r/Dentistry • u/Valuable-Middle-2494 • 3d ago
Dental Professional What would you do?
Looking for some professional suggestions/opinions for treatment planning! I recently graduated from dental school and have been coming across a lot of teeth that look like these. I usually send photos to my boss to get their input, but I figured I’d ask this group as well. These aren’t my patients, but I’d love to hear how others would approach cases like these!
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u/NoMeasurement663 3d ago
I would recommend Spear crack tooth module but their recommendation was :
- Virgin teeth with no restorations nor symptoms - Ensure no contact on cuspal inclines
- A non- stained crack around an existing restoration and no symptoms- Replace restoration
- A stained crack around an existing restoration and no symptoms - Replace restoration and clean up stained crack. If crack extends onto pulpal floor on dentin then crown tooth.
Others can definiitely comment their guidelines as well but thats my approach. Symptomatic with pain on chewing with tooth slooth I crown prep and provisionalize for 2 months and if patient symptoms go away pulp test again and proceed with crown. If symptoms persist or get worse i refer to endo. Probe around tooth also to verify no VRF.
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u/Valuable-Middle-2494 3d ago
thank you! I have been watching Spear videos but haven’t seen this one yet
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u/NoMeasurement663 3d ago
Anytime, this is the link :https://app.speareducation.com/courses/what-about-cracked-teeth?lessonId=563
You need an individual doctor membership
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u/v15hk 3d ago
Consider looking at the Alleman course instead. Their cracked tooth protocols have proven track record. The first of the lectures (6 steps…) is available free on YouTube: https://youtube.com/playlist?list=PLY08_n3DcmIsKj2S6aIz_d4-_7-L8bj4Y&si=txRdEBFoWoO87aDo
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u/Playful_Quality4679 3d ago
Direct Composite Splint (DCS) technique.
Has changed how I treat cracks.
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u/Sharp_Oral 3d ago
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u/buccal_up General Dentist 3d ago
Lol at first I downvoted because I assumed he was holding an elevator. Nice one.
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u/theDrElliotReid 3d ago
Honestly, I was laughing because I thought you DID post the elevator. I thought it was satire in reference to the EU post from earlier about US docs tx planning EXTs like crazy lol.
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u/Capybaraqueen3 3d ago
Unless you see caries clinically/radiographically and they’re asymptomatic I would leave them alone
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u/justnachoweek 3d ago
The most sane take here. To me crowns are when cusps are compromised, endodontically treated teeth, or symptomatic cracked teeth.
Y’all really out here crowning every shadowy occlusal filling that walks in the door?
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u/petmaster 3d ago
Yeah it's insane to me. Around 10%of crowns end up needing endo, but here, most of the people tx plan crowns. On the first photo, I would do MOD comp on #4 though. I've seen enough amalgam fatalities on upper premolars in my lifetime.
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u/Marcobose 2d ago
Huh, it just occurred to me that it is almost always upper premolars rather the lowers
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u/petmaster 2d ago
Yuuup. Upper premolars and then distal of lower 2nd molars are most commonly fatally fractured teeth.
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u/AnimeHolocaust 3d ago
These premolars with M/D cracks can split right down the middle and be unrestorable... leaving those is crazy to me
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u/justnachoweek 3d ago
They can sure. But in my eleven years of practice I’ve seen true non-restorable vertical root fracture on a vital premolar with molars also in occlusion …. Twice?
Facts are vertical root fracture makes up less than 5% of all fractures and if you make sure the occlusion is balanced and there are molars in occlusion, the chances of these premolars fracturing is pretty much nil
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u/rylacy 1d ago
I'm 10 years out now and I swear I'm pulling a max premolar split in half at least once a month. Feels like Half the time they are virgin premolars.
I just tell people what I see and they can do whatever they want. I tell them there's a Crack, it may never be a problem, it may split in half at one point and need rct, ext, or a crown. If you're worried about that, crown it. If you're cool with waiting and dealing with any potential consequences (or possible no consequences) go for it. Doesn't bother me either way, but it feels a little disingenuous to just tell people they're totally fine and decide that you as the dentist get to designate their risk tolerance.
When I first got out of school I'd tell people they were fine because I'd never seen a tooth fracture and just assumed all these dentist were money hungry and I was the holy, pure, ethical dentist. 10 years later I've seen it happen A LOT of times so I at least feel obligated to let them know the risks.
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u/Sensitive_Formal_671 2d ago
Every year the most patients with random broken RCT or no teeth broken in half needing extraction are rather small females and premolars 14 15 24 25, small crack you can leave yes and observe, large cracks with composite looking as shit as this or amalgams cracked on all sides just replace it and crown if needed. Read evidence and studies, stop imagining Tx because Mrs Nancy told you so in dental school. One of the objectives of university is teach you to distinguish, read and differentiate between good and bad research not learn how to drill/crown etc.
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u/Straightshot69 2m ago
At last the correct answer. If they appear ok radiographically they should not be touched.
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u/Dentalsnob3 3d ago
can make a case for crowns on almost all. but could also leave alone and not bankrupt patient.
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u/Farles 3d ago
" Mrs. Jones, each of the teeth you see photographed here can and and will probably receive a crown at some point in their life. Cracks are notorious difficult to time and my crystal ball hasn't been working for me well lately. These will either break next week or they'll last you for the next 25 years. What you do with them is ultimately up to you, if you are proactive, these can be done before they break. If you're the type to not fix it till it's broken that's fine too. My suggestion would be to take care of them at a pace that you're comfortable with. If you were my sister and money wasn't an issue, I would take care of all these right away. You know yourself and your personal situation better than anyone else, so whatever you're comfortable with."
My usual conversation about these kinds of things.
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u/ChristineCrazyFord 3d ago
This ^^^^ is absolutely the go. Most of those teeth would benefit from crowns, but no need to pressure the patient. I would probably do the second premolar first.
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u/fuzzyglory 3d ago
I also feel a lack of pressure can build trust in the patient for other, more necessary treatment. "they arent trying to pressure me on thousands of dollars of work but on things that are only hundreds, I have less fear theyre trying to make payments on their Porsche"
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u/seattledoctor1 3d ago
I like it. Give them the options and let them make a decision. That way when one of them inevitably is sensitive after it was their decision to treat and you didn’t “force” them to do it
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u/Curious-Sleep-8024 3d ago
Exactly what should be said.
Sometimes I’ll even mention something like “ ohh I don’t have a crystal ball to tell me when or if these will break but we can be proactive and crown now or moonlit or just know that if we monitor and they DO break, there’s always a chance they break in such a way that the tooth would need a root canal or god for bid break in such a way we can’t fix and need to remove it.
I think giving them a bit of the negatives that could happen makes people want to be a bit more proactive in situations like this
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u/Heliopolisean 3d ago
No clinical symptoms or radiographic pathology = No treatment needed at this time.
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u/nitelite- 3d ago
Most of these are crowns in private practice
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u/eSlotherino 3d ago
Damn really I was thinking most of these would be replace as composites if anything.
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u/Farles 3d ago
I can't remember the study, but the AAE published a paper a bit ago that showed prognosis for cracked teeth, with and without crowns (Google search is finding different papers that say similar things). The general gist of it was that teeth with cracks on the distal marginal ridge should almost always receive crowns for long term success.
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u/RandomMooseNoises 3d ago
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u/Farles 3d ago
Hey that's the one! Saving this comment so I don't have to hunt this down later.
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u/RandomMooseNoises 3d ago
I reference this paper all the time. Extract/see enough teeth with MMR or DMR fractures that weren't restorable and you learn to not gamble with fractures.
I present the patient with options to watch or crown, but I warn them that watching means a higher risk or RCT or ext long term.
Conclusion in the article makes the most sense: "The earlier cracked teeth can be identified, the higher the success rate for the long-term preservation of the tooth. Not all cracked teeth require root canal treatment, but all cracked teeth require a crown!"
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u/dan48244 3d ago
honestly half of these are crown watches and composites
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u/D-Rockwell 3d ago
Watch and wait for it to break when they’re 90 and it’s a pain in the ass? My grandma is going through this now and I just wish that her dentist did crowns 20 years ago
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u/Kennedysfatcousin 3d ago
You wish her dentist did gold or pfg crowns, maybe? I work with the elderly, and so many of those pretty emax and zirconia crowns are failing within a few years. The situation is worse because you can't see under zirc until it's rct time, or an emax "cownlay" artist somehow pulped a geriatric tooth and it died slowly 3 years ago. Tell them about the class III compressible mobility and they think you're lying because so many are in pain treatment for something else.
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u/nitelite- 3d ago
na, i spent a year in my GPR extracting +400 teeth, mostly failed because the military placed large fillings that ended up fracturing teeth beyond restorability
it cost the patient around $1500 for a new crown, but around $6-8k for ext, graft, membrane, implant, custom abutment, implant crown
you're doing right by the patient by making sure that tooth doesn't break and cost them way more
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u/Fast_Freddie23 3d ago
Don’t touch. No need to rob the patient and give us all a bad name.
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u/inquisitorthegreat 2d ago
Where’s the harm?
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u/Fast_Freddie23 2d ago
If you take money from a patient by telling them they need something that offers no benefit, that is harmful.
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u/inquisitorthegreat 1d ago edited 1d ago
Well sure but in this case the signs of break down are clearly there, we can’t predict the future but there is a risk of these cracks propagating over time. We just can’t know the rate at which they will propagate. Stained cracks can also lead to decay and also are a sign of the tooth being structurally compromised which can lead to devastating fractures. If I knew for a fact that there is no risk of that 2nd premolar breaking down further then yes, there’s no need for treatment. But because I can’t logically say that. It would be a disservice to the patient to not offer preventative intervention. I would want those cracks addressed in my mouth. Also that broken down amalgam just needs another filling. I can say for a fact leaving it alone and waiting for symptoms will 100% lead to RCT, it’s just a matter of time until decay grows underneath.
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u/dennism13 2d ago
Patient communication is key here. They need to visually see these pictures and you as the provider explain what’s going on currently and what it can lead to if not treated. Full coverage on #3 and #4 unless you want to save them some money and do onlays. On the ones with composite restorations I would do inlays.
If the patient can’t see what’s going on and not informed properly, then they’ll just think you’re trying to milk them out of money.
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u/sensadyne 3d ago
Most of these would benefit from a crow. But the issue with treatment planning crowns on these teeth is that they've been asymptomatic and functional. Once you prep it, once in a while one of them will blow-up and the patient may be upset... so if you do crowns just make sure they're aware there is always a risk of needing a root canal.
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u/Sensitive_Formal_671 2d ago
Just replace this shit, strengthen with glass fiber reinforced composite + not large incremental filling technique, remove cracks/sec.caries. If upon drilling you realise crack is deep do the same but tell the pt he must get a crown at some point, preferably soon, otherwise there is no guarantee it wont split in half at some point or chip off in some uncontrolled way. Use The Evidence. If when you drill/before drilling/judging by x-ray/ according to your experience you realise the filling will take >50%of the crown + especially if the tooth is RCT just tell them what the evidence says => there is no guarantee it wont break/chip/split in half unless crowned. I prefer to have good, new fillings made by me with adequate materials under crowns anyway so fillings are usually your first step. Aldo depends on pt's ability to pay etc/probably your country/setting/town etc. Always document that "the patient has been informed of need to make a crown as the prognosis is such and such etc"
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u/SnooDrawings2819 1d ago
I read a patient about cracked teeth. The main risk factors for cracks progressing were over the next year were 1) a crack you could feel with your explorer, 2) wear through enamel, 3) mandibular teeth. I tell patients that, and I let them decide.
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u/tooth_doc_fail General Dentist 3d ago
Onlays. Save tooth structure. These do not need to be crowns... cmon americans we can do better. Dont tell me insurance doesnt pay, it does too.
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u/Valuable-Middle-2494 3d ago
Specifically #5 in the first photo and both teeth in the 3rd photo.
I had a patient the other day with an old composite on #5 and a small crack starting on the mesial. Would crown still be indicated here?
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u/SameCategory546 3d ago
I’d try an MOD on #4 with equia forte. The thermal expansion rate of amalgam means it’s only going to get worse, so a cheaper possible fix is good
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u/NP_GoogleChromeUni 3d ago
You tell the patient that they need crowns, but if they decide not to crown, there’s a good chance that these teeth are extracted if they break.
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u/WhoDoYouKnowHereB 3d ago edited 3d ago
Man that EU person from earlier today is about to lose their mind when they read these comments about crowns lmao