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Occlusal Trauma and Cracked Teeth RestorativeDentistry Bryan Daniel Murchie Complications of an Ageing Dentition Part 1: Occlusal Trauma and Cracked Teeth Abstract: A growing problem in dentistry is complications associated with failing amalgam restorations that have been in place for many years. At present, there is a wide variety of treatment options available in the clinician’s armamentarium when this situation arises, however, without the correct diagnosis, the prognosis for the tooth may quickly diminish, despite the clinician’s best efforts. A confusing array of symptoms and failures may confound even the most experienced dentist, which will inevitably lead to invasive and time consuming approaches in a desperate attempt to rectify the initial problem. This paper, the first part of a three-part series, discusses the possible aetiological factors responsible for restoration failure, including occlusal issues and cracks within the tooth structure. The second part of the series will focus on restorative options and root-treated teeth. The third, and final, part of the series will provide an overview of the previous papers and conclude with a case report. CPD/Clinical Relevance: Failure of amalgam restorations is a commonly encountered clinical problem in general practice and no one case presents in the same way. A competent diagnosis regarding the occlusion and tooth structure, followed with implementation of the most appropriate, minimally invasive treatment option, requires an adequate knowledge of current literature. Dent Update 2017; 44: 295-305 Amalgam has served as an excellent and restored teeth are present on the same ignored. Pathological occlusal contacts can versatile dental restoration for over 100 arch. It is vital that the clinician is aware of be associated with a wide range of clinical years. Traditional preparation designs were the differential diagnoses in order to avoid symptoms, including tooth discomfort initially proposed by GV Black in the mid- unnecessary and overly invasive treatment and sensitivity. In the worst case scenario, nineteenth century. Furthermore, the serial options which are condemned to failure misdiagnoses can lead to unnecessary and replacement of restorations by ever larger because the underlying cause(s) was(were) invasive procedures such as endodontic and more complex restorations, termed overlooked. therapy and even extraction. the ‘restorative cycle’, has made it common This article will focus on practice to see large amalgam restorations occlusal trauma, incomplete fractures and still functioning. However, no restorative endodontic complications. These issues Aetiology solution is eternal and the clinician must are commonly associated with the failure The inter-cuspal position (ICP) be able to detect the early signs of failure of amalgam restorations and they can be is never stable long-term, even during 1 before irreversible damage occurs. When a easily misdiagnosed. It is important to adulthood. This is due to the deteriorating patient does present with a sudden onset mention the other main causes of amalgam effects of micro-organisms, microtrauma of symptoms, the nature of the problem failure, including secondary caries and and physical injury. Consequently, wear, may elude the unsuspecting dentist. restoration fracture, which the reader will restorations, fixed/removable appliances A successful outcome can be further already be well versed in treating on a day- and tooth loss may occur over time, complicated when numerous, heavily to-day basis in practice or in hospital. with inevitable changes to the occlusal relationships. Damaging premature contacts, deflective contacts and Occlusal trauma interferences may occur, which can lead to Bryan Daniel Murchie, BDS, MJDF RCPS, The topic of occlusion is an overloading and trauma of the dentition. PgCert(Implant), MSc(Rest Dent), General area which may be confusing, however, Importantly, if the vigilant clinician Dental Practitioner, Aberdeen, UK. this is an important issue which cannot be identifies the signs of occlusal trauma at an April 2017 DentalUpdate 295 RestorativeDentistry early stage, then the preceding symptoms, suspected of having occlusal trauma there particularly where periodontal support is complications, repeated treatment are a number of clinical and radiographic reduced; failures, breakdown of the patient-clinician signs that may be present. It is important Chipped or fractured restoration(s); relationship and additional treatment costs, to note that each patient will respond Repeated failure and decementation of can all be avoided. differently to the same type of occlusal restoration(s); Damaging occlusal contacts insult and a holistic approach should be Thermal sensitivity and possible can also be the consequence of operator taken for each case to exclude other causes. toothache − pulp hyperaemia, error. These situations arise when the Indications of a traumatic occlusion may compression of the periodontal ligament occlusion has not been planned prior to the include one or more of the following clinical (PDL) and abfraction lesions; commencement of treatment and the new or radiographic signs. Abfraction lesions − V-shaped cervical occlusal scheme has occurred by accident; Clinical notches; the worst occlusal scheme is the arbitrary Mobility (progressive) − primary or A temporomandibular disorder (TMD) − occlusal scheme. The clinician must avoid secondary occlusal trauma; highly debated topic outwith the scope of this predicament by adopting either the Persistent discomfort on eating; this article. conformative or re-organized approach. The Fremitus − tooth movement when Radiographic Dahl Concept is another accepted approach occlusal contact occurs; Widening of the PDL space; with favourable reports in the literature; Occlusal prematurities and discrepancies; Condensation and radiolucency of the relative axial tooth movement is observed Toothwear facets and vertical enamel alveolar bone or root resorption; when a restoration or appliance is placed fracture lines − cracked teeth and fractured Funnelling of the PDL. in supra-occlusion, thereby creating space cusps are a feature of occlusal overload, 2 without tooth preparation. especially where deflective contacts occur Diagnoses on heavily restored teeth. Fractures of the Patient history evaluation Signs and symptoms root may also occur (Figure 1); and clinical assessment involving routine When evaluating a patient Tooth migration and drifting − clinical examination, pulp-testing, Component of the Clinical Occlusal Examination and Clinical Signs which are an Indication of Occlusal Trauma Examination Inter-Cuspal Position (ICP) Broad rubbing contacts can be indicative of occlusal issues compared with small and discrete markings.4 Assess for Shimstock Holding contacts and carefully make a note of them. Ideally, there should be multiple and simultaneous contacts. There should be anteroposterior freedom in ICP to prevent overloading and avoid the sensation of a ‘locked’ occlusion. Empty mouth clenching, aka ‘the clench test’, can help identify an occlusal cause for the pain.1 Retruded Contact Position (RCP) Assess for a premature deflective contact in CR, termed RCP, and make a note of the teeth. The RCP−ICP Slide Approximate the direction and distance of the slide, including whether the movement is predominantly horizontal or vertical. Note any signs of trauma to the teeth involved in the slide or to the anterior teeth, aka ‘the anterior thrust’.4 Excursive Movements Take note of any non-working and working side interferences. Assess for any posterior interferences during protrusion. Canine and group function are both accepted lateral movements. Muscles This includes palpation of the: temporalis, lateral pterygoid, digastric, masseter, shoulder, neck, trapezius and sternomastoid muscles. Temporomandibular Joint Examination includes: Range of movement. Palpation of the joint − ideally assessed using a stethoscope. Assessment for joint sounds − clicking or crepitus. Signs of Parafunction Cheek-ridging, tongue-scalloping, fremitus, tender teeth and/or TMD. Table 1. Occlusal examination and diagnoses. 296 DentalUpdate April 2017 RestorativeDentistry occlusion (Figure 2); 3. Cracked tooth − incomplete ‘green-stick’ Occlusal restorations. fracture which usually extends mesio- For complex cases, such as distally, but may also run bucco-lingually in occlusal equilibration, it is recommended mandibular molar teeth (Figure 4c). that study models are mounted on a 4. Split tooth − the end result of a cracked semi-adjustable articular to assist with tooth, which normally has a poor prognosis treatment planning, trial adjustments and as the tooth is split into two separate diagnostic wax-ups (Figure 3). fragments (Figure 4d).The tooth has often It should be noted that been root-filled and the patient normally additional treatment(s) may also complains of marked pain whilst chewing, be required if damage to the tooth particularly on one cusp. and/or surrounding structures has 5. Vertical root fracture − crack initiated at occurred. For example, periodontitis the root level, usually in a bucco-lingual will be exacerbated by occlusal trauma direction. The crack may be complete or (secondary occlusal trauma). Therefore, incomplete and almost all cases have a periodontal and occlusal treatments must history of root canal treatment. Symptoms occur for a successful outcome. are vague and may mimic periodontal disease or failed root canal treatment (RCT). The cracked tooth Root resection or hemi-section
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