Fractured Teeth: Is There More Than One Type of Fracture? Part 4

In Part 4 of our series on teeth fractures we will discuss two cases of fractures in back teeth (molars) where there were no restorations (fillings), but the fractures were significant enough for the teeth to be lost.

It’s actually much more common to see fractures in teeth that have large fillings, especially in back teeth (molars).  This is because fillings have been placed due to loss of tooth structure and this results in a loss of tooth strength.

Dentist 4-1 In the adjacent photograph, the molar tooth on the right (second molar) is involved with a significant fracture.  The patient came into our office with the complaint of sensitivity when biting on this tooth. It had been sensitive sporadically for some time, and he finally came in because the discomfort had progressed.

The fracture is seen on the right side of the photo and can be differentiated from the natural grooves in the tooth as seen on the left side of the tooth.

This fracture proved to be quite deep. It went down vertically into the roots of the tooth which go into the bone (take a look at the diagram of the anatomy of a tooth in Part 1), and essentially was dividing the tooth into a right and a left half. This tooth was not restorable because of the deep nature of the fracture down below the bone level.

Blog #4The tooth was extracted and the bone was allowed to fill as a function of healing. Then a dental implant was placed to act as a “mechanical root,” to support a full crown restoration and restore it to functionality.

The second case is very similar, in that there was no restoration (filling) in the tooth.  As described previously, the x-ray image of this tooth did not show any fracture line. So how is it determined that a fracture is even there?

Transillumination In this situation a diagnostic tool called trans-illumination was used.  This technique uses a very bright light source and the photograph is taken without benefit of any other light.

The bright light shines through the tooth to the point where the light gets blocked by the fracture, and the tooth past the fracture is dark.  A normal tooth without a fracture would allow the bright light to shine all the way through because there is nothing to stop the light.

Trans-illumination showed that this tooth had a deep fracture, and because it went deep below the bone level this tooth was not restorable, either.

After confirming this to be correct, the tooth was extracted, and a dental implant was placed, allowing the bone to heal around the implant. Once healed, a crown was placed on top of the implant to replace the tooth that was missing.

Dr. Mastrovich discusses these cases of fractures when there are no fillings here:

 

Fractured Teeth: Is There More Than One Type of Fracture? Part 1

Fractured Teeth: Is There More Than One Type of Fracture? Part 2

Fractured Teeth: Is There More Than One Type of Fracture? Part 3

 

 

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Fractured Teeth: Is There More Than One Type of Fracture? Part 3

In Part 3 of our discussion on tooth fractures we will discuss fractures that occur in a back tooth (a molar) secondary to having large restorations (fillings) in the tooth.Photo 1

This photograph shows a lower molar that has a very large silver filling which has been in function for many years. Due to the loss of tooth structure resulting in a weakened tooth and the  thousands and thousands of chewing cycles this tooth has endured, it’s highly probable that stress  fractures can begin to occur.

Recalling the diagram of the anatomy of a tooth in Part 1 the enamel is the outermost layer of the tooth, and in this photograph  the fracture in the enamel of the tooth is visible.

The important question to consider is where does this fracture terminate?  Does it track deeper or does it remain in the enamel of the tooth?

Photo 2In the close-up photograph, the fracture looks significant. However, it is only significant if it is tracking deeper into the second layer of the tooth, called the dentin, as was discussed in Part 1.

To better understand where the fracture goes, the old filling must be removed.

 

Photo 4With the filling removed, we see that the fracture is tracking into the dentin, and moving toward the center of the tooth.  Additionally, there’s another fracture that is tracking from a different direction.

This tooth was sensitive at times, which is a common finding.  Pain with biting pressure, either consistent or intermittent, is a common finding with a fractured tooth.

The remedy for this tooth was to place a full coverage crown, and the tooth then became free of discomfort.

For this situation the tooth was stabilized with a restoration, and now has a significantly improved prognosis.

The second case is very similar – a large silver filling in a molar, a fracture on the front, and what looks like a very large fracture in the back.

2 more pics 2Again, the x-ray image is of no  help diagnosing the extent of the fracture as seen clinically.  More clinical information regarding the extent of the fracture will be facilitated with the removal of the filling.

 

 

Photo 9 Now we can see that the back fracture actually tracks all the way toward the front. This is a very significant finding, as the tooth is causing pain with biting pressure.  At this point it is critical to know how deep this fracture tracks before we can say this tooth can actually be saved.

 

The patient was sent to an endodontist, or root-canal specialist, where the pulp (nerve) chamber was accessed.

The endodontist felt the floor of the pulp chamber was solid and that the fractures ended there. The fracture had gone down far enough that it was involving the pulp of the tooth, but not deeper.

Photo 10You can see the filling material that the endodontist used to seal  the canals in the roots.   There were no visible fractures seen there.

So despite the fact that this tooth presented with a very significant and deep fracture, this tooth could be restored and put back into service and to date has had a very functional result.

 

Watch this video where Dr. Mastrovich describes fractures in molars with fillings:

In Part 4 we will discuss fractures in teeth without fillings.

Fractured Teeth: Is There More Than One Type of Fracture? – Part 1

Fractured Teeth: Is There More Than One Type of Fracture? – Part 2

 

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Fractured Teeth: Is There More Than One Type of Fracture? Part 2

In Part 2 of our series on dental fractures we will look at simple fractures in the enamel of the tooth.

The case study for this type of fracture is an elderly gentleman who was initially seen in another office where he received a diagnosis of severe fracturing of his front teeth. He was told that to prevent the loss of all of his front teeth, they would have to be crowned.

Tooth Fractures Case StudyThis x-ray shows significant fractures and seemingly indicates that the diagnosis is correct – the tooth is about to fall apart.

However, these fractures also appear to be just in the enamel of the tooth, and are not even tracking into the dentin. (See tooth anatomy diagram)

In reality this tooth is not in jeopardy of breaking. Yes, crowning to improve aesthetics would be appropriate, but crowning for protection of the tooth because it will be breaking in half is not necessary in this case.

Enamel fractures are routinely seen in dental offices.

If a tooth fracture comes down through the enamel into the dentin it can exit horizontally or obliquely.  In this first tooth the fracture came out obliquely just above the gum line.

Dental Fractures From FillingsAlthough this fracture at first would appear to be a serious situation, actually this tooth can be easily restored and has a very good prognosis. This fracture came down and out horizontally. There’s still plenty of tooth to work with and restoration is a fairly routine procedure.

 

 

Dr. Mastrovich further explains simple enamel tooth fractures in this video.

In Part 3 of our 4-Part series we will look at case studies of back teeth (molars) with fractures that are actually secondary to the effect that fillings have on weakening the tooth.

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Fractured Teeth: Is There More Than One Type of Fracture?

Dentist 1In a 4-Part series we are going to be discussing fractures in the teeth – what they are and how a dentist can repair them.

In order to best understand a problem with a tooth, we need to first understand what a healthy tooth looks like and how it is made up.

So, in Part 1 we will examine the simple anatomy of a tooth.

At the top of a tooth is the enamel, on the crown of the tooth, which we normally see. The second layer is called the dentin, and the third layer inside the tooth is the pulp, or the nerve tissue. Below this point are the roots in the bone.

1. Crown
Most of the tooth is under the surface, like an iceberg. The portion of the tooth that is above the gum line where we can see it is called the crown.

The purpose of the tooth determines the shape of the crown. For example, the crown of a molar is flat, for grinding, and the crown of a front tooth (incisor) is sharp, for cutting.

2. Enamel
The outer, top-most layer of the tooth is called enamel, and again, this is the layer that we see – it covers the crown. Tooth enamel is the hardest and most mineralized tissue in the entire body. At the same time, this enamel can be easily damaged.

3. Gumline
Where the crown of the tooth and the soft tissue of the gum meet is called the gumline.

4. Dentin

This is the layer in the tooth itself that is just below the enamel. Although it is the layer that protects the nerve, it is porous, with millions of microscopic tubes, called dentin tubules, leading directly to the pulp. These tubules are filled with cellular fluid.

5. Pulp
The soft tissue in the center of the tooth is called the pulp, and is where the nerve tissue and the blood vessels are. Tooth decay that reaches the pulp can cause a great deal of pain.

6. Root
The root is embedded in the bone of the jaw, and anchors the tooth to bone. The root makes up two-thirds of the tooth itself.

Take a look at this video where Dr. Mastrovich explains the tooth in detail:

 

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 Dental fractures can occur in various places on the tooth – they can occur in the enamel or down into the dentin, or even deeper. They can occur obliquely, horizontally, or vertically, and they all have different ramifications of tooth pain and its treatment that we’ll talk about in the rest of this series as we go through the various types of fractures.

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