The tooth I used to monitor
This is the kind of tooth I was leaving every single day.
A narrow occlusal amalgam. No symptoms. No signs on the radiograph. The patient had no idea anything was wrong with it, and why would they?
The crack is obvious, but I wouldn’t have been aware of its significance coupled with a heavy bite. That was my thinking for years: I could see it, I did not know what it meant, so I routinely filed it under keep under observation and may or may not have informed the patient depending on how much time there was.
Then you apply the four red flags, and it stops being a judgement call.
What the assessment actually showed
Two red flags. The restoration isthmus met the 2 mm threshold, and there was an existing peripheral rim fracture mesially.
On top of that, a heavy occlusal load.
That combination puts the tooth in the high-risk band. If you had asked me to eyeball this tooth five years ago, I would have said it was fine, and that patient would have returned with either a broken cusp or, worse, pain on biting.
What was actually in there
Horizontal oblique fractures associated with the palatal cusp, and an early one beginning underneath the buccal cusp too. The palatal cusp was completely undermined so this cusp needed to be removed. We were able to preserve enough width buccally to keep it. That is the whole philosophy with these teeth: you remove the pathology, and preserve everything you possibly can.
Building the base
Immediate dentine sealing, resin coat, Ribbond, and the biobase completed.
Then a scan, and the indirect composite onlay fitted two weeks later.
Why this one is worth writing up
Two measurements and an occlusal assessment identified a high-risk tooth and an indirect restoration recommendation. Everything I found once the filling was removed confirmed this was the right approach.
This is why I now assess every one of these teeth against the same four criteria, rather than deciding how I feel about the tooth on the day.
The four red flags framework and the full assessment chart are here: The four red flags
And if you have a tooth like this one that you are not sure about, send it to me on WhatsApp. Photographs and a radiograph to 07898 738646. No charge and no obligation.
Any questions? Get in touch! Thanks, Amber
