadrant.
Chief Complaint
The patient complained of moderate pain on biting and an ache that had progressively worsened over the past week. He had been unable to sleep for the past two nights.
Medical History
The patient had a history of mild hypertension that was controlled with diet and exercise. He had been taking 400 mg ibuprofen every six hours as needed for pain. His medical history was otherwise unremarkable.
Dental History
The patient was a routine attender to his dentist and hygienist. His most recent visit was three months ago, at which time he had lingering sensitivity to cold and spontaneous aching in the lower left quadrant. His dentist performed a pulpotomy on the lower left second molar (LL7) and referred him to an endodontist. The patient’s pain resolved with the pulpotomy, so he did not see the endodontist until his pain returned.
Clinical Examination
The lower left second premolar and first molar (LL5 and LL6) were both responsive within normal limits to pulp sensibility testing and percussion and were ruled out as the cause of his symptoms. The LL7 was not responsive to pulp sensibility testing (cold and electric pulp testing) and was moderately tender to percussion. There was no swelling or sinus tract. Transillumination revealed a crack on the distal marginal ridge that extended subgingivally. There was a 5 mm probing depth on the direct distal of LL7 along the crack line.
Radiographic Examination
The radiograph of LL7 showed evidence of prior access with an occlusal restoration and a periapical radiolucency (see later Figure 1.6.5a).
Diagnosis
Endodontic diagnosis of LL7: Cracked tooth; previously initiated endodontic therapy with symptomatic apical periodontitis.
What are longitudinal tooth fractures?
Longitudinal tooth fractures are fractures that occur along the long axis of a tooth over time. They include craze lines, fractured cusps, cracked teeth, split teeth and vertical root fractures. It is imperative that the proper diagnosis is made regarding the type of longitudinal tooth fracture, since the recommended endodontic and restorative treatments vary significantly (Table 1.6.1).
What is a cracked tooth?
A cracked tooth is a restored or unrestored tooth with an incomplete longitudinal tooth fracture initiated at the occlusal surface that extends apically and potentially subgingivally over time. The crack is typically directed mesio‐distally, but it can also be present in the bucco‐lingual direction. The most commonly cracked teeth are mandibular molars, maxillary molars and maxillary premolars. Transillumination, dyes and increased magnification can improve the visualisation of cracks in a clinical setting (Figure 1.6.1).
What is a cracked tooth with radicular extension?
A cracked tooth with radicular extension is a subset of cracked teeth where an occlusal crack has extended apically from the crown onto the root surface and potentially into the periodontium (Figure 1.6.2). These teeth have traditionally been deemed unrestorable and have been extracted with little to no supporting evidence. However, recent studies have suggested that teeth with radicular cracks, the extent of which can be visualised into the root canal internally or with narrow, isolated vertical areas of bone loss externally, can potentially be retained for prolonged periods with successful outcomes.
Table 1.6.1 Longitudinal tooth fracture types and their respective characteristics and treatment plans.
| Type of longitudinal tooth fracture | Characteristics | Endodontic treatment plan | Restorative treatment plan |
|---|---|---|---|
| Craze line | Confined to enamel only Transillumination: light transmits through a craze line |
Not necessary | Not necessary unless a cosmetic issue |
| Cuspal fracture (complete and incomplete) | Initiates in the crown of the tooth, extends obliquely undermining cusp(s), involves enamel and dentine, and may or may not involve the pulp Incomplete cuspal fracture: a crack that undermine cusp(s) Complete cuspal fracture refers to those cases where the cusp is lost Transillumination: light will stop at the fracture for incomplete cuspal fracture |
No endodontic treatment:
Root canal treatment:
|
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