6. Cracked Tooth Perio-Endo Relationships Flashcards
- Diagnostics are always important for perio endo lesions and we have new tests that we need to perform aside from the normal tests that we perform thermal tests, EPT, percussion, palpation, but now more important is probing versus sounding where you have anesthetized the patient before the probing then bit tests, transillumination, and mobility that come in addition to the usual tests that are specific for endo perio lesions or lesions where you have perio involvement and for cases with vertical root fracture or crack
- ____ fracture is a death sentence for the tooth unless it is a ____ tooth and just one of the roots are affected you can remove that root and still save the tooth
vertical root
multirooted
Intraoral Exam Periodontal
____: wide, gently sloping craters around multiple teeth
____: isolated vertical loss (fracture/sinus tract)
- There are slight differences if we are looking at a disease or probing depending on if it is related to a perio issue or endo issue
- Endo related issue is a crack in the root so when you walk around the probe going from mesial to distal on both buccal and lingual there is a width of the probing that you are detecting and if you are encountering a perio lesion this is something that is wider from a mesial distal direction then if you compare this to an endo lesion that means you have a crack and an infection inside the pulp space like a vertical root fractures where microbes go into the pulp structure and cause inflammation of the pulp where that crack is propagating in the root and you get break down of the perio tissues and this is very narrow and isolated vertical loss of the bone structure
periodontal
endodontic
Clinical ex
We would do an exploratory surgery where we raise the flap with anesthesia and check if there is root fracture and you would see that there would be very narrow bone loss in MD direction and goes all the way along the crack and there is a faint blue line along the root that we stain with ____ that we use for root and surgical procedures and finds organic tissues like leakages or PDL and stains cracks and fractures
• We see the fracture line here
methylene blue
Interpretation Periodontal
- Very often we have radio for the root fractures and we see a ____ shaped lesions where there is a radio halo around the root structure just like seen here in the apical area and is a typical thing seen
- Small ____ probing and J shaped lesions are characteristic of this
J
vertical
Interpretation periodontal
May have an implication of the perio tissues that is originally only coming from an endo lesion
Have the normal progression of the tooth infection that then once goes through tooth forms and apical perio
If this becomes a chronic apical abscess and in the lower posterior mand and see because the cortical plate of the bone is so thick that you wouldn’t see the sinus tract and it looks for the pathway of least ____ and get a sinus tract that is going through the perio space and that is how you get a ____ shaped lesion
- This doesn’t have to be just a vertical root fracture but could be an endo lesions that goes up the ____ ligament forming a sinus tract there and drains into the sulcus and into the oral cavity
- In contrast to the perio where you have infection on the cementum and inflammation breaking down perio structure and plaque on the root surface and the break down is form the perio margin
resistance
J
perio
Craze Lines Incomplete cracks in teeth confined to \_\_\_\_ only Extend \_\_\_\_ \_\_\_\_ No \_\_\_\_ required
• If you have vertical root fracture where you have combo of apical perio and bone loss all the way around the root
• there can be early forms of the root fracture starting form minimal cracks or craze line into the roots
• There is no need for treatment for craze lines in the enamel structures and many of us have or will have these
• These are tiny little lines in the enamel and there is no need for treatment and usually asymptomatic and goes from occlusal to gingival direction
• Don’t need to do anything about this
• Can have these for many years without
complications
enamel
occluso-gingivally
asymptomatic
treatment
Fractured Cusp
Complete/incomplete fracture initiated from crown and extending ____
____ & facio-lingually
Extensive caries or large restorations
Brief, ____ pain on mastication & with cold, pain on masticatory ____
• Most severe
• See the connection to the trauma to what we see
• But there may not be pulpal exposure and may just
effect the enamel and the dentin
• May be ____ especially if there is no
mobility
• If becomes mobile or extends into the cervical portion of the root then we want to remove the broken portion and replace with a filling or do a complete coronal coverage to protect the tooth from a more severe fracture in the future
• Can use ____ like UV or LED light placed next to the tooth and the point where the transillumination of the light is impede and the transmission of the light stops is by the fracture in that crown
• Can see this in the picture
• May or may not have pain
• Only pain if the ____ are exposed and you get movement of the fluid in them
• Usually pain on ____ from biting on a cotton roll
subgingivally
mesio-distally
sharp
release
asymptomatic
dentinal tubules
release
Cracked Tooth
Incomplete fracture initiated from the crown and extending ____
____
Parafunctional habits, trauma, restorative procedures
Localized pain on mastication (____ or release), ____ brief pain to cold
This is the next worse thing
• Seeing more cracked teeth because people are more stressed and they are grinding their teeth
• You see these cracks where there is no restoration too
• Usually goes from mesial to distal in the tooth and also extends towards the cervical area into the root going below the bone level into a root canal or we see going through the complete pulp floor we recommend extraction
• If we see something going through the pulp floor or below the CEJ area then we cant do any complete coronal coverage and if cant seal this area there will always be a pathway for microbes to get back into the tooth and will affect the tooth and that is why these teeth have a bad prognosis and should be removed
• If you see a tooth with no restoration or if people have a very shallow restoration for very long time and they come with all of the symptoms of ____ pulpitis but don’t see any ____ then this would be an indication that this person has a cracked tooth
subgingivally
mesio-distally
pressure
sharp
irreversible
decay
Cracked tooth
Tooth slooth test of individual cusps gives pain on ____ when tooth is cracked (fluid movement)
Good tooth to diagnose is a tooth slooth that is better than cotton roll or wooden stick
• Put it on one particular ____ on the adjacent teeth and have the patient bite down when they bite down and ask if hurts or not and ask when if was like when biting down or releasing
• Don’t see anything for the adjacent teeth
• Test each cusp
• Then move on to the desired tooth and
this is where you’ll find pain
release
cusp
Treatment of Cracked Tooth • • Location and Extend of Crack
Remove the dentin until crack disappears
If fracture doesn’t terminate on root surface, tooth is restored to bind the fractured segments
Permanent restoration - Full crown is indicated, avoiding posts
If fracture extends through the chamber floor, ____ is indicated
Trying to remove the crack and see how deep it goes
If doesn’t terminate on the root surface below the bone level then can restore the tooth
But if goes below the CEJ then the prognosis for the tooth is really bad and the tooth is ____ because if you have a crack that expands and get complete vertical root fracture will always have invasion of microbes into the area and will have breakdown of bone and this will be bad prognosis for an implant that you would want to place in the area from loss of vertical bone structure
extraction
extracted
Split tooth
Complete fracture initiated from the crown and extending ____
____
Marked pain on ____, periodontal abscess
Visual separation of segments, wedging of segments
If the crack continues and the crack syndrome expands and goes deeper then becomes a split
tooth
•
What is characteristic for split tooth is the patient more often feels pain on ____ and may see that there is a ____ in the area of split and if gets worse and may see there are mobile parts and the parts can split apart and move away form each other and usually a bad sign
• Tooth has to be extracted
subgingivally mesio-distally mastication mastication perio abscess
Treatment of split tooth
Location and extent of crack
If the fracture is deep apically, ____ is indicated
If fracture is not too far apical, remove the fractured segment, crown lengthening or orthodontic extrusion segments
•
If fracture extends apically then extraction is indicated
If this is more to the coronal may still be able to save the tooth with ____ or ortho extrusion to have a good coronal restoration that will seal the tooth off
extraction
crown lengthening
Vertical root fracture (VRF)
“A longitudinally oriented fracture occuring most frequently in endodontically ____ teeth.
Characterized by a crack that begins in the root and extends toward occlusal surface usually in a ____ plane”
• Have the vertical bone loss and can stain
• Indication for ____ unless if this is on
a mesial buccal root of max molar where can take the one root out and with the remaining root can be left if not mobile
• Would be a root ____ or root resection or trisection or hemi section of tooth
• But most likely the tooth is lost completely
treated
bucco-lingual
extraction
amputation
Vertical root fracture - demographics
•
Shows how often this happens in teeth
• Teeth where this most commonly
occurs are ____, mand 1st molars, and mand 2nd molars
• Reason is that these teeth have very slim ____ roots and the molars have a figure ____ shape about them
• Max 1st molar would be in fourth most common because these roots are ____ and thin and get a lot of masticatory stress
max PM
narrow
8
short
Complete VRF
Why do fractures tend to occur in ____ direction ?
bucco-lingual
Factors influencing location & direction of vertical root fractures
\_\_\_\_ morphology Root canal shape \_\_\_\_ of dentin Irregularity of root surface \_\_\_\_ application
external root
thickness
point of force
Detection of vertical root fractures
- direct ____
- broad based and mid-root ____
Sometimes you can see the vertical root fracture directly
• May not just be in the crown but may see soft tissue involvement
Sometimes you have to do indirect exploratory surgery or probing
May start in the coronal aspect of the tooth but can also start in the apical aspect of the root may be connect to wrong forces brought on the tooth like if RCT done along time ago and might see micro cracks in the apical area and to have continuous occlusal forces may also see the fracture begin in the apical area
inspection
swelling
Detection of Vertical Root Fractures - Probing
Pocket adjacent to the ____ site
Deep, ____, isolated periodontal pockets
Deep probing in ____ positions on opposite sides of the infection - Pathognomic of VRF
Have to ____ the probe and make sure that you find the pocket that is very narrow
• Cant just probe mesial and distal
Probing and there is nothing crazy then all of a sudden for one spot there is a 8 or 9 or 10 mm depth pocket
fracture
narrow
2
walk
