"Because people are living
longer and dentists are helping keep teeth longer, teeth are being exposed
to years of crack inducing habits. Particularly, clenching, grinding, and
chewing hard things such as ice can result in cracks and fractures in
teeth. Typically cracks and
fractures do not show on x-rays. Hence, cracked and fractured teeth
can especially be difficult to locate." source:
www.endodovgan.com/Endoinfo_Cracked_Fractured.htm
Symptoms of a cracked or
fractured tooth
A
fractured or cracked tooth will sometimes have a sharp pain when you bite on
it, but not always. Sometimes the pain will come as you release pressure on
the tooth. The symptoms can also be a sensitivity to cold or to hot. And,
you may have symptoms of a cracked or fractured tooth and then ask your
dentist to tell you what is wrong, but he or she may be unable to tell. It
is extremely rare for a crack or a fracture to show up on an x-ray, because
it will only appear if the x-ray happens to be at the exact same angle as
the crack. Therefore, cracks and fractures are often diagnosed from the
associated signs, such as infection, that follow a long-standing crack or
fracture.
Treatment The treatment of a split or fractured tooth has
historically been extraction. Below is a synopsis of Dr. David Hall's
landmark study, demonstrating that these teeth, if the split or fracture
is caught early, can be restored and they can heal. |
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Abstract:
When a vertical tooth
fracture extends subgingivally to below the gingival attachment, the literature
practically universally recommends extraction.[1][2][3][4][5][6]
Walton phrases this recommended treatment thus: Once the clinician
confirms the
diagnosis of a fractured tooth, Maintaining an intact tooth is impossible.
He continues:
If the fracture is severe (that is, deep apically), the tooth must be extracted. If
the fracture shears to a root surface that is not too far apical, the smaller segment will
be very mobile. Then there is a good possibility that the small segment can be removed and
the remainder of the tooth salvaged.[1]
The rationale can be expressed
as the following: When a fracture
traverses the area from the supragingival area to below the attachment, the fracture line becomes
a focal point for inflammation. Simon, Glick and Frank, in their article in
Oral Surgery put it this way: Once this
attachment is breached and the groove becomes involved, a self-sustaining infrabony pocket
can be formed along its length. This condition is nonresponsive to periodontal
treatment.[7]
In the paper referenced below,
Hall, Ourique, and Itikawa offer literature references to provide a rationale
for believing that these teeth can be saved, as well as case studies of
from ten to twenty-one
years duration that show examples of fractured teeth that have been successfully treated. These teeth have
remained intact and fully healthy for as long as they have been observed.
We will present here a
paraphrasing of their original article, and will reference the complete source
at the bottom of the page.
Background (literature
references):
We all know that roots are covered with
cementum. The cells that create cementum are in the periodontal ligament.
Furthermore, it is common knowledge that cementum deposition occurs throughout life.[8]
It doesn't take much of a leap to presume that, if there were to be an injury to a root such as a crack,
and if the proper
conditions were to exist, that there could be a potential for that crack to be able to heal over
with new cementum.
Searching the literature, we
were able to find a few reports of such
healing actually occurring. Hammer[9]
studied tooth fractures in dogs and noted, after two weeks, dentin repair beginning on the
pulpal side of the fracture, and cementum repair on the periodontal ligament
side of the fracture line after three weeks.
Andreasen and Hjørting-Hansen
did their study of cementum healing by observing human teeth.[10]
Their study included 50 horizontal root fractures. By radiographic examination,
they showed the apparent formation of new cementum when the fractured segments were in close apposition.
Furthermore, one of
these teeth was extracted and it showed, clinically, the formation of cementum and
cementoid. As a result of their study, they concluded
that the two most important features in the successful treatment of root fractures are
immediate reposition and fixation.
Both of these studies involved horizontal root fractures
that were entirely below the gingival attachment. The question remains as to
whether the same processes can work to heal vertical fractures that traverse the
attachment.
In a case report by
Hall in the Journal of the American Dental Association,
a traumatic injury to an 11-year-old made resulted in a central incisor being shattered into four pieces,
and being subsequently restored.[11]
The trauma had caused several vertical fractures which traversed the gingival
attachment. Eighteen months postoperatively, in spite of pulpal involvement in
the fractures, the tooth was still vital and apparently completely healthy.
However, in spite of the
initial success of the treatment and after the publishing of the case report, the tooth was re-fractured in a second traumatic
incident. Upon examining the second injury, Hall was able to separate the coronal portions
of the injury only very slightly. The complete resistance to separation of the radicular portions
was consistent with cementum healing having occurred over the first injury. Repair was
attempted after the second injury, but without long-term success. Five years later, the
tooth was extracted. However, the incident suggested a possibility of true cementum
healing of a vertical root fracture.
In the 1980s, Japanese
researcher Masaka[12]
developed a technique for preserving teeth that had suffered vertical root fractures
by using a 4-META
adhesive. What he did was to extract fractured teeth, repair them extraorally, and
then replant them in the patient.
While his success validates the concept of root fracture repair, it doesnt address
the issue of potential biological cementum repair. French researcher Aouate[13]
has also performed similar work in vertical root fracture repair using 4-META.
To read the report of cases in
the work primarily done by Hall,
click here.
Footnotes
[2]
Stanley, J.R. The cracked tooth syndrome. J Am Acad Gold Foil Operators 11:36-47, 1968.
[3]
Snyder, D.E. The cracked-tooth syndrome and fractured posterior cusp. Oral Surg
41:698-704, 1976.
[4]
Ritchie, B..; Mendenhall, R.; and Orban, B. Pulpitis resulting from incomplete tooth
fracture. Oral Surg, Oral Med, Oral Pathol 10:665-671, 1957.
[5]
Linaburg, R.G. and Marshall, F.J. The diagnosis and treatment of vertical root fractures:
report of case. JADA 86:679-683, 1973.
[6]
Plant, J.J., and Uchin, R.A., Endodontic failures due to vertical root fractures: two case
reports. J Endodont 2:53-55, Feb. 1976.
[7]
Simon, J.H.S.; Glick, D.H.; and Frank, A.L. Predictable endodontic and periodontic
failures as a result of radicular anomalies. Oral Surg 31:823-826. June 1971.
[8]
Lefkowitz, W. The formation of cementum. Am J Ortho 30:224-240. May 1944.
[9]
Hammer, H. Die Heilungsvorgänge bie Wurzelbrüchen. Deutsch Zahn Mund Kieferheilk 6:297,
1939.
[10]
Andreasen, J.O., and Hjørting-Hansen, E. Intraalveolar root fractures: radiographic and
histologic study of 50 cases. J Oral Surg 25:414-426. Sept. 1967.
[11]
Hall, D.A. Restoration of a shattered tooth report of a case. JADA 129:105, Jan.
1998.
[12]
Masaka N. Long-term observation of fractured tooth roots preserved by adhesion. Adhesive
Dentistry. Japanese 13:156-170, 1995.
[13]
Aouate, G. Treatment of an intra-alveolar root fracture by extra-oral bonding with
adhesive resin. Information Dentaire. French 26:2001-2008, 2001.
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