Tyler Boss DDS
This is a great educational case.
The patient was referred for treatment of her maxillary first molar. I always perform an oral evaluation prior to initiating any treatment. Unfortunately, evaluations rarely reveal microscopic fractures that may infiltrate root surfaces. If they are visible clinically, their full extent usually can’t be guaged. A cracked marginal ridge or cusp tip may be visualized, and unless an isolated probing depth is found (which is not always associated with a fracture), it is near impossible to tell whether any root surfaces are involved. Radiographs are also poor identifiers of fractures. They can’t be visualized with certainty, and often times the practitioner falsely identifies something as a fracture that really isn’t a frank fracture. Vice versa, most fractures are not recognized on radiographs although they are indeed present clinically. This case demonstrates these point perfectly. No fractures are seen radiographically. No probe depths are present clinically. Only pre-op coronal marginal ridge fractures are visible clinically, but their extent is unknown.
The gold standard for identifying crown and root fractures is direct visualization during endodontic procedures. The surgical operating microscope, with it’s high power magnification and operating field bathed in bright penetrating light, is essential for direct visualization of fractures that can only be vizualized internally during the root canal procedure itself. The attached photographs from this case show fractures that begin in coronal structure and extend vertically, invading the root surface.
Fortunately the referring dentist in this case understands the importance of endodontic therapy being performed under a surgical operating microscope. Had this tooth received root canal therapy without a microscope, chances are that the extent of the fractures would not have been visualized. The root canal would have been finished, and the patient would be stuck with a failing root canal treatment in the short term. Pain and discomfort in a recently treated tooth is always difficult to explain to a patient when extraction should have been the treatment of choice to begin with.
Although I make my living performing root canal therapy, it’s not always in the patients best interest. These patients deeply appreciate saving the time and money that would have been invested in a non-salvagable tooth.