Gerald S. Fine, D.D.S.
Oral and Maxillofacial Surgery
In the past two weeks my office has seen three patients referred for evaluation of non-specific dental pain in otherwise dentally healthy young patients. The most recent patient was a 20 year old male who had pizza for lunch and immediately developed pain involving the Maxillary left first bicuspid tooth, or so he thought. Clinical examination ultimately revealed the Mandibular left first molar tooth was the source of his discomfort.
Incomplete fractures, the third most common cause of tooth loss, are difficult to diagnose. Normal radiographs, normal responses to electric pulp tests and thermal stimulation, and the presence of restorations can make the diagnosis of incomplete coronal fractures difficult. Incomplete coronal fractures occur most often in maxillary first bicuspid and mandibular first or second molar teeth and may extend mesio-distally. Because of tooth anatomy, the non-supporting cusps (mandibular lingual or maxillary buccal) will fracture. Bruxism, malocclusion, vibrations from handpieces, self-threading pins, and masticatory accidents can contribute to fracture development.
Although a variety of symptoms may be present, the most consistent is a sharp pain of short duration while chewing tough or crunchy food. When a crack is suspected a masticatory load test should be performed and radiograph obtained. Enhanced visualization via magnifying lens, transillumination, or use of dye staining may also demonstrate the fracture line. Although cracks are not commonly detected on radiographs, an isolated radioluscency on an otherwise health mouth may indicate an incomplete fracture.
Following diagnosis, initial treatment involves reinforcement, using either orthodontic stainless steel (preferred) or copper bands. A bite test should be repeated following reinforcement to verify diagnosis. Prior to splinting, restorations should be removed so that the split direction and extent can be noted. In cases where endodontic therapy will be performed, however, the split tooth should first be reinforced, in order to prevent further cracking or complete ultimate treatment should be a cast restoration.
Factors which are thought to predispose teeth to cracked tooth syndrome include decreased stability arising from caries and wide and deep restorations. Preventive recommendations include preparing cavities of minimal width and depth, early treatment of caries, proper use of retention pins, and reinforcing extensively restored teeth via partial or complete crowns.
Gerald S. Fine, D.D.S.
Practice limited to oral & maxillofacial surgery