CRACKED TOOTH

SYNDROME

Presented by
Syed.khaja Ali uddin
M.Sc.D (Endo)

INTRODUCTION

What is cracked tooth syndrome?

Cracked toothsyndrome is a condition exactly as

the name implies: a tooth with a crack running
through it. Unlike a fractured tooth, cracked tooth
syndrome usually involves smaller cracks that are
not readily visible. Teeth can crack in many
different ways. Craze lines are cracks on the
enamel. Split or cracked teeth, however, begin on
the outside of the tooth and extend downwards,
affecting the enamel, dentin, and nerve.

What is cracked tooth syndrome?

Cracked tooth
syndrome(abbreviatedCTS) is amedical
condition in which a crack extends through
thedentin, and occasionally through
thepulpof a posteriortooth .

Wikipedia---- http://en.wikipedia.org/wiki/Cracked_tooth_syndrome

What is cracked tooth syndrome?

Incomplete fracture through the body of

the tooth may cause pain of apparently
idiopathic origin ,This is referred to as
the cracked tooth syndrome

ENDODONTIC PRACTICELOUIS I GROSSMAN

11 TH EDITION, pg no 60

What is cracked tooth syndrome?

Cracked teeth are defined as an

incomplete fracture initiated from
crown and extending subgingivally,
usually directed mesiodistally,
involving the marginal ridge.

Principles and practice of endodontics mahmoud torabinejad, 4th

edition. Pg no 113

Pathways of pulp cohen 9th edition, pg no 24.

CRACKED TOOTH IS ALSO CALLED AS

INCOMPLETE (GREENSTICK)FRACTURES

Pg no 67,text book of endodontics anil kohli

ETIOLOGY

What causes cracked tooth

syndrome?

Repetitive chewing, over time, can

cause teeth to develop very fine
cracks, called stress fractures.

Grinding teeth at night (bruxism) can

cause teeth to crack under pressure.

Chewing on hard substances such as

ice, hard candy, or popcorn kernels
can cause teeth to crack suddenly.

Trauma to the jaw or mouth, such as

falling down, can cause a tooth to
crack.

Deep or large fillings can weaken the

tooth predisposing it to cracks.

Periodontal diseasecan weaken

bones and decrease support to a
tooth making it more disposable to
cracks.

Thermal stresses are also thought to be a

cause of fractures, although the evidence
of this is inconclusive.
Supposedly, differences in expansion and
contraction of restorations versus tooth
structure may weaken and crack dentin.

Principles and practice of endodontics mahmoud torabinejad, 4 th

edition. Pg no 114

Few anatomic factors of tooth

increase the susceptibility of the
tooth for crack development,
sometimes mandibular molars
fracture towards faciolingual surface.

Pg no 67,text book of endodontics anil kohli

Incidence

The teeth usually involved are

Mandibular molars

maxillary premolar
maxillary 1st

molar

Pg no 67,text book of endodontics anil kohli

Signs and symptoms

What are some common symptoms

of cracked tooth syndrome?

Because cracks may not be visible to the

human eye or even on dental x-rays, it
may be difficult to diagnose a cracked
tooth. Also, the patient tends to have a
difficult time describing the problem,
usually alluding to a general pain in the
general area of the cracked tooth.

Often crack teeth manifest as the so

called cracked tooth syndrome. This
syndrome is characterized by acute pain
on mastication(pressure or release)of
grainy, though foods and sharp, brief
pain with cold.
These findings are also related to cusp
fracture. however, cracked teeth may
present with a variety of symptoms
ranging slight to very spontaneous pain.
Principles and practice of endodontics mahmoud torabinejad, 4 th
edition. Pg no 116

It can be with irreversible pulpitis, pulp

necrosis, or apical periodontitis. Even
an acute apical abscess, with or without
swelling or draining sinus tract, may be
present if the pulp has undergone
necrosis.
In other words, once the fracture has
extended to pulp, severe pulp or
periapical pathosis will be present. This
explains the variation in sign and
symptoms.
Principles and practice of endodontics mahmoud torabinejad, 4th
edition. Pg no 116

Crack cross one or both marginal ridges.

They generally shear towards the facial

or lingual side towards a root
surface,usually lingual,because the
fracture begins on the occlusal surface,it
grows from this surface toward the
cervical surface and down to the root.

Principles and practice of endodontics mahmoud torabinejad, 4th

edition. Pg no 116

The more centered the fracture (initiated

on the midocclusal surface),the more it
has tendency to extend deeper before it
shears towards the root surface.
The fracture is considered to be green
stick because it incomplete.

Principles and practice of endodontics mahmoud torabinejad, 4 th edition.

Pg no 114

Objective test

Pulp and periapical tests also have

variable results. the pulp is usually
responsive(vital) but may be non
responsive (necrosis).

Periapical tests are also vary, but usually

pain is not elicited with percussion or
palpation if the pulp is vital.
Principles and practice of endodontics mahmoud torabinejad, 4 th

edition. Pg no 114

Directional percussion is also

advocated.
Percussion that separate the crack
cause pain.

Principles and practice of endodontics mahmoud torabinejad, 4th

edition. Pg no 114

Other important objective tests

When a crack is suspected, it is

important to try to visualize the length
and location of the fracture. Direct
inspection (microscope is
useful),staining and transillumination are
usually effective.

Principles and practice of endodontics mahmoud torabinejad, 4 th

edition. Pg no 115

Occlusal and proximal restorations are

first removed.

Then transillumination,which often shows

a characteristic abrupt blockage of
transmitted light, is performed.

With transillumination the portion of the

tooth where the light originates
illuminates to the fracture.

A fracture contains a thin air space,which

doesnot readily transmit light.

Therefore,the crack (or fracture)

blocks or reflects the light,causing the
other portion to appear dark.

Principles and practice of endodontics mahmoud torabinejad, 4 th

edition. Pg no 115

Staining

Staining with methylene blue or

iodine may also disclose fracture,
although not predictably.

A cotton pledged soaked with

methylene blue or other dye is placed
against the cavity floor. the dye may
be washed away immediately to
reveal the crack or is held in by a
sealing temporary such as

intermediately to reveal the crack or

is held in by a sealing temporary
such as intermediate restorative
material(IRM).
The temporary restoration and pledged
are removed after a few days. the
dye may have contacted the crack
long enough to disclose it clearly.
Patients should be advised that the
tooth may temporarily turn blue.

Viewing with a surgical microscope is

particularly useful to both identify the
presence and extent of the fracture.
Occasionally an access preparation is
necessary to disclose the extent of
the crack.

However,the fracture is small and

invisible at the furthest extent(even
after staining).therefore, the crack
probably continues deeper into the
dentin than can be visualized.

Removal of the fracture line in the

proximal portion of the tooth may
provide information on the extent but
also may cause the tooth to become
nonrestorable.

Both of these procedures, particularly

removal of proximal marginal ridge and
tooth structure, remove sound tooth
structure, thereby decreasing tooth
strength and resistance to fracture.

Gorucu j,ozgunaltay G:fracture resistance of teeth with class II bonded

amalgam and new tooth coloured restorations,oper Dent 28:501,2003

Seow LL,Toh cg,Wilson NH : remaining tooth structure associated with various

perparation designs for the endodontically treated maxillary second
premolar ,Eur j prosthodont restor Dent 13:57,2005

Biting test

Selective biting on objects is helpful,

particularly when pain is reported on
mastication.

It is one of the most reliable diagnostic

method to reproduce the pain. when
the patient bites on the cotton
applicator/rubber wheel/tooth sloth, the
fracture segments may separate,

And the pain may reproduced at the

initiation or release of the biting
pressure,
Close examination of the crown of the
tooth may disclose an enamel crack.

ENDODONTIC PRACTICELOUIS I GROSSMAN

60

11TH EDITION, pg no

Radiographic findings

Because of the mesio-distal direction of

the fracture, it is not visible
radiographically.

Newer methods of analysis are currently

being studied, such as cone beam
computed tomography(CT),to help
identify longitudinal fractures in a
nondestructive fashion.

Principles and practice of endodontics mahmoud torabinejad, 4 th

edition. Pg no 115

Treatment

The Cracked Tooth

Syndrome
Christopher D. Lynch, BDS, MFDRCSI
Robert J. McConnell, BDS, PhD, FFDRCSI
J Can Dent Assoc 2002; 68(8):470-5

Introduction

T he term cracked tooth syndrome (CTS)

refers to an incomplete fracture of a vital
posterior tooth that involves the dentine
and occasionally extends into the pulp.

The term was first introduced by Cameron

in 1964, who noted a correlation between
restoration size and the occurrence of
CTS. Mention is made in the earlier
literature of pulpal pain resulting from
incomplete tooth fractures,and also of
greenstick fractures of the crown.

A more recent attempt to define the

nature of this condition describes it
as a fracture plane of unknown
depth and direction passing through
tooth structure that, if not already
involving, may progress to
communicate with the pulp and/or
periodontal ligament.

The condition presents mainly in patients

aged between 30 years and 50 years.

Men and women are equally affected.

Mandibular second molars, followed by
mandibular first molars and maxillary
premolars, are the most commonly
affected teeth.

While the crack tends to have a

mesiodistal orientation in most teeth, it
may run buccolingually in mandibular
molars.

Two classic patterns of crack

formation exist.

The first occurs when the crack is

centrally located, and following the
dentinal tubules may extend to the
pulp.

The second is where the crack is

more peripherally directed and may
result in cuspal fracture.

Separation in dentine results in the

movement of fluid in the dentinal
tubules, stimulating odontoblasts in
the pulp as well as the stretching and
rupturing odontoblastic processes lying
in the tubules.

Thus stimulating pulpal nociceptors.

Ingress of saliva along the crack line
may further increase the sensitivity of
dentine.

Symptoms and Diagnosis

Successful diagnosis of CTS requires

awareness of its existence and of the
appropriate diagnostic tests.

The history elicited from the patient can

give certain distinct clues.

Pain on biting that ceases after the

pressure has been withdrawn is a
classical sign.

Incidences usually occur while eating, or

where objects such as a pencil or a pipe
are placed between the teeth.

The patient may have difficulty in

identifying the affected tooth (there are
no proprioceptive fibres in the pulp
chamber).

Vitality testing usually gives a positive

response, and the tooth is not normally
tender to percussion in an axial direction

: The Tooth Slooth. The

concave surface of the head
is placed
against the suspect cusp.

Using the Tooth Slooth to identify

damaged cusps.

Stained crack lines on the

mesial and buccal surfaces of a
mandibular molar. If this tooth is
asymptomatic, no treatment is
required and the tooth should
be monitored closely.

An extensively restored
mandibular left first molar. The
tooth has been weakened by the
placement of an extensive
intracoronal restoration. The
arrows indicate the areas most
prone to future crack formation.

Significantly, symptoms can be

elicited when pressure is applied to
an individual cusp.

This is the principle of the so-called

bite tests where the patient is
instructed to bite on various items
such as a toothpick, cotton roll,
burlew wheel, wooden stick, or the
commercially available Tooth Slooth.

Pain increases as the occlusal force

increases, and relief occurs once the
pressure is withdrawn (though some
patients may complain of symptoms after
the force on the tooth has been released).

The results of these bite tests are

conclusive in forming a diagnosis.

The etiology of cracked tooth syndrome

Classificatio Factors
n

Examples

Restorative
procedures

Inadequate design
features

Over-preparation of cavities.
Insufficient cuspal protection in
inlay/onlay design.
Deep cuspfossa relationship

Stress
concentration

Pin placement
Hydraulic pressure during seating
of tightly fitting cast restorations.
Physical forces during placement
of restoration, e.g., amalgam or
soft gold inlays .
Non-incremental placement of
composite restorations .
Torque on abutments of long-span
bridges

Classification

Factors

Examples

Occlusal

Masticatory accident

Sudden and excessive

biting force on a piece
of bone

Damaging horizontal
forces

Eccentric contacts
and interferences
(especially
mandibular second
molars)

Functional forces

Large untreated
carious lesions
Cyclic forces

Parafunction

Bruxism

Classification

Factors

Examples

Developmental

Incomplete fusion of
areas
of calcification

Occurrence of
cracked tooth
syndrome in
unrestored teeth

Miscellaneous

Thermal cycling

Enamel cracks

Dental instruments

Cracking and crazing

associated with highspeed handpieces

Case report

INTRODUCTION

Gibbs in 1954 was the first to

describe cracked teeth using the
term Cuspal fracture odontalgia .

In 1957, Ritchey et al reported cases

of incomplete fracture with
subsequent pulpitis .

The term cracked tooth syndrome

was coined by Cameron in 1964.
Camerons cracked tooth syndrome
described fractures that were not
easily visible but the teeth responded
painfully to cold or pressure
applications and became necrotic
despite an apparent healthy pulp and
periodontium.

In the late 1970s, Maxwell and Braly

advocated use of the term
incomplete tooth fracture.

Despite the introduction of further

terms such as hairline fracture,
incomplete crown-root fracture, splitroot syndrome, enamel infraction,
hairline tooth fracture, crown craze,
craze lines and tooth structure
cracks, Luebke considered fractures
as either complete or incomplete

Case report

A 23 year old female patient came to the

Faculty of Dental Sciences, Banaras Hindu
University, Varanasi, India with the chief
compliant of pain in the right mandibular
posterior region.

The pain was sharp, intermittent in nature

which increased on chewing hard
substances. The medical history of the
patient was noncontributory.

Dental history revealed root canal therapy of

the right mandibular first molar 4 years ago.

Clinical examination revealed

fractured tooth with the fracture line
running buccolingually.

The tooth was not restored with a

crown restoration after therapy which
may be the cause of fracture.

Radiographic examination revealed

adequate root canal filling with no
signs of periodontal involvement.

http://medind.nic.in/eaa/t07/i1/eaat07i1p39.pdf

Orthodontic steel band was fabricated

and cemented to the tooth and the tooth
was disoccluded.

After a month, the crack was reinforced

with bonded composite restorative
material and the tooth was finally
restored with a full coverage metal
ceramic crown restoration.

Professor and Incharge, Operative Dentistry, Faculty of Dentistry. **

Senior Resident,Faculty of Dentistry. *** Junior Resident, Faculty of
Dentistry, Institute of Medical Sciences, Banaras Hindu University,
Varanasi

M. Tooth was bonded with

composite and prepared for a
metal crown.

Tooth finally restored with

a metal crown.

Cracked right mandibular

first molar with a metal band
placed on it to prevent crack
propagation.

Tooth was bonded and

prepared to be restored
with
a metal ceramic crown.

The tooth finally restored

with a metal ceramic crown.

Conclusion

Every practitioner should be aware of

the existence of CTS, and the
condition must always be considered
when a patient complains of pain or
discomfort on chewing or biting.

A good history will provide vital

assistance in the search for a
diagnosis.

Careful clinical examination and

inspection, supplemented by specialized
tests such as the non-axial application of
pressure to cusps, will be conclusive.

Treatment of CTS will depend on the

position and extent of the crack.
Management options vary according to
clinical need, from replacement of the
fractured cusp with a simple restoration to
placement of an extracoronal restoration
with adequate cuspal protection.

Thank you all