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Journal of Dental Health, Oral Disorders & Therapy Longitudinal Tooth Fractures Review Case Series Case 1 Introduction Identenfication of tooth fractures is a key point for managment and treatment success. Therefore, such knowledge is necessary for general dentists and endodontists. a. 60 years old male patient. b. Area of interest: tooth #26. Chief complaint 1. I have pain to cold drinks. Also, I can’t chew on that tooth (he pointed to #26). 2. The pain started 2 weeks ago but even before that the patient experienced some discomfort upon chewing (Figure 1). Volume 7 Issue 1 - 2017 Department of Restorative Dental Science, King Saud University, Saudi Arabia *Corresponding author: Abdulla M Riyahi, Department of Restorative Dental Science, Assistant Professor, College of Dentistry, King Saud University, Saudi Arabia, Email: Received: March 28, 2016 | Published: April 13, 2017 Medical history 1. Non-contributory medical history. 2. Medications: None. 3. Major Surgeries: None. 4. Allergies: None. 5. None smoker patient. 6. ASA I (Figure 2). Dental history 1. Bruxism: The pt is using night guard (since 4 years). 2. The pt. had history of loosing teeth due to cracks. 3. Tooth brushing: 2/day. Extra & intra-oral exam Figure 1 1. E/O: Symmetrical face, no head & neck lymphadenopathy, no TMJ clicking, no limited mouth opening. 2. I/O: Occ wear. Figure 2 Submit Manuscript | http://medcraveonline.com J Dent Health Oral Disord Ther 2017, 7(1): 00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review 2/11 Chipped enamel (Q3) (Figure 3-16). Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 3/11 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review Figure 15 Radiographic fining 1. Tooth # 15: Periapical RL. 2. RL in the coronal area (due to the fractured cusp). Diagnosis 1. Tooth #26: Symptomatic irreversible pulpitis with symptomatic apical periodontits (Crack line can be seen clinically). 2. Tooth #15: Necrotic pulp with asymptomatic apical periodontitis (fractured cusp). Treatment Tooth #15: was referred to the pros and them thought is not restorable. 4/11 Figure 16 Clinical Procedure: 1st Visit #26 1. LA: 1 carp. of 1.8 ml lidocaine 2% (1:100,000 epi) bucc infiltration. 2. Rubber dam isolation. 3. Access opening. 4. Initial instrumentation. 5. Ca(OH)2 application. 6. Cotton and Cavit. 7. Tooth was taken out of occlusion. Treatment plan for #26 Prognosis: uncertin (Figure 17). Figure 17 Figure 18 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review Figure 19 5/11 Figure 20 2nd Visit a. No more pain to cold. b. Pain to chewing sill there. c. The two segments can be separated with the crack extending to the temporary restoration. d. The smaller segment couldn’t be removed. e. The case was referred to perio for evaluation of the possibility of crown lengthening after segment removal. f. The fracture was bone level. The tooth has hapless prognosis. g. Extraction (Figure 21,22). Cusp fracture (below CEJ & bone level) (Figure 23). Figure 22 Figure 21 Figure 23 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review 6/11 Case 2 Introduction 1. 54 years old male patient 2. Area of interest: Tooth # 34 Chief complaint I have pain and swelling on that tooth (pt pointed to #34) (Figure 24). Figure 25 Figure 24 Figure 26 History of chief complaint 1. 4 months ago the pt felt some discomfort upon chewing on #34. 2. Pain and swelling started 1 month ago. 3. The patient took amoxicillin for the last 2 weeks. Medical History Noncontributory medical history. Dental history Bruxism, The pt has a night guard but he doesn’t use it. Extra & Intra-oral exam a. E/O: Symmetrical face, no head & neck lymphadinopathy, no TMJ clicking, no limited mouth opening. b. I/O: Occ wear (Figure 25-30). Figure 27 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review 7/11 b. PFM crown c. Bear shape Periradicular RL d. Black lines in the apical third (sign of VRF). Implant replacing tooth #36. Diagnosis i. Tooth #35 a. Previously treated with symptomatic apical periodontitis. b. VRF. Figure 28 c. The pt chose not to have exploratory surgery done. Treatment Prognosis: Hopeless (Figure 31). Figure 31 Outline (Figure 32). Figure 29 Figure 32 Fractured cusp 1. It is a complete or incomplete fracture initiated from the crown of the tooth and extending subgingivally, usually directed both mesio- distally and facio-lingually. 2. The fracture usually involves at least two aspects of the cusp by crossing the marginal ridge and also extending down a facial or lingual groove. Figure 30 Radiographic fining I. Tooth #34 a. RCT b. Gold crown a. Fractured cusp direction (Figure 33). Figure 33 b. Crack origin (Figure 34). II. Tooth # 35 a. RCT Figure 34 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review 8/11 c. Fractured cusp etiology (Figure 35). Figure 38 Cracked Tooth An incomplete fracture initiated from the crown and extending subgingivally, usually directed mesio-distally (Figure 39). Figure 35 Fractured Cusp Diagnosis (Figure 36) a. Tooth Slooth: Often the pain is more distinct upon masticatory release. b. Usually, pulp tests indicate vitality. Figure 39 Cracked tooth clinical features Figure 36 Fractured Cusp Treatment (Figure 37) The fracture may or may not include the pulp. The more centered the fracture, the greater the chance of current or future pulp exposure (Figure 40). a. The cusp is removed and the tooth restored as appropriate. b. Only or full crown extending below or to the fracture margin. Figure 37 Fractured Cusp prognosis Usually good (Figure 38). Figure 40 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi Longitudinal Tooth Fractures Review Cracked tooth aetiologies a. Cracked teeth are often found in patients who chew hard, brittle substances (ice, unpopped popcorn kernels, hard candy, and so on). b. These patients may have prominent masticatory muscles. Cracked tooth clinical finding a. Often cracked teeth manifest as the so-called cracked tooth syndrome. 9/11 Split tooth a. A complete fracture initiated from the crown and extending subgingivally, usually directed mesio-distally through both of the marginal ridges and through the proximal surfaces. b. A split tooth is the end result of a cracked tooth (Figure 41,42). b. This syndrome is characterized by acute pain on mastication (pressure or release). c. The pulp is usually responsive (vital) but may be nonresponsive (necrosis). d. Periapical tests also vary but usually pain is not elicited with percussion or palpation if the pulp is vital. Cracked tooth syndrome? a. Cracked teeth may present with a variety of symptoms ranging from slight to very severe spontaneous pain consistent with irreversible pulpitis, pulp necrosis, or apical periodontitis. b. Even an acute apical abscess, with or without swelling or a draining sinus tract, may be present if the pulp has undergone necrosis. c. In other words, once the fracture has extended to and exposed the pulp, severe pulp and/or periapical pathosis will likely be present. d. This explains the variation in signs and symptoms & therefore the term ‘syndrome’ should not be used. Cracked tooth diagnosis 1. Inspection 2. Staining 3. Transillumination 4. Restorations removal 5. Surgical microscope 6. Wedging forces are used to determine if the tooth segments are separable. 7. Biting test. 8. Periodontal probing. Cracked tooth treatment a. Only or crown. b. In case of deep crack extraction. Figure 41 Vertical root fracture a. A complete or incomplete fracture initiated from the root at any level, usually directed facio-lingually. b. The fracture is located in the root portion of the tooth only and may extend coronally toward the cervical periodontal attachment. Pathogenesis It results from wedging forces within the canal. These excessive forces exceed the binding strength of root dentin, causing fatigue and fracture (Figure 43). Etiologies a. Excessive dentin removal during canal instrumentation. b. Post placement (cementation) and designed (too long or too wide). c. Lateral and vertical Condensation. d. Occlusal forces exerted on the post after cementation. e. Roots that are curved and are deep facially & lingually but narrow mesially & distally are particularly prone to fracture. Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Copyright: ©2017 Riyahi 10/11 Longitudinal Tooth Fractures Review Figure 42 f. Examples are mandibular incisors and premolars, maxillary second premolars, mesio-buccal roots of maxillary molars, and mesial and distal roots of mandibular molars. Diagnosis 3. The post-design least likely to cause fracture dentin is the flexible (including carbon-fiber) or parallel- sided preformed post [3]. a. Often asymptomatic. b. Localized swelling may be present. c. Deep narrow pocket. d. Radiographic findings e. Lesion extending over the apex and along one root f. surface (J-shaped or halo pattern) g. Deep, localized, vertical bone loss. h. Visible separations of fractured root segments in (only a small percentage of teeth). Figure 43 i. CBCT. j. Flap reflection (High magnification, illumination and staining with dye is Helpful). Prognosis a. Hopeless. b. Treatment is removal of the fractured root or extraction of the tooth (Figure 44). Prevention of VRF 1. Avoid excessive removal of intraradicular dentin & minimize wedging forces [1]. 2. More flexible and less tapered finger spreaders are preferred over hand-type spreaders [2]. Figure 44 Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227 Longitudinal Tooth Fractures Review References 1. Eric Rivera, Richard W (2007) Longitudinal tooth fractures: findings that contribute to complex endodontic diagnoses. Endodontic Topics 16(1): 82-111. Copyright: ©2017 Riyahi 11/11 2. Dang DA, Walton RE (1989) Vertical root fracture and root distortion: effect of spreader design J Endod 15(7): 294-301. 3. Sirimai S, Douglas, Steeven (1999) J Prosthet Dent 1999: 81: 262269. Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227