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<< Back to 2006 Case List

May 2006 – Restorability Issues Part 2: Palatal Cusp Fracture of Maxillary Premolar

Endodontists are often called upon to perform endodontic treatment on questionably restorable teeth.  The unfortunate part about this practice is that the Endodontist is the person least likely to know and understand the patient’s financial situation, degree of oral hygiene and compliance level.  Furthermore, factors such as bruxism (whether or not they are actively wearing a night guard) or history of previous cusp fractures may not be apparent to the Endodontist.

This patient was referred to me by the referring dentist and was sent with the two films shown.  The patient had been experiencing symptoms sharp sensitivity to chewing and elevated thermal sensitivity (cold)  on this side but the referral could not localize the problem.  He suspected that the deeply restored first molar could be the source of the problem. It did have a large pinned amalgam and the patient was referred for possible endodontic treatment of #16 to be followed by a crown.

By the time the problem became obvious the palatal cusp had broken off far subgingivally to the level of the bone crest. The subsequent referral film showed a palatal cusp fracture to the level of the bone crest on the mesial distal and palatal sides.  Rehabilitation of this tooth would require endodontic treatment to be followed by crown lengthening /osseous contouring procedure and post and core crown. The costs were approaching  that of an implant, with much more work and a possibly compromised perio situation.

The adjacent teeth are virgin. Should the patient to extract the tooth, this will necessitate preparation of the adjacent virgin abutments for a 3 unit bridge. This would be unfortunate.

I suggested to the referral that he submit a treatment plan that would also include replacement of the tooth with an implant. Although implants are generally not an insured expense, perhaps her insurer would have some flexibility in this case, in order for us to prevent having to prepare two virgin teeth as abutments. 


Fig. 1 Image prior to fracture


Fig. 2 After Fracture