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Case of the Month

<< Back to 2001 Case List

December 2001 Cusp Fracture in a Mandibular Molar

Fig. 1

December's case of the month comes to us in the form of a 37 year old male patient who was complaining of sharp sensitivity when chewing hard foods. He did not have unusual sensitivity to thermal stimulus but was unable to eat anything hard on this side for fear of a sharp sensation when biting "just the right way".

The symptoms are classic for Cracked Tooth. But how involved is the case? Is endodontic treatment required?

Close examination of Fig. 1 gives us a clue as to the problem. The mesiobuccal cusp appears to be much whiter in color than the rest of the tooth. We all are familiar what an undermined cusp looks like when proximal caries has invaded the dentin under a cusp. It does look similar. The real clues lie in: the two surface DO amalgam and the crack in the weak mesial marginal ridge.

 

Fig. 2

Figures 2 and 3 show slightly different views from the Mesiobuccal side. What we now see is the typical weak cusp with the horizontal fracture in a slightly more unusual location than normal.

Fig. 3

The most frequent location for fractures in a mandibular molar are the lingual cups (Fig.4) , just at or just below the level of the gingival attachment. These deeper fractures often necessitate crown lengthening procedures in order to obtain adequate biologic width for restoration.

Fig. 4

In this month's case (Figs. 1,2,3) , the weak mesial marginal ridge fracture extended across the mesiobuccal cusp face and joined with the small buccal pit amalgam. The final extension of the fracture naturally occurred when the patient bit down and the Mesiobuccal cusp became isolated from the distobuccal cusp. Because this area of enamel was no longer continuous with the rest of the tooth, the alteration in refractivity to light resulted in the color change that we see. This can often be a good indication of a weak cusp. Transillumination can also often assist in detecting this change.

The case was sent back to the referring dentist for removal of the weak cusp and possible onlay or crown restoration. The decision to perform endodontics in this case is now ELECTIVE. The patient had no pulpal symptoms. If the referring dentist is satisfied with the remaining core preparation, and if no symptoms occur after temporization, I would not recommend endodontic treatment. However, if the remaining tooth structure is insufficient to retain the restoration, if the crown or onlay preparation is not ideal, if symptoms develop or there is a history of a very deep amalgam, serious consideration should be given to treating this tooth BEFORE the casting is placed.

Conclusion
Symptoms of Cracked Tooth can frequently involve unusual cuspal fractures. Endodontic treatment is not necessarily required for these cases. Each case must be evaluated independently. The extent of the fracture, pulpal responses, previous restorations and the prospective restoration are all factors that must be considered when deciding if endodontic treatment should be performed.