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Has anyone ever been in the situation where they have gotten a dental restoration (onlay, crown, etc.) and then a short time later get a crack or fracture in the tooth under the part where the onlay or crown is? I have this situation. I just went to an endodontist who diagnosed me with a small crack under the cusp where the onlay covers. I made an appointment with my general dentist, but am wondering what the treatment for this might be. If it's a crown, do they have to remove the old one to put the new one on, since I already have an onlay on? I just got the onlay on one month ago, so I am confused as to how this could have happened, as I thought the onlay is meant to protect the cusps from fracturing.
Most likely the fracture was there before the only, though it's possible that the crack occurred later. While a crown is the best way to protect against fractures, it's not perfect. If you got a consultation from the endodontist and he/she didn't diagnose anything more than a crack, I'd guess the nerve is well and, at this time, you don't need a root canal. In time it is possible that the nerve could die and that you may need a root canal. The presence of a fracture also lowers the prognosis for the tooth. The fracture might get worse and make the tooth unusable.
The only will probably need to be removed. It can either be replaced by a new onlay, or probably a better option would be a full crown. In either case, the restoration should cover the crack.
Most likely the fracture was there before the only, though it's possible that the crack occurred later. While a crown is the best way to protect against fractures, it's not perfect. If you got a consultation from the endodontist and he/she didn't diagnose anything more than a crack, I'd guess the nerve is well and, at this time, you don't need a root canal. In time it is possible that the nerve could die and that you may need a root canal. The presence of a fracture also lowers the prognosis for the tooth. The fracture might get worse and make the tooth unusable.
The only will probably need to be removed. It can either be replaced by a new onlay, or probably a better option would be a full crown. In either case, the restoration should cover the crack.
Thanks for your response. The endodontist took an x-ray (normal) and did the bite stick test (which showed pain upon releasing the bite on one cusp--the cusp with the onlay over it). He also did the cold q-tip test which was normal. Thus, he said I don't need a root canal at this time, but should go to my regular dentist for consultation about what to do about the crack. The crack was not seen on x-ray and he said he thinks it's very small.
So the fracture apparently is just on the cusp. Is this better for the prognosis for the tooth?
The onlay already covers the crack. Why, then, will it need to be removed and then a full crown put on? I remember the dentist saying that he put the onlay over that particular cusp b/c the tooth was very thin there, so it was to prevent something like this from happening.
How does the onlay get removed? I imagine that takes a long time and is very uncomfortable? I had a bad experience with this whole round of dental work--and it was just a month ago! I can't believe I have to get the onlay that I just got put on removed and a crown put on. I just shelled out over $1000 for the onlay!
I had a bad tooth that decayed, but the root was saved and a crown lengthening was done. After surgery, root canal, a crown and expense, I was told that the tooth is fractured. I think some of these Dentists just stretch things out to collect $$$$. With changing Dentists because of insurance, I also get different opinions. Go figure.
Cracks are not typically seen on x-rays. Even when a tooth is obviously cracked and the pieces are movable, sometimes it is hard to identify on an x-ray. The films (or sensors) are not sensitive enough to detect them. The prognosis for any fracture is worse than one without a crack. How bad? Dunno. Depends on how bad the crack is and the severity of symptoms. Even then you're not going to get a more definitive prognosis, because no one can predict what happens to the crack. It may stay the same for a long time, or the crack may enlarge and develop into a fracture. With that in mind, you should discuss the prognosis of a cracked tooth versus removing and replacing it. In my mouth, I'd keep the cracked tooth.
A full coverage crown may resolve symptoms... may not. By covering ALL of the cusps the tooth will flex less than if an onlay is covering only one or two cusps. Meaning the tooth could be flexing BETWEEN the onlay and the natural cusp.
An onlay is usually cemented with a glass-reinforced resin cement. They're stuck on there pretty good. Usually you have to drill it off. It's actually pretty easy and quick. Should not be painful as long as the tooth is adequately numbed.
I can't comment on the cost of replacing the onlay. Legally you don't have any standing to request a refund of reduction in price. Procedures are not guaranteed to be successful and you consented to the procedure. BEFORE ANYONE COMMENTS ON THIS... what medical procedure is guaranteed to be successful? Exactly. Now, ethically there's a dilemma. You can make a case for re-doing it at no charge, to charge a partial fee, or charge full fee. There's no harm in discussing your concerns and seeing what your dentist's thoughts are.
I had a bad tooth that decayed, but the root was saved and a crown lengthening was done. After surgery, root canal, a crown and expense, I was told that the tooth is fractured. I think some of these Dentists just stretch things out to collect $$$$. With changing Dentists because of insurance, I also get different opinions. Go figure.
I'm sure there are dentists who are recommending unnecessary treatment, but they're the minority. That's the case in just about every field of work. Bad outcomes such as these happen from time to time. It's very unfortunate. I've had these things happen to me as well. I only hope that your dentist(s) provided you with enough information to make an informed consent, such that you knew both the benefits, risks, and prognosis for the planned procedures. That's really the best we can do. No one knows the future...
The prognosis for any fracture is worse than one without a crack. How bad? Dunno. Depends on how bad the crack is and the severity of symptoms. Even then you're not going to get a more definitive prognosis, because no one can predict what happens to the crack. It may stay the same for a long time, or the crack may enlarge and develop into a fracture. With that in mind, you should discuss the prognosis of a cracked tooth versus removing and replacing it. In my mouth, I'd keep the cracked tooth.
A full coverage crown may resolve symptoms... may not. By covering ALL of the cusps the tooth will flex less than if an onlay is covering only one or two cusps. Meaning the tooth could be flexing BETWEEN the onlay and the natural cusp.
This is what I'm afraid of. I had no symptoms whatsoever in the tooth that had the cracked filling. I was eating carrot sticks on that tooth with no pain. Now I have pain when I eat even soft things on that tooth. That's why I'm so annoyed. The reason I went ahead and had the amalgam removed and the onlay placed was to nip any problems in the bud before they started--and now I have problems. I see my dentist twice a year for an exam and cleaning and it was on my most recent exam that the cracked filling was discovered. Within the month I had it removed and the onlay on, in order to prevent any bad things from happening.
I am hesitant to want to go ahead with a crown if there is no guarantee that my pain will be reduced. The pain is mild in nature, and only occurs when I chew certain things on that tooth. I am thinking about just living with the pain, rather than having to get a crown on this tooth, that may not even work. The endo says the crack must be very small.
I don't know what to do. I have an appt. with my dentist next week, but I am wary now of any further dental work on this tooth. The whole process of getting the onlay on was very traumatic.
Is there any way a bite adjustment could help with this pain? I still feel like my onlay is too high. Sometimes when I bite I feel it contacting first, before my other teeth.
While it's possible that the onlay is high, your symptoms do not suggest it. A high bite IS the first thing that should be addressed. If you can clench your teeth with moderate pressure and feel that tooth is not even with the others, then the bite should be adjusted until it blends in. You can then give it a couple of weeks and re-assess at that point. However, your symptom was pain upon release. That very strongly suggests cracked tooth. If a bite is high, then pain upon pressure will compress the tooth into the socket and trigger nerves. But pain on release is different. What happens is that when pressure is applied, the tooth "separates". When you let go, the tooth "closes", thereby exciting nerves inside the tooth.
Will a crown guarantee resolution of symptoms? No. Can leaving the tooth as is cause more problems? Yes. Not a very good answer, is it? The human body is more complex than we currently can handle. Even teeth. Did you know root canals are not 100% successful either, even when the best endodontists in the world do them? Your best bet is to get the tooth cut for a crown and have a temporary crown put on. Check to see resolution of symptoms. If all is good, have the permanent crown cemented on. If symptoms persist, either opt for root canal therapy or extract the tooth.
One final note. Given your age, which I'm not sure of, whatever tooth you have in that spot will have to last several decades. If you lose that tooth now, what will you replace it with? Implants and bridges have long lifespans, but even they fail over time. Keep that in mind.
Your best bet is to get the tooth cut for a crown and have a temporary crown put on. Check to see resolution of symptoms. If all is good, have the permanent crown cemented on. If symptoms persist, either opt for root canal therapy or extract the tooth.
One final note. Given your age, which I'm not sure of, whatever tooth you have in that spot will have to last several decades. If you lose that tooth now, what will you replace it with? Implants and bridges have long lifespans, but even they fail over time. Keep that in mind.
Thank you for your reply. I am 30 years old, so this whole thing worries me even more: I need this tooth to last! I have read about what happens if I were to have the tooth extracted and leave the space open. My teeth tend to shift easily anyway, so I have no doubt that without an implant or bridge I would get shifting problems. It worries me very much to think that if the crown doesn't solve the pain problem, that I could be looking at losing the tooth at age 30. I have read all about bridges and implants to replace the missing tooth and both options sound awful. Plus, this is a molar, so it's a worse situation than if it were a non-chewing tooth. From now on I am going to be super careful about what I eat. No more carrot sticks or other hard things. I never eat hard candy or crunch things like ice, but I will be ultra careful from now on. I don't want to go through this again if I can at all prevent it.
I am kicking myself for trying to nip things in the bud and getting that cracked amalgam that wasn't causing any problems removed and replaced. I should have left it in. I thought I was doing the right thing but clearly that wasn't the case.
My other thought is: I agree, most likely the bite has nothing to do with my problems, since the pain was pain on release: the endo showed that very clearly with the bite stick. I clearly most likely have a small fracture on the cusp with the onlay covering it, since that is the cusp that had the pain with release of bite. However, can my general dentist just shave off that cusp--with the onlay, thus removing the crack, and then patch up the onlay in that area? One can deal with having a shaved off cusp, right?
Last edited by kibblesandbits; 12-10-2008 at 09:24 AM..
If the crown does not solve the pain, it doesn't automatically mean the tooth should be extracted. A root canal may resolve symptoms. Again, it depends on the severity of the crack. Being careful about what you eat is like worrying about flying in an airplane---bad things can happen, but only once in a blue moon. You've been pounding on your teeth for at least 17 years without significant problems until this one. Get this tooth fixed and stop worrying. If something happens, it happens. You can't live your life in fear. It's ironic that I say this because I'm scared of flying...
I still think you did the right thing by trying to fix the problem. Letting problems fester usually results in more extensive treatments and lower prognosis.
There is no reason to shave the cusp. The crack is likely BETWEEN cusps, not on a cusp. For this reason it's probably between the onlay and a natural cusp, or between two natural cusps. This is why a full crown may be appropriate at this time. Your bite IS a problem, for if you never bite down the pain would never be there. But you can't avoid that...
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