REVIEW ARTICLE 247

Roeland Jozef Gentil De Moor, Filip Luc Gilbert Calberson, Maarten August Meire

And the tooth cracked

Roeland Jozef Gentil

De Moor, DDS, PhD,
MSc
Key words cracked tooth, craze line, fractured cusp, split tooth, vertical root fracture Full Professor, Department
of Restorative Dentistry
and Endodontology, Ghent
Cracked and incompletely fractured teeth are a real challenge for the dentist. A correct and timely Dental Laser Centre, Ghent
diagnosis is not easy, due to the wide variety of complaints and symptoms. The term ‘cracked tooth Dental Photonics Research
Clustre, BIOMAD (Biomedi-
syndrome’ is commonly used to refer to teeth with cracks and fractures. The content of this term, cal Application in Dentistry),
Dental School, Ghent
however, may differ from author to author and has evolved over time. In the end, there is no clear University, Ghent University
description covering the complete genre of cracked, fractured, broken or split teeth. The American Hospital, Gent, Belgium

Association of Endodontists has classified five specific variations of cracked teeth: craze line; fractured Filip Luc Gilbert
cusp; cracked tooth; split tooth; and vertical root fracture. The aim of this review is to provide infor- Calberson, MSc, DDS
Assistant Professor, Depart-
mation for terminology, classification, diagnosis and management. A decision flow chart with five ment of Operative Dentistry
specific variations of cracked teeth and the treatment options is presented. and Endodontology, Ghent
Dental Laser Centre, Ghent
Dental Photonics Research
Paper presented by Roeland De Moor at: VWVT (Flemish Scientific Society for Dentistry), Sympo- Clustre, BIOMAD (Biomedi-
cal Application in Dentistry),
sium ‘Bijten of slijten’ (To bite or to abrade), Antwerp, Belgium, April 18–19, 2013. The ‘broken Dental School, Ghent
University, Ghent University
tooth’ conundrum: terminology, classification, diagnosis and management. Hospital, Gent, Belgium

Maarten August
Meire, DDS, PhD,
MSc
Assistant Professor, Depart-
Introduction to the need for restoration eventually resulting in root ment of Operative Dentistry
canal treatment, and finally to necessity of extrac- and Endodontology, Ghent
Dental Laser Centre, Ghent
Nowadays, the consequences of tooth fractures are tion. Symptoms (ranging from occasional discomfort Dental Photonics Research
frequently seen in daily practice. A number of re- to severe and prolonged pain) do not always occur Clustre, BIOMAD (Biomedi-
cal Application in Dentistry),
ports have demonstrated a higher than expected on a regular or systematic basis and cannot always Dental School, Ghent
University, Ghent University
incidence of cracks and fractures, e.g.: be evoked at the moment of the consultation in the Hospital, Gent, Belgium
t
Fennis et al1 revealed that complete cusp fracture dental office. It can take a long time before the causa-
Correspondence to:
was a common phenomenon in dental practice tive tooth is determined. Intermittent pain on biting is Prof Dr Roeland De Moor
with an incidence rate of 20.5 per 1000 person- the most consistent complaint associated with these Department of Operative
Dentistry and Endodontol-
years at risk. teeth. The depth and the direction of the crack, and ogy
t
Hilton et al2 saw the virtually ubiquitous presence the tissues involved, influence the symptoms. Ghent Dental Laser Centre
Dental School
of cracks in 14000 molars. The term ‘cracked tooth syndrome’ is used to de- Ghent University Hospital
scribe a situation where a tooth fracture (vital tooth) De Pintelaan 185/P8
B-9000 Gent, Belgium
Depending on the severity of the damage, different is incomplete, with consistent symptoms of pain Tel: +32 9 3324000 or 4001
Fax: +32 9 3323851
approaches have to be adopted. This can range from to biting and temperature stimuli, especially cold3. Email: roeland.demoor@
no need for treatment, removal of the broken frag- It is important to determine the extent of damage ugent.be

ment and polishing of the remaining part of the tooth, in time. Once the occasional discomfort evolves to

ENDO (Lond Engl) 2014;8(4):247–266

248 De Moor et al And the tooth cracked
severe and prolonged pain, the tooth with an incom-
plete tooth fracture may need root canal treatment
or is already destined for extraction3.
One of the problems encountered is the incon-
sistency not only in treatment approach among
dentists, but also in the prevention, the diagnosis
and the determination of the type of fracture. The
purpose of this manuscript is to review the literature
for an appropriate classification for cracked teeth, to
determine the risk factors for cracked teeth, and to
establish treatment protocols including prevention,
early and appropriate diagnosis.
Search of the literature
The PubMed and Web of Science databases were
searched for full papers and reviews using the fol-
lowing MeSH terms: ‘cracked tooth’; ‘cracked teeth’;
‘cracked tooth syndrome’; ‘cracked tooth treatment’;
‘cracked tooth diagnosis’; ‘cracked tooth prevention’;
‘cracked tooth syndrome’; ‘tooth fracture(s)’; ‘verti-
cal tooth fracture’ and ‘traumatic tooth fracture’. In
addition, the following keywords were also used:
‘risk factor tooth/teeth fracture’; ‘cuspal fracture’
and ‘cusp fracture’. After an initial screening of the
abstracts, relevant full-length peer-reviewed articles
were selected. The reference lists of the articles were
also screened for additional relevant publications.
The aim of this narrative review was to help clini-
cians in diagnosing cracks and fractures, understand-
ing this phenomenon, and to offer a treatment guide
related to the specific types of longitudinal tooth
fractures.
Definition and terminology
Many terms have been used to describe tooth cracks
and fractures. Different terminologies and defini-
tions as well as classification systems have been pro-
posed (Table 1), resulting in indistinctness and confu-
sion when it comes to reporting such conditions. In
2008, the AAE (American Association of Endodon-
tists) published a document on longitudinal tooth
fractures and proposed a classification based on five
types29. This document is an update of a previous
document from 199730.
ENDO (Lond Engl) 2014;8(4):247–266
A good example of such a description is the
‘cracked tooth syndrome’ (CTS). In 1964, Cameron
coined the phrase ‘cracked tooth syndrome’ (CTS),
describing pain originating from a hairline or incom-
plete fracture of the tooth10. He described fractures
that were not easily visible but the teeth were painful
to cold or pressure application and became necrotic
despite an apparent healthy pulp and periodontium.
In 1976 he revisited the subject31 and also noted a
correlation between restoration size and the occur-
rence of CTS. In both studies, he found that teeth
restored with silver amalgam tended to fracture more
frequently than those with gold inlays10,31. Fractures
were believed to be caused by amalgam expansion or
by the seating of inlays. However, it was Gibbs who
first described the clinical symptoms of incomplete
fracture of posterior teeth involving the cusp, naming
it ‘cuspal fracture odontolagia’4. Maxwell and Braly
concluded in 1977 that many authors had described
the same clinical entity, be it in a modified way15. They
advocated using the term ‘incomplete tooth fracture’,
which was already proposed earlier in 1957 by Ritchey
et al6. Other terms were introduced later (Table 1).
The term ‘cracked tooth syndrome’ remains mis-
leading. The reported symptoms are very variable
and do not form a distinct and reliable pattern. They
may include some of the following3,28,32-34:
t
Pain on biting that ceases after the pressure is
withdrawn (a classical sign). The sharp pain elic-
ited by biting on a certain tooth may also get
worse if the applied biting force is increased.
t
The pain often occurs with soft food that has
small, discrete, harder particles in them, for ex-
ample, bread with hard seeds or muesli.
t
Pain may occur when objects such as a pencil or
a pipe are placed between the teeth.
t
‘Rebound pain’, i.e. sharp, fleeting pain occurring
when the biting force is released from the tooth,
which may occur when eating fibrous foods.
t
Pain when grinding the teeth backwards and for-
wards and side to side.
t
Sharp pain when drinking cold beverages or eat-
ing cold foods; lack of pain with heat stimuli.
t
Pain when eating or drinking sugary substances.
t
Sometimes, but not always, the pain is well lo-
calised, and the individual is able to determine
the exact tooth from which the symptoms are
originating.
 De Moor et al And the tooth cracked 249

Table 1 Chronology of terms and definitions for tooth cracks/fractures.

Year Author(s) Terminology Definition

1954 Gibbs4 Cuspal fracture odontalgia Description of symptoms associated with incomplete tooth fractures (ITFs)
1954 Thoma5 Fissured fracture ‘A crack in the crown of the tooth. It may involve enamel alone or both
1957 Ritchey et al6 Incomplete tooth fracture enamel and dentine’
1957 Down7 Fissural fracture
1961 Sutton8 Crack lines ‘Fractures involving enamel and dentine without loss of tissue’
1962 Sutton9 Greenstick fractures ‘A break in the continuity of the tooth revealed only by the presence of a
visible transverse line’
1964 Cameron10 Cracked tooth syndrome ‘A fracture line forms in a part of a tooth underlying a cusp. The fractured
1972 Wiebush11 Hairline fracture part remains in place except when forced away from the central sulcus by
1973 Hiatt12 Incomplete crown-root fracture a lateral force sufficiently strong to produce bending of that part of the
1974 Talim and Gohi13 Incomplete coronal fracture tootj which s between the affected cusp and the root’
1976 Silvestri14 Split-root syndrome Description of a triad of signs and symptoms of ITFs
1977 Maxwell and Incomplete tooth fracture
Braly15 ‘A fracture of tooth structure which extends into dentine but in which the
tooth remains grossly intact’
1981 Andreasen16 Enamel infraction ‘An incomplete fracture (crack) of the enamel without loss of tooth sub-
stance’
1981 Caufield17 Hairline tooth fracture
1981 Johnson18 Crown craze/crack A fracture of tooth structure which extends into dentine but in which the
1983 Abou-Ras19 Tooth structure cracks tooth remains grossly intact – ‘ .. ... those that do not involve the pulp –
those in which irreversible pulpal damage has occurred’
1984 Luebke20 Crack/craze lines ‘An incomplete fracture (crack) of the enamel without loss of tooth sub-
Incomplete tooth fracture stance and lines in enamel which do not cross the amelodentinal junction’
Complete tooth fracture ‘A line that breaks or splits the continuity of tooth dentine surface but
does not perceptibly separate the surface’
Supraosseous fractures ‘Injury of enamel without loss of tooth structure’ – Located in coronal
Intraosseous fractures enamel
‘A line that breaks or splits the continuity of tooth dentinal surface but
1984 Kruger21 Cracked cusp syndrome does not perceptibly separate that surface’ i.e. a demonstrable fracture but
with no visible separation of the segments along the plane of fracture
1986 Brännström22 Dentinal crack syndrome
‘A demonstrable fracture but with no visible separation of the segments
1988 Williams23 Incomplete vertical tooth fracture along the plane of the fracture’
1989 Lost et al24 Tooth infraction ‘A fracture where there is a visible separation at the interface of the seg-
1989 Schweitzer25 Odontiatrogenic tooth fracture ments along the line of fracture, or the segments can easily be separated’
1990 Ehrmann and Cracked tooth syndrome ‘terminate above the bone not creating a periodontal defect’
1998 Tyas26 Cracked tooth ‘involve the supporting bone and creates a periodontal effect’
2001 Zuckerman27 Incomplete tooth fracture
Ellis28 ‘In most instances a restoration is present in the tooth. Careful inspection
after removal of the restoration reveals a crack nearly always at the junc-
tion of the pulpal floor and the vertical wall of the cavity preparation. ...
the crack rarely extends close to or actually to the pulp chamber’
‘ … commonly seen in posterior teeth that have been extensively restored.
A crack may develop because of expansion of amalgam which results from
continuous corrosion, trauma, or pressure associated with bruxism and
stress’

2008 American Associa- Craze line, fractured cusp, cracked ‘vertical tooth fracture, whether incomplete or complete,
tions of Endodon- tooth, split tooth, vertical root fracture ‘an incomplete fracture of the dentine in a vital posterior tooth, and must
tists29 be distinguished from a split tooth’
Fractured segments are still joined to one another by a portion of that
tooth through which the fracture has not yet extended
‘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’
See Table 2

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250 De Moor et al And the tooth cracked

Table 2 Classification of cracked teeth according to AAE (American Association of Endodontists29).

CLASSIFICATION ORIGIN DIRECTION SYMPTOMS PULP TREATMENT NEED PROGNOSIS

STATUS
Craze line Crown Variable – mostly None Vital None Excellent
occlusogingival
Enamel only Posterior: crossing buccal
and lingual surfaces
Marginal ridges Anterior: commonly long
vertical craze lines
Fractured cusp Crown +/- Mesiodistally and/or Mild and gener- Usually Removal of affected Good
cervical margin buccolingually ally, only to mas- vital cusp
of root Extending subgingivally tication and cold Direct or indirect res-
(cervical third of crown toration depending on
or root – mostly supra- extent of damage
osseous)
Cracked tooth Crown only or In general mesiodistally Acute pain on Variable Location and extent Questionable to poor:
also extending Central biting of the crack determine depends on depth and
from crown into Occasion- treatment plan extent of the crack
root (incom- ally sharp pain
plete fracture) to cold
Though, highly
variable
Split tooth Crown + root Mesiodistally through Marked pain on Often root Deep apical fracture = Poor unless crack
(complete marginal ridges and chewing filled extraction terminates close to
fracture) proximal surfaces When fragment (small) the cementoenamel-
Extension to shears to a root surface junction
proximal sur- = good possibility for
faces salvage of the tooth
Vertical root Roots Buccolingually Vague pain Mainly Apical surgery, root Poor: most of the times
fracture (= a true Mimics periodon- root filled amputation, he- diagnosed too late
vertical root tal disease misection, extraction Poor: root resection in
fracture) depending on extent of multi-rooted teeth
fracture and bone loss Hopeless for fractured
root

If the crack propagates into the pulp, irreversible
pulpitis, pulpal necrosis and periapical periodon-
titis may develop, with the respective associated
symptoms.
in 200829 (an update of a previous publication from
199730). In this document entitled ‘Cracking the
Cracked Tooth Code’, five types of tooth cracks, to-
gether with their treatment approach and prognosis,
were identified (Table 2)29,30.

Classification
Different classifications have been proposed for
cracked teeth in general. The type or location of the
crack, its direction and extent, the presence and the
risk of symptoms and/or pathological processes were
all determinants in these classifications. Several clas-
sifications are either incomprehensive or incomplete
(taking into account the present day occurrence of
cracks and fractures), and not helpful in defining
adequate treatment. The American Association of
Endodontists published a more useful classification
AAE classification
Craze lines
Craze lines are a common finding in adults and
only involve enamel. Most of them are diagnosed
as vertical defects. Craze lines are mostly found on
buccal surfaces in anterior teeth, but can also be
seen on palatal surfaces. In posterior teeth, craze
lines extend over marginal ridges, buccal and lin-
gual surfaces.

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 De Moor et al And the tooth cracked 251

Fig 1 (a) Fractured

distopalatal cusp with a
horizontal crack under-
mining the entire cusp.
(b) Removal of the
fractured cusp shows
that there was leakage
along the distal crack
in the enamel result-
ing in decay. (c and d)
Removal of the filling
and decay followed by
a resin composite res-
toration.
a b

c d

Fractured cusp
A fractured cusp indicates a complete or incomplete
fracture initiated from the crown of the tooth, under-
mining one or more cusps. The fracture extends to the
cervical third of the crown or root (Fig 1). The crack is
often directed both mesiodistally and buccolingually,
involving one or both marginal ridges and a facial or
lingual wall (Fig 1). The pulp is seldom involved.
Cracked tooth
A cracked tooth indicates an incomplete fracture
starting from the occlusal surface and running api-
cally. There is no separation of the fragments. The
crack is more centred occlusally and has a deeper
location apically than the fractured cusp. Pulpal and
periodontal involvement is likely (Fig 2).
Split tooth
A split tooth indicates a complete fracture extend-
ing through both marginal ridges (usually directed
mesiodistally) and splitting the tooth in two separate
segments. A split tooth is the evolution of a cracked
tooth (Fig 3). The fracture usually extends towards
the lingual surface of the root and ends in the middle
or apical third (Fig 4). A crack running straight down
the apex is not a common finding, unless a wedging
post was present.
Vertical root fracture
A vertical root fracture indicates a complete or in-
complete fracture of the root and is usually directed
buccolingually. The fracture is located in the root
portion only and is initiated from the root at any
level. With time, the fracture may extend coronally.
The crack may involve the entire root or only a por-
tion of the root (Fig 5).
Epidemiology
As the AAE classification has not been widely adopted
yet, data on the incidence of fractures are mainly
based on studies investigating cracked tooth syn-
drome. The incidence of longitudinal fractures seems
to increase as a result of prolonged tooth preservation:
patients are aging with less missing teeth35. As a result

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252 De Moor et al And the tooth cracked

a b c

d e

Fig 2 (a) Fractured buccal cusps of tooth 16. (b) Diagnostic radiograph does not demonstrate periodontal involvement yet.
(c) After removal of the filling and the base, a mesiodistal crack was found. (d and e) The crack runs from the mesial wall
(d) into the floor of the pulp chamber. The initial diagnosis of fractured cusps ends up with a non-restorable cracked tooth.

Fig 3 Example of a
cracked tooth: (a) a me-
siodistal crack centred
occlusally and with (b
and c) a deeper location
apically than a fractured
cusp. This type of crack
is ready to evolve into a
split tooth.

a b c

Fig 4 (a) Fracture

through both marginal
ridges. (b) A mobile
buccal fragment. (c)
Fracture runs towards
the buccal surface of
the root and ends in the
middle third.

a b c

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 De Moor et al And the tooth cracked 253

a b c d

Fig 5 (a) Radiograph after completion of root canal treatment. (b) Follow-up radiograph: there is a clear angular defect
running from distal to mesial. Clinical diagnosis of a vertical root fracture of tooth 37 with buccolingual fractured mesial root
without extension in the crown. (c) Crack on the buccal surface and (d) on the lingual surface, indicating a buccolingual root
fracture.

Table 3 Proportion of cracked teeth by tooth type.

Study N Maxillary teeth Mandibular teeth Restored vs non-restored

Premolars Molars Premolars Molars Restored Non-restored
Cameron (1964)10 50 16.00 28.00 2.00 54.00
Hiatt (1973)12 100 1.00 19.00 10.00 70.00 35.0
Talim and Gohil (1974)13 25.00 22.50 7.50 45.00
Cameron (1976)31 102 9.80 23.50 0.00 66.70
Abou-Rass (1983)19 120 19.20 20.80 0.00 45.80 15.8
Cavel et al (1985)40 118 24.60 25.40 5.10 44.90 4.2
Eakle et al (1986)41 206 5.83 25.73 25.24 25.73 8.7
Lagouvardos et al 200 28.50 20.00 5.00 46.50
(1989)42
Bader et al (2001)43 377 20.40 22.00 6.90 36.30
Brynjulfsen et al 46 28.30 39.10 4.30 28.30
(2002)44
Roh et al (2006)45 154 4.60 57.10 1.90 36.40
Krell & Rivera (2007)46 796 8.90 29.90 1.60 59.60
Seo et al (2012)47 107 6.60 44.80 2.80 45.80

of better oral hygiene and health, a decrease in tooth
extraction is seen. More teeth undergo extensive den-
tal treatment and are present longer.
The majority of incompletely fractured teeth
have restorations. There is a strong association be-
tween the presence of cracks and the presence of
intracoronal restorations12,19,26,33,36-38. Restored
teeth show a decreased internal strength39: in almost
all cases, the marginal ridges are opened and there
is extensive loss of sound dentine. Removal of the
pulp chamber roof for root canal treatment results in
further loss of dentine. However, the number of non-
restored caries-free cracked/fractured teeth is also
high: percentages up to 35% have been described.
External forces exceeding dentine strength gradu-
ally alter tooth structure12. Fracture occurs when the
elastic limit of enamel and dentine are exceeded39.
These fractures are not related to age nor to the re-
storative status of the tooth12,26,35.
Table 3 shows the percentages of maxillary and
mandibular molars and premolars, and the total
number of teeth in these studies with cracks and/
or fractures. Averaging the results shows that 48%
of the cracked teeth are mandibular molars, 28%
maxillary molars, 16% maxillary premolars and 6%
mandibular premolars, and about 2% other teeth.

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254 De Moor et al And the tooth cracked

Table 4 Aetiological factors associated with cracked/fractured teeth.

Classification Factors Examples

Natural Developmental Incomplete fusion of areas of Occurrence of cracked tooth syndrome in unrestored teeth
calcification
Occlusal Masticatory accident Sudden and excessive biting force on a hard food component
Damaging horizontal fractures Eccentric contacts and interferences (especially mandibular second molars)
Functional forces Large untreated carious lesions
Cyclic forces
Parafunction Bruxism
Occlusal and Extensive erosion Sport drinks, Anorexia, classical examples of extensive tooth erosion
circumferential
Iatrogenic Restorative Inadequate design Excessive dentine removal during cavity preparation
procedures Sharp line angles buccally and/or lingually at the cavity floor
Insufficient cuspal protection (direct and indirect restoration)
Deep cusp-fossa relationship (wedging effect)
Stress concentration Parapulpal pin
Pulpal posts
Hydraulic pressure during seating of tightly fitting cast restorations
Physical forces during placement of restoration e.g. amalgam
Non-incremental placement of resin composite restorations (polymerisation
shrinkage – tensile stress on cavity walls)
Miscellaneous Thermal cycling Enamel cracks
Dental interferences Tongue piercing and intraoral jewellery
Dental instruments Cracking and crazing associated with high-speed handpieces

Aetiological factors alies; and (ii) restorative procedures, and miscellane-

There are two primary factors predisposing teeth to
cracks32,48:
t
natural predisposing factors such as the steep cusp-
fossa of maxillary premolars and the lingual inclina-
tion of the lingual cusps of mandibular molars
t
iatrogenic factors: induced by any intervention
in the dentition
– at the coronal level, i.e. thoughtless tooth
substance removal during cavity preparation
(insufficiently addressing the final structural
strength and the design of the coronal restor-
ation)
– stress development induced by factors related
to the restorative procedure, and oral (para)
function
– stress development in the root caused by the
use of rotary root canal instruments, obturation
procedure or post placement.
Both groups of aetiological factors (Table 4) can be
classified in two subcategories related to: (i) occlusal
load, and development of the tooth ending in anom-
ous factors. Examples are:
t
Large MOD-preparations and too excessive a re-
moval of tooth structure jeopardising the integrity
of the tooth, once the width of the cavity has ex-
ceeded half of the intercuspal distance13,21,49-51.
t
Excessive depth of an MOD cavity creating ex-
cessive internal tensile stresses19.
t
Reduced supporting tooth structure in case of
extensive MOD restorations (tiny buccal and/
or lingual cavity walls without cuspal protection
(wide isthmus).
t
Tooth damage cause by parafunctional forces,
dental or facial trauma, volumetric changes of
restorations (thermal expansion or contrac-
tion)14,20,51-56.
t
The role of occlusion: wedging effect of cusp-
fossa relationship12,19,40.
t
Cuspal anatomy: non-functional cusps appear to
fracture with a higher frequency57.
t
Influence of oral ornaments such as piercing and
barbells58,59 (Fig 6).
t
Fatigue crack growth resistance of human den-
tine decreases with both age and dehydration60.

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a b
c d
t
Enamel cracks due to thermal cycling and damag-
ing horizontal forces or parafunctional habits26,61.
t
Root canal treated teeth show an increased risk
of fractures due to the unavoidable loss of hard
tooth substance during preparation of the ac-
cess cavity. Between 26% and 72% of root canal
treated posterior teeth restored with MO, OD
and MOD amalgam restorations cracked over a
20-year period62.
t
Adhesive procedures and insufficient compensa-
tion of the polymerisation shrinkage62,63.
Diagnosis
On the one hand, the literature gives evidence of a
diagnostic and treatment problem, and there is the
fact that diagnosis in the past was mostly symptom
related and hence regularly too late. Not all fractures
and cracks are symptomatic, so that a number of
them remain undiagnosed due to their invisible na-
ture or escape the attention of the dentist. On the
other hand, there is an increased present day aware-
ness of the incidence of tooth cracks and fractures.
De Moor et al And the tooth cracked 255
Fig 6 Tongue piercings
are a risk to teeth. (a)
Piercing in rest.
(b to d) Tooth damage
due to movement of
the piercing all around
the mouth and cracked
incisal edges.
The combination of improved diagnostic procedures
such as availability of biting devices, staining agents,
magnification and transillumination, resulting in a
better diagnosis, has also resulted in increased re-
ports on cracked teeth35.
In the past, the diagnosis of the so-called ‘cracked
tooth syndrome’ was based exclusively on tooth
symptoms: localised pain during chewing and biting,
unexplainable sensitivity to cold, and pain on release
of pressure10,32,33,52,53,56,64-67. But there is more.
First, the medical history should be considered
to exclude the occurrence of orofacial pain or psy-
chiatric disorders64. Especially when a crack is sus-
pected, a step-wise approach towards a diagnosis
is advisable. Next, information on the dental his-
tory should be considered, taking into account the
predisposing and aetiological factors for cracks and
fractures in teeth, followed by the registration of
the subjective symptoms and an objective intraoral
evaluation. Interesting indicators are also:
t
The presence of repeated occlusal adjustments
with temporal relief of symptoms.
t
Evaluation by several practitioners without a con-
clusive diagnosis.
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256 De Moor et al And the tooth cracked

Fig 7 (a) Localised

buccal swelling in the
attached gingival. (b)
Extensive coronal res-
toration and a mesial
crack in the marginal
ridge. (c) Radiograph
demonstrates the pres-
ence of a split tooth
(crack running into the
root and radiolucency
extending apically on
the mesial root).

a b c

Fig 8 Root fracture

of tooth 47. (a) Typical
finding of a fistula at
the junction of the at-
tached gingiva and mu-
cosa. (b) Tracing with
a gutta-percha cone
demonstrates that tooth
47 is involved, although
no radiographic signs of
periradicular pathology
are present. (c to e)
Vertical root fracture in
the mesiobuccal root.

a b

c d e

t
A prehistory of other cracked teeth: anatomical
or behavioural factors predispose teeth to crack.
For objective evaluation, the following procedures
and tests are very helpful:
1. Visual inspection and clinical examination
t
Localised swelling in the attached gingiva: deep
periodontal pockets with active infection gener-
ally produce swelling in the area of the oral mu-
cosa. Swelling localised in the attached gingiva,
especially in single rooted teeth, usually refers
to a localised periodontal problem induced by a
crack or fracture (Fig 7). In molar teeth, differ-
ential diagnosis with furcation lesions has to be
made. Periodontal probing is needed to verify if
the area of the swelling refers to a problem asso-
ciated with a localised pocket, indicating a crack
or a true periodontal pocket.
t
The presence of fistula(s): a fistula at the level of
the mucogingival junction is frequently seen in
association with vertical cracks extending subgin-
givally and running into the root (Fig 8). Radio-
graphic examination with a gutta-percha point
inserted into the fistula is needed to determine
the origin of the fistulous tract. In most cases, it
is also possible to insert a periodontal probe or a
gutta-percha cone into the sulcus up to the area
of the fistula.
t
Periodontal probing: a typical finding for a
cracked tooth is an isolated narrow periodontal
pocket running along the fracture. Periodontal

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 De Moor et al And the tooth cracked 257

Fig 9 Vertical root

fracture of tooth 35.
(a) Presence of a buccal
fistula at the level of the
attached gingival. (b)
Probing of a localised
buccal defect. (c to d)
History of root canal
treatment with preop-
erative and postopera-
tive radiographs. (e to f)
Radiographs demon-
strating an asymmetric
defect. The radiolucent
a b area moves along the
root on the radiograph
depending on the X-ray
angulation.

c d e

Fig 10 Mesiodistal
fracture of tooth 27
with a mobile palatal
fragment. Note the
inflamed gingival
border, the presence of
plaque in the fracture
and a pulpal Dentatus
pin perforating the resin
composite filling.

probing is an essential part of the diagnostic pro-
cedure (Fig 9). A side-to-side motion indicates
a pocket along the fracture line, a broad defect
indicates a periodontal pocket68.
t
Evaluation of the occlusal surface for the presence
of wear facets identifying teeth involved in eccentric
contacts and at risk for damaging lateral forces68.
t
A mobile fragment in teeth with extensive dental
treatment (Fig 10).
t
Visible craze lines, cracks and fractures: dark or
brown-coloured cracks and fracture lines refer to
an older prehistory. Recent cracks and fissures are
mostly unstained (Figs 3 and 11).
t
Teeth with extensive intracoronal restorations
especially the ones with fine remaining tooth
structure walls or those where the marginal ridge
is opened (e.g. MOD filling) are candidates for
cracks9,69-72.
2. Confirmation test (symptom reproducers and vi-
sion enhancers)
t
Pulp sensibility testing: the reaction of the dental
pulp to cold, heat and electric stimulation has to
be tested32,56,64,67,73.
t
Bite-tests and wedging forces: the patient is in-
structed to bite on objects such as a tooth pick,

ENDO (Lond Engl) 2014;8(4):247–266

258 De Moor et al And the tooth cracked

Fig 11 Tooth 27 with

clinical symptoms dur-
ing mastication. (a) No
periodontal defect is
seen on the radiograph.
(b) Presence of a large
occlusal amalgam filling,
b c d
and cracks in the mesial
and distal marginal
ridges. (c to f ) Dark
coloured mesiodistal
crack in tooth 27.

a e f g

Fig 12 Tooth Slooth

(Professional Results).

Fig 13 (a) Tooth 36

with persisting sensitiv-
ity, especially during
chewing. (b) Staining
of the occlusal surface
with methylene blue.
(c) Detection of a distal
crack next to the distal
margin of the filling and a b c
crossing the marginal
ridge. (e to f) Removal
of the resin composite
filling and evaluation of
the extent of the crack.
(g) Class II cavity prep-
aration.

d e f

a cotton roll, a wooden stick, or commercially t
As previously mentioned, attention should be

available instruments such as the ‘Tooth Slooth’
(Professional Results, Laguna Niguel, CA, USA)
(Fig 12) or ‘Fracfinder’ (Denbur, Oak Brook, IL,
USA). The patient’s pain is evaluated upon clos-
ing and opening, with pain upon release usually
indicative of a cracked tooth32,34,35,68.
t
Visualisation of the coronal tooth part: magnifi-
cation greatly enhances the detection and evalu-
ation of cracks and fractures. Transillumination
may also be very helpful in crack diagnosis, as
well as the use of dyes such as methylene blue
(Fig 13).
paid to stained and visible cracks/crack lines,
however, not all these stained cracks will lead to
the development of further problems19,56,67,73,74.
Sometimes, restorations need to be removed in
order to stain the internal cavity walls and angles.
t
Visualisation of the radicular tooth part – sur-
gical exploration: the suspicion of a vertical root
fracture may be raised when a radiolucency can
be seen running alongside the root surface. This
observation comes late in the process of root
fracture when microorganisms from the oral
cavity or necrotic pulp reach the length of the

ENDO (Lond Engl) 2014;8(4):247–266

 De Moor et al And the tooth cracked 259

Fig 14 Flap reflection

is an important aspect in
the detection of cracks
and fractures. In this
case there was no peri-
odontal marginal defect
(probing was negative).
It is only after surgical
exposure and also after
staining with Methylene
Blue that the presence
of a root fracture was
confirmed.

a b

c d

a b

Fig 15 Tooth 46 with complaints during chewing. (a to b)

A buccal vertical crack is present running through the buccal
fissure. (c) Diagnostic radiograph demonstrating the pres-
ence of a buccolingual vertical crack and the presence of an
asymmetrical mesial radiolucency. c

periodontal ligament through the fracture. At this
stage the crack may also be seen on the root
surface above the bone level if a diagnostic flap
is reflected. Dyes are helpful to visualise the pat-
tern of the fracture after reflection of the flap30
(Fig 14).
3. Radiographic evaluation
t
Fractured cusps and cracked teeth: radiographic
evaluation is seldom useful as a part of the diag-
nosis of fractured cusps and cracked teeth be-
cause the cracks themselves are usually not vis-
ible radiographically. Nevertheless, radiographic
information can be helpful to determine the peri-
apical status in these cases. Bone loss increases
with the severity of the fracture/crack75 (Fig 15).
t
Split teeth: as long as the incident X-ray beam
does not coincide with the fracture direction,
the fracture will not appear on the radiograph.
Radiographic findings are more likely to reflect
damage to the periodontium and alveolar bone.
In case of a mesiodistally split tooth, angular
loss of interproximal or horizontal loss of inter-
radicular bone can be seen. The extent of the
bone loss can be related to the extent of the
fracture/crack.

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260 De Moor et al And the tooth cracked

Fig 16 Marked bone

resorption along the lat-
eral surface of the root
and seen as an angular
defect.

a b1

166%

b3 b2

Fig 17 Tooth 36 with a vertical root fracture, seen as an angular defect and a hanging
drop on the radiograph (a, b1 and b2). (b3) Root fragments and fractured mesial root.

t
Vertical root fractures: A variety of patterns can
be seen, and at times there are no significant
changes. Typical patterns are:
– Marked bone resorption along the lateral sur-
face of the root and often seen as an angular
defect in the cervical third of the root (Figs 16
and 17).
– A ‘J-shaped’ or ‘halo’ pattern: the resorptive
pattern extends over the apex and along one
root surface76-78(Fig 18).
– A ‘hanging drop’: the lesion resembles a classi-
cal apical lesion of endodontic origin (e.g. failed
root canal treatment)76-78 (Figs 19).
– Separation of the root fragment, though only
seen in a limited number of cases (Figs 20 and
21).
– A radiolucent line between root canal filling
and root canal wall: Confusion is possible with
incomplete root canal filling or an artefact35
(Fig 22).
– A bilateral radiolucency situated at the end of a
post is an indication of a perforation defect or
the end of a root fracture (Fig 23).
It has to be emphasised that radiographs are not
solely diagnostic. The triad of diagnostic means in-
cludes: (i) visual inspection and tactile examination;
(ii) confirmation tests (symptom reproducers and
visualisation enhancers); and (iii) radiographic con-
firmation of the subgingival manifestations.
Management
A decision flowchart is presented in Fig 24. The chart
is adopted from Abbott79 and Kahler34. It is important
to state that cracks in teeth are findings, and that the
pulpal or periapical diagnosis has to be established in
every case as part of the treatment decision.
Craze lines29,35,79
As craze lines are only confined to enamel, it is
unlikely that these lines are a precursor to dentine
fractures. Moreover, the dentinoenamel junction is a
buffer area spreading stresses along the interface be-
tween dentine and enamel when teeth are exposed
to load or stress. No treatment is needed.

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 De Moor et al And the tooth cracked 261

a a

Fig 18 Halo patterns. (a) Mesiodistally cracked central
incisor, with a history of trauma, root canal treatment and
internal bleaching. (b) Mesiodistally cracked tooth 36 with a
very large post in the distal root.
Fig 19 Example of a hanging drop resembling a classical
apical lesion on tooth 45 with an extensive amalgam crown
and amalgam in the root canal. There is a second lateral ra-
diolucency at the level of the cervical third. The combination
of both indicates the presence of a cracked tooth.

1
2
a b

Fig 20 Mesiodistally cracked molar with typical radio- Fig 21 A central incisor
graphic characteristics of a cracked tooth: (b1) mesial angu- with a vertical fracture and
lar defect and (b2) a hanging drop. separated root segment, and
an apical radiolucency.

a b

Fig 22 Example of separated root fragments in a maxillary Fig 23 (a) A large post in a central incisor, with a bilat-
second premolar eral radiolucency at the end of the post. (b) Fractured root
of tooth 21.

Fractured cusp29,35 lumination. The confirmation of older fractures is

easier as they have already acquired stain.
In order to diagnose a fractured cusp, it is sometimes A fractured cusp that is mobile and separable
necessary to remove the existing restoration. The with wedging forces needs to be removed. Depend-
fracture line is disclosed by staining and/or transil- ing on the amount of remaining tooth structure, the

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262 De Moor et al And the tooth cracked

Fig 24 Decision flow

chart for the treatment
Dental history
of five different types
Visual and tactile inspection
of vertical cracks and
fractures (according to Specific diagnostic tests
the AAE). Adapted from
Abbott79 and Kahler34.

Vertical root
Craze line Fractured cusp Cracked tooth Split tooth
fracture

Remove
Root involved
restoration

Dentinal Pulpal
No symptoms Periodontal symptoms
symptoms symptoms

Reversible Irreversible
pulpitis pulpitis

No
treatment Temporary restoration + bonding Tooth extraction
Rooth resection (multi-rooted teeth)
Or covered by temporary crown
Encircling of the tooth

Symptoms Root canal Symptoms

Revision
persist treatment persist

Symptoms Symptoms Symptoms

resolve disappear resolve
pulp test pulp test
positive negative

Revision Cusp-coverage restoration Complete

follow-up direct or indirect RCT

or Permanent crown
Encircling of the tooth

tooth is treated by removing the affected cusp and
restoring with a direct or a indirect restoration with
cuspal coverage (full crown or onlay) that covers the
crack margin20,33,46.
Cusp removal is not indicated when the fractured
cusp is not mobile or separable. Relying on adhesive
techniques to bond enamel and dentine to the res-
toration is not indicated without reducing the cusp
at least 2 mm in height (reduction taking into ac-
count the need for a thickness of at least 2 mm for
the restoration in resin or porcelain). It needs to be
emphasised that cuspal protection is also mandatory
with adhesive techniques80.
Root canal treatment is usually not needed and
certainly not indicated in the absence of signs of ir-
reversible pulpitis.
Cracked tooth29,35
Wedging forces are applied to determine if the
tooth segments are separable. If no movement
is detected, the classification is a cracked tooth;
when the segments separate, it is a split tooth. The
fracture may extend through either or both of the
marginal ridges and through the proximal surfaces.
The fracture is located in the crown portion of the

ENDO (Lond Engl) 2014;8(4):247–266


a b
c d
tooth only or may extend into the root. Periodon-
tal probing is needed to determine the depth and
the severity of the fracture. Supragingival fractures
do not create probing defects, but a deep probing
depth indicates the involvement of the root and a
more adverse prognosis.
It is the pulpal, periapical and periodontal diag-
nosis that determines the treatment options. Lon-
gitudinal fractures are findings, not diagnoses. The
extent of the fracture affects pulpal and periapical
tissues. Once a communication is established be-
tween the oral cavity and the pulp or periodontal
space, bacterial contamination alongside the fracture
line is possible, causing pulp necrosis and infection
and/or periodontal breakdown. However, a deep
fracture does not necessarily communicate with the
pulp.
If root canal treatment is indicated, the pulpal
space needs thorough inspection. Dyes are used
to stain cracks and fractures lines and in combina-
tion with magnification, their extent and location
are determined. If the crack extends through the
pulp chamber floor, further treatment does not make
sense and extraction is needed. Clark and Caugh-
De Moor et al And the tooth cracked 263
Fig 25 (1) Tooth 26
with multiple cracks,
sensitivity to tempera-
ture and also during
chewing. (a to b) Exter-
nal view of the cracks at
the mesial side. (c to d)
Evaluation of the cracks
running through the
cavity walls.
man81 have categorised the prognosis of cracked
teeth as excellent, good, poor and hopeless:
t
Excellent: (a) Cuspal fracture confined to the den-
tine that angles from the facio-pulpal or linguo-
pulpal line angle of a cusp to the facio-pulpal or
linguo-pulpal line angle of a cusp to the cemen-
toenamel junction or slightly below. (b) Horizontal
fracture of a cusp not involving the pulp.
t
Good: A coronal vertical fracture that runs me-
siodistally into the dentine but not into the pulp.
t
Poor: A coronal vertical fracture that runs mesio-
distally into the dentine and pulp but is confined
to the crown.
t
Hopeless: A coronal vertical fracture that runs
mesiodistally through the pulp and extends into
the root.
If incomplete fractures (not terminating on a root
surface) are present, the remaining tooth fragments
are bonded with resin composite. There is no evi-
dence that adhesive techniques are helpful in pre-
venting crack propagation, therefore a partial or full
crown are still preferred as a permanent restoration
solution (Figs 25 i to iii).
ENDO (Lond Engl) 2014;8(4):247–266
264 De Moor et al And the tooth cracked

Fig 25 (2) (a) Prepar-

ation of a partial crown
– central build-up of the
cavity with resin com-
posite. (b) Fabrication
of a partial porcelain
crown. (c) Cementation
of the partial crown
under rubber dam. (d)
Bonded porcelain crown
in situ.

a b

c d

Fig 25 (3) (a) Radio- t
Removal of the fractured segment and crown
graphs after completion
of root canal treatment lengthening or orthodontic extrusion in order to
– there are no peri- have restoration margins respecting the biologi-
odontal problems. (b)
Control radiograph after
cal width.
finishing of the bonded t
Removal of the fractured segment only (and only
partial porcelain crown.
when the tooth has already been restored and
without exposure of root canal filling material to
the oral environment). The aim is reattachment
to the fractured dentine surface.
a a

Vertical root fracture

Split tooth29,35
In this situation the fractured fragments are sepa-
rated. If deep apical fractures, i.e. severe fractures,
are present the only treatment solution is extrac-
tion20,34,56. If the fracture is oblique and ends in
the cervical third, there is a good possibility that the
remainder of the tooth can be salvaged after removal
of the small loose fragment.
Different treatment options exist:
t
Removal of the fractured segment and restor-
ation margin related to the new attachment zone.
The only predictable treatment is surgical removal of
the fractured root (root amputation or hemisection)
or extraction of the tooth.
Conclusion
1. Cracks in teeth are a common clinical finding. Now-
adays, there is a higher awareness of the presence
of tooth cracks/fractures among dentists.
2. Cracks are mostly seen in posterior teeth. There is
a higher prevalence in molars than in premolars,
and in mandibular molars than in maxillary molars.

ENDO (Lond Engl) 2014;8(4):247–266


Maxillary molars present more fractures of buccal
cusps, whereas, mandibular molars more lingual
cusps.
3. The incidence of complete fractures is estimated
5 teeth per year per 100 adults.
4. Aetiological and risk factors for cracked/fractured
teeth can be grouped in two categories: natural
and developmental factors, and occlusal factors.
5. Localised pain during biting, unexplained sensi-
tivity to cold, and general pain during chewing or
biting are indicators for teeth with cracks.
6. There is no evidence for restorative treatment for
asymptomatic teeth with visible cracks.
7. Cuspal coverage (full crown, bonded direct or indi-
rect composite overlay) is recommended in order to
increase the prognosis of the restored tooth with a
history of cracks and also when the remaining walls
are too thin. Adhesive procedures with preserva-
tion of these tiny walls do not guarantee resistance
to future fracture or crack propagation.
8. There is no evidence demonstrating a superior
prognosis of any restorative approach.
9. The term ‘cracked tooth syndrome’ is interpreted
in different ways and there is no consensus as
to which group of clinical symptoms this term
refers. Therefore it is better for the sake of clarity
to adopt the AAE classification with the follow-
ing five terms: craze line; fractured cusp; cracked
tooth; split tooth; and vertical root fracture. Clin-
ical symptoms are indicators. The combination of
visual inspection, tactile examination, confirmation
test (symptom reproducers and vision enhancers),
and radiographic evaluation is required to estab-
lish the diagnosis of longitudinal tooth fractures.
10. Prevention is an essential part of treatment:
awareness of the practitioner of the occurrence
of cracks in symptomless teeth; tooth substance-
saving restorative procedures both for coronal
and intraradicular fillings; minimising or avoiding
internal wedging forces; cuspal coverage of a
cracked tooth; and encouragement of patients
to forego destructive habits.
11. Cracks in teeth are findings; the pulpal and peri-
apical diagnosis has to be established in every
case as part of the treatment decision.
De Moor et al And the tooth cracked 265
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