The detection and diagnosis of the TSC is perhaps the most difficult aspect in the management of the cracked, fissured and fractured teeth in dental practice. In this five parts series the 4Rs operational diagnosis protocol(4RsOD) is used as a best dental diagnosis practice.

The protocol was specifically developed to remedy the shortcomings of the conventional Endodontic diagnosis tests.

The protocol helps the clinician to use the skills of: hearing, seeing and acting to accurately learn the patient problem.

The(4RsOD) protocol provides the clinician with multidisciplinary, systematic approach for collecting, analyzing, and synthesizing the examination data into diagnostic, treatment planning, and prognostic decisions.

The 4Rs OD consists of the followings assessment tests:

R1: Report of the patient assessment
R2: Radiographic assessment
R3: Response testing assessment
R4: Restorative and tooth structure assessment

Clinical management of cracked teeth in dental practice is an area replete with misunderstanding and misinformation. First, the literature lacks prospective studies and clinically useful universal definitions. Second, although cracked teeth problems vary significantly in diagnosis, treatment and prognosis. The literature terminology does not specifically differentiate between “Fractured teeth”, “Cracked teeth”, “Cracked Tooth Syndrome”, “Green stick fractures” and “Incomplete coronal fractures”.

The author’s 3x3 Tooth Structure Cracks (TSC) classification, grouped the various terminologies which relate to the cracked or fractured teeth problems, under one term “Tooth Cracks”. Then defined and classified the “cracks” according to their anatomic, physical and pathologic characteristics.

Physically, “Tooth Cracks” are classified into:

• Line Cracks
• Fissure Cracks
• Fracture Cracks

Anatomically, “Tooth Cracks” are classified into:

• Marginal Ridges
• Grooves
• Surfaces

Pathologically, “Tooth Cracks “are classified into:

• Contributory
• Noncontributory
• Partially Contributory

The webinar presentation shows how to differentiate between the harmless “noncontributory crack” and the harmful “contributory crack”.

Contributory cracks cause reversible and irreversible pulpitis, pulp calcification, pulp necrosis, periapical and periradicular lesions. On the other hand, noncontributory cracks could be microscopically visible microcracks or clinically visible line. These cracks remain at the early initiation or development stages for years. They remain still and stationery, cause no pulpal or periodontal pathology as long as they are not pressured, and stressed by new forces or loads. Forces such as root filling condensation or traumatic fitting of a post.

Updated information about the etiology and initiation mechanism of tooth cracks is presented focusing on:

• Abusive restorative procedures that cause coronal cracks
• Abusive mechanical endodontic procedures that cause radicular cracks
• Abusive post placement procedures
• Dental occlusion factors

In the introduction of the program, the author reveals an alarming 24%-60% global prevalence of Apical lesions in teeth with inadequate root canal treatment. The literature’s histopathologic term used in describing these lesions is Apical Periodontitis. (AP). The statistics are alarming because the “Standard Normal” prevalence of Apical lesions in endodontically untreated teeth is 1½% - 7%.

This program stands for the management of teeth with substandard endodontic treatment failures because of the evidence-based relationship between abusive endodontic treatment, and root structure cracks initiation and propagation. Abusive endodontic treatment is one form and a principal cause of substandard endodontic treatment. More on this relationship discussed in Part III of the master class series.

The program is composed of Seven (7) Chapters planned to include the most clinically relevant facets of the inadequate or sub-standard endodontic treatment.

This program offers concepts, methods and guiding principles based on evidence, and tested clinical practices. The goal is to enhance the clinicians understanding of endodontic treatment diagnostics and the relationship between endodontic treatment and tooth structure cracks.