It is a standard protocol to recommend a full coverage indirect restoration for patients who present with the symptoms we call “cracked tooth syndrome”. I have personally suffered from multiple cracked teeth, and the pain associated with biting down on these teeth is intense. Despite it’s very short duration, it is also exhausting as you struggle to avoid hitting that tooth while eating, and just when you think you have it figured out, “ZING!”. If you have never experienced the symptoms I am describing you are fortunate, and can’t appreciate how much patients look forward to the resolution and being able to eat normally again. Given this anticipation it is truly frustrating when the pain continues after the cementation of your new crown. We have all experienced how frustrating this is for us as providers as well.
Many of these teeth will require endodontic therapy in addition to an indirect restoration, and as we know many of them continue to have symptoms no matter what we do. Given the uncertainty how can we minimize the unmet expectations. The first protocol for me is not to rush into a final solution. These teeth are the prefect opportunity to use a provisional restoration as a diagnostic tool. Prepare the tooth for an indirect restoration, and fabricate a provisional out of a rigid bisacryl like Venus Temp 2 from Heraeus. I cement the provisional with Fynal and then we monitor the tooth for symptoms. The majority of these teeth will be symptom free in the provisional phase. When this happens send the impression to the lab and cement the final crown with confidence. For the group that don’t get better, you can now refer the patient to the endodontist without the stress that they will be cutting a hole in a brand new restoration.
With this approach there are two things to remember. Be clear with the patient that sometimes the crown does the trick and for other patients eliminating their symptoms may require further treatment. Second, charge for the provisional separately from the final crown, as this approach requires extra chair time on your part.
Hi Lee! How long will you wait and watch to see if symptoms persist or subside before you either send the patient to the endodontist or cement the final crown?
If the symptoms are truly coming from the fluid movement int he detinal tubules because of a crack and separation the provisional should work fast, almost as soon as the anesthetic wears off. I normally appoint the patient a month out, just to make sure they are really able to eat don;t find it in an excursion etc. If at a month they still have symptoms of the cracked tooth, it means the theory of containment to prevent movement of the cracked segments isn’t effective, the crack may extend beyond the margins and on to the root. Placing the permanent restoration may make marginal improvement as it is a more rigid material and we can opt to bond it in. At this point alleviating symptoms may require endo, which only prevents the perception of the fluid movement int he dentinal tubules and pain. During the endo access, using high power microscopy we want to ascertain if we can visualize a crack down the pulp chambers or not.